Anaesthetists Of Great Britain And Ireland Research Articles

Designing intelligent anesthesia for a changing patient demographic: a consensus statement to provide guidance for specialist and non-specialist anesthetists written by members of and endorsed by the Society for Obesity and Bariatric Anaesthesia (SOBA).

BackgroundAs a result of the increasing prevalence of obesity in the UK, anesthetists are increasingly encountering overweight and obese patients in routine practice. There is currently a paucity of evidence to guide best clinical practice for anesthetists managing overweight and obese patients. The current guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI), entitled Peri-Operative Management of the Morbidly Obese Patient, give an excellent overview of organizational issues, but leave much clinical detail to the discretion of the individual clinician.MethodsIn May 2010, a panel of experts convened to develop consensus on anesthesia of overweight, obese and morbidly obese patients, in consultation with the Society for Obesity and Bariatric Anaesthesia (SOBA). All Panel members are practicing clinicians from recognized bariatric surgical training centers and have extensive experience of anesthesia for obese patients. This statement aims to provide guiding principles on best practice for this challenging patient demographic, and to increase awareness of current issues so that these can be addressed more appropriately.ResultsIn this document, we emphasize key principles for best practice, rather than giving prescriptive guidance and specific regimens for all clinical eventualities. We provide evidence-based justification for best-practice techniques, where this exists. In areas for which there is no evidence, but there is clear consensus, we offer this as guidance. We also aim to dispel misconceptions that have arisen in the anesthetic practice of overweight, obese, and morbidly obese patients.ConclusionUltimately, the choice of specific technique depends on clinician experience, patient characteristics, and center facilities. As well as providing guiding principles for anesthesia, this consensus statement also highlights other areas where anesthetists can contribute towards the enhanced recovery and overall quality of patient care.

Residual anaesthesia drugs in intravenous lines – a silent threat?

Residual anaesthesia drugs in intravenous lines – a silent threat?

Differences between hip fracture guidelines

We were pleased that the different clinical guidelines related to proximal femoral fractures have been compared and examined 1, but suggest that the nature of the patient cohort has hampered research, and therefore the production of coherent guidance. We agree with the authors that the 6-year time span of the guidelines considered is very likely to have thrown up differences, particularly in areas where improvements in care have been addressed through a multidisciplinary approach, such as peri-operative analgesia. Many randomised controlled trials (RCTs) have struggled with trial design, recruitment, bias and issues surrounding consent and capacity 2, to the extent that they may not be included in any rigorous Cochrane review. The largest UK-based study on anaesthesia for hip fracture has been underway in Peterborough for the last three years and is very unlikely to find any meaningful difference, owing to all these inherent problems 2. Instead, the use of prospective observational studies has been proposed to collate data about anaesthetic management, to inform and/or promote future research. Data about the mode of anaesthesia has recently started to be collected by the National Hip Fracture Database (NHFD) 3. Of real concern in the NHFD's 2012 report was the finding that 6.5% of 59 000 patients received combined spinal and general anaesthesia. More recently still, the Association of Anaesthetists of Great Britain and Ireland (AAGBI) has funded a sprint audit (‘ASAP’), for the NHS Hip Fracture Perioperative Network (HiPeN), in collaboration with the NHFD, to collect peri-operative management information on more than 10 000 hip fracture patients 4. Anaesthetists in Scotland cannot contribute to this audit, but many have contacted HiPeN about collecting local data. Kearns et al. mention newer papers that have not been considered, possibly due to their publication date. We can confirm, for example, that the meta-analysis by Luger et al. 5 was not considered by NICE owing to the timings of the meetings. However, other papers were quoted inappropriately: the FOCUS study (quoted as reference 41) concerns transfusion policies in a rehabilitation, rather than a peri-operative setting, and so is of limited relevance to inclusion in future guidelines, excepting its implication that [haemoglobin] should be measured in the recovery room because of peri-operative blood loss equivalent to a mean of 2.5 g.dl−1 haemoglobin. Inevitably, as a result of ASAP, the recent AAGBI guidelines 6 will be submitted to a form of continuous improvement 7 through review, in the same way that the NICE guidance is already under review, less than two years since publication. Finally, we would like to suggest that from a medicolegal point of view, the guidelines most likely to be referred to in determining the peri-operative standard of care given by anaesthetists are those provided by the specialty itself, in this case the AAGBI guidelines 6.

