Abstracts of the AAGBI GAT Annual Scientific Meeting, 11-13 June 2014, Newcastle, UK.

A completed audit cycle investigating the adherence to national and local guidelines of ward based monitoring in patients with epidurals in situ in East and North Hertfordshire Trust C. Finlay, S. May and C. Borkett-Jones East and North Hertfordshire NHS Trust

A prospective audit was conducted over a four week period in November 2012. This investigated adherence to nationally and locally set standards on the monitoring of non-obstetric adult patients with epidurals in situ. As a result of this audit a new epidural observation chart was designed and introduced across the Trust. One year later in November 2013 practice was re-audited.

Methods The audit standard was set at 100% adherence to national and local guidelines. The national guidelines [1] recommend observations be taken hourly for the first 12 hours following epidural insertion and thereafter every 4 hours while the epidural is in-situ. Observations should also be recorded when top-up injections are administered and after a change in the infusion rate. Observations should include heart rate, blood pressure, respiratory rate, sedation score, temperature, pain score and degree of motor and sensory block. Local guidelines [2] recommend that the epidural site and the rate of infusion be checked every 12 hours. An audit pro-forma to monitor adherence to the standards was designed with the Trust’s pain team. All epidurals, excluding those inserted for obstetric patients, were included in the audit over a four week period. In response to the initial audit a new epidural monitoring chart was designed and introduced to the wards. This new chart replaced a small epidural monitoring section on the modified early warning score chart. The audit was repeated one year later using the same audit pro-forma over a four week period.

Documentation of tracheal cuff pressure on intensive care L. Giesen, A. Dunn, L. Morrison, R. Renfrew and M. Thomas North Bristol NHS Trust Prolonged mechanical ventilation on intensive care (ICU) places patients at risk of damage to delicate tracheal mucosa from the cuff on the tracheal tube. We noted that tracheal cuff pressure was measured infrequently and that the recorded pressures were often high; an audit cycle was conducted to assess and improve this issue.

Methods National guidelines advise that cuff pressure should be less than 35 cmH2O and should be measured and documented daily [1, 2]. Data was gathered retrospectively from daily ICU charts; all patients admitted in May and intubated (via endotracheal tube or tracheostomy) for at least one complete day were included. Each full day for each patient was counted as a ‘patient day’. Patient days were excluded if the patient was at the end of life or if the cuff was down to enable speech. The audit was repeated in October following nurse education. This included one-to-one teaching, group emails and posters to raise awareness.

Results In May, the pressure was documented on 171 of 245 patient days (69.8%), this improved to 96.1% (273 of 284 patient days) in October. In addition, there was a clear trend towards lower cuff pressures during October; it was rare for the cuff pressure to be above 35 cmH2O or below 20 cmH2O during both periods (Figure 1). During the re-audit, cuff pressure was checked at least twice per day on 77% of patient days. Discussion with nurses revealed that they had a good understanding of the risks of excessively high or low cuff pressures but were unsure of recommended ranges. They also felt that frequency of pressure checks was limited by a lack of manometers.

Results Table 1 Compares the results of the audit in 2012 and 2013. 2012 (%)

2013 (%)

Observations monitored hourly for the first 12 hours

55

61

Observations monitored 4 hourly thereafter

58

88

Observations following a bolus injection

25

38

Observations following a rate of infusion change

40

66

Epidural site check every 12 hours

74

88

Infusion rate check every 12 hours

44

57

Figure 1 Percentage of recordings within each pressure range

Discussion

Discussion

The introduction of a dedicated epidural observation chart has improved adherence to monitoring guidelines by 6-30%. However practice continued to fall short of the standard set at 100%. To improve adherence further a programme of ward based teaching for nurses to reinforce the importance of careful monitoring in patients with epidurals has been introduced across the Trust.

The measurement and documentation of tracheal tube cuff pressure is an important patient safety issue. Adversely high pressure may result in ischaemia, necrosis, ulceration and ultimately perforation or tracheoesophageal fistula formation, whilst low pressure predisposes to aspiration and inadequate ventilation. Guidelines suggest a range of 20-35 cmH2O. Our initial audit demonstrated poor compliance with these guidelines, in line with other centres [3]. However, by applying a multi-faceted, individualised educational intervention we have brought about marked improvements in practice, both in frequency of checks and pressures recorded. Addressing structural barriers, such as a lack of manometers, should lead to further progress and inclusion of cuff pressure in the ‘Ventilated Patient Care Bundle’ will act as a prompt to action and facilitate ongoing audit.

References 1. Rowbotham D, Cashman J, Counsell D. et al. Best practice in the management of epidural analgesia in the hospital setting (Faculty of Pain Medicine of the Royal College of Anaesthetists) 2010: 7–8. 2. van Raders E. The care of the adult patient receiving an epidural infusion (East and North Hertfordshire NHS Trust) 2011: 6.

References 1. Intensive Care Society. Standards for the care of adult patients with a temporary tracheostomy. ICS; 2008: 24–25. 2. Nightingale P, Griffiths H, Clayton J. Tracheal tube cuff pressure. In: Raising the Standard: A Compendium of Audit Recipes for Continuous Quality Improvement in Anaesthesia. London: Royal College of Anaesthetists; 2006: 204–205. 3. Burke N, Baba R, Moghal A, Hosahalli Vasappa C. National survey of the routine measurement of tracheal tube cuff pressure in ICU. Anaesthesia 62: 299.

© 2014 The Authors. Anaesthesia © 2014 The Association of Anaesthetists of Great Britain and Ireland

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AAGBI GAT ANNUAL SCIENTIFIC MEETING - FREE PAPERS

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Increasing the effective use of capnography in recovery: a multi-faceted, trainee-delivered approach to quality improvement in anaesthesia

ELPQuiC (Emergency Laparotomy Pathway Quality Improvement Care-bundle): reducing mortality after emergency major general surgery

D. Hall, K. Gibson, D. Morley, M. Wylie and S. Rae NHS Lothian

S. Huddart,1 C. Peden,2 M. Swart,3 B. McCormick,4 M. Mohammed,5 N. Quiney1 and LPQuiC Collaborators6 1 Royal Surrey County Hospital NHS Foundation Trust; 2Royal United Hospital, Bath; 3Torbay Hospital; 4Royal Devon and Exeter Hospital; 5University of Bradford; 6Royal Surrey County, Royal United, Royal Devon and Exeter and Torbay Hospitals

The AAGBI recommends that measuring end-tidal CO2 using continuous capnography is an essential component of routine monitoring during anaesthesia, and that a capnograph must be immediately available during recovery from anaesthesia [1]. The Fourth National Audit Project of the Royal College of Anaesthetists reported that up to a third of airway incidents occurred during emergence from anaesthesia [2]. Anecdotal experience at our institution suggested that capnography was often omitted during recovery from anaesthesia, and that a lack of confidence in interpreting capnography by nursing staff in the recovery suite may have contributed to this.

Methods

Methods We conducted a prospective audit of the use of capnography during recovery from general anaesthesia in consecutive general surgical and urological patients in our institution. Following the first cycle, a multi-pronged quality improvement approach was instituted. Structured, small-group, interactive presentations were delivered by novice anaesthetic trainees to recovery room staff, preceded by a test of their ability to correctly interpret four standard capnograph traces. All monitors in recovery (Datex Ohmeda S/5, GE Healthcare, UK) were re-programmed to default to a mode requiring capnography. Laminated aide-memoires of common capnography traces were placed by every recovery bed. The audit cycle was completed and self-report scores evaluating the teaching programme were collected.

Results Forty-nine of 103 patients (47.5%) in the initial audit were monitored using continuous capnography. Following the intervention, capnography was used in 175 of 187 (93.4%) consecutively audited patients (endotracheal tube, 73; laryngeal mask airway 114). 19 out of a total of 23 recovery nurses in our institution participated in the training (83%). In the pre-training test of capnography interpretation, the mean score was 69% and 15 of 23 (65.2%) of participants reported they would seek help with significantly abnormal tracings. Median self-reported confidence in capnography interpretation, as rated by a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree), improved by 2.3 before training to 4.3 after training.

Discussion Both the use of capnography, and interpretation of the capnography trace were poor in our institution. A trainee-delivered quality-improvement programme successfully increased the use of capnography in recovery, and improved the knowledge and skills of recovery staff in interpreting the information provided by this.

References 1. Birks RJS, Gemmell LW, O’Sullivan EP, Rowbotham DJ, Sneyd JR. Recommendations for standards of monitoring during anaesthesia and recovery, 4th edn. London: The Association of Anaesthetists of Great Britain and Ireland, 2007. 2. Cook TM, Woodall N, Frerk C. Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. British Journal of Anaesthesia 2011; 106: 617–31.

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Emergency laparotomy surgery is performed for a number of life-threatening emergencies. Over 50,000 cases are performed in the UK per year. It is the highest-risk procedure of all general surgery. The UK Emergency Laparotomy Network (ELN) Audit reported a 30-day mortality of 14.9%, rising to 24.4% in patients over 80 years of age, and varying between centres from 3.6% to 41.7%. The report also demonstrated inconsistencies in the standard of care [1].

The ELPQuiC bundle was developed from national guidelines [2]. The steps are focused on resuscitation, diagnosis, perioperative management and intensive care. Baseline data was collected from consecutive cases over 3 to 6 months. ELPQuiC was introduced simultaneously in four hospitals and data collected over 8 months. Representatives from each site met every 6 weeks to report data, successes, challenges and individual implementation strategies.

Results 30-day mortality rates are reduced in all four trusts. Predicted risk of death was calculated for each patient using P-POSSUM (Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity). The data is analysed using risk-adjusted cumulative sum charts which demonstrate improvement in risk-adjusted mortality rates in all four sites, amounting to 7.5 additional lives saved per 100 cases (p < 0.001) after implementation. Overall the number needed to prevent an additional death before 30-days is 14.3, and a relative risk reduction of 42% (p < 0.001). There are associated improvements in compliance to key aspects of the care bundle.

Discussion Collaboration has been a successful strategy for improvement. Each site has faced specific challenges and developed individual solutions based on the experience of other hospitals. Improvements in specific measures are different for each centre, demonstrating the difficulties in quality improvement for such a variable and complex patient pathway. However the data demonstrates improvement in key quality indicators for all four trusts. These improvements were achieved without any increase in resources (Health Foundation funding for data collection only). Changing attitudes by increasing awareness of this high-risk group and the inadequacies of their care has improved care and individual patient outcomes. Some specific measures have remained a challenge, highlighting the essential need for continuous improvement, locally-focused strategies and high-quality data collection. The ELPQuiC bundle project represents a successful improvement strategy that could be adopted in other centres in order to improve outcomes for this high-risk group.

References 1. Saunders DI, Murray D, Pichel a C, Varley S, Peden CJ. Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network. British Journal of Anaesthesia 109(3): 368–75. 2. The Royal College of Surgeons of England, Department of Health. The Higher Risk General Surgical Patient. 2011. Available from: http://www.rcseng.ac. uk/publications/docs/higher-risk-surgical-patient.


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Assessment of the usefulness of peri-operative intravenous lidocaine infusions for enhanced recovery after surgery

A safer epidural service: an audit of compliance with standard monitoring of patients with epidurals for labour

E. Paterson and I. Foo Western General Hospital, Edinburgh

K. Stacey, L. Beard, S. Millett and J. Marriott Worcester Royal Hospital

Intravenous lidocaine infusions are increasingly being used during major colorectal surgery [1]. We assessed their role in enhanced recovery after surgery, focusing on quality of recovery.

Departmental and National guidelines [1, 2] both stipulate the recording of hourly sensory block checks for epidurals during labour. During investigation of a serious untoward incident within the Trust it was discovered that sensory block checks were not being performed adequately and therefore a formal audit was carried out.

Methods This was an observational study performed at a tertiary referral centre for major colorectal surgery. Ethical approval was deemed unnecessary by the Lothian Ethics Scientific Officer as lidocaine infusion was an established practice in this unit. Patients who were 2-4 days post major colorectal surgery completed the Quality of Recovery 40 (QoR-40) questionnaire – a validated measurement of quality of recovery [2]. Five dimensions of recovery are assessed with total scores ranging from 40 to a maximum of 200. Fifty-six consecutive patients completed the questionnaire between September and November 2013. Twenty eight had received the intravenous lidocaine infusion intra-operatively and up to 12 hours post-operatively, whilst the other twenty eight patients had not. Patients who had an epidural as alternative analgesia were excluded. The QoR-40 score was calculated for each patient and statistical analysis performed using the Mann Whitney test.

Results Seventeen males and eleven females were present in each group. The age range was 22-86 years (median 63.5 years) in the lidocaine group and 29-82 years (median 63.5 years) in the non-lidocaine group. Ten patients in the lidocaine group and nine patients in the non-lidocaine group had laparoscopic surgery. The table below shows the QoR-40 scores and significance for each group. Table 1 Median QoR-40 scores. Lidocaine Group

Non-lidocaine Group

p value

Laparoscopic

175 (n = 10)

159 (n = 9)

p = 0.48

Open

182 (n = 18)

168 (n = 19)

p = 0.0352

Total

176 (n = 28)

166 (n = 28)

p = 0.0251

Discussion Patients who received intravenous lidocaine intra-operatively and up to 12 hours post-operatively had significantly better QoR-40 scores and hence enhanced recovery after surgery. Nursing staff looking after the patients subjectively confirmed this observation. A significant difference persisted in open but not laparoscopic surgery. Investigation should continue with increased numbers of patients within an enhanced recovery programme and compared with other opioid reducing strategies e.g. epidural analgesia. Intravenous lidocaine infusions may be an alternative strategy in improving the enhanced recovery process.

References 1. Vigneault L, Turgeon AF, Cote D, et al. Perioperative intravenous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials. Canadian Journal of Anaesthesia 2011; 58: 22–37. 2. Myles PS, Weitkamp B, Jones K, et al. Validity and reliability of a postoperative quality of recovery score: the QoR-40. British Journal of Anaesthesia 2000; 84: 11–15.

Methods Audit Committee approval was obtained prior to data collection. Audit 1: A random selection of notes from patients who had received epidurals during labour were reviewed and information was obtained regarding the frequency of blood pressure monitoring, fetal monitoring and sensory and motor block checks. Audit 2: A pilot epidural observations chart was introduced and the same information was obtained from a second set of randomly selected patient notes. Audit 3: Educational video demonstrating block assessment made available on midwifery intranet page. Following feedback from staff, minor alterations were made to epidural observations chart to facilitate recording of parameters. The same information is currently being audited.

Results Table 1 Percentage of patients meeting national epidural observation standards. Audit 1

Audit 2

Fetal Monitoring

100%

100%

Five minute BP checks up to 30 minutes

55%

71%

Sensory block check at 30 minutes

27%

50%

Motor block check at 30 minutes

13%

50%

Hourly BP check

100%

83%

Hourly block check

0%

67%

Discussion Other than hourly blood pressure monitoring documentation of all parameters improved considerably. Most notably 30 minute sensory and motor block checks and subsequent hourly block checks were being performed and documented in over 50% of cases. Whilst this improvement was encouraging it still fell short of the required 100% national standard. A number of factors were identified to explain the complete absence of block checks by midwifery staff. Changes to midwifery mandatory training in 2011 was a confounding factor with staff admitting to a lack in confidence in assessing motor and sensory levels. A training video was produced demonstrating correct assessment of motor block and sensory level in a patient with a labour epidural in situ. This has been made available to all midwifery staff. A third audit to assess the effectiveness of the video is on-going.

References 1. NICE clinical guideline 55 (2007) http://www.nice.org.uk/nicemedia/live/ 11837/36280/36280.pdf. 2. OAA/AAGBI Guidelines for Obstetric Anaesthetic Services 2013 http://www. aagbi.org/sites/default/files/obstetric_anaesthetic_services_2013.pdf.


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Airway management of obstructing chondrosarcoma of the larynx

Paediatric resuscitation: time to say goodbye to uncuffed endotracheal tubes

V. Kale, F. Mir, P. O’Flynn and A. Patel Royal National Throat, Nose and Ear Hospital, London

E. Skibowski and B. McConville Ulster Hospital

We report the anaesthetic management of a rare obstructing laryngeal chondrosarcoma. This tumour presents a challenge for airway management during surgery because of its location and bone-like consistency.

Paediatric resuscitation is a highly stressful situation. Initial focus includes advanced airway manoeuvres to facilitate oxygenation and ventilation. We report a case where ventilation could not be established with an uncuffed endotracheal tube (ETT) but then subsequently successfully with a cuffed one. This has led to the routine use of cuffed ETTs in children undergoing emergency intubation in our department.

Description A 64 years-old man diagnosed with the above tumour was planned for surgical laser excision. He had presented with worsening shortness of breath and stridor on exertion. Clinically, he had a hoarse voice with no features predicting a difficult supraglottic airway. Contrast CT neck showed a solid locally invasive tumour arising from posterior cricoid ring causing significant narrowing of tracheal lumen. Due to the fixed solid state of the tumour and our experience dealing with obstructive airway lesions [1, 2], we were of the view that it would behave functionally similar to subglottic stenosis and not like a ball valve lesion. Our primary ventilator strategy was intravenous induction followed by supraglottic jet ventilation, with rescue plan including transtracheal catheter and surgical tracheostomy in place. Intravenous induction followed by intubation was not considered because of the solid nature of lesion and likely inability to pass endotracheal tube. Accordingly, he was induced with fentanyl, propofol and rocuronium. Bag mask ventilation was easy. Videolarngoscopy showed a grade 1 view of the laryngeal inlet. Vocal cords were sprayed with lignocaine and classic LMA size 5 was inserted followed by pressure control ventilation. In theatre, the LMA was removed and the surgeon performed Dedo-Pilling laryngoscopy. Supraglottic jet ventilation (frequency 100, FiO2 1.0, IT 40%, DP 1.5-2.5 bar) was administered with good chest movements and SaO2 of > 97% throughout. Anaesthesia was maintained with propofol infusion. Direct laryngoscopy showed the chondrosarcoma arising from the posterior part of cricoid ring extending up to 4th tracheal ring with a significantly narrowed airway. Given the extent, carbon dioxide laser was used to debulk rather than completely excise the tumour. Following the procedure, paralysis was reversed with sugammadex, the LMA was reinserted and patient woke up uneventfully.

Description A 6-year-old girl was admitted to our hospital in respiratory arrest. She had had a tonic clonic seizure at home, followed by cyanosis and the ambulance service initiated bag mask ventilation. On arrival in the emergency department she had an adequate cardiac output, her oxygen saturation was 88% on 100% 02 however. She was unresponsive and appeared mottled. Capnography showed a weak trace and an arterial blood gas revealed severe hypercarbic respiratory acidosis. Despite an easy intubation (Grade 1 larynx) 3 attempts amongst 2 anaesthetists with an uncuffed 5.5 ETT failed to establish good oxygenation and ventilation with no CO2 trace evident. No obvious leak was noted. Successful intubation with a 4.5 microcuffed ETT then established a patent airway with CO2 evident on capnography. Fine bore catheter suctioning of her lungs revealed significant aspiration. The girl was stabilized, admitted to paediatric intensive care unit and went on to make a full recovery.

Discussion A combination of altered lung compliance due to aspiration and possibly an undetectable leak from an uncuffed ETT in a noisy resuscitation environment made establishing good ventilation impossible. Traditionally uncuffed tubes have been used in paediatrics but there is mounting evidence that cuffed tubes are safe to use [1]. The latest consensus from 2010 in paediatric resuscitation reflects our change in practice by stating that both cuffed and uncuffed tubes are acceptable for infants and children undergoing emergency intubation [2].

References 1. Weiss M, Dullenkopf A, Fischer JE, et al. Prospective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small children. British Journal of Anaesthesia 2009; 103: 867–873. 2. Kleinman ME, de Caen AR, Chameides L, et al. Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Pediatrics 2010; 126(5): e1261–318.

Figure Obstructing Chondrosarcoma from posterior cricoid ring

Discussion Laryngeal chondrosarcoma is a rare, slow growing, locally aggressive solid tumour accounting for up to 1% of all laryngeal malignancies [3]. Given its characteristics, voice-sparing surgery is the preferred option. Our case highlights use of supraglottic jet ventilation as a safe primary ventilator strategy to be considered for laser surgery of this tumour. To our knowledge, its use in this setting has not been described previously.

References 1. Ross-Anderson DJ, Ferguson C, Patel A. Transtracheal jet ventilation in 50 patients with severe airway compromise and stridor. British Journal of Anaesthesia 2011; 106 (1): 140–144. 2. Patel A, Pearce A. Progress in management of the obstructed airway. Anaesthesia 2011; 66 Suppl 2: 93–100. 3. Thompson LD, Gannon FH. Chondrosarcoma of the larynx: a clinicopathologic study of 111 cases with a review of the literature. American Journal of Surgical Pathology 2002; 26(7): 836–51.

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Call-Fleming syndrome: a cause of postpartum blindness K. Whitehouse and S. Thomas Royal Victoria Infirmary, Newcastle upon Tyne

We describe an interesting case of a woman presenting postpartum with headache and cortical blindness due to Call-Fleming syndrome and features of posterior reversible encephalopathy syndrome (PRES).

Description A 28 year-old primip presented in labour at 39 weeks gestation following an uncomplicated pregnancy. She had a labour epidural which was topped up for an emergency caesarean section. She was re-admitted 5 days post-operatively with a thunderclap occipital headache and hypertension; a CT head was negative. A diagnosis of post dural puncture headache was made and simple management initiated. 2 days later she reported visual changes and an epidural blood patch was performed with no benefit. She continued to deteriorate, with confusion, fluctuating consciousness and worsening vision. She was transferred to the regional centre for neurology (also a tertiary obstetric centre). On arrival she was agitated and hypertensive with cortical blindness. The diagnosis of CallFleming syndrome was made. She was transferred to the neuro intensive care unit for invasive monitoring and management of her blood pressure (with intravenous labetalol and magnesium sulphate). MRI showed changes consistent with PRES. She responded dramatically to treatment, with improvement in her vision within 12 hours. She was discharged home on oral anti-hypertensives. She has made a full recovery with no residual neurology.

Discussion Call-Fleming syndrome is one of the presentations encompassed by the Reversible Cerebral Vasoconstriction Syndrome (RCVS). Patients experience thunderclap headache and neurological symptoms (cortical blindness is common) [1]. Cerebral angiography shows a typical ‘string of beads’ appearance, reflecting the alternating arterial vasoconstriction and vasodilatation responsible for symptoms [2]. One third of patients may experience hypertension [3], either as a primary phenomenon or secondary to associated conditions [1]. A number of precipitants have been described including pregnancy, the postpartum period and preeclampsia (12% of patients according to a recent case series [2]). Diagnosis can be difficult, CT and LP are often normal and MRI shows changes of PRES in 10% of patients [2] (with a possible overlap in the pathophysiology of these syndromes). The condition usually resolves within 1-3 months, most patients recover with no residual symptoms. One of the issues in this case was the choice of agent used for treatment. The co-existence of hypertension led us to choose agents with which we were familiar in the treatment of pregnancy induced hypertension. Evidence suggests that calcium channel blockers are helpful, although no definitive studies exist [2].

References 1. Singhal A, Levine S. Clinical Summary: Reversible Cerebral Vasoconstriction Syndromes. Medlink. 2011. Available at www.medlink.com. Accessed 14/04/ 2014. 2. Sattar A, Manousakis G, Jensen M. Systematic review of reversible cerebral vasoconstriction syndrome. Expert Review of Cardiovascular Therapy 2010; 8 (10): 1417–1421. 3. Chen S, Fuh J, Wang S. Reversible cerebral vasoconstriction syndromes: an under-recognized clinical emergency. Therapeutic Advances in Neurological Disorders 2010; 3(3): 161–171.

10 An audit of pre-operative fasting times in elective surgical patients: are we meeting standards? J. Alldis1 and N. Uwubamwen2 1 CMFT; 2Central Manchester Foundation Trust

Methods Based on revision of the American Society of Anasthesiologists (ASA) guidelines on fasting times for patients undergoing anaesthesia for elective surgery, we undertook a prospective audit of 50 patients at a District General Hospital to identify actual fasting times. New guidelines state that clear fluids can be safely consumed up to 2 hours prior to induction of anaesthesia in healthy adult patients undergoing elective surgery [1]. Fifty patients scheduled for ‘same day admission surgery’ received a questionnaire in theatre recovery prior to going into the anaesthetic room that was filled out with assistance of the theatre staff. The questionnaire comprised of 6 questions covering areas including how the patient received information on fasting and their awareness of its importance in practice and when they had last consumed clear fluid. The questionnaire reviews the time spent in pre-operative assessment lounge and whether patients were offered water if surgery was delayed. For all questionnaires theatre staff then completed the final question to identify whether anaesthesia went ahead as planned.

Results Only 32% of patients are currently adhering to guidance and drinking fluids up to 2 hours prior to anaesthesia. 35% of patients had clear fluids between 3 and 6 hours leaving 40% that are still not consuming clear fluids for over 6 hours prior to anaesthesia, significantly longer than recommendations. Despite these disappointing results it is reassuring that none of the patients audited consumed clear fluids within 2 hours prior to anaesthesia which would have resulted in delay or cancellation of surgery. Of the 27 patients that waited for more than 2 hours in the pre-operative assessment lounge for their surgery only 33% of these patients were offered a drink of water. 80% of patients admitted to receiving verbal information at preoperative assessment and 72% to receiving a leaflet containing fasting information which is reflected by 70% of patients aware on the day of surgery of the 2 hour period they should not consume clear fluids. 60% of patients did not understand the reasons behind fasting and its importance.

Discussion ‘Nil by mouth after midnight’ has been rigidly adhered to by practitioners due to fear of aspiration of gastric contents and its life threatening consequences [2]. Revised guidelines take into account different rates of gastric emptying of solids and clear liquid. The advantages this brings to patients are to reduce incidence of dry mouth, hunger, vomiting and other adverse effects. It is evident that at present patient adherence is low and could be due to lack of understanding of reasoning and importance of fasting.

References 1. The American Society of Anesthesiologists. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures. Anesthesiology 2011; 114: 495–511. 2. Scarlett M, Crawford-Sykes A. Preoperative starvation and pulmonary aspiration. New perspectives and guidelines. West Indian Medical Journal 2002; 51(4): 241–5.


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AAGBI GAT ANNUAL SCIENTIFIC MEETING - FREE PAPERS/POSTER ABSTRACTS

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AAGBI GAT ANNUAL SCIENTIFIC MEETING - POSTER ABSTRACTS

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Few know, all should: newly qualified doctors’ knowledge of anti-emetics and sedatives S. Curtis, R. Lin and J. Bhular Watford General Hospital The ability to prescribe commonly used drugs safely and effectively is a core competency of the newly qualified doctor. Anti-emetic and sedatives are examples of medicines that are often poorly prescribed. This survey aimed to examine the pharmacological knowledge of these important drugs in foundation year 1 doctors (FY1).

Methods A survey of 30 FY1 doctors was conducted in January 2014 at Watford General Hospital (WGH). A combination of multiple choice, extended matching and single best answer questions focused on the pharmacological principles of the mechanism of actions, pharmacokinetics and pharmacodynamics of anti-emetics and sedatives. One of the authors (SJC) asked colleagues to complete the survey in his presence.

A total of 30 responses were received. The overall average score for the questionnaire was 29%. The average scores in the mechanism of actions, pharmacodynamics and pharmacokinetics sections were 29%, 22% and 19% respectively. In a clinical scenario question where respondents were asked to correctly identify the single-best sedative prescription for a distressed patient, 78% of FY1 doctors were correct. 1. Ondansetron acts upon which receptor? (T/F) Acetylcholine Muscurinic 5HT3 5HT1a Dopaminergic

Metaclopramide Droperidol

Perioperative hypothermia is a frequent complication of anaesthesia and surgery and is associated with many serious adverse perioperative outcomes. NICE guidelines CG65 from 2008 state patient warming should be commenced if the preoperative temperature is below 36 degrees, in high risk patients (which includes those with any two of an ASA grade II-V, preoperative temperature below 36 degrees, combined general and regional anaesthesia, major or intermediate surgery or at risk of cardiovascular complications), and all patients with an anaesthesia time of >30 minutes. It also states that IV fluids of > 500 ml and all blood products should be warmed to 37 degrees using a fluid warming device. This is a national survey assessing whether hospitals across the UK are compliant with these criteria.

Lorazepam Diazepam Midazolam 8. Can you name 2 conditions in which haloperidol should be avoided? 5HT3 antagonist Dopamine antagonist Anticholinergic Antihistamine

3. Which one of these anti-emetics should be avoided in small bowel obstruction? (T/F) Domperidone Cyclizine Metaclopramide Ondansetron 4. Which of these drugs should be avoided in Parkinson’s patients? (T/F) Cyclizine Domperidone Metaclopramide Ondansetron Droperidol 5. Side effects of Cyclizine include: (T/F) Bradycardia Drymouth Tachycardia Confusion Urinaryretention 6. Which of these anti-emetics is prokinetic? (T/F)

A list of 383 anaesthetic clinical leads was compiled by contacting hospitals across the UK between July-December 2013. An online survey was created and linked to an introductory email sent out inviting the anaesthetic clinical leads to take part in this survey. Unfortunately 54 email addresses were undeliverable. A reminder email was sent on 23rd September 2013. There were 52 responses in total. Using the Survey Monkey programme the data was collected and formulated and put in a Microsoft Excel spreadsheet.

Results

7. What in the half life of the following benzodiazepines?

2. Correctly pair the following anti-emetics with their mechanism of action?

Cyclizine Domperidone

A. Elvy and R. Alexander Worcestershire Acute Hospitals NHS Trusts

Methods

Results

a) Cyclizine b) Ondansetron c) Metaclopramide d) Domperidone

National Patient Warming Survey

9. You are on call and have been asked see a frail 85 year old lady with a background of dementia a dmitted with a UTI. She is very aggressive and attacking nursing staff and other patients. You deem in necessary to give a sedative. What would you use at what dose? Lorazepam 0.5-1mg Lorazepam 4mg Diazepam 2.5-5mg Haloperidol 0.5-1mg Haloperidol 2.5-5mg 10. Can you name 3 important signs and symptoms of neuroleptic malignant syndrome? 11. Which of these drugs can cause neuroleptic malignant syndrome? (T/F) Cyclizine Lorazepam Haloperidol Metaclopramide Ondansetron

Sixty-three point five percent (63.5%) had a registered patient warming protocol in their hospital. Sixty percent (60%) were aware of the NICE guidelines but only 16.8% of clinicians used these for their patient warming criteria. Forty two point one percent (42.1%) stated their practice was not driven by guidelines and 10.5% stated that guidelines were not felt to be necessary. Anaesthesia time and major surgery were popular criteria to warm their patients but only 5.3% would alter their patient warming management according to ASA grade. Thirty nine point one percent (39.1%) stated they would use warming only if surgery lasting >1 hour. Fifty one point one percent (51.1%) said they would not warm all IV fluids of 500 ml or greater. Thirty three percent (33%) said this was due to lack of hospital protocol and guidelines and 29.2% felt it was unnecessary in IV fluids below 1000 ml. Reasons not to warm patients included time pressures and financial reasons.

12. Name 3 anticholinergic side effects? 13. Which of these drugs has anticholinergic side effects? (T/F) Cyclizine Metaclopramide Ondansetron Domperidone Haloperidol Lorazepam

Discussion From this survey it is clear that there is poor awareness and compliance with the NICE guidelines. Guidelines are evidence-based to support clinical decisionmaking by making recommendations to guide clinical practice but do not replace knowledge and skill. However, raising awareness of these guidelines would ensure optimal clinical care and patient safety.