The following abstracts were presented at the Winter Scientific Meeting of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) in London, January 2013

The following abstracts were presented at the Winter Scientific Meeting of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) in London, January 2013

Capnography Outside the Operating Rooms

ISTORICALLY, anesthesiologists seem to be the forerunners in implementing tools and standards for safety in the medical fraternity. In the United States, since 1985, there has been a dramatic decrease in the malpractice insurance premiums of anesthesiologists. Such a decrease has not been seen in other medical or surgical specialties over this time frame. Thanks to the foresight of the American Society of Anesthesiologists (ASA), Anesthesia Patient Safety Foundation (APSF), Association of Anaesthetists of Great Britain and Ireland (AAGBI), and the Association of Anesthesiologists in Holland, capnography was embraced and incorporated into the standards of monitoring during anesthesia to enhance patient safety. Currently, anesthesiologists in many developing countries follow these recommendations (India, Government of Andhra Pradesh Order, AST/775/F25/dated September 2011. Capnography is mandatory for laparo

Increased Use of Twitter at a Medical Conference: A Report and a Review of the Educational Opportunities

BackgroundMost consider Twitter as a tool purely for social networking. However, it has been used extensively as a tool for online discussion at nonmedical and medical conferences, and the academic benefits of this tool have been reported. Most anesthetists still have yet to adopt this new educational tool. There is only one previously published report of the use of Twitter by anesthetists at an anesthetic conference. This paper extends that work.ObjectiveWe report the uptake and growth in the use of Twitter, a microblogging tool, at an anesthetic conference and review the potential use of Twitter as an educational tool for anesthetists.MethodsA unique Twitter hashtag (#WSM12) was created and promoted by the organizers of the Winter Scientific Meeting held by The Association of Anaesthetists of Great Britain and Ireland (AAGBI) in London in January 2012. Twitter activity was compared with Twitter activity previously reported for the AAGBI Annual Conference (September 2011 in Edinburgh). All tweets posted were categorized according to the person making the tweet and the purpose for which they were being used. The categories were determined from a literature review.ResultsA total of 227 tweets were posted under the #WSM12 hashtag representing a 530% increase over the previously reported anesthetic conference. Sixteen people joined the Twitter stream by using this hashtag (300% increase). Excellent agreement (κ = 0.924) was seen in the classification of tweets across the 11 categories. Delegates primarily tweeted to create and disseminate notes and learning points (55%), describe which session was attended, undertake discussions, encourage speakers, and for social reasons. In addition, the conference organizers, trade exhibitors, speakers, and anesthetists who did not attend the conference all contributed to the Twitter stream. The combined total number of followers of those who actively tweeted represented a potential audience of 3603 people.ConclusionsThis report demonstrates an increase in uptake and growth in the use of Twitter at an anesthetic conference and the review illustrates the opportunities and benefits for medical education in the future.

'Do Not Attempt Resuscitation' (DNAR) decisions in patients with femoral fractures: modification, clinical management and outcome

increased provision of orthogeriatric expertise for patients with femoral fractures has led to implementation of 'Do Not Attempt Resuscitation' (DNAR) decisions prior to anaesthesia and surgery for fixation of their fractures. Review and modification of the DNAR decision by the medical team is necessary before surgery and is recommended by guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the General Medical Council. over a 17-month period, DNAR decisions were already present or were implemented for the first time in 22 patients prior to scheduled surgical fixation of their femoral fractures. Data were collected prospectively on each patient's management, including modification of their DNAR decision, and outcome at 30 days and 1 year. two patients died prior to surgery. In eight of the 20 patients who underwent surgical fixation, there was no documentation regarding the status of the DNAR decision in the perioperative period. The 30-day mortality rate for those undergoing surgery was 15% (3/20). At 1 year, eight patients survived with six living in their own homes. despite the favourable outcomes for hip fracture patients with pre-existing DNAR decisions, this audit showed inadequate review and documentation of the DNAR decision in advance of surgery.