Discussion Studies have shown that FY1 doctors believe that their undergraduate and postgraduate training in clinical pharmacology and therapeutics is insufficient to prescribe safely and rationally [1]. WGH receives a large influx of FY1 doctors every year, the majority coming from the most competitive foundation school in 2013 [2]. The results of this survey demonstrate poor knowledge of commonly prescribed medications which has the potential to lead to morbidity in patients. Evidence suggests that the deficiencies highlighted by this survey are widespread throughout the country [3]. In particular our survey highlighted poor awareness of the anticholinergic side effects of cyclizine, an important consideration in the elderly. In addition, the majority of respondents underestimated the half-life of diazepam with 70% thinking it had a half-life of less than 8 hours. This knowledge of pharmacological agents is essential when assessing patients with a low concious level post sedative administration. Anaesthetists are regarded as experts in the use of these drugs and may be looked upon to provide teaching to newly qualified doctors regarding these drugs. Improved knowledge of these medications may also serve to benefit anaesthetists by minimising frustrating clinical scenarios such as poorly managed PONV and over sedation.

References 1. Putzu M, Casati A, Berti M, Pagliarini G, Fanelli G. Clinical complications, monitoring and management of perioperative mild hypothermia: anesthesiological features. Acta Biomedica 2007; 78: 163–169. 2. Reynolds L, Beckmann J, Kurz A. Perioperative complications of hypothermia. Best Practice and Research Clinical Anaesthesiology. 2008; 22(4): 645–57. 3. NICE guidelines: Perioperative hypothermia CG65. 4. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0010093.

References 1. Tobaiqy M, McLay J, Ross S. Foundation year 1 doctors and clinical pharmacology and therapeutics teaching. A retrospective view in light of experience. British Journal of Clinical Pharmacology 2007; 64: 363–372. 2. FP/AFP 2014 Applicant’s Handbook 2014. The UK Foundation Programme Office. 3. BBC News. Concerns over Medics Drug Skills. [2006-September-4]. Available at http://news.bbc.co.uk/1/hi/health/5192372.stm.

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14

Do patients become hypothermic whilst waiting for operations?

Red cell transfusion in critical care: an audit on recent British Society of Haematology Guidelines

M. Johnston and D. Mayne Queen Elizabeth Hospital, Gateshead

K. Kendrick and S. Watson North Bristol NHS Trust

Perioperative hypothermia is common and associated with worse outcomes [1]. Notably it is associated with significant increases in perioperative blood loss, postoperative infection and postoperative myocardial events [2]. NICE 2008 Inadvertent Perioperative Hypothermia Guidelines expects 100% adherence to all standards for surgical patients [1]. A previous audit performed at our centre showed poor adherence to this guideline with 43% of patients having pre-operative temperature documented, and 46% were noted hypothermic [3]. Based on these results an awareness campaign to promote documentation of temperature at induction of anaesthesia was instituted. The aim of this audit was to ascertain if patients were becoming hypothermic whilst waiting for operations and to reaudit our adherence to the aforementioned NICE guidance.

Anaemia in intensive care is common, with approximately 50% of patients receiving a red-cell transfusion. Most cohort studies show a positive relationship between red cell transfusion and adverse outcomes. Recognised complications from transfusion include transfusion-associated lung injury, infection and organ failure progression [1]. In 2012, the British Committee for Standards in Haematology (BCSH) issued guidelines for red-cell (RBC) transfusion in critical care. They recommend a haemoglobin transfusion trigger of below 70 g/dL, unless the patient is bleeding, has acute sepsis, neurological injury or an acute coronary syndrome [2]. Based on these guidelines our audit and quality improvement project is set to improve the appropriateness of RBC transfusions for patients without major haemorrhage in a 9-bedded intensive care unit (ICU).

Methods

Methods

All elective and emergency operations were audited over one day against the NICE guidance, exploring the preoperative and intraoperative phases. Retrospective data collection was performed from anaesthetic charts and medical records. Specifically we audited; pre-operative temperature documentation, temperature documentation at induction, presence of hypothermia, appropriate warming of patients and warming of intravenous fluids (>500 ml).

Results The sample size was 32 with 6 inpatients and 26 elective patients. We noted 15 out of 32 patients (47%) had a temperature documented pre-operatively. Two of these 15 patients were hypothermic preoperatively, both of whom were appropriately warmed but remained hypothermic at induction. Temperature was documented at induction in 26 out of 32 patients (81%), of which 12 (46%) were noted to be hypothermic. Ten of the hypothermic patients (81%) were normothermic on their last documented temperature check. Only 13 of the 23 patients (56%), who should have been warmed to be adherent with NICE guidance were actively warmed. Appropriate fluid warming was instituted in 5 of the 31 (16%) patients who received >500 ml of IV fluids.

Firstly, doctors’ knowledge of critical care transfusion appropriateness was assessed via a clinical effectiveness audit. Secondly, a clinical audit of RBC transfusions were prospectively assessed transfusions. Each transfusion was categorised with a traffic-light system; red for inappropriate, green for appropriate and amber for those that were not clearly appropriate or inappropriate (when compared to guidelines). A local ICU blood transfusion guideline poster was created. Two quality improvement interventions were made: 1) guidelines posters were placed in the ICU; and 2) the guidance was attached to the transfusion prescriptions. Audit data was collected after each intervention. A total of 30 random adult RBC transfusions were audited and analysed between August 2013 and February 2014.

Results Doctors’ knowledge was good, though actual prescribing practices differed. Our baseline data showed only two transfusions as green, one red and seven amber. After introducing our guideline and emailing doctors this figure improved to 7/10 with the number of red/inappropriate transfusions reduced to nil. Additionally, trustbased ICU transfusion records showed an overall reduction in RBC transfusions; from 41 to 18 following the first intervention in October 2013 (almost a 50% reduction).

100%

8

90% 7 Intervention 2 - A5 guideline attached to RBC prescription November 2013

70% 6

60% 50%

Number of Transfusions

Percentage of Patients

80%

40% 30% 20%

5

Green (appropriate)

4

Amber (borde line) Red (inappropriate) 3 Intervention 1 - A4 Guideline poster on display in ICU October 2013

10% 0% Temperature Hypothermic Warmed Appropriately PreDocumented PrePreoperatively operatively operatively

Temperature Hypothermic Warmed Documented at Induction Appropriately Intraat Induction operatively

>500ml of Fluids Warmed

2

1

Figure 1. Adherence to NICE Guidance

Baseline audit - prior to intervention August 2013 0

Discussion After an awareness campaign we observed a doubling of temperature documentation at induction of anaesthesia. Worryingly, we noted a significant proportion of patients were becoming hypothermic whilst waiting for operations. Elective patients have a one off temperature documented at admission, often there is no repeat until induction of anaesthesia, and therefore hypothermia is often missed. Adherence to NICE guidelines regarding warming of fluids was highlighted to be particularly poor in both audits, perhaps due to scepticism regarding the necessity of this in short elective procedures, and possibly driven by limited resources.

References 1. National Institute for Health and Care Excellence. [Inadvertent Perioperative Hypothermia Guidelines] (CG65). London: National Institute for Health and Care Excellence, 2008. 2. Reynold L, Beckmann J, Kurz A. Perioperative Complications of Hypothermia. Best Pract Res Clin Anaesthesiol. 2008; 22(4): 645–57. 3. Johnston M, Mayne D. Inadvertent Perioperative Hypothermia Guidelines Audit. Gateshead, Queen Elizabeth Hospital. 2013.

1

2

3

Figure 1. Run chart demonstrating the improvement in transfusions after each intervention.

Discussion Our audit demonstrates that we often assume we are adopting best practices for our patients. Testing changes on a small scale can have a big impact. By using simple, cost effective and easily adapted interventions such as surveys, posters and reminders we can dramatically improve RBC prescribing in accordance to evidence based guidelines.

Acknowledgments Jasmeet Soar, Janet Birchall, Matt Thomas, Tim Wreford-Bush, Thomas Milne.

References 1. Marik PE, Corwin HL. Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Critical Care Medicine 2008; 36: 2667–2674. 2. Retter A, Wyncoll D, Pearse R et al. Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients. British Journal of Haematology 2012; 160(4): 445–464.


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15

Naso-gastric tube placement confirmation in intensive care unit

An audit of dexamethasone treatment in bacterial meningitis

T. Nicholls, S. El-Ghazali and M. Eid James Cook University Hospital, Middlesbrough

V. Lee-Shrewsbury and P. Jefferson South Warwickshire Foundation Trust

The Department of Health defines a never event as serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. In addition there is provided a core list of never events of which one is misplaced naso-gastric tube not detected prior to use [1].

Bacterial meningitis carries a high mortality rate and furthermore, survivors can be left with deafness and other neurological deficits. The National Institute of Clinical Excellence (NICE) have published guidelines recommending that dexamethasone is given to children, aged 3 months to 16 years, with suspected bacterial meningitis [1]. In addition, the Meningitis Research Foundation recommends that dexamethasone is considered in the management of bacterial meningitis in adults [2]. The recommendation is that 0.15 mg/kg of dexamethasone is given either prior to, or within 4 hours of the first dose of antibiotics, especially when suspecting pneumococcal meningitis in adults [1, 3]. Recent clinical experience suggested dexamethasone was not commonly used in the management of suspected bacterial meningitis and so a retrospective review was completed to assess local practice.

Methods In February 2013, we audited the documentation of naso-gastric tube (NGT) placement confirmation in ICU and HDU at James Cook Hospital. We subsequently re-audited practices in May 2013 following education of health care professionals and encouragement of trust wide stickers usage. For both audits a proforma was developed with the following criteria: documentation of NGT insertion, Chest x-ray confirmation documentation, Trust approved sticker used in notes, Other means of placement confirmed. 43 patients were identified in the audit and 55 in the re-audit who required NGT for enteral feeding on admission over a 2 month period for each audit.

Methods A retrospective audit was performed identifying cases of confirmed bacterial meningitis by hospital coding over the previous 3 years. Patient notes were reviewed and use of dexamethasone noted.

Results The initial audit results revealed a lack of documentation of NGT insertion (Table 1). 26% of the original NGT audit had documentation in the patients’ notes. Comparing this to the re-audit results there was an improvement to 76% of the NGT. Trust stickers were used much more consistently in the patients’ notes. There was an improvement from 7% in the original audit to 64% of patient notes having the official sticker used. Another improvement was seen in the documentation of chest x-ray confirmation. The initial audit showed only 33% of patients had radiological confirmation documented at time of feeding. However our recent data showed 80% having radiological confirmation documented in the notes.

Results Twelve patients were identified with confirmed bacterial meningitis between 2011 and 2014. Patient ages ranged from 3 months to 83 years. It was found that no patients received dexamethasone in accordance with the national guidelines. All patients’ received broad-spectrum antibiotics and had lumbar punctures (LPs). Nine LPs confirmed the diagnosis of bacterial meningitis, and 3 were negative. Only 2 (17%) patients received dexamethasone. In both cases, they were only single doses and were given over 12 hours after commencing antibiotics.

Discussion

Discussion

The evidence has shown that dexamethasone as an adjunctive therapy reduces the incidence of hearing loss in children, especially in cases of H. influenza meningitis [4]. Furthermore, dexamethasone has been shown to decrease morbidity and mortality in adults with bacterial meningitis, most apparent in pneumococcal meningitis [3]. National guidelines need to be adhered to in order to maintain best patient outcome. This audit has highlighted the lack of awareness surrounding the use of dexamethasone in bacterial meningitis, and shown a need for development. Our intentions to improve practice include adding an alert notice in the local antibiotic guidelines reminding staff to prescribe dexamethasone when considering bacterial meningitis, disseminating this knowledge through teaching sessions, especially amongst Junior Doctors, and placing posters in the Emergency department and the Acute Medical Unit.

Trust guidelines state that following insertion the trust approved documentation sticker should be used to document insertion. The position must then be confirmed by either pH aspirate testing or radiological means. In ICU it is frequently difficult to measure pH aspirates as many patients require IV proton-pump inhibitors or drugs that raise the gastric pH. This is noted in trust guidance and as such radiographic confirmation is the first line in intensive care patients at James Cook [2] Patient safety is paramount in medicine and correct documentation is key to avoid critical incidents. Before NGT are used for feeding, there should be documentation of the confirmation of positioning clearly in the notes. The green trust stickers provide an easy and effective way of documenting insertion, confirmation of position and size of tube. They are easy to see and identify in the notes.

References

References

1. National Institute for Clinical Excellence. Bacterial Meningitis and meningococcal septicaemia in children. NICE Clinical Guideline 2010. 2. Meningitis Research Foundation. Early Management of Suspected Bacterial Meningitis and Meningococcal Septicaemia in Immunocompetent Adults. http://www.meningitis.org/assets/x/51738 (accessed 15/03/2014). 3. de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. New England Journal of Medicine 2002; 347: 1549–56. 4. McIntyre P, Berkey C, King S, Schaad U, Kilpi T, Kanra G, Perez C. Dexamethasone as adjunctive therapy in bacterial meningitis. A meta-analysis of randomized clinical trials since 1988. Journal of the American Medical Association 1997; 278: 925–31.

1. National Patient Safety Association. Misplaced naso or orogastric tube not detected prior to use, 2008 www.nrls.npsa.nhs.uk/neverevents (accessed 10/ 03/2014). 2. South Tees Hospitals NHS trust general policy 27 (G27). Insertion, Management & Care of Nasogastric Tubes Policy. Sept 2012.

Table 1 Audit and re-audit results CXR

CXR

Other

Other

Insertion

Insertion

Documentation

Documentation

Sticker

Sticker

Confirmation

Confirmation

Audit

Re-audit

Audit

Re-audit

Audit

Re-audit

Audit

Re-audit

Documented

11

42

14

44

3

35

12

13

No documentation

32

13

29

11

40

20

31

8

Unsure of documentation

0

0

0

0

0

0

0

0

Percentage documented

26%

76%

33%

80%

7%

64%

28%

24%

20


Acute kidney injury in neck of femur patients: getting perioperative care right. A retrospective cohort study at a UK major trauma centre B. Robinson University Hospitals Coventry and Warwickshire NHS Trust

Acute kidney injury (AKI) is seen in 13-18% of all hospital admissions [1] with the incidence thought to be higher in the elderly. It is associated with increased length of hospital admission, cost, and morbidity. Importantly it is preventable. Patients with neck of femur fractures (NOF) are classically elderly with multiple co-morbidities. Surgery can be high risk but is necessary to decrease mortality. There are currently no studies on the incidence of AKI in this high risk group, or if AKI is specifically associated with increased mortality. The aim of this study was to identify the burden of AKI in patients treated for NOF at University Hospital Coventry and Warwickshire, as a pre-requisite to developing a risk management tool to try to reduce this burden.

Methods A retrospective review of the medical notes and clinical results systems for 211 surgically treated NOF was conducted. Patients were identified from the National Hip Fracture Database at a single institution between January and May 2013. Post-operative bloods were assessed for AKI as defined by NICE guidance (CG169). The relative risk of death during admission for patients who developed an AKI in the immediate 7 day post-operative period was calculated.

Results Forty-four out of 211 patients (20.8%) developed AKI in the immediate 7 day post-operative period. Seven out of 44 (15.9%) patients with AKI died before discharge compared with ten out of 167 (5.9%) patient deaths in the group without AKI. RR death = 2.67 (95% CI 1.07 to 6.58, p = 0.03)

18 Acute pain management in a University Hospital Trauma Centre Emergency Department A. Rogan, M. Auldin, S. Millerchip and A. Kelly University Hospital Coventry, Warwickshire

Timely administration of analgesia in the trauma patient is an essential component of their acute management, but literature suggests this is often poorly performed [1, 2, 3]. We audited the analgesia administrated in the Emergency Department (ED) for all patients admitted to our trauma ‘Enhanced Care Unit’ (ECU) – an acute area of the orthopaedic ward with level one nursing care. Our aim was to assess compliance with College of Emergency Medicine Standards [4] for the recording and timely treatment of acute pain. In addition we aimed to delineate the analgesic regimens being prescribed.

Methods We prospectively collected data on all patients admitted to Trauma ECU between November 2013 and February 2014. Data was collected from the paramedic and ED documentation. Specific data was collected on time to analgesia administration, type of analgesia given and pain score documentation.

Results Patients had a varied range of injuries, including rib fractures, long bone fractures, and vertebral fractures. Most patients had multiple injuries. We had 53 patients in total, 40 (75.5%) were male. Pain score was documented in 32% of patients by paramedics but only one patient in ED. 89% of patients received analgesia in ED. Mean time to analgesia in the ED was 46 minutes (SD 52 minutes). Of the patients receiving analgesia 87% had intravenous morphine. Less common analgesics were ketamine (10%), Entonox (4%), Morphine PCA (10%), peripheral nerve block (4%). Table 1 Pain Documentation and Time to Analgesia

Discussion The risk of death after surgery for NOF at this institution was found to be 2.67 times higher if you develop AKI post-operatively. NICE guidance recommends assessment of the risk of developing AKI before surgery. Pre-operative assessment at this institution is performed by junior surgical trainees with no formal risk assessment tool in place. The best ‘‘treatment’’ of AKI is prevention [2]. A NCEPOD report found the need for clinical improvement in AKI management [3]. The development and implementation of a risk assessment tool to identify patients at high risk of AKI, so that these patients can be optimised pre-operatively by senior anaesthetists, may help to decrease mortality. Evidence based optimisation could include addressing known risk factors for AKI such as omitting nephrotoxic medications perioperatively, and appropriate intravenous fluid hydration.

References 1. National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management of acute kidney injury up to the point of renal replacement therapy, 2013. http://guidance.nice.org.uk/CG169. (accessed 10/03/14). 2. Fliser D, Laville M, Covic A, et al; A European Renal Best Practice position statement on the Kidney Disease Improving Global Outcomes clinical practice guidelines on acute kidney injury: part 1: definitions, conservative management and contrast-induced nephropathy. Nephrology Dialysis Transplantation. 2012; 27(12): 4263–72. 3. National Confidential Enquiry into Patient Outcome and Death. Acute kidney injury: adding insult to injury, 2009. www.ncepod.org.uk/2009aki.htm (accessed 10/03/14).

Discussion Pain score documentation was poor however most patients received analgesia usually reserved for high pain scores. Timing to analgesia was good compared to other studies in similar patients [5, 6]. A range of analgesic techniques were used which shows the heterogeneity in this population. We suggest that the integration of pain scores with patient observation recording will be a simple intervention to allow early and regular documentation of patients pain score. This will allow further review of whether analgesia is appropriate and sufficient.

References 1. Keating L, Smith S. Acute pain in the emergency department: the challenges. Reviews in Pain 2011; 5(3): 13–6. 2. Karwowski-Soulie F, Lessenot-Tcherny S, Lamarche-Vadel A, et al. Pain in an emergency department: an audit. European Journal of Emergency Medicine 2006; 13(4): 218–24. 3. Rupp T, Delaney KA. Inadequate Analgesia in Emergency Medicine. Annals of Emergency Medicine 2004; 43(4): 494–503. 4. College of Emergency Medicine. Clinical Standards for the Emergency Department Sep 2013; p8. 5. Silka PA, Roth MM, Geiderman JM. Patterns of analgesic used in trauma patients in the ED. American Journal of Emergency Medicine 2002; 20(4): 298–302. 6. Grant P. Analgesia delivery in the ED. The American Journal of Emergency Medicine 2006; 24(7): 8.


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Evaluation of PlasmaLyte 148 as a maintenance solution in elective craniotomies

An audit of opioid prescribing in general practice

L. Ryan,1 A. Vinogradov2 and G. Eapen1 Sheffield Teaching Hospitals; 2Sheffield Teaching Hospital

N. Suarez Gloucestershire Hospitals NHS Foundation Trust

Crystalloids commonly used in intracranial surgery to maintain intravascular volume and electrolyte replacement include Normal saline and Hartmanns. Large volumes of these solutions can be associated with electrolyte abnormalities [1– 3]. We evaluated the effects of PlasmaLyte 148, a balanced crystalloid solution on the pH, pCO2 and electrolyte concentrations when used as maintenance solution during elective supratentorial craniotomy

Opioids are useful in managing chronic pain but due to their risks their use must be carefully considered [1] and is increasingly polemic [2–4]. National guidance [1, 5] states that initial assessment and regular review to assess efficacy, side effects and concordance should be performed and documented to ensure present and future safe and successful analgesia. We hypothesise that these standards are often not met in General Practice (GP). To address this we conducted a teaching session and introduced an automated assessment and review template which could be completed by the patient unsupervised if needed.

1

Methods A randomly selected group of 22 patients (15 female, 7 male) undergoing an elective supratentorial craniotomy received PlasmaLyte 148 as the maintenance fluid. Boluses of Plasmalyte were given if required. Serial arterial blood gas (ABG) measurements were taken at induction, 1 hour, 2 hours and in post-operative care unit. Statistical significant variability in pH, pCO2, sodium, chloride and lactate over time were analysed using one-way ANOVA.

Results The average age of the patients was 52.2 16.1 years and average BMI 25.5 4.7. The average volume of PlasmaLyte administered was 1745 ml 379 mL (Range 1000-2000 mL). A one-way ANOVA demonstrated no changes in plasma concentration of sodium, chloride and lactate throughout surgery and post-operatively. Analysis of ABG demonstrated a small but statistically significant decrease in pH postoperatively and converse change in pCO2

Methods Using a practice’s electronic patient record system the records of active opioid users over a 3 month period were retrieved. Their demographics, prescription details, pain assessment, frequency of follow up and information taken at review were collected. Prescribing practice was compared to the Royal College of Anaesthetists [1] and British Pain Society [5] guidance. This requires all patients to: have a comprehensive assessment; use non-opioid drugs first; undergo regular review including assessment of compliance and side effects; use modified release preparations if possible; avoid injectable preparations and pethidine and use >180 mg/ day of morphine (equivalent) with specialist advice only. The definition of a comprehensive assessment was taken from a recent review article [6]. To improve practice we gave a teaching session to the practice GPs and designed an electronic pain assessment and review template to be launched automatically when opioids were prescribed. Data were recollected 2 months following the intervention.

Results The number and characteristics of opioid prescriptions, and the frequency and average time to review are given in Table 1. Pre-intervention, comprehensive assessment was performed at the first prescription in 3%. When the 6 months prior to this prescription and any time after it were included, this rose to 45%. Post-intervention these figures were 3% and 67%. At review, side effects and compliance were documented rarely (pre-intervention 13% and 9%, post-intervention 30% and 44% respectively). Table 1 Number of opioid prescriptions, their characteristics and review details

Discussion Administration of PlasmaLyte maintained electrolytes in the normal range. A small alteration in pH which mirrored pCO2 concentrations may be due to ventilation effects. Our study demonstrates that PlasmaLyte can be utilised safely as a maintenance fluid in neurosurgical patients where normal sodium values are critical to maintenance of serum osmolality and preventing cerebral oedema.

References 1. Hadimioglu N, Saadawy I, Saglam T, Ertug Z and Dinckan A. The Effect of Different Crystalloid Solutions on Acid-Base Balance and Early Kidney Function After Kidney Transplantation. Anesthesia and Analgesia 2008; 107(1): 264–9. 2. Morgan TJ. The meaning of acid-base abnormalities in the intensive care unit: Part III–Effects of fluid administration. Critical Care 2005; 9: 204–11. 3. Young, JB, Utter GH, Schermer CR, Galante JM, Phan HH, Yang Y, Anderson BA, Scherer LA. Saline Versus Plasma-Lyte A in Initial Resuscitation of Trauma Patients: A Randomised Trail. Annals of Surgery 2014; 259(2): 255–62.

22

Before

After

intervention

intervention

Number of opioid prescriptions

28

30

Previous or concurrent use of non-opioids (%)

97

100

Using 50% [1]. An airway plan should be decided early and subsequent backup plans made as per Difficult Airway Society guidelines [2]. Best practice states this should ideally occur in the operating theatre with 2 senior anaesthetists and avoid insertion of airway adjuncts while the patient is light [1]. During inhalational induction, it is important to avoid ventilation attempts during apnoeic periods, but wait for CO2 to rise to aid spontaneous ventilation. If obstruction occurs a nasopharyngeal airway can be inserted until assessment of the laryngeal anatomy is possible [1]. In this case the use of video laryngoscopy was believed to aid intubation. Another technique to be considered is awake fibreoptic intubation. Current literature recommends early intubation in any suspected case of epiglottitis with airway symptoms.

References 1. Charles R, Fadden M, Brook J. Acute epiglottitis. British Medical Journal 2013; 347: f5235. 2. Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59: 675–94. http://www.das.uk.com/files/ddl-Jul04-A4.pdf (accessed 08/03/ 2014).

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Attitudes and use of audible alarms as a patient safety tool in the theatre environment

Failed extubation on the intensive care unit of a district general hospital

D. Harpham Maidstone and Tunbridge Wells NHS Trust

1

Methods

Methods

An online survey was circulated to all levels of anaesthetists working within a district general hospital, exploring attitudes and perceived utilisation of audible alarms in theatre, gaining 20 responses. The results of this questionnaire were then compared to actual observations of audible alarm use using a spot audit without the anaesthetists’ knowledge over 1 month on 100 anaesthetic theatre cases.

Retrospective data collection including all intubated patients on the intensive care unit between March and September 2012. The audit department provided a random sample of 60 sets of notes of patients in this group. Failed extubation was taken as need to replace endotracheal tube less than 72 hours after extubation. National data suggests 10% is the average failed extubation rate in intensive care units [1] so this standard was used.

Results

Results

Attitudes towards audible alarms were positive, with all anaesthetists surveyed in agreement that audible alarms act as an early warning of deteriorating patient condition and should be routinely used. Despite these attitudes and 100% awareness of the recommendation audible alarms should always be enabled and appropriately set, only 18% claimed to enable and check all alarms before every case. Results showed perceived use of audible alarms in theatres is very different to actual use, with most anaesthetists exaggerating their use of alarms. Despite 80% stating they enable all alarms, less than 10% of cases had all audible alarms activated. When given a standard case on which to base audible alarm parameters, no two anaesthetists selected the same parameters. In practice 85% used the identical default parameters intraoperatively. Initial response to an alarm was to disable it temporarily and look for a cause. 75% adjusted parameters to reduce noise, the rest only adjusted to support identification of clinical deterioration.

Data obtained included age, sex, admitting specialty, diagnosis, reason for respiratory failure, number of organs supported on admission and extubation, weaning data and reason for extubation failure (if applicable). The primary outcome (extubation failure rate) was 12%. Secondary outcomes including intensive care and hospital length of stay were found to be prolonged in the failed extubation group (ITU average length of stay 6 days versus 8 days; hospital length of stay 17 days versus 37 days).

Discussion Audible alarms are regarded as a mandatory standard of monitoring during anaesthesia, with governing bodies recommending audible alarms must be reviewed, enabled and appropriately set [1]. Audible alarms alert staff to critical incidents and act as an early warning of patient deterioration, thus improving patient safety by allowing early identification and intervention. Default alarm settings incorporated by the manufacturer are often inappropriate and should be adjusted based on patient baseline parameters and comorbidities in order to effectively detect abnormality [2]. Alarms are potentially lifesaving, but if set incorrectly can compromise safety, quality of care and compliance by frequent false alarms [3]. We should check and calibrate audible alarms at the start of each case and subsequent regular intervals or after a change in a clinical status to reduce these false alarms [3]. Compliance can be further improved by raising awareness of the discrepancy between perceived and actual use of auditory alarms in the theatre environment. All audible alarms should be enabled as the default setting.

D. Harpham1 and M. Satisha2 Maidstone and Tunbridge Wells NHS Trust; 2Dartford and Gravesham NHS Trust

Discussion Extubation failure has been associated with poor intensive care and patient outcomes in both tertiary and district general hospitals [1]. Compared to patients successfully extubated these patients have prolonged intensive care and hospital length of stay with increased morbidity and mortality of 35% [2], also incurring increased costs (2x total and per day). Strategies for identifying patients at high risk for extubation failure is essential to improve the management of weaning and extubation and reduce adverse outcomes [3]. As such, extubation criteria can be helpful focusing on groups of prediction factors including mentation, airway, secretions, respiratory muscle strength and cardiovascular reserve [3]. This audit raised awareness of the issue of failed extubation and as a result all extubations in the unit are now consultant decision only. Criteria used nationally as suggested by the intensive care society should be used to guide the decision for extubation and this is being implemented.

References 1. Seymour C W et al. The outcome of extubation failure in a community hospital intensive care unit. Critical Care 2004; 8: 322–327. 2. Dupont H, LePort Y, Paugham-Burtz C, Mantz J, Desmonts M. Re-intubation after planned extubation in surgical ICU patients: a case-control study. Intensive Care Medicine 2001; 27: 1875–1880. 3. Thille AW et al. The decision to extubate in the intensive care unit. American Journal of Respiratoy Critical Care Medicine 2013; 15: 1294–02.

References 1. Imhoff M, Kuhls S. Alarm algorithms in critical care monitoring. Anesthesia and Analgesia 2006; 102: 1525–37. 2. Solsona JF, Altaba C, Maull E, Rodriguez L, Bosque C, Mulero A. Are auditory warnings in the intensive care unit properly adjusted? Journal of Advanced Nursing 2001; 35: 402–6. 3. Koski EM, Makivirta A, Sukuvaara T, Kari A. Clinicians’ opinions on alarm limits and urgency of therapeutic responses. International Journal of Clinical Monitoring and Computing 1995; 12: 85–8.


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Ensuring correct placement of nasogastric tubes in intensive care

Safer surgery: an improvement project using the World Health Organization surgical checklist

S. Hillier,1 K. Vidale-Ellis2 and N. Hames2 1 University Hospitals Leicester; 2Northampton General Hospital

N. Hogan, J. Smith, C. Targett, L. Dubiel, A. Davie and J. Seeley NHS Tayside

Methods Patients on an adult intensive care unit in a large district general hospital were identified over a two week period as eligible for inclusion after insertion of nasogastric feeding tubes. Chest radiographs, case notes and prescription charts were then examined for evidence that nasogastric tube positioning had been confirmed before commencing feeding, in line with national standards [1]. Findings were presented locally, and recommendations implemented, including; modification of enteral feeding prescription charts to include confirmation of position; adding decision making aids to end of bed charts for nursing staff; and introduction of documentation stickers as a prompt to check and document position. A second period of data collection was carried out 6 months after the implementation of recommendations.

Results 25 radiographs in 14 unique patients were identified in phase one of data collection and 28 radiographs in 11 unique patients were identified in phase two of collection. Documentation in medical notes of nasogastric tube position on radiographs increased from 36% (9) before intervention to 50% (14) after intervention. Documentation on enteral feeding prescription charts increased from 12% (2) to 96% (27). We also found that confirmation of nasogastric tube position in 57% (12) of radiographs that had been ordered for that purpose compared with only 28% (2) if they had been ordered for another purpose.

Discussion Any nasogastric tube inserted has the potential to lead to the serious complication of aspiration of enteral feed through misplacement of the tube [2]. The national patient safety association (NPSA) classified this as a ‘never event’ and issue guidelines on confirmation of nasogastric tube position [1]. The gold standard for confirmation of ng tube position in intensive care is assessment of chest radiograph [2]. Before intervention we found a low rate of documentation in medical notes and on the enteral feeding prescription chart. Following presentation and implementation of findings through a number of key interventions, we found an increase in the documentation of nasogastric tube position, greatest on prescription charts, and in medical notes. We conclude that working to modifying behaviours around enteral feed administration, as well as reminders and decision making tools is a more comprehensive approach to improving safety of nasogastric tubes in intensive care. We plan to continue to educate doctors about the best practice for ng tube insertion, and to support nurses in requiring radiograph confirmation of position before starting enteral feeding.

The World Health Organization (WHO) has urged the use of a formal 3 part surgical checklist in an effort to make surgery safer [1]. It includes sign-in (pre-induction), surgical pause (pre-incision) and sign-out (at end of procedure). NHS Tayside has used an adapted WHO perioperative checklist since 2009. We audited its current use focussing on action and communication between team members rather than on ticked boxes. The project was prompted by avoidable incidents involving anticoagulation pre-epidural, incomplete consent, wrong side marked and double dosing of medication. End of case communication and planning was also noted to be suboptimal. We aimed to improve perioperative patient safety by increasing compliance with the sign-in and sign-out components to 95%.

Methods Trainees observed current practice in different theatres for 1 week. It was confirmed that the checklist was rarely read aloud and often ticked in retrospect (sign-in) or pre-emptively (sign-out). Using the Model for Improvement, ‘plan, do, study, act’ (PDSA) cycles were audited in one theatre for a number of interventions [2]. Fifty-six cases were observed over 4 months. Cycle 1: Discussion with theatre staff requesting participation. Visual prompts displayed. Cycle 2: Senior nurse roll as sign-out leader. Daily reminders at morning briefing. Cycle 3: Renewed communication, information and simulated educational video. Improved simplified checklist trialled.

Results Initial data confirmed checks were not done as a team or read aloud as intended despite being ticked. All 8 cases in week 1 were marked as sign-in completed but it was only done pre-induction in 3 cases. We achieved improved compliance of sign-in with 100% during the final week [Fig.]. Sign-out performance was more variable with ~30% compliance throughout and no improvement. In later cases checklist boxes were not ticked for omitted actions reflecting more accurate documentation.

References 1. Lamont T, Beaumont C, Fayaz A, et al. Checking placement of nasogastric feeding tubes in adults (interpretation of x ray images): Summary of a safety report from the national patient safety agency. BMJ 2011; 342: d2586. 2. Rassias AJ, Ball PA, Corwin HL. A prospective study of tracheopulmonary complications associated with the placement of narrow-bore enteral feeding tubes. Critical Care 1998; 2(1): 25–8.

Discussion Reliable performance of a perioperative checklist can reduce morbidity and mortality [3, 4]. The sign-in and sign-out processes were poorly used in our hospital. We introduced several interventions to raise awareness and engage staff to comply with the checklist. The PDSA cycle was a useful tool for implementing change promptly and demonstrating effective interventions. Drawbacks were a labour-intensive process and small numbers per cycle. We plan to implement correct checklist performance in all Tayside operating theatres. Compliance does depend on attitude and so we hope to instigate a gradual cultural change. Further engaging surgical colleagues may help address poor sign-out compliance as may the new revised checklist.

References 1. World Alliance for Patient Safety. WHO guidelines for safe surgery. Geneva: World Health Organization, 2008. 2. Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd Edition). Jossey Bass, San Francisco, 2009. ISBN-13: 978-0470192412. 3. Haynes AB, Weiser TG, Berry WR et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine. 2009; 360: 491–9. 4. de Vries EN, Prins HA, Crolla RMPH et al. Effect of a Comprehensive Surgical Safety System on Patient Outcomes. New England Journal of Medicine. 2010; 363: 1928–1937.

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A nightmare scenario A. Hurry NHS Greater Glasgow & Clyde

There are few events in medicine which we would consider to be a nightmare situation, however being presented with a rare scenario, in a critically unwell patient, surrounded by junior staff, in an isolated hospital with multiple patients probably fits the bill. Resuscitation and cardiac arrests scenarios are common practice for many anaesthetic trainees; however there are special circumstances in resuscitation guidelines that are not seen on a regular basis and demand an altered approach. Cardiac arrest in the pregnant patient is one of these.

Description This case involves the massive ante partum haemorrhage and subsequent cardiac arrest of a 36 year old who was 36 weeks pregnant. The patient had a known moderate placenta praevia last seen less than 72 hours ago in the ante natal clinic. Due to the nature of the patient’s condition and the size of the hospital, anaesthetic and intensive care support was summoned as soon as the call from the ambulance was received. Obstetric and surgical help had been summoned but were at least 15 minutes away off site. 4 minutes of CPR was quickly reached with no change in the patient’s state and no signs of life. The decision to perform perimortem caesarean section was made and the most appropriate person to perform this was the senior anaesthetic trainee. With CPR ongoing the abdomen was prepared with betadine and a pfannenstiel incision was made. Dissection through a bloodless field to the gravid uterus was made. After hysterotomy a baby delivered within 90 seconds. Approximate 20 minutes after delivery and with transfusion of blood products the mother began to show signs of life. Full return of stable circulation occurred 35 minutes after initial arrival in the emergency department. A decision to transfer to theatre to allow full control was taken and she was transferred to the operating department.

50 Intra-operative damage to the endotracheal tube pilot balloon – a significant risk to patient safety D. Hutchins and B. Ivory Royal Devon & Exeter Hospital We describe a incident of accidental severing of the pilot balloon of a nasal endotracheal tube and a novel approach to temporary cuff re-inflation.

Description An 88 year old man presented for elective neck dissection and mandibulectomy. Induction of anaesthesia and nasal intubation with a size 6.5 pre-formed Portex nasal endotracheal tube was undertaken without incident and surgery completed without complication. After surgical closure, the drapes were cut off by the scrub team, at which point there was a reduction in tidal volume and pressure with loss of end tidal CO2 trace. After initial inspection of the anaesthetic circuit, the problem was identified as secondary to cuff deflation following accidental severing of the pilot tube. After administration of 100% oxygen and transfer to manual ventilation, a 23G needle was inserted into the now free end of the pilot balloon and the cuff was inflated with a 20 ml syringe until no gas leak was audible (Fig 1). Oxygen saturations were maintained at 99% throughout this event. By this stage of the procedure, anaesthesia was being lightened with a view to imminent extubation, and given that a good seal was being maintained with the now re-inflated cuff, it was decided not to re-intubate the patient but instead to continue to lighten anaesthesia and extubate. One member of the anaesthetic team maintained manual pressure via the syringe to keep the cuff inflated whilst the patient emerged from anaesthesia. The patient was extubated 10 minutes later without incident.

Discussion This is an extreme and rare scenario and is the only reported case in medical literature of a perimortem caesarean section being performed by an anaesthetist of any grade to date. As such it is unlikely to be repeated in the near future, however it does highlight one of the specialist resuscitation scenarios at which we could find ourselves and be expected to lead a team through and reminds us of the importance of early caesarean section.

References 1. The Confidential Enquiry into Maternal and Child Health Saving Mothers Lives: Reviewing mothers deaths to make motherhood safer 2003-2005. London Royal College of Obstetrics and Gynaecologists press, 2007. 2. Nolan J et al. Advanced Life Support – Course Manual 6th Edition. Chapter 12 Resuscitation Council UK London; 2011. 3. Whitten M, Irvine LM. Postmortem and perimorten caesarean section: what are the indications? Journal of the Royal Society of Medicine 2000; 93: 6–9. 4. Katz VL, et al. Perimortem cesarean delivery. International Journal of Obstetrics and Gynecology 1986; 68: 571–6.

Discussion A review of the literature reveals few case reports of accidental severance of the pilot balloon, but anecdote suggests that it may be more common than the literature suggests. Whilst replacement of the damaged endotracheal tube should remain the default management following such an incident, there may be specific times when a pragmatic approach such as that described here should be considered. In our case, the level of anaesthesia was already being lightened at the time of the incident, and re-intubation would have necessitated re-sedation and muscle relaxation. We felt that the balance of risk favoured continuing with the rescue technique. Another situation which may favour continuing with the original tube would the patient in the prone position [1]. We believe that this is the first report of this technique for rescue cuff inflation. Other methods described include the use of a 22G catheter for inflation and a ‘hubless’ needle to bridge the gap between severed ends of the pilot balloon [1, 2]. In retrospect, we would suggest the addition of a 3 way tap to enable the maintenance of cuff inflation.

References 1. Yoon KB, Choi BH, Chang HS, Lim HK. Management of detachment of pilot balloon during intraoral repositioning of the submental endotracheal tube. Yonsei Medical Journal. 2004; 45: 748–50. 2. Whitesides LM, Exler AS. Intraoperative damage and correction of pilot balloon during orthognathic surgery. Anaesthesia Progress 44: 38–39.


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A case of complete power failure

Daily medical review of the ICU patient: hands on! Quality improvement survey assessing hands-on approach to ICU daily medical reviews

E. James Great Western Hospital, Swindon.

A female patient presented for Endoscopic Subacromial Decompression. The procedure was performed under a combination of regional and general anaesthesia.

J. Keough and H. Keir St Helens and Knowsley NHS Trust, Mersey Deanery

Description

Methods

An interscalene block was performed awake and the patient was then intubated and ventilated for the procedure. Approximately 40 minutes into the procedure the intermittent fire alarm sounded and fire was confirmed in the adjacent department to theatres. Within minutes there was complete mains power failure throughout the theatre suite. The generator and backup generator had failed because of the fire. All theatres and recovery were in complete darkness, we did not have any windows within these areas. In our theatre, surgery was stopped and endoscopes removed from the patient. The only light source in the room was the monitor from our anaesthetic machine. The ventilator (Blease 900) continued to deliver anaesthesia on battery power. Due to uncertainty of duration of battery power we had left, Oxygen cylinders, propofol and syringe drivers were set up as a backup plan to deliver anaesthesia. Once we had established that the canopy lights in theatre had battery backup, the operation was completed and the patient was woken up and recovered in theatre. Power was restored after approximately 90 minutes. All non emergency surgery in the hospital was cancelled until all mains and generator power was returned.

Clinical examination of the ICU patient is an essential part of the medical daily review. This should not simply be assessment of physiological parameters, but a hands-on physical examination. The invasive nature of ICU places patients at risk of complications affecting every system [1–4]. This survey aimed to ensure systematic physical examination was taking place daily. The primary outcome measure was ‘yes’ or ‘no’ as to whether patients had evidence of any hands-on examination during each daily review e.g. chest auscultation or abdominal palpation. The second outcome was to assess which systems were the most and least frequently examined. All level 3 or level 2 ICU patients over the study period (2012–2013) were included. Burns and ‘ward ready’ patients were excluded. Once a patient was included 20 of their ICU daily review sheets were evaluated. The following systems were assessed: cardiovascular, respiratory, neurological, gastrointestinal, legs. Convincing evidence of a hands-on examination e.g. diagrams of lungs or ‘HS I+II+0’ would lead to ‘yes’ being recorded and if not ‘no’ was recorded. The audit would continue until 200 daily review sheets had been analysed. Medical records were used primarily and the audit was conducted by trainees under the supervision of an ICU consultant.

Discussion Complete power failure is a rare but serious event. Whilst a number of articles have discussed isolated power failure to anaesthetic machines, few have addressed power failure affecting the whole theatre. This case presentation highlights learning points for the anaesthetist and theatre team regarding the importance of familiarity with the equipment that we have available to us in such an emergency situation and the potential for training needed in this area.

Results We found that in 33/200 ICU daily reviews, the patient had no evidence of any hands-on examination at all. Furthermore, we found evidence of hands-on neurological examination in just 27/200 daily reviews, and cardiovascular examination in 40/200 reviews (figure 1). Furthermore, only 11/200 had their legs examined. The most frequently examined system was the respiratory system; with 135/200 physical chest examinations being performed. Furthermore, there was evidence of 133/200 physical abdominal examinations.

Discussion Too often on our ITU, patients are undergoing a daily medical review without a single hand being placed upon them, many simply having their physical parameters recorded by doctors. Some systems in particular are infrequently examined. Possible barriers include time, staffing, unawareness, equipment and leadership. We suggested an evidenced-based tutorial on induction of junior trainees’ to the complications of the ICU and importance of a hands-on, systematic, daily clinical examination. We also suggest that ‘daily examination?’ be added as part of the consultant ward round checklist, and that wherever examination is actually performed as part of the ward round. Furthermore a stethoscope and tendon hammer at the end of every bed is essential.

Acknowledgements Dr Kevin Sim, ICU Consultant, Whiston Hospital

References 1. Gammon RB, Shin MS, Groves RH Jr, et al. Clinical risk factors for pulmonary barotraumas: A multivariate analysis. American Journal of Respiratory and Critical Care Medicine 1995; 152: 1235–1240. 2. Mutlu G, Mutlu E, Factor P. GI complications in patients receiving mechanical ventilation. Chest 2001; 119: 1222–1241. 3. Hirsch DR, Ingenito EP, Goldhaber SZ. Prevalence of deep vein thrombosis among patients in medical intensive care. JAMA 1995; 274: 335–337. 4. Chrissoheris MP, Libertin C, Ali RG, Ghantous A, Bekui A, Donohue T. Endocarditis complicating central venous catheter bloodstream infections: A unique form of health care associated endocarditis. Clinical Cardiology 2009; 32: E48–54.

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Beware the cold case – a patient with unsuspected bleeding following nasal temperature probe insertion

The use of information leaflets as a tool to reduce preoperative anxiety in patients undergoing emergency surgery

H. Leaman Royal London Hospital

T. Leith and C. Kilduff West Hertfordshire Hospitals NHS Trust

Description A 29 year old ASA 1 female was listed for elective laparoscopic cholecystectomy as a day case. She was a Mallampati 1 with normal airway. General Anaesthesia was an uneventful IV induction with 100 mcg fentanyl, 200 mg propofol, 30 mg atracurium, easy bag-mask ventilation and grade one intubation, size 7.0 cuffed Portex endotracheal tube; positive pressure ventilation maintained with sevoflurane air-oxygen mixture. Patient temperature was monitored using an oro-nasal oesophageal temperature probe. Initially the probe was passed via the right nostril; resistance was met but no obvious trauma to the nasal passage was noted on the single attempt. The probe was then placed successfully in the oropharynx and surgery proceeded successfully. Laparoscopic cholecystectomy was completed, with surgical time of ninety minutes. The patient was routinely reversed with neostigmine and glycopyrolate. Prior to extubation, the temperature probe was removed, and blood-stained secretions were noted. Routine suction to the oropharynx revealed larger than expected blood with the secretions. Due to the unexpected blood on suctioning, direct laryngoscopy was performed to reveal a large posterior pharyngeal blood clot, which when removed measured 50 x 20 x 20 mm. The clot could easily have been missed without direct laryngoscopy and potentially be regarded as a ‘coroner’s clot’. The oropharynx was further suctioned, and the patient recovered sitting upright. The endotracheal tube was not removed until she was fully awake. The patient was informed in recovery that she may experience some haemoptysis post-operatively.

Discussion Aspiration of retained clots on extubation is a well-documented complication of ENT surgery. There has also been documentation to suggest that nasal placement of temperature probes can cause severe epistaxis [1]. General anaesthesia causes a reduction in the laryngotracheal reflexes, which can increase the risk of aspiration. Any blood located in the airway is significant when the airway reflexes are obtunded, as aspiration of blood clots can cause complete airway obstruction [2]. The Difficult Airway Society recommends suctioning of the airway prior to extubation in their recent extubation guidelines [3]. NAP4 identified the ‘coroner’s clot’ as an area of danger, whereby aspiration of blood can result in complete airway obstruction and death, and recommend special vigilance during pre-extubation laryngoscopy [4]. A simple procedure of passing nasal temperature probes can cause potential harm, the extreme being delayed airway compromise from dangerous concealed blood clots. Such a procedure should be performed with caution.

References 1. Sinha et al. Massive epistaxis after nasopharyngeal temperature probe insertion after cardiac surgery. Journal of Cardiovascular and Vascular Anaesthesia 2004; 18(1): 123–4. 2. Cook T, Frerk C. Aspiration of gastric contents and blood. 4th National Audit Project: Major Complications of Airway Management in the UK: Royal College of Anaesthetists, 2011: 155–64. 3. Difficult Airway Society. Guidelines for the management of tracheal extubation, Anaesthesia 2012; 67: 318–340. 4. Quinn A, Woodall N. The End of Anaesthesia and Recovery. 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Major complications of airway management in the UK: Royal College of Anaesthetists, 2011: 62–70.

Many anaesthetic and surgical departments supply patients with preoperative written information; this is especially common in elective surgery. Patients who require emergency surgery are particularly anxious and may be overwhelmed by the amount of information they are expected to understand, retain, and weigh. Anaesthetists may underestimate the anxiety that patients feel in the preoperative period, and how this affects their experience of the care they receive. We designed and prepared an emergency surgery information leaflet to give to patients preoperatively, in the hope of reducing anxiety. The leaflet includes a summary of what will happen before, during and after surgery, with a flow chart to consolidate this. We also included a ‘meet the team’ section, which introduces the different members of the operating team.

Methods Fifty patients who required emergency surgery were selected prospectively. At the end of the anaesthetic preoperative assessment, they were asked to rate on a scale of one to ten how anxious they felt. They were also asked to rate how well informed they felt about the process, and how well they understood the different roles of the members of the operating team. They were given the leaflet to read before surgery. They were then asked the same questions in order to assess whether the leaflet had reduced anxiety levels.

Results Fifty two percent of patients (26/50) were female, 48% (24/50) were male. The average preoperative patient anxiety score, using the numerical rating score of 1 - 10, was 6.62 (SD 2.12). After reading the leaflet, the average patient anxiety score was 5.38, an 18.73% reduction. Patient’s perception of how well informed they felt was increased by 17.87% (6.48 before reading the leaflet compared to 7.9 after). Patient’s understanding of the role of the different members of the operating team was also increased by 19.44% (6.38 before reading the leaflet compared to 7.92 after)

Discussion Previous studies have shown conflicting results as to whether providing preoperative written information can reduce patient anxiety. Some studies have shown a reduction in patient anxiety [1–2], whereas others have shown written information can actually increase anxiety levels [3]. However, much of the literature focuses on patients undergoing elective surgery. We have shown that providing written information can reduce anxiety, and improve understanding of the surgical journey. We would like to state that patient information leaflets should act as an adjunct to verbal communication; not replace it.

References sie et de reanimation. Impact 1. Albaladejo P et al. Annales francßaises d’anesthe of an information booklet on patient satisfaction in anesthesia. 2000; 19(4): 242–8. 2. Jlala HA, French JL, Foxall GL, Hardman JG, Bedforth NM. Effect of Preoperative Multimedia Information on Perioperative Anxiety in Patients Undergoing Procedures Under Regional Anaesthesia. British Journal of Anaesthesia. 2010; 104(3): 369–374. 3. M. Gillies, FJ Baldwin. European Journal of Anaesthesiology. Do patient information booklets increase perioperative anxiety? 2001; 18(9): 620–2.


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Improving the preoperative assessment clinic J. Lennard and R. Sinclair Royal Victoria Infirmary, Newcastle

Ageing population is neglected in research studies – a representative study of patients with traumatic brain injury A. Longworth1 and T. Veenith2 1 Barnet and Chase Farm NHS trust; 2Birmingham University Hospitals NHS Trust

Methods Using a simple questionnaire we asked anaesthetists to comment on how well patients were assessed in the preoperative assessment clinic (PAC) at the Royal Victoria Infirmary, Newcastle-upon-Tyne. The study was completed twice, three years apart: before and after the introduction of a number of changes in PAC. Service quality improvements over the last three years have altered PAC structure to an anaesthetic consultant-led service. NICE guidance on the use of preoperative investigations and a local medications management policy have been adopted to assist the PAC nurses with assessing and investigating patients [1, 2] There are now six consultant sessions during the week in clinic and an easy route for referral and advice for the PAC nursing staff to seek assistance and consultant review. The PAC survey was repeated in 2014 to assess whether these improvements had impacted upon patient preparation for surgery.

Results In 2011 and 2014 we surveyed 58 and 70 general, gynaecological and plastic surgical PAC assessments respectively. The table below shows the improvement in the use of appropriate history taking, investigations and medications management after the changes to PAC. The referral system to PAC has improved with 96% vs 81% of patients being seen in clinic in 2014 vs 2011. In the recent survey three patients were not assessed before admission: one travelled from Wales, one travelled from Carlisle and one was an inter-hospital transfer for tertiary plastic surgery input. A smaller proportion of patients are now reviewed directly by a consultant which we hypothesise to be a result of increased consultant support and education in clinic. The NICE guidance has improved the appropriate use of investigations. Similarly, medications management has improved such that 94% of prescriptions were given or withheld as per local guidance preoperatively. There was one short delay to surgery when a Group and Save was taken on the day of surgery unit. Overall satisfaction with the service has improved from 79% to 92%.

Table 1 PAC Questionnaire Results 2011

2014

Number of pts assessed

58

70

Number of pts seen in PAC

81% (47/58)

96% (67/70)

Number of pts seen by PAC nurse

100% (47)

100% (67)

Number of pts seen by Anaesthetist

13% (6)

9% (6)

Appropriate Blood Tests performed (as per

86%

98%

ECG performed (as per NICE guidance)

90%

95%

Medications Managed Appropriately as per

83%

94%

The UK population is ageing and by 2032 the cohort of people over 65 years is expected increase to 16.1 million. The aims of this study were: 1. To identify the national demographics of patients admitted with traumatic brain injury (TBI). 2. To assess the evolution of mortality of patients admitted to Addenbrooke’s Hospital neurocritical care unit (NCCU) between 2000 to 2011 3. A systematic review of literature from 1997 to 2012 to identify whether there is an age bias amongst researchers studying TBI.

Methods Cambridgeshire central ethics committee considered this as non research and a waiver was issued. Patients with TBI admitted to Addenbrooke’s Hospital NCCU were identified and were divided into 3 age groups (4000 mg/L). She made a full recovery and was discharged 48 h later.

Discussion Ethylene glycol poisoning is a potentially serious condition that can have major deleterious effects if not recognised and managed promptly [1]. It presents as a constellation of non-specific signs and symptoms therefore diagnosis is often reliant on the history and indirect indicators such as raised anion and osmolar gaps or crystalluria. Ethylene glycol levels (or those of its metabolites) may not be readily available locally and delay definitive treatment. However, the major metabolite of ethylene glycol, glycolate, can cause false elevation in some POC analysers leading to the ‘lactate gap’ [2] – the difference between POC and laboratory lactate levels. Identification of the lactate gap can be used as a sensitive test to aid rapid diagnosis of ethylene glycol toxicity and direct further management.

Acknowledgements Published with the consent of the patient

References 1. Kruse JA. Methanol and ethylene glycol intoxication. Critical Care Clinics. 2012; 28(4): 661–711. 2. Brindley PG, Butler MS, Cembrowski G, Brindley DN. Falsely elevated point-ofcare lactate measurement after ingestion of ethylene glycol. Canadian Medical Association Journal 2007; 176(8): 1097–1099.

Audit of mechanical venous thromboembolism prophylaxis in surgical patients in a district general hospital J. Macrae, M. Eid and S. Law Northern Deanery

Prevention of venous thromboembolism (VTE) is a major issue for the NHS. It has both clinical and cost implications. However implementation is not always straightforward. Where mechanical prophylaxis is indicated, NICE recommends application of one of; Graduated Compression stockings (GCSs), Intermittent Pneumatic Compression Devices (IPCDs), or Foot Impulse Devices (FIDs). The aim of this audit was to assess compliance with mechanical VTE prophylaxis against our local VTE policy (based on NICE guideline CG92 2010[1]). Both GCSs and IPCDs are readily available at our hospital and must be prescribed on the drug chart.

Methods Local guidelines were consulted and standards were set at 100% for completion of risk assessments and appropriate prescription and application of mechanical prophylaxis. Data were collected prospectively on a pre-printed proforma from 70 randomly chosen patients over working five normal working days. This included a mix of general, orthopaedic, gynaecological and urological surgeries. Paediatric and obstetric patients were excluded. Data collected included patient demographics, presence of a VTE risk assessment and prescription, and details of any devices applied.

Results Of 70 patients, four (6%) were not risk assessed. 20 (28.5%) patients at risk for VTE had no prescription for mechanical prophylaxis. However, 11 (15.7%) of these had mechanical prophylaxis applied. A further 8 patients (11.4%) had no mechanical prophylaxis applied but received pharmacological prophylaxis. 1 patient (1.4%) failed to have any form of mechanical prophylaxis applied. An additional 16 (22.8%) patients had both GCS and IPCDs applied.

Discussion Over a third of the patients we reviewed had inappropriate mechanical prophylaxis prescribed and/or applied. Of note were the high numbers of patients receiving both GCSs and ICPDs. There is no recommendation for dual application of GCSs and IPCDs as no compelling evidence exists to demonstrate a risk reduction in VTE when combined [2]. Reducing the number of such prescriptions would be cost effective, reducing appliance cost at no extra risk of VTE related complications. If GCSs alone were used (£6.36/pair [1]) then the cost IPCD sleeves could be avoided (£26.12/pair [1]); a saving of over £400 in this sample with projected savings of over £20,000 a year. We aim to re-audit after clarifying our local VTE policy with all directorates involved and implementing an education programme. Our findings are likely to be relevant not only to surgical patients in the immediate perioperative stages but also to medical patients and post-operative surgical patients at later stages of their recovery.

References 1. National Institute for Health and Care Excellence. Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital CG92(2010); Full Guidance 2. National Institute for Health and Care Excellence. Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital CG92 (2010) Appendix E.


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Gynaecology post-operative analgesia – does regional analgesia have a significant role?

Post-operative sore throat – a forgotten problem

D. Magee, R. Sun and G. Arnold St. Mary’s Hospital, London

D. Magee, H. Wydell, R. Russai and L. Allan Northwick Park Hospital, Harrow

Postoperative pain is associated with decreased patient satisfaction, unexpected admission of day surgery patients, and chronic pain [1, 2]. The Royal College of Anaesthetists (RCOA) recommends that >95% of patients have a pain score 6 hrs Duration of mechanical ventilation: (include all cases ventilated >2 hrs) Ventilation parameters: Mode of ventilation: PC VC Tidal Volume (ml): Tidal Volume ml/kg predicted body weight: PEEP:

Rapid sequence induction (RSI) of general anaesthesia is a core competency for anaesthetic trainees and a component of the Royal College of Anaesthetists’ (RCoA) initial assessment of competence [1]. Safe performance depends on the skill of the airway technician and also on effective communication and coordination among the airway team. The fourth National Audit Project of the RCoA highlighted that RSI is associated with complications of airway management in the emergency department and the intensive care unit, and recommends that a checklist is developed and used for intubation of all critically ill patients [2]. After canvassing opinion from trainees and anaesthetic assistants in our Trust, we designed and implemented a question-response checklist for controlled RSI.

Discussion

Gender: Height:

20 questions: a question-response checklist for controlled rapid sequence induction

Baseline: End of surgery:

Number of recruitment maneuvers:

Discussion Less than 50% patients included were given LPV and only 11% received recommended PEEP. We have subsequently put ideal body weight charts in anaesthetic rooms to encourage use of LPV and aim to carry out another survey to assess for improvement. In the future we are planning on a regional survey into LPV and possibly a multi-centre trial looking at intra-operative ventilation strategies and their impact on outcomes, e.g, length of hospital stay, unplanned ICU admissions, prolonged recovery, increased cost of healthcare etc.

References 1. Arozullah AM, Daley J, Henderson WG, Khuri SF. Multifactorial risk index for predicting postoperative respiratory failure in men after major non-cardiac surgery: the National Veterans Administration Surgical Quality Improvement Program. Annals of Surgery 2000; 232: 242–53. 2. Serpa Neto A, Cardoso SO, Manetta JA et al. Association between use of lungprotective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis. Journal of the American Medical Association 2012; 308: 1651–9. 3. Futier E, Constantin JM, Paugam-Purtz C et al. A trial of Intraoperative LowTidal-Volume Ventilation in Abdominal Surgery. The New England Journal of Medicine 2013; 369: 4.

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Fast bleep audit – to determine the appropriateness of fast bleeps received and the quality of communication relayed

Airway management knowledge among medical students, can we improve undergraduate airway training?

C. Mitchell1 and D. Johnston2 1 Ulster Hopsital, Dundonald; 2Antrim Area Hospital

I. Mohamed,1 M. Gardener2 and V. Hampton2 1 Airedale General Hospital; 2Bradford Royal Infirmary

Methods Emergency fast bleep calls received by the anaesthetic team were audited over a three-month period. Our aim was to assess the amount of time spent attending unnecessary call outs and to evaluate the quality of the information communicated. The anaesthetist completed a questionnaire on appropriateness of the fast bleep, delay on getting through on the phone and use of the SBAR (situation, background, assessment, recommendation) tool. Standards for SBAR tool usage and fast bleep appropriateness were set at 100%. After areas for change were identified the audit was repeated using the same methodology.

Results During the initial audit 25 fast bleeps were received, of which 11, originated from the Emergency Department (ED). There was a delay in getting through on the phone in 45% of cases and suitable communication delivered in 50% of these. Fast bleeps from the ED were deemed appropriate in 35%, (compared to 75% from maternity and wards). After discussion with the ED team the SBAR tool wall chart was placed beside the ED phone. This was accompanied by education at the ED morning meetings on implementing SBAR information sharing and when a fast bleep call should be initiated. There were 18 fast bleeps in the repeat audit, five from the ED, less than half than previous audit. Enhanced communication was noted, with only one delay in answering the phone and failure to use the SBAR tool in another. Appropriateness improved from 35% to 100%. The majority of fast bleeps in this audit originated from maternity to which the anaesthetist attended immediately in all cases. There was failure to use the SBAR tool in 86% of cases with reduced appropriateness of 57%. Appropriateness of calls from the wards remained at 75%.

Discussion Reducing the frequency of inappropriate anaesthetic fast bleeps has not only the potential to improve theatre productivity but also inter-team relationships. The audit highlighted short fallings in communication, which is crucial in emergency situations. The link between poor communication and patient harm is well established [1, 2]. Implementation of simple communication aids such as the SBAR tool has been shown to reduce the incidence of harm [3]. This audit has demonstrated successful application of the SBAR tool by the ED, which has improved structure and quality of information given to the anaesthetist. It has also highlighted the need to address communication with our maternity unit. Similar SBAR education has been scheduled and we plan to re-audit maternity fast bleeps following this.

References 1. NHS institute for Innovation and Improvement. http://www.institute.nhs.uk/ safer_care/general/human_factors.html (Accessed 15/03/14). 2. Confidential Enquiry in Maternal and Child Health. Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer – 2003-2005. December 2007 Lewis et al. 3. NHS Institute for Innovation and Improvement. The Handbook of Quality and Service Improvement Tools. Page 247–251 www.institute.nhs.uk/qualitytools (accessed 15/03/14).

The care of the acutely ill hospitalised patient presents problems for health services worldwide [1]. Sub-optimal care is frequently related to poor management of simple aspects of acute care – those involving the patient’s airway, breathing and circulation, oxygen therapy, fluid balance and monitoring [2]. Effective earlier intervention requires that staff are trained in the care of the acutely ill patient. Ideally, competence (knowledge, skills and attitudes) in caring for these patients should be a clearly defined component of healthcare curricula, starting at undergraduate level. However, previous studies have shown that resuscitation and intensive care training is neglected in the undergraduate curriculum [3, 4], with UK medical schools only recently managing to deliver universal training in basic life support [3]. We conducted a survey looking at airway management knowledge among medical students including attendance at formal training in airway management.