The following abstracts were presented at the Winter Scientific Meeting of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) in London, January 2012

The following abstracts were presented at the Winter Scientific Meeting of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) in London, January 2012

Smartphones, Twitter and new learning opportunities at anaesthetic conferences

Smartphones and their apps are extremely popular with anaesthetists [1]. Smartphones were originally developed for communication; we now have the potential to use this technology for real-time, online discussion via social networking sites such as Twitter. Although most consider Twitter as a method of personal communication, it is now used widely in business and academia. Twitter has been used extensively at non-medical conferences for some time, and is now becoming more commonplace at medical meetings [2, 3]. Table 1 describes commonly used Twitter terminology. A hashtag “#AAGBIlinkman” was created for the 2011 Association of Anaesthetists of Great Britain and Ireland (AAGBI) Linkman conference in Edinburgh to determine whether spontaneous Twitter activity would result. Disappointingly, no Twitter activity was generated. Despite this lack of activity, a further Twitter hashtag was created for the AAGBI Annual Congress in Edinburgh: “#AAGBIcongress”. This time, spontaneous Twitter activity did result, and four people posted 36 tweets under the hashtag. Most were posted during the Congress itself, with a few before, and one after. Twenty-five (69%) of the tweets were used to post notes or learning points from lectures and workshops. Tweets were also used to describe plans to attend the meeting and the session being attended, to support colleagues who were speaking, and for social reasons. This activity demonstrates the potential to use Twitter at future anaesthetic conferences to enhance the experience not only of those at the conference but also those unable to attend. Despite the small numbers achieved, the pattern of tweeting followed the trends that have previously been reported at both medical and non-medical conferences. There are many other uses of Twitter at conferences, for both the organisers and the attendees, that could be adopted by anaesthetists [2–4]. Full engagement and promotion by the conference organisers would be required to achieve this potential. Conference organisers would have an obligation to educate participants regarding Twitter etiquette, protecting their personal identity as well as appropriate legal and ethical considerations.

The Effect of Repeated Audit on the Quality of Transfer of Brain-Injured Patients into a Regional Neurosciences Centre

Brain injury is common and transfer of such patients to a neuroscience centre is a frequently occurring event. Transfer is a time of potential instability and can contribute to physiological changes that could cause secondary brain injury. UK data suggest that there has been a gradual improvement in quality and outcome of transfers of brain-injured patients during the last three decades. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) have published guidelines to improve the safety and quality of transfers. Over a seven-year period, we audited transfers four times and implemented three successive interventions aimed at improving the quality of transfers of brain-injured patients into the regional neurosciences centre. We observed a significant improvement in the transfer of patients according to AAGBI guidelines across most domains of patient care. The use of repeated cycles of audit and intervention significantly improved the quality of transfer of brain-injured patients, which could improve patient safety and outcome.