Methods Data was collected from medical students who attended the Cutting Edge Leeds’ 4th annual national student conference on the 1st of March 2014 at St James University Hospital. Eighty students were asked to fill out a paper based questionnaire consisting of 10 questions regarding airway management knowledge. A score was given out of 10. Data was analysed using Microsoft Excel 2011.

Results A total of 80 students were asked to fill in the survey. Sixty-eight students completed it. Eleven were A level/Clinical science students. The rest consisted of medical students from year 1 (10), year 2 (26), year 3 (17) and year 4 (4). Thirty-four out of the 68 students (50%) had had formal training in airway management. This included either lectures, practical training or both. The mean score was 5.8 out of 10 with minimum and maximum scores being 2 and 10 out of 10 respectively.

Discussion The study population of this survey consisted of students from a variety of medical schools, including Leeds, Warwick, Sheffield and Nottingham. It demonstrates that 50% of these medical students have received some form of training in airway management. As it includes the different years as mentioned above, this percentage could reflect that students in their final years receive this training more than those just starting medical school. These findings were discussed with the UGAS Leeds president (Undergraduate Anaesthetics Society-Leeds) in an attempt to improve medical student knowledge and skills in airway management from an early stage by organising a variety of learning sessions such as lectures and workshops.

References 1. Bion JF, Heffner JE. Challenges in the care of the acutely ill. Lancet 2004; 363: 970–977. 2. McGloin H, Adam SK, Singer M. Unexpected deaths and referrals to intensive care of patients on general wards. Are some cases potentially avoidable? Journal of the Royal College of Physicians London 1999; 33: 255–259. 3. Phillips PS, Nolan JP. Training in basic and advanced life support in UK medical schools: questionnaire survey. BMJ 2001; 323: 22–23. 4. Harrison GA, Hillman KM, Fulde GW, Jacques TC. The need for undergraduate education in critical care. (Results of a questionnaire to year 6 medical undergraduates, University of New South Wales and recommendations on a curriculum in critical care). Anaesthesia and Intensive Care 1999; 27: 53–58.


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Snapshot 4 day case note audit of emergency general surgical admissions

Spinal dosing in patients of low stature: a safe approach

D. Morris, L. Spencer and M. McMenamin Aintree University Hospital NHS Foundation Trust

Z. Nassa, L. Beard and J. Marriott Worcester Royal Hospital

Time constraints surrounding preoperative assessment of emergency patients mean that disorganised medical records can lead to potentially adverse outcomes [1]. ‘Medical record keeping serves many functions but the primary purpose is to support patient care’ [2], failings highlighted by the Francis report have shown the effect chaotic patient files can have on patients’ immediate care [3]. The benefits of utilising computerised medical records can only be fully realised with accurate and high quality paper records [2]. This audit aimed to evaluate the quality of filing and clinical record keeping of emergency general surgery patients 24 hours post admission.

Anaesthesia is a complicated procedure with potential morbidity and mortality in the Achondroplastic patient (AP). We present a case of a pregnant AP requiring an emergency c-section.

Methods 94 acute general surgery patients’ medical records were reviewed twice daily over a 4 day period. Patients were only included if they had been admitted to hospital for over 24 hours. Standards applied were that records must be filed securely in chronological order, under correct subsections, in a permanent hospital patient folder.

Results 47 of the 94 medical records were excluded as they were reviewed within the first 24 hours of admission. Out of the remaining 47 patients, 25 (53.2%) met the audit standards, 16 (34%) were misfiled and 6 (12.8%) were not filed. Throughout the audit period the quality of medical record keeping seemed to improve, on the first day 35.3% met the audit standards compared to 77.8% on the final day. The time of admission to the surgical assessment unit did not seem to impact on the quality of medical record keeping.

Discussion Only 53.2% of audited case notes met the standards. This raises a number of clinical governance issues; Clinical effectiveness, Risk management, and Information Management. All of which not only have an impact on daily anaesthetic practice but also overall patient outcomes. The improvement in medical record keeping throughout the audit period could have been down to greater ward clerk presence in the week, as none were present over the weekend, as such we have used the audit data to open talks with our hospital’s financial department to discuss greater ward clerk cover. We are currently liaising with our surgical colleagues to assess whether a restructuring of admission paperwork could improve the accuracy and efficiency of medical record keeping. We aim to reaudit in the near future to assess the impact of these changes on our medical record keeping.

References 1. Carpenter I, Bridgelal Ram M, Croft GP, Williams JG. Medical records and record-keeping standards. Clinical Medicine 2007; 4: 328–31. 2. Mann R, Williams J. Standards in medical record keeping. Clinical Medicine 2003; 3: 329–32. 3. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, Chaired by Robert Francis QC.

48

Description We present the case of a 28-year-old Achondroplastic woman (short limb dwarfism, 136 cm height, BMI 32. G3, P2) who presented to labour ward at 37 weeks gestation with symptoms of irregular uterine contractions and required an emergency c-section. She had two previous caesareans and was scheduled for an elective c-section at 39 weeks. She was medically well with no neurological or anatomical abnormalities. General and regional techniques were discussed with her highlighting that both carried increased risk. We decided to perform a spinal anaesthetic using 2.2 mls heavy Bupivacaine with 300 mcgs Diamorphine, whilst seated at L3/L4 vertebra body. A Phenylephrine infusion was immediately commenced. She remained seated for 60 seconds then placed left laterally and ramped 30 degrees head up. Assessment of the block to cold and pin prick was performed, at 6 minutes a T3 block was confirmed bilaterally. Surgery commenced delivering a healthy baby weighing 3.1 kg

Discussion We are unable to find any protocols for the management of AP undergoing csection. Extensive anatomical and neurological abnormalities are associated with Achondroplasia [1]. Airway management can be challenging due to limited neck extension and marked cervical kyphosis, as can regional techniques due to spinal canal stenosis and vertebral deformities. If a subarachnoid technique is used controversy exists over dose/volume of local anaesthetic/opioid mixture. Some centres advocate a significantly reduced volume based on height and weight [2]. Using their formula this case would have indicated a dose of less than 1.4 mls 0.5% Bupivacaine. Another study achieved T4-T6 sensory block for emergency csection in an AP (109 cm tall) using 1 ml 0.5% Bupivacaine with 10 micrograms Fentanyl [3]. We opted for a higher volume and manipulated patient positioning. A smaller dose may have substituted equally well and diminished the risk of a high or total spinal block. We present a case where, block height and patient position were monitored closely, allowing a much higher dose to be safely given. A potential complication is increased Phenylephrine use but benefits include a dense, faster onset block. There are obvious difficulties in quoting rigid volumes (for given heights of patients) due to differences in local anaesthetic spread. However, we feel that some guidance is required especially for training working out of hours. Of course, this would have to be interpreted on a case by case basis.

References 1. J.S DeRenzo. Failed regional anaesthesia with reduced spinal Bupivacaine dosage in AP presenting for urgent caesarean section. International Journal of Obstetric Anaesthesia 2005; 14: 174–175. 2. J.M Harten. Effects of a height and weight adjusted dose of local anaesthetic for spinal anaesthesia for elective caesarean section. Anaesthesia 2005; 60: 348–353. 3. Y Beilin. Anaesthesia for an Achondroplastic dwarf presenting for urgent caesarean section. International Journal of Obstetric Anaesthesia 1993; 2: 96– 97.


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Paediatric retrieval – a review of local practice between 2012 and 2014

‘Sedation in foundation’: a survey of sedation practices amongst foundation doctors

J. Neely and M. Alousi Royal Free London NHS Foundation Trust

N. Kennedy, A. Nicklin and A. Shah Homerton University Hospital, London

As a secondary centre commissioned to provide care to acutely unwell children, we have a dedicated Paediatric Anaesthetic on-call rota, comprising 10 consultants. We undertook to review our Anaesthetic Department’s contribution to resuscitation and stabilisation of paediatric patients requiring transfer to tertiary Paediatric Intensive Care Units, and compare this to national guidelines outlined in the ‘‘Tanner Report’’, 2006 [1].

Sedation by non-anaesthetists is common outside the theatre environment, but where do foundation doctors come into this? We conducted a survey to determine the current sedation practice amongst a cohort of Foundation Doctors, to establish if there was a need for teaching on safe sedation practices.

Methods Retrospective data were collected for every patient retrieved by the local Children’s Acute Transport Service (CATS) between January 2012 and February 2014. Individual transfer letters for each patient were interrogated for demographics, location of referral and timing of retrieval by CATS, along with details of interventions performed locally.

Results A total of 48 referrals for retrieval were made; there were missing data for 2 referrals, 1 patient died and 1 patient improved on-site. A median of 2 referrals were made a month, with a maximum of 7 patients being transferred in a single month. Half of the referrals were made out-of-hours. Three patients were transferred multiple times; accounting for 9 retrievals. There was no obvious consistency in age distribution for each 12-month period within the 2 years under review. Approximately half of patients were referred from the Emergency Department, with the remainder coming from the general Paediatric Ward and Adult Intensive Care Unit. The median age was 17 months [IQR 3 to 34 months]. Thirty-four patients (75%) were intubated and ventilated prior to arrival of the retrieval team, necessitating anaesthetic input. Eleven of these patients were intubated in the Emergency Department. Twenty-eight patients required retrieval as a result of respiratory pathology, with an increase in presentation rate in colder months. Neurological reasons for transfer were confined to the summer months.

Methods A 10 question internet survey of Foundation Year 2 trainees in North East Thames, was carried out (adapted from Fanning and Landham et al [1, 2]), to determine their current sedation practice, and training.

Results There was a 55% response rate to the survey (66 of 120). Results revealed 18% of respondents had recevied formal training in sedation, 32% informal training and no training by 50%. Only 41% of trainees said they were fully aware of the complications of sedation. Thirty-two of the trainees surveyed had been asked to perform sedation, 33% of these had not received prior training. The common places sedation was performed include A&E (33%), wards (29%) and radiology (23%). Pulse oximetry (PO) (75%) was the most common monitoring used during sedation and only 50% of trainees had all three, PO, blood pressure (BP) and Electrocardiogram (ECG) recording during the procedure. These trainees had performed sedation multiple times and numerous sedation agents were used alone or in combination. Midazolam was the most common agent used (79%), 25% had used opiates alone, with 25% also using benzodiazepines in combination with opiates, 15.% had used propofol and one doctor had used ketamine. Adverse events occured with 29% of trainees during sedation; hypoxia, hypotension and prolonged sedation were all encountered. Most trainees (94%) wanted sedation training included in their teaching programme.

Discussion

These data are important to inform our local practice and can be used to support interdisciplinary training to enhance our delivery of care. The latter is important as 2 patients per month is unlikely to represent a sufficient volume of clinical exposure to ensure skills are maintained [1]. We have proposed a departmental data collection form to highlight areas for improvement, identify resource limitations, and from which scenario-based and simulation training can be developed to account for the range of ages and diagnoses of our critically ill children locally. Further engagement with the CATS network has also been stimulated from this audit, to encourage open discussion and feedback.

This survey highlights major concerns on the use of sedation by foundation doctors. Patients are put at risk if safe sedation practice is not implemented [2–3]. It is concerning that junior doctors in the hospital are involved in giving sedation to patients and without any prior training. This encourages complacency and could have horrific consequences. PO, BP monitoring and ECG are the most basic monitoring requirements for conducting sedation [4]. The results show that this cohort is not achieving this, with only 50% of trainees using all of them; this highlights a gap in training for junior doctors. Since this survey, one of the hospitals involved has introduced sedation teaching for their trainees. We realise that basic training does not equate to competence however it will develop knowledge that it is a risk prone procedure and should only be performed by those who have the experience and competence to do so safely.

Acknowledgements

References

Dr Shye-Wei Wong, Consultant Paediatrician, Royal Free Hospital

1. Fanning RM. Monitoring during sedation given by non-anaesthetic doctors. Anaesthesia, 2008; 63: 370–374. 2. Landham PR, Butt, U Sanaullah A, Taekema HC, Eid AS. Sedation by Surgeons: Is patient safety being compromised by non-anaesthetists? British Journal of Medical Practitioners. 2011; 4(2): a421. 3. Webb ST, Hunter DN. Is Sedation by Non-anaesthetists Really Safe? British Journal of Anaesthesia, 2013; 111(2): 136–138. 4. Association of Anaesthetists of Great Britain and Ireland. Recommendations for Standards of Monitoring during Anaesthesia and Recovery. Guidelines of the Association of Anaesthetists of Great Britain and Ireland. London: AAGBI, 2000.

Discussion

Reference 1. ‘‘The Acutely or Critically Sick or Injured Child in the District General Hospital: A Team Response.’’ London, Department of Health, 2006.


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Use of epidural blood patch as a treatment of post-dural puncture headaches in obstetrics: a review of departmental practice

A review of current anaesthetic practice of invasive monitoring for elective vascular surgery: could ultrasound aid the siting of arterial lines?

D. Nielsen, Y. Arunan and P. Yoxall St Helens & Knowsley Teaching Hospitals NHS Trust

L. Peltola, N. Boyer and U. Jaffer St Mary’s Hospital

Epidural blood patch (EBP) is viewed as the ‘‘gold standard’’ treatment for headaches caused by accidental dural puncture (ADP), although it is not supported by strong evidence [1]. The mechanism of action is also poorly understood. Moreover, the success of EBP in treating headaches due to labour epidural related ADP is variable (30-75%) and 40% of patients will need a second EBP for complete relief of symptoms [1]. Complications reported include failure, back pain (may progress to become chronic), febrile reactions, second ADP, facial nerve palsy, cauda equina syndrome, seizures, epidural infections, arachnoiditis and meningitis although exact risk is not easily quantified due to insufficient data [1, 2].

Vascular surgery patients form a complex cohort, often requiring invasive monitoring. Due to their comorbidities and previous surgeries, they frequently present with difficult venous and arterial access. It is hypothesised that use of ultrasound may improve first pass success rate, and reduce the time taken to achieve arterial access when compared with palpation alone. It may also reduce posterior wall puncture, possibly decreasing patient morbidity [1]. The data from this study will be used as baseline data to assess the feasibility of elective ultrasound use to site arterial lines.

Methods We retrospectively reviewed the cases of post dural puncture headache (PDPH) that were identified and treated in an 8 month period at our hospital.

Results Between 1/1/2013 and 31/8/2013, 2452 women delivered at the hospital. In 597 epidurals inserted during labour (24%), 10 PDPHs resulted (1.8%). In 8 of the identified PDPHs, ADP was suspected on initial insertion. All PDPHs identified required EBP (100%) and 5 required a second EBP (50%). All EBPs were carried out by consultant obstetric anaesthetists using 10-20 ml of autologous blood. 3 women reported back pain or discomfort on injection. Time interval between epidural and EBP varied between 1 and 9 days, with 5 patients (50%) receiving their first EBP with 2 days. Post-natal analgesia was prescribed according to local protocols. Paracetamol and codeine were used by 6 patients, 4 of whom combined these with a non-steroidal anti-inflammatory drug (NSAID). Three women used oral morphine sulphate solution along with paracetamol, codeine and an NSAID. Six women reported immediate relief of headache although 5 of these were after the second EBP. One patient did not obtain any relief from EBP.

Discussion The incidence of PDPH is within the national average although the number of patients requiring EBP is higher than previous studies (59%).[3] The number requiring a second EBP was also higher (15-40%) [1, 3]. All other aspects of PDPH management were in line with published national figures and guidelines. Whilst sufficient analgesia was prescribed, it is unclear whether there were problems with administration on the ward or with compliance especially after discharge. We feel that these factors may contribute to the high rate of uptake of EBP. Due to the higher than average need for EBP, further work is warranted to introduce a robust multidisciplinary protocol in the management of PDPH in the immediate post-natal period including a standardised optimal analgesic regimen with future re-audit.

Methods All adult elective vascular surgery patients requiring arterial cannulation at a London teaching hospital were included. Data were collected in December 2013 and January 2014. A pro forma was designed, recording details of the experience of the anaesthetist, the time taken for different parts of the anaesthetic, and details of invasive monitoring. Other invasive anaesthetic procedures were also recorded. Anaesthetic staff were asked to time the siting of invasive lines with a stopwatch. The most senior anaesthetist for each case completed the pro forma contemporaneously. Completed forms were anonymous. Data was analysed with Microsoft ExcelTM.

Results Data for 21 cases were collected. Thirty-two anaesthetists were involved, with a median (IQR [range]) duration in anaesthetic practice of 6 (4-11.5 [2-28]) years. Forty-eight percent of cases involved two anaesthetists. Of the trainees and consultants involved, the majority (66% & 71% respectively) had experience of >50 cases of ultrasound-guided vessel puncture. Median (IQR [range]) anaesthetic time was 55 (48-70 [25-80]) min.

Table 1 Results of invasive line insertion.

n; % of cases Median (IQR [range]) time; min

Arterial

Central

Lines

Venous Lines

21; 100

14; 67

5 (1.7-6.3

9 (8-10 [5-

[0.5-31])

25])

Patients awake for line insertion; %

48

0

Success with single puncture; %

48

71

Success with single device; %

62

93

Success by single anaesthetist; %

81

100

Number of skin punctures; median (IQR [range])

2 (1-4 [1-6])

1 (1-2 [1-4])

Number of devices used; median (IQR [range])

1 (1-4 [1-4])

1 (1-2 [1-2])

Number of locations tried; median (IQR [range])

1 (1-3[1-6])

1 (1-2 [1-4])

Ultrasound used; %

5

73

Intentional posterior wall puncture; %

16

0

Probable posterior wall puncture; %

8

7

Discussion

References 1. Paech M. Epidural blood patch – myths and legends. Canadian Journal of Anesthesia 2005; 52: 6, R1–R5. 2. Gaiser R. Post dural puncture headache: a headache for the patient and a headache for the anesthesiologist. Current Opinion in Anesthesiology 2013; 26: 296–303. 3. Van de Velde M, Schepers R, Berends N, Vandermeersch E, De Buck F. Ten years of experience with accidental dural puncture and post-dural puncture headache in a tertiary obstetric anaesthesia department. International Journal of Obstetric Anesthesia 2008; 17: 329–335.

Our findings documenting the difficulties of siting arterial lines by palpation are consistent with previously published data [2]. Arterial line insertion appears to be more challenging than central line insertion in this cohort and such difficulties may be associated with increased patient morbidity and cost, although there was no direct correlation with overall anaesthetic time. Interestingly, difficulties were not directly related to years of anaesthetic experience. In contrast to arterial lines, ultrasound was electively used for the majority of central lines, which were inserted with a more consistent first-hit success rate, reduced posterior wall puncture and less variation in time taken. A few studies [2, 3] document the improved success of arterial cannulation in different patient cohorts with ultrasound use, and we will aim to answer whether this is applicable to vascular patient with the next stage of this work.

References 1. Seto AH, Abu-Fadel MS, Sparling JM et al. Real-time ultrasound guidance facilitates femoral arterial access and reduces vascular complications: FAUST (Femoral Arterial Access With Ultrasound Trial). JACC: Cardiovascular Interventions, 2010; 3: 751–758. 2. Shiver S, Blaivas M, Lyon M. A prospective comparison of ultrasound-guided and blindly placed radial arterial catheters. Academic Emergency Medicine, 2006; 13: 1275–1279. 3. Levin PD, Sheinin O, Gozal Y. Use of ultrasound guidance in the insertion of radial artery catheters. Critical Care Medicine, 2003; 31(2): 481–484.

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Audit of the anaesthetic management of patients presenting with hip fracture L. Potter, A. Langton and E. Pillai Lincoln County Hospital

With hip fractures continuing to be a common presenting condition in the increasingly elderly hospital population, it remains an important area to audit adherence to best practice to ensure patients receive timely and safe definitive treatment.

Methods A prospective audit was designed for the period from 30/09/13 to 30/11/13, to investigate the peri-operative anaesthetic management of all patients who had surgical fixation of a hip fracture, at Lincoln County Hospital. The Royal College of Anaesthetist’s audit standards [1] recommend; 100% of patients should be assessed and fluid resuscitated prior to surgery; 100% of patients should have an operation during the day, within 24 hours [2] and be anaesthetised by experienced doctors; 2) and treated empirically with TMO+AMX or PIP/TAZ were reviewed retrospectively. Any patient who had treatment for 37.5°C) (range 37.6-39.8°C). We suggest that this passive method of warming should be used in conjunction with regular temperature recording.

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Acknowledgments

40

We wish to thank the International Relations Committee (IRC) of the AAGBI for their support. We would also like to thank the Northern Cleft Foundation for offering us the opportunity of joining the team. Thanks also the Rotary Club of Nagpur West for hosting us at Mure Memorial Hospital, Nagpur.

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tu nc

da

D

References

ve

1. Murray, J. Gene/environment causes of cleft lip and/or palate. Clinical Genetics 2002; 61, 248–256. 2. Gunawardana, R. H. Difficult laryngoscopy in cleft lip and palate surgery. British Journal of Anaethesia 1996; 76: 757–759.

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103

Risk associated with procedure

Image 1: Proportion of patients for which specific risks were documented in the notes, as labelled ( ), and proportion of patients for which incidences of these risks were documented ( ). Graph also shows proportion of patients who were able to recall specific risks documentes, as labelled ( ), and those able to recall incidence of risk quoted ( ).

Discussion It is the legal duty of the anaesthetist administering the anaesthetic to explain a procedure and its inherent risks, their incidences, benefits and alternatives in order to satisfy requirements for informed consent [4]. This discussion should be documented in the patient notes [3], absence of this increases risk of a successful claim for negligence. We highlighted inadequate documentation of the consent process in all cases audited. We also noted poor patient recollection of consent. We recommend using pre-printed stickers or incorporating a section in the anaesthetic sheet specifically stating regional anaesthesia risks and incidence quoted. We also recommend that patients be given information leaflets at their pre-assessment appointment, outlining risks of regional anaesthesia, aiding retention of risks quoted and serving as a reference point.

References 1. Your Spinal Anaesthetic, Information for patients. 3rd Edition. Royal College of Anaesthetists. May 2008. 2. Epidurals for pain relief after surgery. 3rd Edition. Royal College of Anaesthetists. May 2008. 3. Consent for Anaesthesia. The Association of Anaesthetists of Great Britain and Ireland. 2006. 4. Guidelines for the Provision of Anaesthetic Services (GPAS) 2013. Key Points, pages 9-10. Royal College of Anaesthetists.

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Preoperative starvation times in Zambian paediatric patients L. Bowen and J. Kabwe University Teaching Hospital, Lusaka, Zambia

Prolonged preoperative fasting may cause dehydration and hypoglycaemia, especially in tropical countries [1]. University Teaching Hospital, Zambia is the tertiary paediatric surgery centre, yet it does not follow the current recommended international preoperative fasting guidelines (2 hours: clear fluids, 4 hours: breast milk; 6 hours: solids) [1]. This audit compared the present preoperative fasting with international standards.

106 A survey of the knowledge of local anaesthetics and their toxicity amongst obstetric unit staff in a University Teaching Hospital S. Law, R. Khaffaf and J. Brand Department of Anaesthetics, James Cook University Hospital, Middlesbrough

A prospective audit was carried out in November 2013. Data for all elective surgeries was collected from anaesthetists, nurses and parents.

The use of local anaesthetics (LA) within obstetric units is common. They are used by both obstetricians and midwives for a number of differing indications, often without the involvement of an anaesthetist. LA toxicity is a rare, but lifethreatening complication of using LA in clinical practice [1] which requires both prompt recognition and management. The aim of this survey was to assess the knowledge of obstetric unit staff regarding basic LA pharmacology and in the recognition and management of LA toxicity according to National guidance [2].

Results

Methods

Methods

Data was collected for 120 cases. 32(27%) were females and 88(73%) were males with ages ranging from one month to 14 years. Breastfed children were starved preoperatively for a median of 8 hours (IQR: 6.5 – 9.8 [range: 4 -18]) and non-breastfed children for 13.8 hours (11.7 – 15.1 [5 – 22]). Twenty-nine children (24%) received intraoperative fluids. The total time of fluid deprivation (time of last fluids to adequate intraoperative fluids/postoperative drink) had a median of 14 hours (10.75 – 16.5 [5.5 – 24]). Eighteen cases were cancelled on the day of surgery with median fasting time 15 hours (12.6 – 17.5 [7 – 20.8]).

Discussion The internationally recognized standards were not achieved in any child. All children were fasted for significantly longer periods of time than recommended. Breastfed children were starved twice as long as recommended and non-breastfed children seven times. Total fluid deprivation was prolonged and surprisingly 40% of children did not have fluids for over 15 hours in this tropical environment. Children remain with their parents at theatre reception postoperatively until collected by ward nurses thus drinks are unavailable until back on the ward. Anaesthetists play a key role in education and need to be vigilant for prolonged starvation and consider administering fluid intraoperatively. Nurses require re-educating away from traditional nil by mouth from midnight. Coupling this with improved planning of the surgical lists to indicate approximate operative times and education and empowerment of parents could lead to dramatically decreased starvation times. Preoperative fasting needs a multidisciplinary approach (surgeons, nurses, anaesthetists and parents). Since this audit the following changes have been introduced and a re-audit is planned in April: * Preoperative fasting guideline established * Educating nurses, anaesthetists and surgeons * Information posters for parents * 6am preoperative drink on nursing ward round * Surgeons to indicate times on operating list * Parents encouraged to give fluids during postoperative wait

References 1. Smith I, Kranke P, Murat I, Smith A, O’Sullivan G, Søreide E, Spies C and in’t Veld B. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. European Journal of Anaesthesiology 2011; 28: 556–569.

An anonymous paper questionnaire was given to a sample of obstetric unit staff (medical and midwifery) for prospective completion under ‘exam’ conditions. The questionnaire consisted of ten questions pertaining to; training in LA pharmacology, clinical uses of LA’s, dose calculations, maximum safe doses, signs and symptoms of LA toxicity alongside knowledge of its appropriate management and definitive treatment. All anaesthetic staff were excluded from the study.

Results Forty two questionnaires were completed with 35 responses from midwives. All participants use LA in their daily practice with 1% lignocaine being the most commonly used in 41 (97%) responses. Thirty three (79%) respondents were aware of a maximum safe dose for their chosen LA, although none (0%) were aware of its value, and only 10 (24%) could correctly identify the quantity of LA in 1 ml of their chosen solution. General recognition of the signs and symptoms of LA toxicity were also poor and despite 26 (62%) respondents being aware of a specific drug used in the treatment of LA toxicity, only two (5%) correctly named it. Knowledge of the National LA toxicity management guideline [2] was also poor with 36 (86%) respondents being unaware of its existence.

Discussion The use of LA on our obstetric unit is common. However, global knowledge of LA pharmacology, maximum doses and recognition of the signs, symptoms and management of LA toxicity is very poor. This study has highlighted an immediate need for formal education and training for all obstetric unit staff which will be addressed during routine staff training sessions. In addition, an ‘educational LA poster’ has been produced for display in all staff areas with pertinent information on LAs including maximal doses, the signs and symptoms of toxicity alongside details of the management of LA toxicity and the nearest supply of intralipid. A further survey is planned following implementation of the above measures.

References 1. Cox, B., Durieux, M.E. & Marcus, M.A. Toxicity of local anaesthetics. Best Practice & Research Clinical Anaesthesiology, 2003; 17: 111 – 136. 2. Association of Anaesthetists of Great Britian and Ireland: Guidelines for the management of local anaesthetic toxicity, 2010. http://www.aagbi.org/sites/ default/files/la_toxicity_2010_0.pdf (accessed 16/03/2014).


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Conversion of labour epidural analgesia to surgical anaesthesia for emergency caesarean section: audit of current practice

WITHDRAWN

D. Buchanan,1 V. Salota2 and M. Agarwal2 1 Guys and St thomas’ NHS Trust, London; 2Maternity Unit, University Hospital Lewisham, London

Epidural local anaesthetic solutions with adjuncts convert labour analgeisa to surgical anaesthesia for emergenc C-Section. There is no consensus about the most appropriate choice of LA solution despite previous studied [1, 2]. Given the rising C-Section rate in UK [3] and enhanced recovery programmes for C-Sections [4] we sought to establish how extension of epidural blockade was achieved in a busy maternity unit in outer London

Aims To determine choice of La solutions with or without opioids for ‘‘topping-up’’ epidural analgesia to provide surgical anaesthesia for Em-LSCS. We aimed to discover which anaesthetic solutions were used, volumes, where administered, did they get a test dose, was an epidural opioid administered and where removed.

Methods 4 week observations study usibng a simple questionnaire to all Obstetric Anaesthetise in Labour Ward

Results Response rate 25/32 replies [ >78% response rate] 5/10 CT1-2; 11/12 SpR/ST; 4 CF Range of LA Solutions & Volumes 16 Trainees[ SpR & CT1-2]-65% Bupivacaine alone /+ 2% lignocaine[10-18mls]; 35% 0.75% Ropivacaine 5/7 Consultants: 0.75% Ropivacaine[5-10mls] Epidural Opioids:Epidural Diamorphine [2.53 mg] at end Topped Up: Delivery room Removed:Theatre or Recovery

Discussion Topping up in-situ epidural gives excellent surgical anaesthesia for Em-LSCS. Most Consultants used 0.75% Ropivacaine in small incremental doses 5-10 ml. Trainees used 0.5% Bupivacaine alone or with 2% lignocaine in larger doses [1018 ml]. Choice of LA depended on operator preference and familiarity. Test dose given in >70% cases. All epidural top-ups were undertaken in a monitored environment. The addition of epidural opioids enhanced analgesia, mobilisation and faster recovery. Working epidurals provide good anaesthesia avoiding General Anaesthesia even in Category 1 C-Sections with timely choice and volume of LA with opioids. Enhanced recovery programmes occur after Em-LSCS [4]. Given concerns about NSAIDS & Codeine in pregnancy, expression in breast milk, foetal respiration, optimising regional analgesia & anaesthesia reduces post-operative pain and shortens hospital stay

References 1. Extending Epidural Blockade for Emergency Caesarean Section. Lucas DN, Ciccone GK, Yentis SM. Anaesthesia 1999: 54: 1173–7. 2. The Extension of Epidural Blockade for Emergency Caesarean Section. Survey of UK Practice. Regan KJ, O’Sullivan G. Anaesthesia 2008: 63: 136–142. 3. Office for National Statistics: Birthsand Deaths in England & Wales 2011. HTTP://www.ONS.gov.uk/final2012. 4. Enhanced Recovery in Obstetrics. A New Frontier: Editorial. Lucas DN, Gough KL. Intl. J. Obst. Anaesthesia 2013: 22: 92–95.

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Welsh pre-hospital traumatic cardiac arrest audit

Undiagnosed mixed mitral valve disease presenting during an elective caesarean section

J. Chinery and G. Roberts Welsh Ambulance Service NHS Trust

M. Cole St Georges Hospital

Resuscitation following traumatic cardiac arrest (TCA) until relatively recently was considered futile given the poor survival seen in such patients historically [1]. Recently published management algorithms have advocated the rapid correction of hypovolaemia, maximising oxygenation and decompression of the chest [2, 3] Simultaneous reversal of the causes of TCA can achieve return of spontaneous circulation (ROSC) and with rapid transport to a major trauma centre, complete neurological recovery rates comparable to all cause out-of-hospital cardiac arrest [4]. With the introduction of specific guidance on TCA in the latest UK Ambulance Services Clinical Practice Guidelines [5] and the advent of PHEM training in Wales in 2013 we undertook a retrospective audit of the preceding year’s TCA pre-hospital data.