Fractured neck of femur: guidelines and beyond

Fractured neck of femur: guidelines and beyond

Day case and short stay surgery: 2

Day case and short stay surgery: 2

A reply

Thank you for the opportunity to respond to the letter by Dr Hogan concerning resuscitation for cardiac arrest caused by anaphylaxis during anaesthesia. First, Dr Hogan questions the use of a pulse check to diagnose cardiac arrest with pulseless electrical activity (PEA). Second, Dr Hogan suggests that external chest compressions are potentially harmful in PEA caused by anaphylaxis and other states where there is a profound decrease in systemic vascular resistance because loss of a palpable pulse can occur in the presence of a cardiac output and low systemic vascular resistance. Cardiac arrest secondary to anaphylaxis can occur rapidly following a rapid decrease in the patient’s blood pressure [1]. The precise moment when PEA cardiac arrest occurs is difficult to diagnose clinically. Palpation of the pulse as the sole indicator of the presence or absence of cardiac arrest is unreliable [2]. A pulse check alone to diagnose cardiac arrest has not been part of advanced life support guidelines for many years [3]. Dr Hogan is therefore correct that the absence of a palpable pulse alone should not indicate the need for chest compressions if there are other reliable indicators of the presence of an adequate cardiac output. During anaesthesia, continuous monitoring of vital signs in addition to clinical signs will help make the diagnosis. The most recent guidelines for advanced life support reinforce the important diagnostic role of waveform capnography to indicate the return of a spontaneous circulation [4]. Current guidance for the treatment of anaphylaxis from both the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the Resuscitation Council UK suggests using an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach with adrenaline and intravenous fluids as key treatments [5, 6]. Adrenaline should be given in small intravenous increments (e.g. 50 μg in adults) or an infusion, if necessary, to treat anaphylaxis during anaesthesia. These treatments may have already started before cardiac arrest occurs and may be useful in the scenario Dr Hogan describes. If cardiac arrest does occur, standard advanced life support guidelines should be followed [7]. These include high quality chest compressions combined with adrenaline and fluid resuscitation. The recommended doses of adrenaline used during cardiac arrest are much higher (1 mg intravenously in adults). Care therefore needs to be taken to confirm cardiac arrest before giving this significantly higher dose of adrenaline. Although chest compressions are undoubtedly less effective in the presence of hypovolaemia, we are not aware of any evidence that chest compressions reduce cardiac output in the presence of a low blood pressure, regardless of whether this has been caused by a low cardiac output or a vasodilatory state. There are few data to provide a basis for specific guidance on the treatment of cardiac arrest from anaphylaxis during anaesthesia. The current guidance may prevent cardiac arrest in many circumstances, and ensures that cardiopulmonary resuscitation with advanced life support measures is started early if cardiac arrest occurs. Following standard guidelines for advanced life support importantly acknowledges the fact that there may be clinical uncertainty about the cause of cardiac arrest during anaesthesia. If the anaesthetist is unable to feel a pulse, chest compressions should be started unless there are other convincing and reliable indicators of the presence of an adequate cardiac output. JS chairs the anaphylaxis working group of the Resuscitation Council UK and contributed to the AAGBI anaphylaxis guidance. He is an editor of Resuscitation. JPN is a member of the anaphylaxis working group of the Resuscitation Council UK and is Editor-in-Chief of Resuscitation. No external funding declared. Previously posted at the Anaesthesia Correspondence website: http://www.anaesthesiacorrespondence.com.

Safety in magnetic resonance units: an update

The number of anaesthetists who are involved in magnetic resonance (MR) units is increasing. Magnetic resonance systems are becoming more powerful and interventional procedures are now possible. This paper updates information relating to safety terminology, occupational exposure, reactions to gadolinium-based contrast agents and the risk of nephrogenic systemic fibrosis. Magnetic resonance examinations of patients with pacemakers are still generally contra-indicated but have been carried out in specialist centres under strictly controlled conditions. As availability of MR increases, so the education of anaesthetists, who are occasionally required to provide a service, must be considered.Anaesthesia in MR units was first described in the 1980s. Guidelines on the provision of anaesthetic services in MR units were published by the Association of Anaesthetists of Great Britain and Ireland (AAGBI) in 2002 [1]. Since then, the number of hospitals with MR units, and hence the number of patients requiring anaesthesia for MR, has increased. While the issues relating to setting up anaesthetic services in MR have not changed, there have been a number of developments that warrant this update:Safety terminology and guidelines have changed.MR systems utilise higher magnetic-field strengths and more open designs are available.Interventional and intra-operative MR are now routine in some centres.Mobile MR scanners are increasingly used to reduce waiting lists.Although still generally contra-indicated, some patients with pacemakers have been scanned under strictly controlled conditions in specialist centres.‘MR safe’ medical implants are now being produced.New equipment is now available for use in MR.Out-of-hours availability of MR investigations has increased.Reports of allergic reactions to MR contrast media have increased.Gadolinium based contrast agents (Gd-CAs) are associated with a varying degree of risk of nephrogenic systemic fibrosis in patients with impaired renal function.

Availability of and use of Intralipid (lipid rescue therapy, lipid emulsion) in England and Wales

There is increasing evidence for the use of Intralipid in the management of acute local anaesthetic toxicity. This is supported by the recent Association of Anaesthetists of Great Britain and...