Undiagnosed mixed mitral valve disease in women may become unmasked during the haemodynamic stresses involved during pregnancy and labour. Maternal heart disease complicates 0.2% – 3% of pregnancies1, the majority of which have an underlying cause of rheumatic heart disease, endocarditis or congenital heart disease. This report describes such a case of a 28 year old woman presenting for an elective caesarean section.

Methods Scanned anonymised patient clinical records (PCRS) were obtained via the Welsh Ambulance Service NHS Trust Clinical Audit Department for the period 1/8/12 to 31/7/13. One hundred and seventy two cardiac arrest PCRS were reviewed which either were attributed as having a traumatic origin on the cardiac arrest report form or had an accompanying traumatic injury code recorded by the attending paramedic.

Results

Description She had a recently been treated for an asthma exacerbation and an acute pulmonary embolism following hospital admission at 22 and 32 weeks gestation respectively. Her symptoms included dyspnoea, wheeze, reduced exercise tolerance and blood stained sputum. At 39 weeks she was admitted for her elective caesarean section. Her preoperative assessment was unremarkable, and she had an uneventful spinal with bilateral block to T4. Soon after surgical incision, she became asystolic for 20-30 seconds with an unrecordable blood pressure. She was treated with anticholinergics and became stable enough for the procedure to continue. A transthoracic echocardiogram (TTE) in recovery showed moderate mitral stenosis, severe mitral regurgitation, pulmonary artery systolic pressures of 100 mmHg, with a dilated left atrium and right ventricle. She underwent a period of medical optimisation followed by a mechanical mitral valve replacement 6 weeks post-delivery.

Of the fifty patients not resuscitated, thirty-two showed signs of non-survivable injury, rigor mortis, decomposition, or incineration. In the remaining eighteen the reason for not commencing resuscitation was unclear. Of the fourty-seven patients actively resuscitated ROSC was achieved in six. Patients with ROSC had either a blunt (n = 3) or asphyxial (n = 3) aetiology. Survival to discharge and neurological recovery for these patients was beyond the scope of this audit. No pre-hospital thoracotomies or surgical thoracostomies were performed. Two patients received bilateral needle thoracostomies.

Figure Preoperative transthoroacic echocardiographic images: a and b) mitral valve stenosis: typical hockey stick appearance, c) mitral valve planimetry d) mitral valve regurgitation

Discussion

Discussion Whilst TCA is relatively uncommon, ROSC is achievable and improved awareness of this might influence pre-hospital practitioners decision making to commence resuscitation in TCA. A TCA management algorithm tailored to pre-hospital practitioners competencies could improve ROSC rates. Future targeted training, combined with appropriate dispatch of physician-paramedic teams are essential to improve the number of neurologically intact TCA survivors.

References 1. Rosemurgy AS, Norris PA, Olson SM, et al. Prehospital traumatic cardiac arrest the cost of futility. Journal of Trauma 1993; 35: 468–474. 2. Lockey DJ, Lyon RM, Davies GE. Development of a simple algorithm to guide the effective management of traumatic cardiac arrest. Resuscitation 2013; 84: 738–742. 3. Sherren PB, Reid C, Habig K, Burns BJ. Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician staffed helicopter emergency medical service. Critical Care 2013; 17: 308. 4. Lockey DJ, Crewdson K, Davies GE. Traumatic cardiac arrest: who are the survivors? Annals of Emergency Medicine 2006; 48(3): 240–244 5. Fisher JD, Brown SN, Cooke M. UK Ambulance Services Clinical Practice Guidelines 2013, 4th edn.

Maternal cardiac disease may only become evident in the late stages of pregnancy and can also mimic the normal physiological changes that occur during pregnancy, complications of pregnancy or pre-existing co-morbidity. As clinicians, we need to have a high index of suspicion of undiagnosed cardiac pathology, particularly in cases with multiple hospital presentations. When considering delivery by caesarean section, expert opinion recommends anaesthetic technique should be individualised with a clear understanding of the relationship between the patients’ pathology and physiology of pregnancy together with the impact of any pharmacological therapy, alongside a multidisciplinary team approach. With retrospect, this patients’ respiratory symptoms, were likely secondary to pulmonary hypertension rather than a pulmonary embolism or astasthma exacerbation, highlighting the diagnostic difficulty of maternal cardiac disease. The growing popularity of echocardiography as a diagnostic tool amongst anaesthetist and critical care physicians proved pivotal in this case.

Acknowledgements Patient consent gained

References 1. Kuczkowski KM, van Zundert A, Anesthesia for pregnant women with valvular heart disease: the state of the art, Journal of Anesthesia 2007; 21: 252–7. 2. Lerman TT, Weintraub AY, Sheiner E, Pregnancy outcomes in women with mitral valve prolapse and mitral valve regurgitation, Archives of Gynecology and Obstetrics, 2013; 288(2): 287–91. 3. Weiner MM, Vahl TP, Kahn RA, Case Scenario: Cesarean section complicated by rheumatic mitral stenosis, Anesthesiology 2011; 114: 949–57. 4. Hamlyn EL, Douglass CA, Plaat F, Crowhurst JA, Stocks GM, Low-dose sequential combined spinal-epidural: an anaesthetic technique for caesarean section in patients with significant cardiac disease, International Journal of Obstetric Anesthesia, 2005; 14(4): 355–361.


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Macroglossia following posterior fossa surgery in a patient taking angiotensin converting enzyme inhibitors

Too fast? Too bad. Timing of the epidural blood patch for postdural puncture headache and how it affects the success rate

T. Cominos and P. Klepsch Frenchay Hospital, Bristol

A. Cormack1 and V. Clark2 1 NHS GG&C; 2NHS Lothian, SCRH

We report a case of delayed tongue swelling following posterior fossa craniotomy in the prone position. This severe macroglossia caused symptomatic airway compromise and resulted in a difficult emergency intubation.

The aim of the audit was to establish the timing of epidural blood patches (EBP) and how it affects the success rate.

Methods

Description A patient with a history of hypertension treated with ramipril and bisoprolol presented for resection of a posterior fossa cystic tumour. Following prolonged but uncomplicated surgery the patient was extubated normally and transferred to recovery but developed significant obstructing macroglossia around two hours post-extubation. The patient required emergency airway management, resulting in a difficult intubation in the recovery ward. The tongue swelling necessitated a prolonged ICU stay and tracheostomy. Treatment was largely supportive during this time and the swelling subsided spontaneously after more than a week.

Discussion Previous case reports have described post-operative macroglossia with varying levels of airway compromise in a variety of clinical situations. Several theories have been proposed to explain this phenomenon, including mechanical compression to the arterial, venous or lymphatic systems with subsequent reperfusion injury. Neurogenic tongue swelling, similar to neurogenic pulmonary oedema and due to instrumentation or interruption of the blood supply of the parasympathetic nuclei has also been suggested. Relevant to this case, we also discuss the important effects of angiotensin converting enzyme (ACE) inhibitors and their potential to cause angioedema with macroglossia in the anaesthetic and critical care settings. We describe a case of macroglossia following posterior fossa surgery in the prone position. Although the pathophysiology remains unclear, there exist several theories attempting to explain this occurrence, relating to the surgery, patient positioning and to ACE inhibitor-related angioedema. An understanding of this rare but important phenomenon may help anaesthetists predict at-risk groups and prepare for this potentially catastrophic event.

Review of the obstetrics audit charts completed over 2010-2012 in tertiary maternity unit, identification of cases with postdural puncture headache (PDPH) with subsequent review of the interventions, timing of EBP and the outcomes. Chi-square test was applied for calculation of the p-value.

Results A total of 83 cases with postdural puncture headache were identified over a 3 year period, during which 21,040 deliveries occurred. There were 5778 epidurals performed, 3122 spinals for caesarean delivery (CD) and 360 combined spinal-epidural (CSE) blocks. PDPH after an epidural developed in 55 women (0.95%), and in 11 parturients after spinal for CD (0.35%). Fifteen cases of PDPH followed spinals for other obstetric procedures and 2 cases after CSE (0.55%). There were 49 cases of accidental dural puncture (ADP) noted and 24 of them required EBP. There were a total of 54 primary EBP performed, 78% of them post epidural (n = 42) and 22% after a spinal (n = 12). Most EBP were performed over 48 hours post primary procedure (89%, n = 48) and 9.2% (n = 5) 24-48 hours following the primary procedure. All of the EBP performed within 24-48 hours required repeated EBP (100%, n = 5) whereas only 10% (n = 5) of the EBP done after 48 hours required repatching (p = 0.006). There were a total of 10 cases of second EBP: 5 of them completely successful, 2 gave partial relief, 1 refused follow up, 2 required further EBP.

References El Hassani, Narata, Pereira, Schaller. A Reminder for a Very Rare Entity: Massive Tongue Swelling after Posterior Fossa Surgery. Journal of Neurological Surgery 2012; 73: 171–4. Lam, Vavilala. Macroglossia: Compartment Syndrome of the Tongue? Anesthesiology 2000; 92: 1835–7. Moore, Chaudhri, Moore, Easton. Macroglossia and Posterior Fossa Disease. Anaesthesia 1988; 43: 382–5. ja Vu. Anesthesia & Analgesia 1999; 89: 531–8. Drummond. Macroglossia, De Weber, Messerli. Angiotensin-Converting Enzyme Inhibitors and Angioedema: Estimating the Risk. Hypertension 2008; 51: 1465–7. Brown, Vaughan. Angiotensin-Converting Enzyme Inhibitors. Circulation 1998; 97: 1411–20.

Discussion Timing of the EBP is important factor influencing the outcome. In our audit all primary EBP performed within 48 hours required repeated EBP, compared to only 10% of EBP performed after 48 hours. So delaying EBP to >48 hours gives a higher success rate for the procedure [1].

Reference €vall S, Kein€anen M, Kokki H. The influence of timing on the 1. Kokki M, Sjo effectiveness of epidural blood patches in parturients. International Journal of Obstetric Anaesthesia. 2013; 22(4): 303–9.

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Review of outcome of postdural puncture headache and accidental dural punctures over 3 years in a tertiary maternity unit A. Cormack1 and V. Clark2 1 NHS GG&C; 2NHS Lothian, SCRH

The aim of the audit was to establish the incidence of postdural puncture headache (PDPH) in our unit during 2010-2012, factors increasing the risk of PDPH, rates of recognised accidental dural puncture (ADP) and spinal catheters.

Methods Review of obstetrics audit charts completed over 3 years, identification of cases with PDPH and recognised ADP with subsequent review of the interventions, outcome and follow-up data.

Results A total of 83 cases with PDPH were identified over a 3 year period, during which 21,040 deliveries occurred. There were 5778 epidural blocks performed, 3122 spinals for caesarean delivery (CD) and 360 combined spinal-epidural (CSE) blocks. PDPH after an epidural developed in 55 women (0.95%), and in 11 parturients after spinal for caesarean delivery (0.35%). Fifteen cases of PDPH followed spinals for other obstetric procedures, and 2 cases after CSE (0.55%). Mean BMI of the group was 25.8 (range [17.6 – 46]) but 79.5% of those whose BMIs were 30. Thirty cases of ADP followed by epidural resite were noted over this period: 12 (40%) did not develop PDPH, and 18 (60%) required an EBP. Spinal catheters were sited in 19 cases of recognised ADP: 10 had no subsequent PDPH (53%), 3 cases developed PDPH, which settled with conservative treatment (15%) and 6 cases required an EBP (32%).

Discussion The incidence of PDPH post epidurals in our unit is 0.95% and that following spinals 0.35%, which is not dissimilar to the accepted average [1]. Women who are obese have a lower risk of developing PDPH [2]. Only 55% of recognised ADP developed PDPH. The audit showed that risk of requiring EBP was lower after spinal catheter rather than after epidural resite in case of recognised ADP (32% vs 60%).

114 Quality improvement: inter-deanery collaboration to improve trainee induction J. Critchley,1 K. Nicholson,1 D. Fallaha1 and P. Morris2 1 South East Scotland School of Anaesthesia; 2Northern School of Anaesthesia and Intensive Care Medicine Rotational training and exposure to different working practices benefits trainees. Frequent post changes create challenges for doctors in training, their supervisors and hospitals. There is increased risk to patients during doctor changeover periods [1–3]. The GMC state that ‘hospital induction is important to ensure doctors deliver safe, effective and efficient care for patients’. We aim to improve trainee induction in the South-East Scotland School of Anaesthesia (SESSA) – a deanery where trainees rotate frequently through 7 hospitals across 4 health boards. SESSA’s poor performance for satisfaction with induction in the 2010 GMC trainee survey [4] prompted this project.

Methods In 2011 SESSA and Northern School of Anaesthesia (top performing for induction in the GMC survey) were compared. Departmental induction packs from hospitals in both schools were analysed and trainees surveyed regarding induction. Northern trainees received more detailed information, found it more useful, more often received it in advance of post and had access to online resources. Key findings from this first cycle led to an improved SESSA induction for 2012. Updated induction materials were made available via an upgraded trainee website which acts as a central repository for induction information. In 2012 the project’s second cycle focussed on SESSA trainees. Issues identified in 2012 were addressed for the 3rd cycle and trainees were resurveyed in 2013.

Results The 2012 upgraded induction packs were rated more useful than in 2011 but the proportion of trainees receiving packs prior to post fell compared to 2011. Departments had relied on the website to provide information yet the survey revealed that the majority of trainees were unaware the new website hosted induction materials. Following improvements in the 3rd cycle (including better domain name & publicity) the 2013 survey results were more encouraging: all trainees received induction packs, the majority found them useful and most had accessed the website.

References 1. C. C. Apfel, A. Saxena, O. S. Cakmakkaya, R. Gaiser, E. George, O. Radke. Prevention of PDPH after accidental dural puncture: a quantitative systematic review. British Journal of Anaesthesia 2010; 105(3): 255–263. 2. Oswald AL. Postdural Puncture Headache. In: Suresh M, ed. Shnider and Levinson’s Anesthesia for Obstetrics. 5th ed. Lippincott, 2013: 425–8. Figure 1: SESSA trainee survey results 2011-2013.

Discussion Collaboration with another deanery identified key points to improve induction. These include providing comprehensive material, written with trainee input, prior to post. The website has become a valuable and popular resource. This project enables SESSA to continually analyse and update the induction process with trainee input. We plan to improve online access with a Smartphone app.

Acknowledgements Dr Lynn Carragher for initiating this endeavour, SESSA management team and College tutors for support and implementation, and the Edinburgh Anaesthetic Research and Education Fund.

References 1. Jen MH, Bottle A, Majeed A et al. Early in hospital mortality following trainee doctors’ first day at work. PLoS ONE 4(9): e7103. 2. Inaba K, Recinos G, Teixeira PG et al. Complications and death at the start of the new academic year: is there a July phenomenon? Journal of Trauma 2010; 68:19–22. 3. Haller G, Myles PS, Taffe P et al. Rate of undesirable events at the beginning of academic year:retrospective cohort study. BMJ 2009; 339: b3974. 4. General Medical Council, National Trainee Survey 2010. London, GMC. http:// gmc-onlineeducationreports.org/ComparativeDetails.aspx?agg=AGG28%7c2010 &groupcluster=14%7c2&group=All&indicator=IND&set=Anaesthetics. © 2014 The Authors. Anaesthesia © 2014 The Association of Anaesthetists of Great Britain and Ireland

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The case of a primiparous woman with postural orthostatic tachycardia syndrome undergoing general anaesthesia for an emergency category II caesarean section R. Cunningham and R. Smith Royal Gwent Hospital

Postural orthostatic tachycardia syndrome, or POTS, is a dysfunction of the autonomic nervous system defined by orthostatic intolerance. Those with POTS develop a tachycardia on standing of greater than 120 bpm or an increase in heart rate greater than 30 bpm. POTS affects mainly young adults and has a five times greater preponderance in females than males. POTS in the context of anaesthesia has been described, but less well described is POTS in the obstetric population, where regional anaesthesia has been used to attenuate the stress of labour and avoid precipitation of symptoms.

Description The patient in question was 22 years old, and was primiparous. She was diagnosed with POTS using a tilt table test, having suffered from pre-syncopal and syncopal episodes for a number of years. At term the severity of her symptoms was such that she was taking 250 mg of metoprolol per day in divided doses. Antenatally it was decided that an early epidural was the best anaesthetic plan. The patient’s labour was induced at 40 weeks gestation. Epidural anaesthesia was attempted by two anaesthetists, both of whom failed. After the second attempt, a foetal blood sample demonstrated foetal acidosis. A category 2 caesarean section was declared and it was decided that a general anaesthetic was most appropriate. The patient was induced with thiopentone and suxamethonium. Anaesthesia was maintained with sevoflurane and nitrous oxide. Prior to induction the blood pressure was 135/75 and the pulse was 100 bpm. Post induction both blood pressure and pulse rose to 140/85 and 110. During the first 20 minutes of the operation the pulse and blood pressure continued to rise. At their peak the blood pressure was 145/92 and the pulse was 118 bpm. Pain, awareness and hypovolaemia had been ruled out as causes. After skin closure a TAP block was performed, the patient was awoken and extubated. In the immediate 48 hour recovery period was asymptomatic of her POTS syndrome.

Discussion The use of general anaesthesia for a patient with POTS undergoing caesarean is appropriate under certain circumstances but must be carefully managed. Undesirable cardiovascular effects must be anticipated. The observed intra-operative physiology occurred during uterine manipulation and vaginal swabbing. This is perhaps unsurprising when one considers the autonomic innervation of the uterus and the fact that POTS is a disease of autonomic dysfunction. Such patients can be appropriately managed using general anaesthesia, but an early labour epidural remains the anaesthetic method of choice.

Audit of mortality after emergency laparotomy K. Dasari, P. Carroll and R. Lloyd Ipswich Hospital NHS Trust

There is wide variation (3.6% to 41.7%) in mortality after emergency laparotomy with the national rate being 14.9% (1) Although age, co-morbidities and underlying pathology cannot be altered, the accessibility of care provided can be modified. Prompt assessment, risk stratification, early resuscitation and timely access to theatre with senior staff involvement and appropriate postoperative care all modifiable factors of the perioperative care pathway [1, 2].

Methods We audited our practice of Emergency Laparotomy against this national study. We reviewed a mix of prospective and retrospective case notes for 50 patients who underwent Emergency Laparotomy between May’13 to Aug’13.

Results Our overall mortality figure was 10% (national average 14.9%). Mortality rates in ASA 3, 4 and 5 groups were 4.6%, 30% and 100%respectively. Of the total 8 patients who received Goal directed fluid therapy, none of them died. Our relaparotomy rate was higher than the national average (18% vs 15.6% national figure), but with a lower mortality rate (11.1% vs 14.5%). Due to increasing severity of sickness, the mortality figures based on postoperative destination – i.e. ward, HDU and ICU were 4.3%, 11.8% and 20% respectively as opposed to national figures of 6.7%, 10.1% and 30.7% respectively. Consultant anaesthetist and surgeon’s presence at different time periods were higher than the national average. (96.7% vs 75.2%, 76.5% vs 54.8% and 50% vs 40.8% for consultant anaesthetists’ presence and 87.1% vs 80.8%, 58.9% vs 67.7% and 100% vs 61.8% for consultant surgeons’ presence between 08:00to 17:59 hrs, 18:0023:59 hr and 00:00 to 07:59 hrs respectively.)

Discussion We believe a consultant led service, and a multidisciplinary approach amongst surgical, anaesthetic and medical specialties may have been the reasons for our better mortality figures. The reasons for mortality of all the patients were discussed locally and, the importance of Goal direct fluid therapy re-emphasized, along with the need for early referral and timely surgery with perioperative optimisation

References 1. Saunders D.I, Murray.D, Pichel A.C, Varley.S, Peden C.J: Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network. British Journal of Anaesthesia 2012; 109: 368–75. 2. Saunders D.I, Murray.D, Peden C.J, Pchel A.C, Varley.S: Reply from the authors. British Journal of Anaesthesia 2013; 110: 143–144.

Acknowledgements This case report is described with the patient’s kind permission.

References 1. W. L. Corbett1, C. M. Reiter1, J. R. Schultz1, R. J. Kanter2 and A. S. Habib, Anaesthetic management of a parturient with the postural orthostatic tachycardia syndrome: a case report, British Journal of Anaesthesia 2006; 97 (2): 196–9. 2. Alaa A Abd-Elsayed MD, MPH1; Lesley Gilbertson MD, Anaesthesia for an Obstetric Patient with Postural Orthostatic Tachycardia Syndrome, Abstract t39, SOAP 2012 (published in supplement to anaesthesia and analgesia). 3. J Ghoshdastidar, BS Baytug, M Doraiswami. Postural orthostatic tachycardia syndrome and caesarean section: A heart racing case, Poster OAA 2013 4. A K Agarwal, R Garg, A Ritch, P Sarkar. Postural orthostatic tachycardia syndrome. Postgrad Medical Journal 2007; 83: 478–480.

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Reducing nasal trauma from nasal intubation – a survey of current practice

Throat pack safety – critical incidents as a catalyst for audit and improvement

C. Donohue and I. Sohanpal University College Hospital (UCLH)

C. Donohue, U. Ranasinghe, I. Bouras and S. Clarke University College Hospital (UCLH)

Nasal intubation is commonly performed for patients undergoing maxillofacial and dental procedures. It offers enhanced surgical oral access and determination of jaw alignment. Nasal intubation can cause trauma. Blood or debris can lead to laryngospasm, bronchospasm, obstruction or impair laryngoscopic view. Techniques to minimise trauma include nasal preparation with vasoconstrictors such as co-phenylcaine, use of pliable or thermosoftened tubes and lubrication. An additional technique is described in which a urethral catheter is attached to the distal end of the tube creating a smooth atraumatic cap which both dilates and reduces tube contamination [1]. Having passed through the nose the catheter is lifted out through the mouth with forceps and removed from the end of the tracheal tube, which is then guided through the cords. We surveyed anaesthetists’ current clinical practice to determine what measures they took to minimise nasal trauma and ascertain awareness of the catheter technique.

Throat packs (TP) may be inserted to absorb and prevent debris created by intra-oral surgery tracking into the oesophagus or trachea. Retention of a TP can lead to airway obstruction with potential morbidity and mortality. The National Patient Safety Agency (NPSA) produced a safety notice in 2009 aimed at reducing risk of TP retention by improving and standardising visual and documentary safety procedures [1]. In the 2012 Department of Health update retention of foreign body post surgery was stated as a never event [2]. Following two critical incidents in our trust involving retention of TP, practice was reviewed and improvements implemented to minimise future risk. In one case procedural failure led to retention of pack while in the other a portion of an inadvertently torn TP remained concealed. Neither patient came to harm but willingness to learn from near misses focused attention on the issue. Interventions included introduction of a tear-resistant TP, emphasis on inclusion of TP in the swab count and as part of the world health organization (WHO) checklist and circulation of locally adapted safety procedures to staff. Following this, awareness of the NPSA safety procedures and a snapshot of actual practice were audited.

Methods A 6 question survey was distributed to anaesthetists in London via a social media site.

Results Seventy seven responses were collected from 110 site views, representing a 70% response rate. Forty five percent were trainees and 55% were consultants. Thirteen percent perform nasal intubation weekly, 32% do so monthly, 27% had performed a nasal intubation in the past six months and 28% do so rarely. Seventy nine percent of respondents had not heard of the catheter technique, 10% had read about it, 5% seen it used and just 5% currently use the technique. Almost all anaesthetists (90%) use a vasoconstrictor, commonly co-phenylcaine and 82% lubricate the tube. Thirty percent use thermosoftened tubes and 19% use a fibreoptic scope to guide insertion. The use of serial dilators is uncommon.

Methods Awareness of safety procedures was assessed with a survey distributed to the multi-disciplinary team (MDT). Statistical analysis was performed using chisquared with significance at P < 0.05. During 20 cases in which a TP was used, practice was assessed against the NPSA algorithm.

Results Fifty three survey responses were obtained. Labelling the patient/airway was the most commonly cited visual safety procedure (89% of responders). Scrub staff were more likely to identify inclusion of TP in the swab count as a documentary safety procedure than anaesthetic trainees, with statistical significance (Χ2 (1) = 4.68, P = 0.03), reflecting differences in roles. Only 15% of responders were aware of the local safety policy to keep the TP visible until the patient has left theatre in order to confirm removal. Audit of practice revealed 100% achievement of minimum safety procedures: in all 20 cases at least one visual and one documentary procedure were implemented.

Discussion Critical incidents can be a catalyst for education and safety development. Awareness of procedures was good across the MDT though there is room for improvement. Implementation of safety measures exceeded the minimum standards set by the NPSA. Regular education and ongoing attention to the quality of communication and WHO checklists will be required to maintain standards. TPs are rarely used in the US compared with the UK suggesting subjectivity rather than evidence based practice [1]. Rationalising TP usage represents an important additional safety measure.

Discussion The catheter technique is little known and under utilised by the majority of survey responders despite the fact that 45% are performing nasal intubations at least monthly. A blinded randomised controlled trial in 2002 showed a statistically significant reduction in visible trauma amongst paediatric dental patients in whom the rubber catheter technique was used [2]. We are not aware of a similar trial in an adult population and suggest this is warranted to ascertain whether the catheter technique has any additional benefit in reducing nasal trauma and improving postoperative patient comfort compared with current routine practice. A quality improvement educational program to disseminate use of this simple technique for nasal intubation, particularly in paediatrics, could be introduced.

References 1. National Patient Safety Agency – Safer Practice Notice. Reducing the risks of retained throat packs after surgery. www.nrls.npsa.nhs.uk/resources/? entryid45 = 59853 2009. 2. Department of Health. The never events policy framework. Available from https://www.gov.uk/government/uploads/system/uploads/attachment_data/ file/213046/never-events-policy-framework-update-to-policy.pdf 2012.

References 1. Wong A, Subar P, Witherall H, Ovodov KJ. Reducing nasopharyngeal trauma: the urethral catheter assisted nasotracheal intubation technique Anaesthesia Progress 2011; 58: 26–30. 2. Elwood T, Stillions DM, Woo DW, Bradford HM, Ramamoorthy CM. Nasotracheal intubation: A randomized trial of two methods. Anesthesiology 2002; 96: 51–53.


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A 13 year review of epidurals on a single delivery suite

An analysis of workload over 13 years in a single delivery suite

T. Duncan,1 R. Jone2 and G. Jackson2 Oxford Deanery; 2Royal Berkshire Hospital

T. Duncan,1 R. Jones2 and G. Jackson2 1 Oxford Deanery; 2Royal Berkshire Hospital

Methods

Methods

All anaesthetic interventions on the unit are recorded onto an anaesthetic database. Data related to epidural insertion and outcome was extracted and analysed in Excel. Patient identifiers and grade of anaesthetist were not used in the analysis. Data was analysed by financial year as this allowed for triangulation with other data sources.

Anaesthetic interventions on our delivery suite have been recorded on a Microsoft Access database since 1998. We have extracted this data and using estimates of the anaesthetic time associated with each procedure, created an estimate of overall anaesthetic workload.

Results

A total of 41,286 interventions were identified across 13 years where either a spinal or general anaesthetic had been used or an epidural sited. These were categorised and then grouped where appropriate. Overall 44,927 hours of anaesthetic time was logged. The data appeared consistent over the 13 years. Overall, unplanned work (anything other than elective LSCS) accounted for 77.97% of the overall time spent and 53.83% of the workload was done in hours (Mon-Fri 0800-1800). Excluding follow up visits which would be done in hours, 36.64% of the unplanned work took place ‘in hours’. The total logged workload per 24 hours has increased from 8.89 hours in 99/00, peaked at 12.46 hours in 09/ 10 and in 11/12 it was 11.11 hours. The changes in workload are reflective of changes in obstetric and midwifery practices and birth numbers. Triangulating the data against reported caesarean section rates would suggest good data completeness with the number of LSCS recorded in the database being over 95% of unit reported number.

1

A total of 18,728 Epidurals were identified. We collected data about effectiveness for the last 8 years. Overall, of those women who were followed up (13,198, 70.5% of total) 86.6% said it was effective for the 1st stage, 73.1% said it was effective for the 2nd stage, and 83.7% said they would have it again. Of those that were recorded as having a partial or asymmetric block (415 women in total), 51 are recorded as having their epidural resited. Cervical dilation was recorded for 18,378 women and ranged between 0 and 10. The median, and mode, dilatation at point of epidural insertion was 4 cm (4098 women). Overall there were 12,740 nulliparous women (68.03% of total), of which a mode of delivery was known for 10072 (79.06% of total). Of these 10,072 women, 26.1% went on to have a normal vaginal delivery (NVD), 39.2% had an emergency caesarean section (CS) and 33.1% had an instrumental delivery (forceps or ventouse). These instrumental deliveries may have been in the delivery room or theatre, this is not coded for on the database. Due to issues with data normalisation, 1.7% of deliveries were not coded. Technical difficulties (one or more of: bloody tap, difficulty threading catheter/finding space / dural tap) were encountered in 17.8% of cases The dural tap rate ranged from 0.45% per year to 2% per year, with an overall average of 0.79%. Hypotension was recorded as occurring in only 72 epidurals. A total of 316 (1.7%) epidurals were resited over the 13 year period. From year 1 to year 13 there was an increase in the mean depth to the epidural space from 5.18 cm to 5.91 cm. Increasing depth to space was significantly correlated with difficulty in finding space (r = 0.968) and difficulty threading catheter (r = 0.861). It did not significantly correlate with bloody tap (r = 0.340) or dural tap (r = 0.576). Required correlation coefficient for p < 0.05 significance is 0.62.

Discussion The data on technical difficulties would appear to be consistent with previously published data [1] as well as guidance on complications rates associated with epidural insertion [2], with the exception of a reduced rate of hypotension and resiting epidurals.

Results

Discussion Analysis of logged data does not create a full picture of the anaesthetic workload and only averages are reported. The estimates time spent are again, averages. Waiting time is not included although allowances have been made for preoperative assessment and consent for epidurals. Unlogged activity is not included. This may include discussions with women who do not subsequently have an intervention, small duties such as cannula insertion. There is considerable day to day variation in workload and staffing needs to be available for peak requirements. In 2010/11 There were 46 days where no epidurals were sited, yet there were 11 days where 6 were placed. Because of the short wait times that are associated with anaesthetic practice (30 mins to attend for epidural insertion, or category 1 or 2 LSC), having the resident working for too much of the time will lead to a rise in delays. There is no way to manage demand for unplanned work. Working patterns therefore need to recognise that in order to have zero (or very short) wait times, the resident cannot be busy all the time.

Acknowledgements We would like to thank Dr Reuben Abraham, without whose hard work the database would not exist

Acknowledgements We would like to thank Dr Ruben Abraham, without whose hard work the database would not exist

References 1. Paech, M. J., R. Godkin, and S. Webster. Complications of obstetric epidural analgesia and anaesthesia: a prospective analysis of 10 995 cases. International Journal of Obstetric Anesthesia 1998; 7: 5–11. 2. Epidurals in labour – what you need to know. Published by the obstetric anaesthetic association. Available from: http://www.oaa-anaes.ac.uk/ assets/_managed/editor/File/Info%20for%20Mothers/EIC/2008_eic_english. pdf (Accessed 9th March 2014).

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Quality indicators for anaesthesia related discomfort

Haemorrhage and sepsis: the commonest causes for obstetric related critical care admissions to a central London teaching hospital

M. Eid,1 S. El-Ghazali2 and S. Jambulingam3 1 James Cook University Hospital; 2Sunderland Royal Hospital; 3Darlington Memorial Hospital

S. Esprit, A. Pool, S. Griffiths, D. Abell and P. Hopkins King’s College Hospital

Anaesthesia poses certain challenges in the identification of valid outcome indicators sensitive to variations in anaesthetic care. Metrics collected during the immediate post-anaesthetic recovery period, such as patient temperature, patient-reported quality of recovery, and pain and nausea, provide potentially useful information for the anaesthetist, yet this information is not routinely fed back.