Pride and prejudice

Pride and prejudice

Manual handing and back pain in anaesthetists: from AAGBI guidelines to bespoke course

Obesity has become more common in the last decade with increasing numbers of obese patients presenting for surgery. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) published guidelines in 2007 relating to the physical and medical management of obese patients. One of the key steps suggested was staff training in manual handling, covering the physical management of the morbidly obese patient. In recent years very few doctors have attended the manual handling courses provided by the Trust. We conducted an audit, by means of an interview of members of the department to assess: the perceived need for training; those who had previously attended formal training; those who considered themselves to suffer from back problems. The audit standard, as recommended by the AAGBI and as stipulated in Trust policy, was for 100% of staff to have attended formal training. Forty-eight interviews were conducted in total. There were no members of staff off on long term sick during the interview period. Interviewees: consultants 22, SpR 12, SHO 14. 6/48 had received formal training in the past. two consultants recently in Swansea; one consultant 10 years ago in another Trust; one consultant when doing a plumbing course; one SHO when working in nursing; one SHO as part of induction in another Trust. Many had not attended because they had not been offered a place or weren’t sure it was needed. 39/48 didn’t know there was a Trust policy relating to manual handling. 23/48 considered themselves to have back problems (13 work related). 3/48 had required time off work with back problems. Our impression was that there is: generalised ignorance about manual handling among anaesthetists; the nature of the problem is not appreciated (in particular the difference between static and dynamic loads); ergonomics of the anaesthetic rooms required attention. This audit has achieved heightened awareness of these issues in the departments. A specific one-day course for anaesthetists has been devised and started. It is proving popular and has become part of the induction programme. To date over 30 anaesthetists have received training this year. We have received positive feedback from course delegates. Dr William McFadzean, consultant anaesthetist, Mr Martin Thomas, Health and Safety Department, Abertawe Bro Morgannwg University NHS Trust.

Self testing machines – enhanced reliability or the source of a serious fault

We wish to highlight a serious problem with a Dräger Primus (Dräger Medical, Hemel Hempstead, Hertfordshire, UK) anaesthetic machine. This machine had been purchased 6 months previously and had apparently been functioning normally for that time. Following a successful self testing procedure the patient was connected to the machine. A steadily increasing inspired carbon dioxide level was noted. No leak was apparent, the carbon dioxide absorber and the tubing were changed and all the sampling lines were checked. This made no difference to the inspired carbon dioxide. The machine was withdrawn from service. Urgent servicing by a Dräger engineer found no fault with the machine and no leak on self testing. The machine was passed as fit for purpose having had the tubing changed and the soda lime canister replaced. On repeat use however, a similar problem occurred. The machine was again taken out of service. On repeat servicing, again, there was no apparent leak, but following removal of the top cover (Fig. 5a, b) the fault was immediately apparent. The blue rubber seal, which sits on the soda lime canister and prevents leakage from the soda lime canister, was missing. When replaced, the problem was solved and the machine went into service successfully. The soda lime canister opening with (a) and without (b) seal. One of the guidelines for checking the anaesthetic machine from the Association of Anaesthetists of Great Britain and Ireland (AAGBI) states [1]: ‘Some anaesthetic workstations may enter an integral self-test programme when switched on; those functions tested by such a programme need not be retested’. This fault could not be detected despite compliance with the guidelines from the AAGBI. On self testing the machine did not detect a leak or mixture of expired gases with inspired gases even though the rubber seal was missing. Nor was this leak detected by the standard occlusion leak test of the top circuit. There was no other means of testing for this problem. This fault has not previously been highlighted. We do not know when this seal became displaced or when this problem first occurred. We can only presume the seal was removed when the machine was being serviced or cleaned. With any unexplained problem with either patient or anaesthetic equipment, the equipment must be immediately taken out of service. Mr Gareth Thomas, Head of the Operation Department Assistants, West Wales Hospital, Carmarthen for his help with this problem.

Reflections on ‘Needlestuck’

Reflections on ‘Needlestuck’

Obituary

Obituary