Methods In order to assess quality indicators for various aspects of anaesthetic care provided in our hospital Day Case Surgery, we used a questionnaire to assess Patient Reported Outcome Measures (PROMs) from the patient perspective. The questionnaire looked at 12 questions on anaesthesia related discomfort & patient satisfaction. Patients were asked to score each indicator between 02, with 2 = comfortable,1 = Satisfactory,0 = uncomfortable. Each patient score was accumulated to give an overall score out of 24 where 0-12: poor, 12-18: satisfactory, 18-24: good.

(% of Patients)

1

Feeling of thirst before operation

2

Pain at the site of anaesthetic injection

3

Feeling sore throat or hoarseness of voice

4

After waking up the area of surgery was

Score 2

A retrospective analysis was performed of the obstetric patients admitted to the CCUs at King’s College Hospital between January 2012 and December 2013. Our CCU admission database was used to identify and determine the reason for obstetric admissions to CCU. Mode of delivery and any pre-existing maternal medical conditions were also ascertained.

Thirty obstetric patients were admitted to the CCU between January 2012 and December 2013. The reason for admission is summarized in Table 1. Eight (27%) of these women had pre-existing medical conditions including diabetes mellitus, cystic fibrosis, sickle cell disease, asthma and tuberculosis (TB). There was one maternal death from sepsis and multi-organ failure secondary to a pelvic abscess and one late death from cystic fibrosis.

Patient discomfort score

Question

Methods

Results

Table 1 Quality care indicator questionnaire & results breakdown.

No.

King’s College Hospital, London is a busy tertiary referral centre in South-East London, with 5500 deliveries per year serving a high-risk multi-cultural population. The Centre of Maternal and Child Enquires (CMACE) [2] triennial report has reassuringly revealed that the Maternal Mortality Rate in England is falling, but serious events continue to occur in the perinatal period resulting in obstetric admissions to Critical Care Units (CCUs). We analysed recent obstetric CCU admissions to identify areas for focus of care.

Score 1

Score 0

32

37

31

59

37

4

39

36

25

48

40

12

Table 1 Summary of obstetric related CCU admissions.

after surgery

Reason for Admission

Number of Patients (%)

Post-partum haemorrhage (PPH)

13 (43%)

hysterectomy

4 (30%)

known risk factors•

4 (30%)

Sepsis

painful 5

Feeling sick after waking up

75

14

11

6

Feeling confused and drowsy after waking

46

51

3

†

Pre-eclampsia Cardiac arrest Complications of neuraxial anaesthesia

up

6 (20%) 4 (13%) 2 (7%) 2 (100%)

Acute fatty liver of pregnancy

1 (3%) 1 (3%) 9 (29%)

7

Feeling cold & shivery after waking up

61

37

2

Acute liver failure

8

Pain therapy after surgery was adequate

79

21

0

Mode of delivery Spontaneous labour

9

Surgical information given was adequate

93

7

0

Induced labour

6 (20%)

10

Anaesthetic information given was

100

0

0

Elective caesarean section

5 (18%)

11

Care provided by our team

100

0

0

12

The atmosphere of your stay

100

0

0

Emergency caesarean section

adequate

Results 58 patients were recruited & the overall results are shown in Table 1 below. Individual patient perception score for all patients was greater than 12, showing all patients were satisfied with the anaesthetic related quality care provided in our Hospital Day care Unit.

Discussion The main issues encountered by patients from the care provided was feeling thirsty prior to surgery, sore throat and post-operative nausea and vomiting (PONV). As anaesthetists, we commonly inform patients about the risk of sore throat and PONV and take steps to minimise this. However we need to focus on the reduction of unnecessary prolonged fasting in order to prevent feeling thirsty. Although there are national guidelines regarding fasting, we developed patient information leaflets to reinforce this. Improving patient satisfaction with anaesthesia ensures patients have an improved anaesthetic experience, which in turn increases the expectations for subsequent anaesthetics [1]. A continuous quality improvement process is needed to maintain patient satisfaction at the highest level. The NHS Next Stage Review report High Quality Care for All aims to improve the quality of patient care by focussing on the reporting & measurement of quality indicators representing effectiveness, safety and patient experience [2].

References 1. J. Benn, G. Arnold, I. Wei, C. Riley, & F. Aleva. Using quality indicators in anaesthesia: feeding back data to improve care. British Journal of Anaesthesia 2012; 109(1): 80–91. 2. Department of Health. High Quality Care for All: NHS Next Stage Review Final Report. London: Department of Health, 2008.

10 (32%)

*

Prolonged labour; abnormal placentation; uterine fibroids. † Influenza, chorioamnionitis, pneumonia, urosepsis, TB meningitis.

Discussion Analysis of obstetric CCU admissions to our hospital revealed PPH was the commonest cause, in keeping with the Intensive Care National Audit and Research Centre (ICNARC) data series [1]. This study demonstrated hypertensive disorders as the second commonest cause for admission. In contrast, our data has shown sepsis as the second commonest cause for admission to CCU. This may highlight a trend as data published in the most recent report by CMACE showed sepsis had overtaken thromboembolism as the leading cause of direct maternal death [2]. There were no clear risk factors in terms of pre-existing medical problems or mode of delivery. The high prevalence for sepsis related admissions highlights the need for vigilance with early recognition and a timely response to mothers with ‘‘red flags’’ indicative of sepsis [3]. Early identification and prompt treatment of acute illness is vital in maintaining a high standard of care for the obstetric population.

References 1. Harrison D, Penny J, Yentis S et al. Case mix, outcome and activity for obstetric admissions to adult, general critical care units: a secondary analysis of the ICNARC Case Mix Programme Database. Critical Care 2005; 9(Suppl 3): S25–37. 2. Cantwell R, Clutton-Brock T, Copper G et al. Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006–08. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. British Journal of Obstetrics and Gynaecology 2011; 118(Suppl 1): 1–203. 3. Lucas D, Robinson P, Nel M. Sepsis in obstetrics and the role of the anaesthetist. International Journal of Obstetric Anesthesia 2012; 21: 56–67.


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Antifreeze poisoning diagnosed from a falsely high arterial blood gas lactate level WITHDRAWN

S. Esprit King’s College Hospital, London

Ethylene glycol (EG) is widely used in commercial antifreeze preparations, hydraulic brake fluid, some fabric cleaners and industrial chemicals. EG poisoning causes a severe metabolic acidosis and individuals present with drunkenness, vomiting, coma, convulsions, circulatory collapse, acute renal failure and possible death. Prompt diagnosis and treatment is essential.

Description A 67 year old man presented with reduced consciousness and agitation. His only past medical history was a recent admission after an accidental overdose of ibuprofen for dental pain, causing an acute kidney injury, which was managed conservatively. He was on no regular medications. It was reported that he was intoxicated with alcohol and agitated. He was only responsive to pain. Arterial blood gases (ABGs) revealed a severe metabolic acidosis and a high lactate level (level unrecordable). Full blood count and liver function tests were normal, and his renal function was slightly impaired with a urea of 6.1 and creatinine level 130. CT scan of his head was normal. Repeat ABGs had a worsening metabolic acidosis and lactate remained unrecordable. A laboratory lactate level was normal, and consultation of the ABG machine manual revealed that only ethylene glycol produces a falsely high lactate reading. Treatment commenced with intravenous bicarbonate, ethanol, fomepizole and haemodialysis, he was intubated and ventilated for five days. His EG level was 629 mg/L from bloods taken on admission. He has survived, but requires surveillance of renal and cognitive impairment. A police investigation of this poisoning is underway.

Discussion EG is not toxic, it is colourless, odourless and sweet tasting [1]. However, it has toxic metabolites. A high index of suspicion of poisoning is needed in apparently inebriated patients whose breath does not smell of alcohol [1], with a metabolic acidosis of unknown origin [2]. Survivors can be left with acute renal failure or with neurologic abnormalities [3]. The clinical course of EG intoxication is always severe; however, prompt treatment can reverse the poor prognosis, death is uncommon with prompt treatment of EG poisoning [3]. Bicarbonate corrects the acidosis, and ethanol and fomepizole reduce toxic metabolite production. The newer drug fomepizole, specifically indicated for EG poisoning, can minimize renal impairment when started before the serum creatinine concentration rises [4]. This case also highlights the need to corroborate deranged values from ABGs, with values obtained by a laboratory. The falsely high lactate gave the early diagnosis of EG poisoning and enabled prompt treatment. The patient has given consent for this case report.

References 1. Vale, J A and Meredith T J. ‘‘Ethylene glycol poisoning.’’ Poisoning Diagnosis and Treatment. Springer Netherlands, 1981. 131–134. 2. Scalley, R D, Ferguson, D R, Piccaro, J C, Smart, M L & Archie, T E. Treatment of ethylene glycol poisoning. American Family Physician 2002; 66.5: 807–812. 3. Mallya K B, Mendis T, Guberman A. Bilateral facial paralysis following ethylene glycol ingestion. Canadian Journal of Neurological Science 1986; 13: 340–341. 4. Brent J, McMartin K, Phillips S, Burkhart K K, Donovan J W, Wells M, et al. Fomepizole for the treatment of ethylene glycol poisoning. Methylpyrazole for Toxic Alcohols Study Group. New England Journal of Medicine 1999; 340: 832–8.

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Documentation of emergency intubations outside of the anaesthetic room V. Ferrier, S. Phillips and M. Kigozi St George’s Healthcare NHS Trust

A number of reports and expert bodies have highlighted that poor care within the ‘golden hour’ after acute brain injury may adversely affect neurological outcome. The standard of care is described in guidelines produced by the Association of Anaesthetists of Great Britain and Ireland [1]. Part of the provision of this care requires the keeping of clear, accurate and legible records [2]. Here we report on our audit on the standard of documentation of the acute management of intubated patients admitted to our tertiary referral neurosciences intensive care unit.

Methods This was a prospective review of the medical records of all intubated patients admitted to our critical care unit over a four month period.

Results 65 sets of patient notes were assessed. 54% of intubations took place in an intensive care unit, 41% in an emergency department (referring or local hospital) and 5% on a ward. The majority of intubations (56) were performed by anaesthetists. 20% of operators recorded the monitoring used. There was variable documentation on the components of the rapid sequence induction (RSI) (e.g. use of cricoid pressure, pre-oxygenation, airway soiling and grade of laryngoscopy). Only 85% of operators documented the drugs used and as such it was not always clear that efforts to obtund the laryngeal response to intubation were made. Only 15% of cases had any transfer documentation or observations documented post intubation.

Discussion Our observational study demonstrates a varied standard of documentation throughout our catchment area. Whilst management may comply with national standards, this is not reflected in the documentation. Possible reasons for this include: time-pressure, out-of-hours working and relatively junior trainees performing the procedures. Our data has supported the introduction of the following potential improvements: 1 2 3

126 Compliance with national quality improvement framework for amputations for the year 2012: a retrospective audit J. Fletcher, M. Safar and J. Smout Royal Liverpool University Hospital

Lower limb amputation has a high 30 day mortality (17%) [1]. In 2012 the Vascular Surgical Society developed a Quality Improvement Framework (QIF) for major amputation surgery. This emphasises the importance of good pre-operative preparation, involvement of senior surgeons and anaesthetists, cases being performed on scheduled lists (8am-8 pm Mon-Fri) and appropriate levels of post-operative care. Since recently becoming a tertiary vascular referral centre, we aimed to determine the case load of lower limb amputation, our 30 day mortality rate, and whether we are meeting standards specified in the QIF. These include: 75% of patients to receive surgery in normal working hours 100% of patients to receive care from senior surgeon and anaesthetist (consultant or senior trainee) All cases to be entered on National Vascular Database

Methods We conducted a retrospective audit of all lower limb amputations performed in our trust from 01/01/12 to 31/12/12. We used 3 operation codes to identify above, below and through knee amputations, and accessed records from the theatre software programme (ORMIS).

Results 54 patients were identified as undergoing lower limb amputation in 2012. 8/54 cases (15%) were orthopaedic cases and have been discounted from further analysis. The remaining 46/54 cases (85%) were vascular or joint vascular/ orthopaedic and have been included. The 30 day mortality rate was 6/46 (13%) With respect to QIF standards: 40/46 patients (87%) had their surgery during normal working hours. 45/46 patients (98%) had a senior surgeon, and the same proportion had a senior anaesthetist. 40/46 cases (87%) were entered on the National Vascular Database.

An RSI ‘shadow board’ and checklist An RSI sticker, which brings documentation to the national standard Feedback and education to referring hospitals, emergency departments and intensive care units

Re-audit will be carried out after implementation of these measures.

References 1. Association of Anaesthetists of Great Britain and Ireland. Recommendations for the Safe Transfer of Patients with Brain Injury. 2006. Available at: http:// www.aagbi.org/sites/default/files/braininjury.pdf. Accessed March 1, 2014. 2. Association of Anaesthetists of Great Britain and Ireland and the Royal College of Anaesthetists Joint Committee on Good Practice. Good Practice. A guide for departments of anaesthesia, critical care and pain management. Third edition, 2006. Available at: http://www.rcoa.ac.uk/system/files/CSQ-GoodPractice 2006.pdf. Accessed March 1, 2014

Discussion 54 amputation cases were identified for the year 2012. Following the recent merger of vascular services this number is likely to increase over the coming years. Targets were achieved with respect to timing of surgery and seniority of staff involved, and although the case numbers in this audit are relatively small, our 30-day mortality rate is lower than the national average (13% vs 17%). Vascular surgeons are addressing the recording of data on the National Vascular Database. Of the 6 cases not entered onto the database, 3 were elective and 3 were emergencies, and all survived past 30 days. All cases resulting in death within 30 days were recorded on the database.The commencement of an NCEPOD audit of amputations later this year will allow comparison of our standards of care with national results.

Acknowledgements Thanks to Dr L. Dagg for her assistance.

Reference 1. Vascular Society of Great Britain and Ireland. 2012. [online]. [Accessed 02/ 04/2013].


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127

128

A child with low oxygen saturations on the ward To be published in Pediatric Critical Care Medicine, in press.

Education, education, education. Improving knowledge of difficult airway trolleys T. Fregene1 and T. Davies2 Royal London Hospital; 2Barnet & Chase Farm NHS Trust

1

Difficulty or failure in airway management is a significant factor in much anaesthesia-related morbidity and mortality [1, 2]. Knowledge of the location and contents of the ‘advanced airway set’ is poor among UK anaesthetists [3].

Methods In May 2010; with relation to the standards set out by the Royal College of Anaesthetists and the Difficult Airway Society [4, 5]; anaesthetists of all grades working in a large district general hospital were surveyed about the locations and the contents of the difficult airway trolleys. They were also asked about the training that they had received on the difficult airway equipment and what they would use in the ‘‘Can’t Intubate, Can’t Ventilate (CICV)’’ scenario. Following this survey, a rolling teaching programme was introduced to the hospital. All new starters at the hospital were shown the locations and contents of the trolleys at induction. There were also opportunities for established members of the anaesthetic team to have training on the equipment that they were less familiar with. In October 2013, the audit cycle was closed by repeating the survey with the anaesthetists working at the same hospital at the time.

Results Table 1 Key findings of the two surveys. No. (%) of

No. (%) of

anaesthetists

anaesthetists

answering

answering

correctly

correctly

%

2010

2013

Change

21/23 (91%)

28/30 (93%)

+2%

8/16 (50%)

15/21 (71%)

+21% +7%

Where is difficult airway trolley. . . . . .in Main Theatres? . . .in the SurgiCentre? . . .in Maternity Theatres?

15/18 (83%)

18/20 (90%)

Where is the AMBU bag?

23/23 (100%)

30/30 (100%)

0%

What would you use in

21/23 (91%)

28/30 (93%)

+2%

14/23 (61%)

26/30 (87%)

+26%

CICV scenario? Have you had training on all airway equipment? What should be on the

40%

47%

+7%

Difficult Airway Trolley? (average score)

Discussion The results show that the teaching programme is effective in increasing the knowledge of the location and contents of the difficult airway trolley. Also, there was an improvement in the number of anaesthetists who have had training on the difficult airway equipment. This effect is still seen after three and a half years. The 100% ‘‘gold standard’’ recommended by the Royal College of Anaesthetists was still not met in the majority of fields. This emphasises the continuing need for the teaching programme and suggests that a greater focus on the contents of the difficult airway trolley is required.

References 1. Gannon K. Mortality associated with anaesthesia. A case review study. Anaesthesia 1991; 46: 962–966. 2. Domino K, Posner K, Caplan R, Cheney F. Airway injury during anaesthesia: a closed claims analysis. Anesthesiology 1999; 91: 1703–1711. 3. Green L. Can’t intubate, can’t ventilate! Can you do it? Manual from annual meeting of the Difficult Airway Society, Lille November 2005. London: DAS, 2005; 71. 4. Trelett M. Intra-operative care. In: Colvin R, Peden C, eds. Raising the Standard: a compendium of audit recipes. London: Royal College of Anaesthetists, 2012; 92–93. 5. Difficult Airway Society. Equipment List 2005. Available from http://www.das. uk.com/equipmentlistjuly2005.htm (accessed 12th March 2014).

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Pregnancy and sepsis: acute respiratory failure associated with antepartum pyelonephritis C. Frith, S. Wintle and A. Wolff Barnet and Chase Farm NHS Trust

Acute respiratory failure at 25 weeks gestation of pregnancy requiring mechanical ventilation is a rare event. We describe a case of a woman presenting with pyelonephritis, who rapidly developed acute respiratory failure requiring invasive ventilation and ITU admission.

Description A 31-year-old woman of 25/40 gestation, with a history of type I diabetes mellitus, essential hypertension, and recurrent UTIs, attended the Early Pregnancy Unit with a 2 day history of fever, fatigue, and malaise. She was admitted under the obstetricians with a diagnosis of pyelonephritis, based on a positive urine dipstick, a dilated pelvicalyceal system of the right kidney on ultrasound, and CRP 65 mg/L. Urine culture was E.coli positive. Despite treatment with IV cefotaxime and significant fluid resuscitation, her condition deteriorated. On day 2 her inflammatory markers had worsened (CRP 245 mg/L) and her swinging pyrexia persisted. She was referred to the critical care team with pyrexia, tachycardia, hypertension, tachypnoea, and severe hypoxia with an SpO2 of 81% on high-flow oxygen. Immediate intubation and fluid resuscitation were performed. A diagnosis of hospital acquired pneumonia was made, with a differential of ARDS secondary to urinary sepsis. The ITU admission ABG on FIO2 1.0 showed pH 7.17, PaO2 8 kPa, PaCO2 7.5 kPa, BE -7.5 mmol/L, lactate 0.8 mmol/L. Central venous saturations were 78.7%. CXR post-intubation demonstrated a right lower lobe consolidation and effusion with left sided infiltrates. She underwent mechanical ventilation with 10 cmH2O PEEP, with propofol and reminfentanil sedation. Her shunt improved markedly over the next 12 hours, PaO2 rising to 9.5 kPa on FIO2 0.4. An MDT discussion concluded a caesarean section could be avoided. She was extubated after 3 days, discharged from ITU on day 7, and discharged home at 27/40 gestation. She delivered by category-2 caesarean section at 32/40 gestation, after spontaneous onset of labour, mother and baby are doing well.

Discussion Respiratory failure associated with pyelonephritis during pregnancy was first described in 1984 [1]. In the subsequent 13 years there were 10 published cases of obstetric patients requiring mechanical ventilation, with pyelonephritis as a putative causative agent [2]. This case highlights important issues regarding appropriate targets for maternal oxygenation, timing of delivery, and sedative agents used in pregnancy. BTS guidance [3] states target oxygen saturation in pregnant women with sepsis should be 94-98%, however Catanzarite at al. state foetal oxygenation is dependent on maternal mixed oxygen venous oxygenation and uterine blood flow, not PaO2.

130 Anaesthetic machine check S. Gajree and D. Ball NHS Dumfries & Galloway For safe anaesthesia, a correctly functioning anaesthetic machine is essential [1]. Prior to case commencement it is the responsibility of the anaesthetist to ensure all anaesthetic equipment is in working order. Research has shown that up to 10% of critical incidents are attributable to equipment failure [2, 4]. Following our involvement in a critical incident due to machine failure, we conducted an audit of anaesthetic machine checking in Dumfries & Galloway Royal Infirmary against current AAGBI guidelines [2]. We aimed to assess whether correct machine check completion varied with the clinical scenario.

Methods Using an anonymous questionnaire, we surveyed all anaesthetists working in the anaesthetic department of Dumfries & Galloway Royal Infirmary. We asked them to document their job title and list the steps included in their routine machine check prior to starting the following emergency and elective case: 1 2

Emergency: category 1 caesarean section Elective: hemicolectomy

We allowed 3 weeks for responses to be completed.

Results 18 responses were received: – 10 consultants, 4 associate specialists and 4 trainees. This gives a response rate of 82% (18/22) from the department. We analysed responses received against AAGBI guidelines for correct machine check. NB: This audit asked anaesthetists to state their routine machine check prior to an emergency and elective case. We did not observe the check in a real-time clinical scenario due to the unpredictable timing of emergency cases. Table 1 Summary of results: (where response declared “check as per AAGBI guidelines” we assumed full check performed).

AAGBI check:

Emergency: Category 1

Elective: Hemi-

C-section

colectomy

% Completion

% Completion

Self-inflating bag available

11%

100%

Manufacturer check done

56%

100%

Power Supply

100%

100%

Gas supplies & Suction

72%

100%

Breathing System

61%

89%

Ventilator

39%

89%

Scavenging

17%

89%

100%

100%

Monitors

References

Discussion

1. Cunningham FG, Leveno KJ, Hankins GDV, Whalley PJ. Respiratory insufficiency associated with pyelonephritis during pregnancy. Obstetrics & Gynecology 1984; 63(1): 121–125. 2. Catanzarite VA, Willms D. Adult Respiratory Distress Syndrome in Pregnancy: Report of Three Cases and Review of the Literature. Obstetrical & Gynecological Survey 1997; 52(6): 381–392. 3. O’Driscoll BR, Howard LS, Davison AG Guideline for emergency oxygen use in adult patients. Thorax 2008; 63 (Suppl VI): vi1–vi68.

The AAGBI state the importance of a full anaesthetic machine check to minimise critical incidents and hence patient morbidity and mortality [1, 3]. RCOA guidelines state all anaesthetists must perform a full check of anaesthetic equipment and document this prior to starting a case [4]. This audit has shown that in an elective environment the majority of anaesthetists state they perform and document a machine check to the required standard. However, in the emergency ‘‘time-critical’’ category 1 C-section, the results are less encouraging. This may be due to the pressure required to start immediately, to minimise the risk of adverse neonatal outcome. However, as checks are designed to reduce critical incidents, poor compliance may contribute to a higher rate of critical incidents within this group. The full AAGBI guideline on machine check is time consuming. Without comprising patient safety, it may be time to consider producing a condensed version of the check for use prior to starting an emergency ‘time-critical’ case.

References 1. Magee P. Checking anaesthetic equipment: AAGBI 2012 guidelines. Anaesthesia 2012; 67: 571–574. 2. Hartle A, Anderson E, Bythell V, et al. Checking anaesthetic equipment 2012. Anaesthesia 2012; 67: 660–8. 3. Sebastian T, Jose Z, Lamb, FJ. Record of anaesthetic machine check. Anaesthesia 2006; 61: 817. 4. MacLeod, A. RCOA, Raising the Standard: a compendium of audit recipes: Intra-operative care: Machine Check, 2006. http://www.rcoa.ac.uk/system/ files/CSQ-ARB-Contents_intro.pdf (accessed 02/08/13). © 2014 The Authors. Anaesthesia © 2014 The Association of Anaesthetists of Great Britain and Ireland

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Anaesthetist-led education to support NICE guidelines on IV fluid prescribing – improving patient outcomes S. Gleeson, A. Cooper and M. McMenamin University Hospital Aintree

Recent NICE guidelines on the prescription of IV fluids for hospital in-patients stated that doctors need better education and training to enable them to prescribe safely and cut down the 20% complication rate associated with current prescribing practice [1].

Methods We conducted a survey based on doctors’ knowledge of the guidelines and basic principles of fluid prescribing. We identified 3 groups; F1 doctors, anaesthetic CT1 trainees and senior anaesthetic trainees (ST4-7) to determine their current knowledge and practices. Each group was approached at their respective teaching sessions, where an anonymised questionnaire was distributed to all attendees.

Results There was a good response rate to the questionnaire across the groups [F1 28/ 32 (87.5%), CT1 27/27 (100%), SpR 18/19 (95%)]. Previous mandatory training in fluid prescribing was greatest in the CT1 group (40.7%), and lowest in SpRs (10.2%). CT1 trainees also scored highest on their knowledge of the NICE guidelines, with 29.6% aware of the guidelines compared to 7.1% of F1s and 10.5% of SpRs. Knowledge of daily requirements of water, sodium and potassium, as well as the constituents of frequently prescribed IV fluids, increased with increasing grade. Daily sodium requirement was the most frequent incorrect answer across all groups. F1 doctors scored highest in the assessment and monitoring of a patient on IV fluids.

Post-operative epidural analgesia and morphine consumption T. Heinink, B. Baker, T. Addison, V. Yates and J. Williams Royal Derby Hospital Epidural placement is historically considered to be the gold standard in post-operative analgesia for open abdominal surgery [1]. However, it is unclear how long it should be continued for post-operatively; Enhanced Recovery After Surgery (ERAS) guidelines suggest removal of the catheter after 48-72 hours [2], but this may limit mobility and delay recovery from surgery. We sought to assess analgesic requirements following discontinuation of epidural analgesia to try and define the optimal time for catheter removal.

Methods Data were collected by nurses from the acute pain service as part of a prospective service evaluation. All patients receiving post-operative epidural analgesia following open abdominal surgery were visited daily until the epidural catheter was removed. Reason for catheter removal and the amount of opioid required in the subsequent 24 hours, converted into intravenous morphine equivalents (MEQ) using the British National Formulary conversion ratios [3], were recorded. Data were analysed using a Kruskal-Wallis test.

Results 881 epidural catheters were inserted during the period January 2010 – February 2013. The overall failure rate was 27.2% at 48 hours and 33.9% at 96 hours. The median amount of MEQ used in the 24 hours following epidural removal was 28 mg (IQR 10-57 [range 0-388]). Patient age appeared to effect MEQ requirement (aged ≤65 (40 mg, (IQR 10-87 [range 0-388]) vs aged >65 20 mg, (IQR 5-40 [range 0-157]), p < 0.01). Regardless of whether epidurals were removed as part of planned care or due to failure, subsequent 24-hour analgesic requirement was higher if epidurals were removed in the first 24 hours postoperatively (median 67 mg, IQR 32-67 [range 0-388]) than if it was removed at 25-48 hours (median 30 mg, IQR 10-34 [range 0-271]), 4972 hours (median 20 mg, IQR 5-40 [range 0-218]), 72-96 hours (median 20 mg, IQR 5-40 [range 0-220]) or >96 hours (median 20 mg, IQR 8-43 [range 0-240] p < 0.01) (Figure 1).

Discussion Our results support the need for further education. It can be seen that as clinical experience and education increase, the core knowledge required to prescribe IV fluids appropriately also improves. The majority of IV fluid prescribing within hospitals is undertaken by the most junior doctors and, as it can be seen from our results, only a very small proportion of these doctors are aware of patients’ basic daily electrolyte and water requirements, making accurate IV fluid prescribing almost impossible. This is in keeping with findings in a recent BMJ news article about the introduction of these NICE guidelines, where 90% of junior doctors were unaware of patients’ daily water, sodium and potassium requirements [2]. Encouragingly their knowledge of patient monitoring was good. Fluid physiology and management make up a major part of the curriculum that anaesthetists study for their exams and as such, senior anaesthetic trainees would be well placed to deliver this training to the junior doctors, ideally at the earliest possible opportunity after F1 doctors start their clinical work. We will institute anaesthetist-led teaching for F1 doctors on fluid prescribing, reassessing their knowledge following this intervention, hopefully decreasing morbidity.

References 1. National Institute for Health and Care Excellence. Intravenous fluid therapy in adults in hospital. Dec 2013. www.nice.org.uk/CG174. 2. Torjesen I. Patients are at risk because doctors don’t know how much IV fluid they need, NICE says. British Medical Journal 2013; 347: f7396.

Discussion Morphine consumption for the 24 hour period following epidural catheter removal is significantly reduced once the catheter has been in-situ for greater than 24 hours. Current practice in our institution is to avoid the use of epidural catheters for patients undergoing routine open or laparoscopic colorectal resections, so as to allow early mobilisation as part of an ERAS programme. However, this may require the use of significant doses of parenteral or intrathecal opioids, which may lead to decreased gut motility, urinary retention, nausea, or pruritus. These data would suggest that epidural analgesia may still have a role to play in these patients, by permitting the avoidance of systemic opioids and that if the epidural catheter were removed after 24 hours effective analgesia could be provided whilst minimising opioid consumption and allowing early patient mobilisation.

References 1. Cook TM, Eaton JM, Goodwin AP. Epidural analgesia following upper abdominal surgery: United Kingdom practice. Acta Anaesthesiologica Scandinavica 1997; 41: 18–24. 2. Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World Journal of Surgery 2013; 37: 259–84. 3. Joint Formulary Committee. British National Formulary, 66th edn. London: BMJ Group and Pharmaceutical Press, 2013.

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Gaining practical experience of NHS management: a trainee’s perspective on the NHS institute for innovation and improvement D. Hewson1 and P. Hayden2 1 Guy’s and St Thomas’ NHS Foundation Trust, London; 2Medway NHS Foundation Trust

Methods The case for clinicians to increase their participation in the management and leadership of the NHS is one which was argued as early as 1954 [1] and been expressed with increasing urgency in reports and recommendations ever since. The managerial expectations placed upon practicing anaesthetists of all grades were revised in 2012 by the GMC [2]. With this document in mind the authors enrolled in the NHS Institute for Innovation and Improvement’s Vanguard Management Programme. The programme, devised in conjunction with the National Leadership Council, enables emerging leaders to design and implement local business critical projects in quality and productivity while building leadership skills.

134 Maintaining patient dignity in obstetrics. An audit of theatre door openings J. Holland,1 R. Sykes2 and W. Donaldson2 1 Ulster Hospital Dundonald; 2Antrim Area Hospital

The topic of this audit is maintaining patient dignity in obstetric theatres by decreasing theatre door openings. It was performed in a district general hospital in Northern Ireland. The issue was highlighted during an operative delivery by the patients partner asking; ‘‘who were the people standing by the door?’’ The structural layout of theatres in this unit meant that there are two routes into maternity theatre, one via the main theatre door which risks exposing and embarrassing the patient and one via the dirty utility with the potential to introduce infection. The main theatre doors open onto a corridor with no preparation room between, thus exposing the patients perineum to the outside corridor when in the lithotomy position.

Methods We documented the number of times the main doors opened into theatre exposing the patient, the type of surgery and whether it was an emergency or elective procedure. The initial audit was performed during the month of October 2012 and the audit cycle completed in February 2014. We only included the times the door opened once the patient was ready for surgery. Current guidelines suggest door openings should be avoided for infection control reasons and in this case to maintain patient dignity.

Results

Results

The author’s quality improvement project introduced a new fascia iliaca nerve block service for the management of pre-operative pain in patients with hip fractures. The provision of analgesia for hip fracture patients has been addressed by national guidelines [3], which recommend nerve blockade for patients whose pre-operative pain is not adequately controlled by simple oral analgesics. By applying the suggested theories and techniques described by the Vanguard Programme (including project management, user involvement, process mapping, measurements for improvements, demand and capacity management) we have launched a nerve block service locally.

The initial audit captured 12 cases with the number of door openings ranging from 7 to 64, the average being 31. The reaudit after implanting our changes captured 6 cases with a range of 1422 and an average of 17.3. Reasons for opening doors included access to notes, requesting case update, retrieving paperwork/surgical instruments and requesting analgesia for other patients. All members of the multidisciplinary team were involved. The results are summarised in Table 1.

Discussion The 6-month programme was delivered through online lectures and tutorials, access to online resources and face-to-face regional presentations. Lectures were structured around the NHS ‘Handbook of Quality and Service Improvement Tools’ and provided the theoretical basis of organisational development. They were delivered via a Webex portal, attended by the hundred or so participants nationally. Tutorials, conducted in small groups with a mixture of clinicians and non-clinicians, gave the authors the opportunity to discuss barriers to change, and successes in their project. Discussing projects with non-clinicians from a range of NHS bodies was a useful reminder that departments must strive to deconstruct artificial ‘us and them’ barriers between clinicians and managers. The Vanguard Programme provided structured learning on NHS management and practical experience in the implementation of new services. The demands of completing this programme had to be carefully balanced with normal clinical duties and the requirements of training, but provided your department is supportive the authors would commend this programme to others.

References 1. Bradbeer Committee Report, Ministry of Health: Central Health Services Council. Report of the Committee on the Internal Administration of Hospitals, 1954. 2. Leadership and management for all doctors. Code: GMC/LMAD/0613. General Medical Council 2012. 3. CG124 Hip fracture: NICE guideline. Downloaded from http://publications.nice. org.uk/hip-fracture-cg124. Accessed 19/02/14.

Table 1 October 2012

February 2014

Audit Date

Door Openings

Door Openings

Elective LSCS

20

22

Elective LSCS

53

14

Elective LSCS

7

16

Elective LSCS

14

—

Elective LSCS

35

—

Elective LSCS

19

—

Elective LSCS

25

—

Elective LSCS

12

—

Elective LSCS

28

—

Emergency LSCS

64

15

Emergency LSCS

—

19

Emergency Trial

41

18

Emergency Trial

54

—

Discussion Following the initial results we decided to inform and educate staff in an attempt to minimise door openings and maintain patient dignity. To do so we discussed the results at the anaesthetic, obstetric and midwifery audit meetings, put signs on the doors to prevent unnecessary opening and encouraged the use of the phone in theatre. There will always be a need to enter and leave theatre in a few emergency situations but non urgent entries should not happen. Our interventions led to a significant reduction in door openings shown by the reaudit. In addition to the reaudit results we hope to achieve further reduction in door openings by creating checklists for equipment and paperwork to be kept in theatre. Additionally we aim to have a dedicated elective theatre team to minimise interruptions with respect to advice for other delivery suite patients.

References 1. Woodhead K, Taylor EW, Bannister G, Chesworth T, Hoffman P, Humphreys H. Behaviours and rituals in the operating theatre. Journal of Hospital Infection 2002; 51: 241–255. 2. Hoffman P, J. Williams J, Stacey A, Bennett AM, Ridgway GL, Dobson C, Fraser I, Humphreys H. Microbiological commissioning and monitoring of operating theatre suites. Journal of Hospital Infection 2002; 52: 1–28. 3. Gemmell L, Birks R, Radford P, et al. Infection Control in Anaesthesia. Anaesthesia 2008; 63: 1027–36.


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135

136 SOPPCAS – a cardiothoracic patient satisfaction survey

WITHDRAWN

J. Hoyle, A. Kirkwood and Y. Price Barts Health NHS Trust

Patient satisfaction with health services is an important component of both the General Medical Council re-validation process and the new friends and family test implemented by the current government [1]. Assessing patient satisfaction however is challenging in a specialty in which the patient has no memory of the majority of the clinical encounter. We set out to explore patient satisfaction after cardiac surgery by utilizing a pre-validated tool - the Scale of Patients’ Perceptions of Cardiac Anaesthesia Services (SOPPCAS) [2].

Methods All patients presenting for cardiac surgery over a 5 week period were given the questionnaire on day 4 post-op. The questions focused on 4 main areas: patient preoccupation, patient-anaesthetist interaction, experience of anaesthesia and pain. Patients were excluded if they could not speak English or were still in intensive care (ITU). Questions were scored according to a 6 point Likert scale with 1 being ‘not at all’ and 6 being ‘very much’. There were also free text questions, and specific questions relating to side effects of anaesthesia. All questionnaires were anonymized

Results 31 patients completed the questionnaire. Of these, only 61% remembered meeting an anaesthetist pre-operatively, however 84% did remember having the side effects of anaesthesia explained to them. 68% reported pain post-op, but of these 81% stated that their pain was well controlled. The most common side effects were sore throat (48%) and nausea (42%). Worryingly, 4 patients out of 31 answered yes when asked ‘Do you remember being conscious between the moment you fell asleep and your first awakening after the operation?’ 3 out of 4 reported that this was in ITU, but 1 reported that this occurred in the operating theatre. Overall, 27 out of 31 patients reported being satisfied or very satisfied with the anaesthetic services they had received

Discussion This audit represents a first attempt to quantify patients’ satisfaction with anaesthesia services in our department. Although the majority of patients did report being satisfied, several areas of concern were highlighted. These included the fact that very few patients remembered meeting an anaesthetist, the high levels of post op pain and PONV, but most significantly a possible unrecognised incidence of awareness. This underlines the importance of assessing patient satisfaction and utilising the information to improve anaesthetic services.

References 1. General Medical Council (2012) A guide for doctors to the General Medical Council (Licence to Practise and Revalidation) Regulations 2012. London. 2. Le May S, Hardy J-F, Harel F, Taillefer M-C, Dupuis G. Patients’ perceptions of cardiac anesthesia services: a pilot study. Canadian Journal of Anaesthesia 2001; 48(11):1127–1142.

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Assessing epidural block for caesarean section: a review of the literature J. Hoyle and S. Yentis Magill Department of Anaesthesia, Chelsea and Westminster

138 Improving pre-operative fasting times in adults and children in BHR University trust: an audit of practice R. Hutchison,1 L. Guthrie2 and G. Kaleekan2 London Chest Hospital; 2Barking Havering and Redbridge University Hospitals NHS Trust 1

Trends in how obstetric anaesthetists assess regional blocks before caesarean section (CS) may be ascertained from repeated surveys of practice but response rates are often poor and responses may represent ‘common practice’ rather than what might be considered ‘best practice’. Another method of examining practice is to look at published studies over the same time period, since methods used in such studies are more likely to represent ‘best practice’. We have previously reviewed the literature relating to assessment of spinal block over the past 30 years, and found a lack of a consistent ‘gold standard’ method of assessment (in press: to be presented at the Obstetric Anaesthetists’ Association Annual Meeting, May 2014). As a follow-up, we have examined the assessment methods for epidural block for CS reported in clinical trials over the same period.

Methods We searched PubMed in January 2014 for English-language randomised controlled trials (RCTs), indexed with CS and epidural anaesthesia as major topics, and recorded the methods of block assessment.

Results 138 papers were identified, of which 18 could not be obtained in full text and 18 made no mention of assessment of block. Of the remaining 102, 50 (49%) assessed sensory block only and 52 (51%) assessed both sensory and motor block, of which 45 (87%) used the Bromage scale. Assessment of height of block is shown in Figure 1. The most common method of sensory block assessment was pinprick (38% 1984-1993, 43% 1994-2003 and 38% 2004-2013). Both assessment of touch and the use of more than one modality of assessment increased from 3% and 5% in 1984-1993, to 11% and 19% in 2004-2013, respectively. No studies defined the dermatome used.

We audited the fasting practices in Adults and Children across the Barking, Havering and Redbridge NHS trust (BHR trust) for patients attending for surgery. The current trust policy is based upon the November 2005 RCN peri-operative fasting guideline, endorsed by the RCOA [1].

Methods The first audit round included 50 randomly selected patients attending for surgery from 21st January to 9th March 2012. Patients were interviewed on the day of surgery, with a standard proforma, no patients were excluded once entered into the audit. Following the first audit round we recommended that the pre-operative fasting letter was changed to encourage patients to take fluid at least 2 hours before there procedure. In addition, we educated staff involved in the perioperative care of surgical patients. The fasting guidelines were posted on all the surgical wards and day surgical units. An intranet login page was also created to remind trust members of the current fasting guidelines. A further 50 patients were recruited for the 2nd audit round between 30th April to 25th May 2013.

Results Demographics were similar between the two audit groups. The 1st round of the audit included 47 electives case and 3 emergencies, the 2nd round included 45 elective cases and 5 emergency patients. For elective patients mean fluid fasting times decreased from 10.6 hours 1st round to 5.9 hours (p < 0.05) 2nd audit round. Food fasting times did not change significantly, 13.7 hours to 12.2 hours. For children ( 65 yrs should have heart sounds recorded on the anaesthetic chart. There are guidelines from AAGBI1 or NICE [4] on preoperative assessment but they don’t advise on mandatory chest auscultation in elderly, however, it is a good clinical practice.

Methods Anaesthetic records were scrutinized for documentation of cardiovascular examination in patients over 65 years. Data was collected as per designed format and analyzed across wide range of patients in theatre, recovery and Critical Care by auditors over four weeks period, at Norfolk & Norwich University Hospitals NHS Trust.

Results

S. Kashimutt Huddersfield and Halifax NHS Foundation Trust

Henna is obtained from the dried leaves of a shrub, Lawsonia alba, which is very common throughout Asia and Africa. It is applied to hair, nail or skin to create the yellow-orange, brown or black colour through temporary staining. Natural henna, when applied to skin, gives an orange- red colour but if it combined with synthetic dyes such as para-phenylenediamine (PPD) it gives a black pigmentation to the skin, and is termed black henna. In the Middle East, East Africa and Indian subcontinent henna is commonly used as skin decoration for celebrations such as weddings, festivals and child birth.

Description A 30 year patient of Sudanese origin was scheduled for an elective caesarean section. In theatre whilst applying the pulse oximeter it was evident that all her finger tips, toes and plantar aspects of her feet were pigmented with black henna (Image). We attempted to measure her haemoglobin saturation using pulse oximeter from various digits but each time we were unable to obtain any trace (Image 1). We eventually used a paediatric ear probe on the ear lobe to measure the oxygen saturation.

Total 101 Patient Anaesthetic records were audited. Eighty one percent of patients had no heart sounds recorded on the chart. Fifty percent of patients were handed over to other clinician to anaesthetise. Eighty four percent of patients had 1 or more risk factors. There was significant percentage with multiple risk factors & many of these didn’t have heart sounds auscultated.

Discussion Significant number of high-risk patients did not have cardiovascular examination. How many of these have ‘‘haemodynamically significant’’ murmurs, we don’t know. A second anaesthetist assessed half of these and auscultation findings may affect anaesthetic technique. Full clinical cardiovascular examination may diagnose unsuspected lesions, which may be referred for appropriate management & ‘‘last minute cancellations’’ avoided. It should be mandatory part of our pre-anaesthetic visit in patients > 65 years or with recognised risk factors. Results were presented at anaesthetic clinical governance & auscultation in all patients was recommended. It was reaudited with positive outcome of overall improvement in chest auscultation rates. Divisional recommendations were made to record heart sounds in ALL high-risk patients. Once we achieve cardiovascular documentation in almost 100% patients then next step will be how many of these have positive findings, which could be of clinical importance requiring further intervention.

References 1. http://www.aagbi.org/publications/publications-guidelines/M/R. 2. Van Klie WA1, Kalkman CJ, Tolsma M, Rutten CL, Moong KG, Pre-operative detection of valvular heart disease by anaesthetists. Anaesthesia 2006 Feb; 61(2): 127–32. 3. Attenhofer Jost CH, Turina J, Mayer K, Seifert B, Amann FW, Buechi M, Facchini M, Echocardiography in the evaluation of systolic murmurs of unknown cause. American Journal of Medicine 2000 Jun 1; 108(8): 614–20. 4. http://wwwnodelaysachiever.nhs.uk/ServiceImprovement/Tools/IT130_PreOp Assessment. 5. Shahbudin H. Rahimtoola, Valvular heart disease: a perspective on the asymptomatic patient with severe valvular aortic stenosis. European Heart Journal 2008; 29: 1783–1790 doi:10.1093/eurheartj/ehn272.

Discussion It is known that changing the colour of the skin in hyper-pigmentation and hyperbilirubinemia may influence the reading of pulse oximeter due to their effects on differential light absorption [1, 2]. Al-Majed et al. demonstrated in their study that artificially colouring the skin with black henna substantially limited pulse oximetry when compared to natural henna [3]. Henna is a very popular cosmetic dye used in Africa and Asia. Pure henna it will not significantly affect pulse oximeter readings, but if combined with chemical dyes such as PPD to create black henna then the resultant intense staining can significantly affect the pulse oximeter reading or will not give any reading at all. Another significant problem with black henna is the relatively high incidence (3-15%) of allergic reactions to the compound dye, potentially causing permanent scarring or a lifelong sensitivity to similar dyes. Such reactions are almost unknown when using natural henna. We remind anaesthetists and midwives treating pregnant woman from East Africa, Middle East and Indian subcontinent to be aware of the cultural practice of henna application during celebrations like child birth. They should be advised to avoid application of black henna to finger and toe tips. If they insist, then encourage the use of natural henna.

References 1. Brunell W, Cohen NH Evaluation of the accuracy of pulse oximeter in critically ill patient. Critical Care Medicine 1988; 16: 432. 2. Ries Al, Prewlt LM, Johnson JJ. Skin colour and ear oximetry. Chest 1989; 68: 546–547. 3. Al-Majed SA, Harakati MS. The effect of henna paste on oxygen saturation reading obtained by pulse oximetry. Tropical and Geographical Medicine 1994; 46: 38–39.

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Fractured neck of femur – 30 day mortality data S. Kashimutt Huddersfield and Halifax NHS Foundation Trust

Over 70,000 operations are performed annually for fractured neck of femur. These patients often have significant co-morbidities which may be overt. The mortality rate for this group at one year is 30% of which one-third is directly contributed to the surgery. 30 day mortality has remained consistently around 810% for the last two decades [1–2]. National average for the year 2011-2012 is 8.1% according to National hip fracture database [3]. There is a minimal evidence base for determining the optimal anaesthetic technique, but the Scottish Intercollegiate Guidelines Network (SIGN) recommends that ‘spinal/epidural anaesthesia should be considered for all patients undergoing hip fracture repair unless contraindicated [4].

He’s not waking up! J. Keaveney and A. O’Shea Mayo General Hospital

A 78 year old man was admitted to the intensive care unit following in hospital cardiac arrest. He had been admitted 10 days previously with a cerebellar infarct from which he had recovered and was due to be discharged. His discharge had been delayed due to a lower respiratory tract infection which was being managed with antibiotics.

Description

Retrospective audit of patients who have had operation for the neck of femur fracture (NOF) over a period of year 2011-2012 in Huddersfield Royal Infirmary, which is a busy district general hospital.There were a total of 491 patients were operated in that period. We audited our practice with the standards set by National hip fracture data base (NHFD). The following practice were audited: 1) Prompt orthogeriatric review 2) Surgery within 48 hours of admission and within normal working hours 3) General anaesthesia for operation 4) 30 day mortality We also looked in to the causes of 30 day mortality, type of anaesthesia and grade of anaesthetist .

At the cardiac arrest the underlying rhythm was pulseless ventricular tachycardia, which responded to one DC shock and 1 mg of adrenaline, with a downtime less than five minutes. At the arrest, air entry was decreased on the right side and chest xray showed right upper and lower zone collapse. A bronchoscopy was performed and several mucus plugs were washed from the lungs which had reinflated by the next morning. The next morning the patient’s sedation was weaned and weaning from the ventilator was commenced. He failed to breathe up and was noted to have absent cough reflex and had no movement of his arms or legs. A brainstem lesion or an extension of his cerebellar infarct were suspected and an urgent CT brain performed. This did not show any new lesions, so the decision was taken to perform a CT cerebral angiogram. This again failed to show any new lesions or insufficiency of the vertebrobasilar tree. The medical team was consulted and a lumbar puncture was performed which showed a high level of protein. Guillaine Barre syndrome was now suspected. The following day the patient’s neurological condition had further deteriorated so that he was no longer making facial movements. An MRI of his brain failed to demonstrated a new lesion and after discussion with neurology the diagnosis of Guillain-Barre Syndrome was confirmed.

Results

Discussion

Methods

There were a total of 491 cases of neck of femur fracture operated during the year 2011-2012. Male: Female ratio 138:353 Total number of death within 30 days of operation: 48 Huddersfield Royal

National

Infirmary

average

In hindsight on further review of the history, although the patient had recovered from his infarct, it was noted that he had been having episodes of unsteady gait and decreased ambulation and bulbar symptoms which had initially been put down to his stroke. It was probable that Guillain – Barre was a significant contributing factor to this man’s cardiac arrest. This case highlight’s the fact that one has to be mindful of secondary more unusual diagnoses when dealing with critically ill patients.

Peri-operative geriatric review

30.34%

43%

General Anaesthesia

28.75%

40%

Reference

Surgery within 48hours of

87.5%

82.4%

Hughes RAC, Cornblath DR. Gillian-Barrie Syndrome. The Lancet 2005; 366: 1653–1666.

10.14%

8.1%

admission 30 day mortality

Discussion Our audit showed that we had slightly higher 30 day mortality rate compared to national average but it’s a downward trend compared to previous years. Our General Anaesthesia rate were lower that the national average. Our rate of patient review by orthogeriatric physician was low, as in our trust we have staff shortage and trying very hard to recruit staff. Our recommendation were 1) To record pre and post abbreviated mental test score for all the patients 2) Record Nottingham hip fracture score on admission 3) Experience trauma surgeons to operate 4) Prompt orthogeriatric review of all patients during peri-operative period to optimise medical conditions 5) Avoid cancellation for logist

References 1. The National Hip Fracture Database. National Report, 2011. 2. White SM, Griffiths R, Holloway J, Shannon A. Anaesthesia for proximal femoral fracture in the UK: first report from the NHS Fracture Anaesthesia Network (HIPFAN). Anaesthesia 2010; 65: 243–8. 3. The National Hip Fracture Database. National Report, 2012. 4. Scottish Intercollegiate Guidelines Network. Management of hip fracture in older people. National clinical guideline 111. 2009.


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Facemask anaesthesia – useful but too much effort?

Neck of femur fractures: to transfuse or not to transfuse?

D. Keightley, M. Das and A. Skinner Northern Deanery

1

D. Kelly,1 D. Dowen1 and B. Gibson2 Health Education North East; 2Northumbria NHS Foundation Trust

Methods Regional survey sent via email to all anaesthetics trainees and consultants. The first 100 responders were included in result analysis. Questions included those on formal training, assessment and confidence in the use of facemasks.

Results 64% of responders were trainees (CT1 to ST7) and 36% were consultants or speciality doctors. Two thirds of these anaesthetists had received formal training in the use of facemasks, however only one third had any formal assessment. More than 90% of the responders felt confident in the use of facemasks yet more than half felt that airway skills could be further improved with increased use of facemasks. Results indicate that only approximately one third of people achieve the 50 facemask target in training which is substantially lower than evidence suggests for competence [1, 2].

Discussion The facemask is an essential piece of equipment in anaesthesia with multiple roles including induction and maintenance of anaesthesia as well and in resuscitation. Safe use is a core skill for an anaesthetist. However, in the advent of supraglottic airways, the use of facemasks for maintenance of anaesthesia is dwindling. As a consequence, the number of cases that novice anaesthetists undertake using facemasks alone is decreasing. Advantages of using facemasks in anaesthesia and resuscitation include: 1) less airway instrumentation: decreasing trauma, airway complications, laryngospasm and disruption of anatomical structures when used on appropriate patients. 2) Cheaper than using endotracheal tubes (ETT) or laryngeal mask airways (LMA). 3) Fewer drugs required at induction. Despite disadvantages which include: unprotected airway from tracheal aspiration and difficulties in maintaining an open airway some patients (edentulous or facial hair), attaining solid skills with facemasks is fundamental to any anaesthetist’s training [3]. We felt it important to assess anaesthetists’ exposure and training in facemask anaesthesia with a view to improving skills which prompted designing this training survey. Evidence suggests that novice anaesthetists should have a sufficient numbers of anaesthetics using facemask alone, ETT and LMAs (50 of each) [1, 2] and propose that 100% should achieve this target early in training. However, due to the decreased exposure and increased use of the LMA, this is not always achieved. The 2010 curriculum now has a specific competency relating to ‘‘the maintenance of anaesthesia with a facemask in the spontaneously breathing patient’’ for basic level training airway management. Further surveys should assess increased exposure to the use of facemasks and achievement of case recommended numbers.

References 1. Konrad C et al. Learning manual skills in anesthesiology: is there a recommended number of cases for anesthetic procedures. Anesthesiology 1998; 86: 635–639. 2. Mulcaster JT et al. Laryngoscopic intubation. Learning and performance. Anesthesiology 2005; 98: 23–27. 3. http://e-safe-anaesthesia.org/e_library/05/Facemask_anaesthesia_Update_ 2011.pdf. 4. http://www.rcoa.ac.uk/CCT/AnnexB.

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No formal transfusion guidelines currently exist for patients with neck of femur fractures (NOF#s) within Northumbria Healthcare Trust. Current guidelines by the Association of Anaesthetists of Great Britain and Ireland advise consideration of pre-operative transfusion if; Hb 12 hrs vs 21%). Most patients were advised not to eat after midnight (n = 58, 94%). Advice regarding fluids was equally split between midnight (n = 28, 45%) and 07:00 (n = 28,45%).

The guidelines in our ICU were last updated in 2007. All new ICU nurses undergo a training day on arterial lines. There is no separate area for storage of arterial line fluids, nor a routine two-person check for fluid attachment. Nineteen nurses completed the survey. All were aware that only saline should be used as a continuous flush. Volume discarded varied from 1-3 ml, with seven (37%) discarding 2 ml, four (21%), 1 ml and four (21%), 1.5 ml. Sixteen of 37 (43%) anaesthetists responded to the online survey. All but one (15, 94%) stated they would always use 0.9% saline as a flush. The volume discarded varied from 1-10 ml, with 2-3 ml being the most common (6, 40%). Six (38%) had received no training regarding arterial line management and 10 (62%) had received informal training in theatre or ICU. Eight (50%) were not aware of any formal recommendations.

Discussion

Discussion

This audit demonstrated excessive fasting. This is clinically unnecessary and has a negative impact on patient experience. The high incidence of ketonuria in our population suggests dehydration, which can lead to a prolonged hospital stay and recovery. Very few patients were given fasting advice as per trust guidelines. Addressing prolonged starvation times is difficult as the majority of LSCS patients need to be fasted from 02:30 and are unlikely to want to eat at that time. Therefore it is more realistic to target the poor adherence to the recommended 2 hour fast for clear fluids (2). This can be improved by educating patients and allied healthcare professionals. A further inexpensive intervention under consideration is the introduction of a carbohydrate drink, taken alongside the morning dose of Ranitidine.

Our results indicate fair knowledge about which fluids to use as a flush, but lack of awareness of current recommendations. Of interest was the wide variety of volume discarded during sampling. The dead space in our system is 0.6 ml. The recommended volume to discard is three times the dead space [2], although five times the dead space may be insufficient to prevent contamination [3]. We did not obtain full coverage of staff, thus selection bias is likely. We have updated our local guidelines to include NPSA recommendations. This is supplemented by moire on the arterial line fluid prescription sheet, which is included an aide-me routinely in each ICU admission bundle. We plan a re-audit to find out whether these interventions have improved local knowledge and practice, with the ultimate aim of minimising iatrogenic harm to our patients.

References

References

1. Sjetne S, Krogstad U, Ødegard S, et al. Improving quality by introducing enhanced recovery after surgery in a gynaecological department: consequences for ward nursing practice. BMJ Quality and Safety in Health Care 2009; 18: 236–40 (accessed on 24/02/2013). 2. Powell-Tuck J, Gosling P, Lobo D N, Allison S, Carlson G L, Gore M et al. British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP). Page 6. March 2011. http://www.bapen.org.uk/pdfs/ bapen_pubs/giftasup.pdf

1. National Patient Safety Agency (2008) Rapid Response Report: Problems with infusions and sampling from arterial lines. Available from: http://www.nrls. npsa.nhs.uk/resources/clinical-specialty/anaesthesia/?entryid45=59891&p=4 (accessed 05/03/14). 2. Medicines and Healthcare Products Regulatory Agency. Glucose solutions: false blood glucose readings when used to flush arterial lines, leading to incorrect insulin administration and potentially fatal hypoglycaemia. Drug Safety Update 2012; 5(12). 3. Brennan KA, Eapen G and Turnbull D. Reducing the risk of fatal and disabling hypoglycaemia: a comparison of arterial blood sampling systems. British Journal of Anaesthesia 2010; 104(4): 446–451.

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Bilateral absence of ulnar arteries and the implications for regional anaesthesia T. Mahendrayogam Anglia School of Anaesthesia

We present the case of a 56 year old gentleman with a history of bilateral fasciectomies for dupytrens contracture who was found to have absent bilateral ulnar arteries. This was noted during ultrasound scanning for a mid-forearm ulnar nerve block following an axillary nerve block for a right sided ring finger fasciectomy, release contracture of the thumb and little finger and zplasty of thumb. The ulnar nerve was identified by it’s appearance and position in the wrist and was followed up to mid-forearm where it was blocked. No ulnar artery accompanied the ulnar nerve from wrist to forearm bilaterally. The incidence of an absent ulnar artery is rare - quoted at less than 0.015% [1] and even less so when bilateral. The literature suggests that for peripheral ulnar nerve blocks (below the elbow) done under ultrasound guidance the ulnar artery should be identified first either at the wrist or mid-forearm. The ulnar nerve lies immediately medial to the ulnar artery [2] and both are followed proximally from wrist to mid-forearm until they separate.

Description The ulnar artery is a terminal branch of the brachial artery along with the radial artery at the level of the neck of the radius. It passes deep to the pronator teres and fibrous arch of flexor digitorum superficialis and descends on flexor digitorum profundus with the ulnar nerve lying medial to it and flexor carpi ulnaris overlapping it in the proximal half of the forearm. At the wrist both the ulnar artery and nerve lie lateral (radial) to flexor carpi ulnaris and pass over the flexor retinaculum [3]. In this case no ulnar artery was identified. In addition to landmarks, nerve identification can be made on ultrasound appearance. Similar to the radial and median nerves, the ulnar nerve has a triangular to oval shape [4] and internal fascicular appearance characterised by hypoechoic fascicles surrounded by hyperechoic connective tissue (honeycomb pattern) [5]. Usually the ulnar nerve joins the medial side of the ulnar artery mid-forearm between the flexor digitorum superficialis, flexor digitorum profundus and flexor carpi ulnaris muscles. Local anaesthetic typically injected near this junction confirms nerve identification before performing nerve block [4].

Audit on WHO checklist in maternity K. Manoharan and M. Millar Sunderland Royal Hospital

The WHO safety checklist has been widely followed for all surgical procedures across the UK since its implementation in June 2008. The WHO safety checklist for Obstetric patients was launched in November 2011 as a collaborative project by NPSA and Royal college of Obstetricians and Gynaecologists. This is a modification of the WHO checklist to make it relevant and applicable to maternity. Local adaptation is encouraged to ensure it is effectively integrated in clinical practice. The Maternity WHO checklist in our trust is slightly modified and has four parts namely 1. Preoperative team brief, 2. Sign in (completed before the start of procedure), 3. Sign out (completed before leaving theatre) and 4. Handover in recovery. The aim of this audit was to find out if the checklist was adopted in all maternity theatre cases.

Methods We conducted a prospective audit for a two week period. Approval was obtained from our local audit department and all data were collected by the anaesthetic assistants. Data were collected regarding name of the procedure, time of surgery, completion of each part of the checklist and if any part not completed the reason for this was sought.

Results Data from 27 procedures was analysed. These included 9 elective caesarean sections, 11 emergency caesarean sections, 6 trial of forceps and 1 manual removal of placenta. The team brief before the procedure took place in only 18 procedures (67%). Only 9 (33%) checklists had all parts completed. The parts two, three and four of the checklists were incomplete in 15 (55%), 17 (62%) and 16 (59%) procedures respectively. The main reasons given for not completing were lack of time, not considered as a priority and unavailability of team members.

Discussion The audit showed lack of compliance and inconsistencies in completing the WHO checklist in maternity. The recommendations from this audit were 1. Work to improve awareness and 2. Education to improve the compliance with the checklist. As a result of this audit we redesigned the checklist to ensure consistency in completing the checklist. We are committed to re audit it in six months time.

Reference 1. National Patient Safety Agency. http://www.nrls.npsa.nhs.uk>Home>Patient safety resources.

Discussion This case presentation highlights the importance of recognising the physical appearance of nerve structures on ultrasound (in this case the ulnar nerve) as well as knowing nerve anatomy and course for successful forearm blockade [6]. Identifying nerves by locating neighbouring arteries on ultrasound is not always reliable.

References 1. M. Rodriguez-niedenfuhr et al. Variations of the arterial pattern in the upper limb revisited: a morphological and statistical study with a review of the literature. Journal of Anatomy 2001; 199: 547–566. 2. Brennan et al. Ultrasound-guided local anaesthetic blocks of the forearm. Anaesthesia Tutorial of the week no. 208. 2011. 3. Faiz & Moffat. Anatomy at a glance. 2002. 4. Nysora. Ultrasound-guided forearm block. 2013. 5. Gray AT et al. Ultrasound guidance for ulnar nerve block in the forearm. Regional Anesthesia and Pain Medicine 2003; 28: 335–339. 6. RA McCahon et al. Peripheral nerve block at the elbow and wrist. CEACCP 2007; 7(2): 42–44.

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Pilot study to assess the feasibility of a post anaesthetic ward round in emergency patients

Acute adult subglottic stenosis; an uncommon culprit

J. Maycock, J. Thorp, A. Brammar and S. Varley Central Manchester Foundation Trust

D. Mayhew Royal Liverpool & Broadgreen University Hospitals NHS Trust

One of the most commonly unmet standards from the Anaesthesia Clincial Services Accreditation (ACSA) is that there is a policy for the post procedural review of all patients [1]. We felt we could meet this standard by the implementation of a post anaesthetic ward round.

A previously well 78 year old female presented to our emergency department with a 4 hour history of progressive dyspnoea, hoarseness and a short coryzal prodrome.

Methods

On examination she was distressed with a pCO2 of 2.4 kPa and quiet biphasic stridor. External examination revealed minor lymphadenopathy and an unremarkable oropharynx. Nasendoscopy demonstrated Myers & Cotton Grade 3 inflammatory subglottic stenosis, with 10% tracheal patency. Intravenous dexamethasone 6.6 mg and intravenous Cefotaxime 2 g were administered immediately, and adrenaline nebulised. We observed a rapid subjective and objective response. The patient was transferred to the Critical Care Unit for monitoring and on-going conservative therapy. She was found to have a white cell count of 16.5 9 109/L and a provisional diagnosis of acute bacterial tracheitis was made. The patient responded well to conservative therapy and repeat endoscopy at 48 hours demonstrated Myers & Cotton grade 1 disease.

We initially wanted to focus on patients that were on the emergency list and decided to run a pilot study to assess the feasibility of a post anaesthetic ward round conducted by the on call team at Manchester Royal Infirmary. We researched patient satisfaction measures in anaesthesia and as the emphasis initially would be on establishing a system, we choose simple measures for the pilot, which included pain, post-operative nausea and vomiting and general satisfaction.

Results We completed 10 ward rounds during the pilot, the mean time taken was 33 minutes (range 20-45) with approximately 3-4 minutes per patient. Fortythree patients were included in the pilot; the breakdown of those is included in Figure 1. Of the patients seen twenty reported no nausea and vomiting and three mild nausea. Two reported no pain, twelve mild pain, seven moderate pain and two severe pain. We were able to address the pain issues during the ward round by making changes to the drug chart or requesting analgesia from the nursing staff. With regards to satisfaction fourteen patients reported they were very satisfied and nine were quite satisfied.

Description

Discussion Bacterial tracheitis is rare outside of paediatric practice, and can be catastrophic. Meticulous planning of airway management and close liaison with ENT are mandatory. The supraglottis is often normal, meaning straightforward direct laryngoscopy, however passing an endotracheal tube can be challenging. Rapid clinical response to nebulised adrenaline demonstrates the presence of soft tissue oedema; therefore easier intubation may be predicted. The Myers & Cotton system is a useful tool for assessing severity and response to treatment.

Reference Jonas T. Johnson, MD; Stephen L. Liston, MD Bacterial Tracheitis in Adults Archives of Otolaryngology - Head & Neck Surgery 1987; 113(2): 204–205.

Discussion Our study showed that the vast majority of time it is possible for the on call team at our hospital to conduct a post anaesthetic ward round of emergency patients. There are many options for our project going forward. We could continue to focus on emergency patients and with engagement from other trainees conduct the ward round on a daily basis. By conducting the ward round earlier in the day I would hope we could capture more patients prior to discharge. The questionnaire could be changed to a validated questionnaire such as Bauer et al. 2001, which focuses on both anaesthesia related discomfort and satisfaction with anaesthesia care[2]. We could broaden the project to include trauma and elective patients, in this case due to numbers involved we would need to look into administration staff conducting the initial ward round and trainees following up any problems highlighted. Finally we would like to look at the possibility of using an automated online questionnaire that could feedback to the anaesthetic team highlighting potential problems on the ward, so that trainees could conduct a review of selected patients.

References 1. Venn P, Lester O. ACSA Pilot Project wash up. The Royal College of Anaesthetists Bulletin 2013; 82: 31–34. €hrer H, Aichele G, Bach A, Martin E: Measuring patient satisfaction 2. Bauer M, Bo with anaesthesia: Perioperative questionnaire versus standardised face-to-face interview. Acta Anaesthesiologica Scandinavica 2001; 45: 65–72.


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A paturient with complex von-Willibrands Disease

Trainee led ultrasound teaching in regional anaesthesia in a district general hospital

D. Mayhew1 and C. Wild2 Royal Liverpool & Broadgreen University Hospitals NHS Trust; 2Countess of Chester Hospital

B. McConville and E. Skibowski Ulster Hospital Dundonald

1

Description A 39 year old woman (G1P0) presented for elective caesarean section at 28 weeks gestation. Her medical history included lifelong type 1 von-Willibrands Disease (vWD) characterised by haemarthrosis of the hip, recurrent severe endometriosis, recurrent spontaneous rectus sheath haematoma, and catastrophic temporomadibular joint (TMJ) haemarthrosis requiring joint reconstruction. The patient was overweight, her Mallampati score was 4, Calder A, neck movement and teeth were normal. The patient complained of severe coccydynia and reduced hip movement due to previous haemarthosis. Neuraxial anaesthesia was deemed inappropriate due to her severe bleeding tendency and other complaints. Specific advice regarding the management of her coagulopathy was sought from a consultant haematologist as she previously had demonstrated anaphylaxis to Desmopressin (DDAVP). Two thousand units of Haemate P were administered 1 hour prior to incision, with further Haemate P doses available for the post-operative period. Blood and clotting products were ordered and cell salvage was operated in theatre. A fibrescope and difficult airway trolley were in theatre and prepared for use on induction in case of difficult airway. Prior to induction two large bore intravenous access sites were secured and blood was obtained for a baseline ROTEM assessment, which was normal. General anaesthesia was induced with thiopentone and suxamethonium. A grade 2B view was obtained on laryngoscopy with a standard Macintosh laryngoscope and a 7.5 cuffed, oral endotracheal tube was passed over a bougie on the first attempt. Uterine tone was restored post delivery with two 5 unit boluses of syntocinon, a syntocinon infusion, and a 250 mcg bolus of ergometrine. Estimated blood loss was less than 1000 ml, and no sufficient volume of blood was available to process in the cell saver. In recovery the patient was again discussed with the haematology team and a post op plan was initiated. Post op ROTEM was normal. The patient was discharged from recovery without complication.

Discussion Haemarthropathy is not a prominent feature of type 1 vWD but if present can be catastrophic. In this case previous TMJ reconstruction limiting mouth opening complicated the decision to use general anaesthesia. Neuroaxial anaesthesia has been used in patients with vWD however in this case the patients bleeding tendency was deemed too severe and general anaesthesia was the preferred choice following MDT discussion.

References Hara K1, Kishi N, Sata T. Considerations for epidural anesthesia in a patient with type 1 von Willebrand disease. Journal of Anesthesia 2009; 23(4): 597–600. Englbrecht JS1, Pogatzki-Zahn EM, Zahn P. Spinal and epidural anesthesia in patients with hemorrhagic diathesis: decisions on the brink of minimum evidence? Anaesthesist 2011 Dec; 60(12): 1126–34.

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Ultrasound scan (USS) guided regional anaesthesia is gaining popularity amongst anaesthetists. Benefits for patients include avoidance of general anaesthesia and safe application of nerve blocks [1]. Success in performing ultrasound-guided peripheral nerve blockade demands sound knowledge of sonoanatomy, good scanning techniques, and proper hand-eye coordination [2]. Teaching in USS guided regional anaesthesia is usually delivered in regional or national courses which can be expensive and time consuming. We developed a local trainee led regional anaesthesia course primarily aimed at junior trainees in our department.

Methods Our goal was to teach sonoanatomy and its application, a prerequisite for safe nerve blocks, via live scanning of human models. We developed seven USS workshops, which were held during lunchtime breaks. Each workshop had a theme and covered common USS guided blocks. The workshops consisted of a brief PowerPoint based presentation by a senior trainee (ST6/ST7), followed by a live demonstration of the sonoanatomy and then supervised scanning by the participants. A consultant with experience in USS guided regional anaesthesia was present at each workshop. An internet-based survey was sent to participants gather feedback.

Results Two senior trainees designed and facilitated the USS workshops. Nine trainees participated in giving feedback through an online internet survey. Nine responders (100%) felt the workshops were worthwhile. Nine respondents (100%) are more confident using ultrasound scanning and are more confident with sonoanatomy having attended the workshops. Eight responders (89%) felt more confident either performing or being supervised doing a USS guided regional nerve block having attended the workshops.

Discussion Education in sonoanatomy is vital for the safe application of USS guided regional anaesthesia. A locally organized course is a good way to transmit knowledge and minimize disruptions to clinical services and training. Trainee led teaching can have a positive effect on creating an informal learning atmosphere resulting in good learning and increased confidence.

References 1. Ultrasound-guided regional nerve block (IPG285), NICE guidance, January 2009. http://www.nice.org.uk/guidance/IPG285 2. Niazi AU, Haldipur N, Prasad AG, Chan VW. Ultrasound-guided regional anesthesia performance in the early learning period: effect of simulation training. Regional Anesthesia & Pain Medicine 2012 Jan-Feb; 37(1): 51–4.


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Implementing a ventilator associated pneumonia prevention bundle in intensive care at university teaching hospital, Zambia C. McCue,1 L. Bowen,1 S. Brosnan1 and J. Kinnear2 University Teaching Hospital, Lusaka, Zambia; 2Southend University Hospital

A perfect storm: lithium induced nephrogenic diabetes insipidus complicating the management of hypernatraemic seizures in severe hyperosmolar hyperglycaemic state

1

University Teaching Hospital in Lusaka is the largest hospital in Zambia with over 1600 beds, serving a population of around 2 million. The 10-bedded Intensive Care Unit (ICU) is currently undergoing development as part of the ongoing improvements within the anaesthetic department and has recently introduced daily consultant ward rounds. One feature of quality improvement is to implement care bundles to reduce hospital-acquired infection (HAI). Ventilator associated pneumonia (VAP) is the most common ICU HAI, with rates of 45% [1]. VAP is associated with increased mortality, duration of ventilation, ICU stay, and cost [2]. Compounding this problem in developing countries is the lack of adequate infection control surveillance programmes, and subsequently no awareness of institutional VAP rates [3].

A. Morgan Edinburgh Royal Infirmary

Hyperglycaemic Hyperosmolar State (HHS) is a rare endocrine emergency when compared with Diabetic Ketoacidosis (DKA). HHS is characterised by severe hyperglycaemia, hyperosmolality and hypovolaemia in the absence of significant ketoacidosis. Patients presenting with HHS are often but not exclusively elderly with co-morbidities that can significantly compromise treatment protocols.

Methods

Description

We implemented a low cost VAP prevention bundle for all ventilated patients with 4 elements:oral care with mouthwash, head of bed elevation, regular suctioning, and antacid prophylaxis. Implementation was supported with staff education, display of posters and daily compliance checks on ward rounds. Pre-implementation data was collected retrospectively from admission logs and case notes. Post implementation, daily review of ICU admissions was performed. Diagnostic criteria for VAP included worsening gas exchange or increased ventilation requirements, plus signs of sepsis or new chest x-ray changes. To improve data collection; a database of ICU admissions was initiated.

We report a case of HHS in a 42-year-old lady complicated by previously undiagnosed Lithium induced Diabetes Insipidus (DI). Over the previous 2 years her weight had doubled to 120 kg secondary to polydipsia related excessive milk consumption. Hypertriglyceridaemia induced pancreatitis was thought to have precipitated HHS. Initial serum osmolality was 400 mOsm/kg with a glucose concentration of 55 mmol/l and urea 20.8 mmol/l. Sodium concentration increased to 175 mmol/L from 162 mmol/L during fluid resuscitation precipitating generalised seizures. She was intubated, started on vasopressors for hypotension and had a normal CT head. Sodium concentration could not be normalised due to the DI. She required a dextrose infusion, NG water, a low sodium diet, Amiloride and Bendroflumethiazide to normalise both serum osmolality and sodium concentration over 9 days within Intensive Care.

Results Table of pre and post bundle implementation data Pre-implementation data

Post-implementation

Results

(4 weeks)

data (5 weeks)

Discussion

Male:Female ratio

1.9:1

1.8:1

Age range (years)

9 months–80

6–73

In HHS the admission sodium is often low due to the osmotic flux of water from the intra-cellular to the extra-cellular space in the presence of hyperglycaemia. An increased or even normal serum sodium concentration indicates a profound degree of water loss. These electrolyte shifts may have taken several days to occur and rapid correction could result in cerebral oedema, seizures and Central Pontine Myelinolysis (CPM). An initial rise in sodium is normal and reflects both a decrease in serum glucose concentration and increased intra-cellular water concentration resulting from the actions of exogenous insulin. Recent guidelines from The Joint British Diabetes Societies suggest that serum osmolality should be used to monitor free water deficit correction rather than serum sodium concentration. Lithium induced Nephrogenic Diabetes Insipidus meant that free water replacement to correct profound volume depletion failed to normalise sodium concentration. In complicated cases in which urinary concentrating ability is impaired, using a combination of free water and Amiloride may be necessary to correct serum osmolality and avoid the neurological consequences of hypernatraemia. Lithium enters the collecting duct cells predominantly via an epithelial sodium channel (ENaC). ENac is inhibited by Amiloride, improving renal concentrating ability.

Total patient number

47

76

Mortality (%)

47%

32%

Patients ventilated

13 (27%)

10 (13%)

77%

1.3%

>48 hours (%) VAP rate

Bundle compliance was difficult to assess, however drug prescription and mouthwash use was universal as observed in charts and from daily discussion with nursing staff.

Discussion This study has confirmed that VAP is a significant issue in this ICU population. There are a number of obstacles to be overcome in a resource poor setting to reduce HAI including staff and equipment shortages, and inadequate surveillance. We have demonstrated even with low cost interventions that improvements can be achieved. Limitations of this study include lack of microbiological support for VAP diagnosis, retrospective data collection, which may explain the high initial VAP rate, and the confounding factor of simultaneous initiation of consultant led ward rounds. However via the process of initiating this bundle we have improved data collection by setting up a computerised database within the unit,and encouraged regular surveillance of healthcare associated infection.

Acknowledgements All staff in ICU at UTH, Dr D Snell, ZADP.

References 1. Vincent JL, Bihari DJ, Suter PM, et al. The prevalence of nosocomial infection in intensive care units in Europe: Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. Journal of American Medical Association 1995; 278: 639–644.

References 1. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic Crises in Adult Patients with Diabetes. Diabetes Care 2009; 32: 1335–1343. 2. The Management of the hyperosmolar hyperglycaemic state (HHS) in adults with diabetes. Joint British Diabetes Societies Inpatient Care Group. August 2012. 3. Bedford JJ, Weggery S, Ellis G, McDonald FJ, Joyce PR, Leader JP, Walker RJ. Lithium-induced nephrogenic diabetes insipidus: renal effects of amiloride. Clinical Journal of the American Society of Nephrologists 2008; 3: 1324–31. 4. Alexander MP, Farag YMK, Mittal BV, Rennke HG, Singh AK. Lithium toxicity: a double-edged sword. Kidney International 2008; 73: 233–37.

2. Rello J, Ollendorf DA, Oster G et al. Epidemiology and outcomes of ventilator associated pneumonia in a large U.S. database. Chest Journal 2002; 122: 2115–2121.

3. Rosenthal VD. Health care associated infections in developing countries. Lancet 2010; 377: 186–8.


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Paediatric resuscitation and re-validation for anaesthetists at a busy district general hospital R. Morris,1 D. Eastwood,2 J. Briscoe1 and M. Denton2 Sheffield Teaching Hospitals; 2Doncaster Royal Infirmary

A DGH experience: do blocks really rock? ‘‘Pain management the morning after’’ peripheral nerve blocks in day surgery

1

A. Mustafa and S. Farrell Hairmyres Hospital

At a large district general hospital such as Doncaster Royal Infirmary (DRI), many anaesthetists will be faced with anaesthetising children either on a regular basis or infrequently both for elective operations or whilst on call. Maintaining paediatric resuscitation skills and recognising the sick child is therefore important to anaesthetists. Guidance on the provision of paediatric services from The Royal College of Anaesthetists state that all consultants and career grade staff who provide anaesthetic cover for children should participate in Continuing Professional Development (CPD) relating to paediatric anaesthesia and resuscitation. With the introduction of revalidation, all anaesthetists need to demonstrate proficiency in paediatric resuscitation skills highlighted in the CPD matrix [1]. Our aim was to determine the current level of paediatric resuscitation training amongst anaesthetists at DRI and to determine if staff felt prepared to manage paediatric emergencies.

Methods A survey of all anaesthetists working at DRI in 2012 was undertaken to assess current level of paediatric resuscitation training. Results were presented at the trust audit meeting. This raised awareness of the importance of keeping up to date with paediatric resuscitation skills both for safe practice and to provide evidence for revalidation. Access to trust based EPLS courses was made easier (no need to claim for funding) and all permanent staff were encouraged to attend. We then repeated the survey 2 years later.

Results There are a total of 54 anaesthetists working at DRI., 32 consultants, 10 associate specialists and 15 trainees. The response rate was 78% in 2012 and 74% in 2014. The spread across grade of anaesthetist was similar. The results are summarised in the table. Where permanent staff are referred to, these are associate specialists and consultants. Table Level of paediatric training and exposure to paediatric cases in Anaesthetists at DRI. Values are percentages.

Effective analgesic nerve blocks are satisfying for both patient and Anaesthetist. Transition pain however as a nerve block wears off can be severe and in our centre has not been assessed. Further, we were interested in whether discharge analgesia was sufficient to cover this transition and the period thereafter. A telephone call was made by the Acute pain Sister on day 1 post op, having obtained prior permission. If the patient was not contactable on day 1 further attempts were made. We asked when the block wore off, and pain score when it did using the numeric pain scale (1-10) on rest and on movement. Our standard take home prescription includes Paracetamol 1 g or Cocodamol 30/500 (2 tablets) and/or Diclofenac 75 mg. We asked whether discharge pain relief was sufficient and whether there was a need for additional pain relief from the GP/ A&E.

Results Data from 51 orthopaedics day case patients were collected. There were 25 males and 26 females. Forty nine received general anaesthesia while 2 received spinal anaesthesia. Forty five had a lower limb procedures, 6 had Upper limb procedures. All patients received one or more peripheral nerve block(s). The most commonly performed peripheral nerve blocks were combined saphenous and popliteal nerve blocks (25) followed by popliteal (12), saphenous,SNB (5), interscalene,ISB (5), ankle(2), femoral(1) and axillary (1). All blocks were ultrasound guided except the ankle blocks. Forty seven blocks were performed by a consultant while 4 blocks were performed by a trainee. Five patients did not fulfil the criteria for discharge on day of surgery, mainly because of pain and 3 patients felt that the discharge analgesia were not sufficient and visited their GP to obtain stronger painkillers.Four patients were uncontactable despite several attempts. Average pain scores at rest was 2.7 and 3.7 on movement. The onset of pain was gradual in 31, sudden in 5 and difficult to tell in 15 patients. The time of pain onset was on average 11 hours after the block was performed.

2012

2014

Discussion

55

68

Paediatric update attended in past 2 years

45

65

Paediatric update attended in past 2 years (permanent staff)

28

66

Exposure to paediatric cases within the past year (permanent

69

94*

Overall Regional Block Analgesia was sufficient, for all patients were satisfied with their nerve blocks. Despite the small study group there were some patterns in specific blocks(ISB and SNB) in that analgesia offset would appear to be related to the smaller total dose of LA used. The optimization of pain management especially in patients with complex and chronic pain issues could be better anticipated by utilizing multi-modal analgesia and sending the patient home with a short course of stronger analgesia than is currently our practice. These patients should receive further counselling prior to discharge.

Anaesthetic staff with current valid paediatric resuscitation certificate

staff) *

Methods

Remaining 6% never anaesthetise children.

References

Discussion By carrying out the intial survey and presenting it at a trust audit meeting, we raised awareness of the importance of keeping paediatric resuscitation skills up to date. The process of carrying out audits and surveys such as these motivates staff to examine their own weaknesses and identifies areas of need for further training. This training needs to be easily accessible by all staff. By making access to paediatric updates and mandatory training easier and having funding readily available, we have given staff the opportunity to update their skills in managing what are rare and stressful situations whilst providing evidence for revalidation

1. Boezaart AP, Davis G, Le-Wendling L. Recovery after orthopedic surgery: techniques to increase duration of pain control. Current Opinion in Anaesthesiology 2012; 25(6): 665–672. 2. Chakravarthy V, Arya VK, Dhillon MS et al. Comparison of regional nerve block to epidural anaesthesia in day care arthroscopic surgery of the knee. Acta Orthopaedica Belgica 2004 Dec; 70(6): 551–559. 3. Zaric D, Boysen K, Christiansen J, Haastrup U, Kofoed H, Rawal N. Continuous popliteal sciatic nerve block for outpatient foot surgery–a randomized, controlled trial. Acta Anaesthesiologica Scandinavica 2004; 48(3): 337–341.

Reference 1. Royal College of Anaesthetists, Paediatric Anaesthetic Services, revised 22.4.2010 – Guidance on provision of paediatric anaesthesia services.

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Post operative outcomes of patients undergoing retropubic radical prostatectomy since introduction of ERAS

Multidisciplinary observer accuracy of visual blood loss estimations in a simulated obstetric clinical scenario in a district general hospital

A. Naik Wrexham Maelor Hospital

A. Nath, S. Gajree and D. Macnair NHS Dumfries and Galloway

Traditionally open retropubic radical prostatectomy surgery had been carried out under general anaesthesia with epidural analgesia .Although this technique provided satisfactory post-operative analgesia there was concern that there were delays in peri-operative recovery causing prolonged length of stay mainly due to delay in mobilization, resuming oral diet, normal independent daily activities and postoperative nausea and vomiting. A change in anaesthetic practice (guideline) was introduced in October 2012 with the aims to improve mobilization and reduce length of stay. Intrathecal Diamorphine (1-1.5 mg) was introduced as the main form of analgesia on the basis of its beneficial effects in the ERAS pathway for Colorectal surgery .We thought it timely to review the effects of the change in practice and as a preliminary step to developing local protocols

Methods We conducted a single blinded, prospective study of the accuracy of visual estimation of volumes of blood in three ‘mock up’ obstetric haemorrhage scenes. Three model pelvises were positioned to create the appearance of a real life clinical scenario of a patient in lithotomy position, and expired units of blood were applied to the models. Volumes of 2500 mls, 1250 mls, and 500 mls were used. volunteers estimated blood loss for each scene. The speciality of the participant and experience level was noted.

Results

We collected data retrospectively from 24 patients who underwent radical retropubic prostatectomy at the University Hospital of Wales following the introduction of a change in anaesthetic practice. Authorization to perform the study was obtained and notes reviewed. We looked at time to first oral fluids and solids, time to sitting in a chair, walking and discharge from ward. We measured post operative pain and PONV scores at 4, 12, 24 and 48 hrs

8 midwives, 25 theatre nurses, 11 theatre health care assistants, 12 anaesthetists, 10 obstetricians participated. The median percentage difference from the true blood volumes for scenario 1, 500 mls, was an underestimate of 40% (IQR 70.55 [-56.55-20]. The median percentage for scenario 2, 2500 mls, was an underestimate of 40% (IQR 43 [-63- 20]). The median percentage for scenario 3, 1250 mls, was an underestimate of 20% (IQR 77 [-57- 20]). When plotted graphically, the results revealed no difference in accuracy between groups of differing experience.

Results

Discussion

Methods

The study suggests that health care providers are inaccurate when visually estimating blood loss volumes in obstetric cases, consistently underestimating blood loss, particularly so with large volumes. This has been highlighted in other studies 1,2

Measurement

Measured value

Gold Standard

Time to oral fluids

4 hrs 55 mins

4 hrs

Time to oral solids

19 hrs 53 mins

8 hrs

Time to sitting in chair

25 hrs 19 mins

24 hrs

References

Time to walking

48 hrs 15 mins

36 hrs

Time to discharge

87 hrs 15 mins

56 hrs

1. Yoong W, Karavolos S, Damodaram M, et al. (2010) Observer accuracy and reproducibility of visual estimation of blood loss in obstetrics: how accurate and consistent are health-care professionals? Archives of Gynecology and Obstetrics 2010 Feb; 281(2): 207–213. 2. Gharoro EP, Enabudoso EJ (2009) Relationship between visually estimated blood loss at delivery and postpartum change in haematocrit. Journal of Obstetrics and Gynaecology 2009 Aug; 29(6): 517–520.

Discussion Although the measured pain and PONV scores remained low due to effective analgesia and anti emetic regimen, time to mobilization and length of stay remain concerns that need to be addressed. Some of this variance identified was as a result of the timing of the surgical procedure in the afternoon as opposed to the morning. A major pitfall of this project was the poor documentation in medical and nursing entries in the post-operative notes. This demonstrates the need to improve awareness about the enhanced recovery process amongst the medical and nursing staff and to prepare a formal pathway for audit purposes .Uniformity of anaesthetic practice between individual clinicians by adhering to local guidelines also needs to be addressed.

[Correction added on 10 July 2014, after first online publication: Author A. Nath has been inserted.

Reference 1. Arumainayagam N,McGrath J,Jefferson KP,Gillatt DA .Introduction of an enhanced recovery programme for radical cystectomy. British Journal of Urology International 2008 Mar; 101(6): 698–701.


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Reducing unplanned day case laparoscopic cholecystectomy surgical admissions in a district general hospital L. O’Connor and A. Hussey North Tyneside General Hospital Day case surgery is rapidly becoming a default pathway with the Department of Health setting a target of 75% of all elective surgical procedures to be carried out as day case [1]. National guidelines recommend unplanned admission rates should be 2-3% however data from a recent Cochrane review evaluating laparoscopic cholecystectomy surgery disclosed a rate of 15% [2]. A preliminary 6 month audit of 404 day case general surgical procedures at North Tyneside General Hospital identified more than 50% of unplanned general surgery admissions were following laparoscopic cholecystectomy. This equated to 35% of all patients undergoing day case laparoscopic cholecystectomy requiring admission post procedure.

Methods A retrospective case note audit of unplanned admissions was conducted between June and November 2011. Reasons for admission and modifiable factors to reduce unplanned admissions were identified. The results were presented to the multidisciplinary team and a re-audit was conducted between January and June 2012.

Results June - November

January - June 2012:

Patient Demographics

2011: initial audit

second audit

Number day case Laparoscopic

16

98

Median age (years)

37.5 (19–74)

59.6 (22–82)

Male:Female

1:7

1:5

Median ASA Grade

2

2

Median anaesthetic and

82.5 (30–150)

58.5 (20–135)

Cholecystectomies

surgical time (minutes)

Anaesthetic registrars in Zambia: a survey of experience E. O’Donohoe,1 E. Lillie,1 L. Bowen2 and R. McKendry3 1 Great Ormond Street Hospital; 2Royal Gwent Hospital, Newport; 3University Teaching Hospital, Lusaka

Global Health is emerging as an important issue for the government [1]. Since 2010, the Royal College of Anaesthetists have recognised higher training in ‘Anaesthesia in Developing Countries’ [2]. The Zambia Anaesthesia Development Project (ZADP) started in August 2012, and facilitates six-month placements for senior UK registrars to support the training of Zambian physician anaesthetists (MMeds) in Lusaka. This survey reports the experience of both Zambian and UK trainees involved in the programme to date.

Methods A 5-question survey was given to all 21 MMeds and all 3 ZADP registrars. It addressed the important facets of the ZADP: clinical workload, teaching and training, audit and quality improvement, management, and pastoral care.

Results 16 MMeds and 3 UK ZADP registrars replied to the survey (79% return rate). 60% of the MMeds reported that they were supervised on 1-5 theatre lists per month by the ZADP registrar. 58% felt that this number was too few. UK registrars felt that in total, they supervised many more than 10 lists per month, and that this was an appropriate number. Nearly 90% of MMeds said they received 2-5 non-clinical teaching sessions per month from the ZADP and that this was appropriate. This agreed with the results reported by the UK registrars. Over 90% of MMeds recorded that the ZADP contributed to departmental development and research project support, with over half saying this contribution was ‘a lot’. This corresponded well with ZADP registrar reporting. 81% of the MMeds felt pastoral support from the ZADP was important, with 94% grading the level of pastoral support given as ≥7/10. All ZADP registrars agreed pastoral support was important, and felt they had provided levels of support ≥8/10. 100% of respondents felt the ZADP registrar was an appropriate role model.

Discussion

June – November 2011: initial audit Overall 43.8% of admissions were unpredictable, 31.2% were avoidable and a further 25% would have been avoidable if the surgical day case unit extended working hours to 2100. Following presentation of these audit results, modifiable risk factors were identified and a subsequent audit between January & June 2012 showed a reduction in admissions to 14%. JanuaryJune 2012: second audit There was an overall reduction in admissions after addressing predictable factors including pain using multimodal analgesia and PONV by risk stratification and increasing use of total intravenous anaesthesia. Extending the surgical day case unit working hours to 2100 could again have reduced the number of admissions in this period. There was an overall reduction in admissions after addressing predictable factors including pain and PONV.

Discussion The implementation of audit findings focusing on the reduction of pain and PONV reduced the number of unplanned admissions in day case laparoscopic cholecystectomies from 35% to 14.1% This is still outside the national target of 2-3% thus further areas for improvement have been identified. A formal laparoscopic day case cholecystetctomy proforma has been developed and was implemented in January 2013. Ongoing audit following this implementation will hopefully show a sustained reduction in admissions with improved patient satisfaction.

This small survey demonstrates concordance between the ZADP experience of UK and Zambian anaesthetic trainees. The MMeds value the clinical supervision and teaching provided, but it is likely that the low ZADP:MMed ratio explains the discrepancy between how many supervised lists was felt to be appropriate. Possibly more importantly on a broader scale, however, was the importance placed on pastoral support, role modelling, and contribution to departmental clinical governance and management. It appears worthwhile for the ZADP to continue supporting anaesthetic training in Zambia.

References 1. All Party Parliamentary Group on Global Health. Improving Health at Home and Abroad: how overseas volunteering from the NHS benefits the UK and the world. July 2013. http://www.appg-globalhealth.org.uk/reports/ 4556656050 2. Royal College of Anaesthetists. Curriculum for a CCT in Anaesthetics August 2010; 2nd edn.

Acknowledgements Gail Taylor and nursing staff on the surgical day case unit, NTGH. Mr L Horgan, consultant surgeon, NTGH. Dr N Corbitt, consultant anaesthetist, NTGH

References 1. National Good Practice Guidance on Pre-Operative Assessment for Day Surgical Units. September 2002. Modernisation Agency: Operating Theatre PreOperative Assesment Programme. 2. Cochrane review lap cholecystectomy Anaesthetic regimens for day-procedure laparoscopic cholecystectomy (Review) Vaughan J, Nagendran M, Cooper J, Davidson BR, Gurusamy KS

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A survey of subclavian line insertion in anaesthetists C. OTI and M. Khan King’s College Hospital, London

In our experience subclavian line access is not a very common procedure taught and performed whilst training as an anaesthetic doctor. It has it’s own clinical relevance [1] especially for patients in intensive care with long standing central line requirements and perioperatively (High BMI, thrombosed jugular veins). We set out collecting information on competence and confidence in subclavian line insertion by trainees and consultants in this survey to identify current trends. One aim was to find out if current form of training is adequate to ensure competency in the insertion of subclavian lines by the trainee junior anaesthetist and to identify if required, a potential area of training which would need to be addressed.

Methods A questionnaire was sent out to Anaesthetists – Trainees and Consultants in mainly London Hospitals via e-mail. The survey was conducted with a popular survey tool. The results were analysed and the results are presented below.

Results One hundred and forty three questionnaires were completed and analysed. Twenty five percent (25%) of respondents were Consultants which enabled us to have a good spread. Fifty six percent (56%) of respondents received training by informal demonstration by a colleague and forty eight (48%) received formal training from a Consultant or Registrar. Seventy five percent (75%) had inserted less than 5 in the last year while some trainees had never done some. Sixty seven (67%) said the reason for not inserting subclavian lines was due to clinical requirements not dictating the need. Thirty seven (37%) were not confident to do so, thirty (30%) did not feel competent and thirty nine (39%) would not insert them because they did not feel they got enough practice with subclavian lines. Twelve (12%) felt they could insert subclavian lines with distant supervision and the same trcentage with indirect supervision. Only thirty six (36%) felt able to teach. A low figure, twenty eight (28%) used the ultrasound for insertion of subclavian lines. Sixty percent (60%) said c-spine collar in situ would be an indication for a subclavian line insertion and the commonest contraindication was coagulopathy

Discussion With this survey we have attempted to highlight the growing need of a formalised training approach for performing subclavian line insertion. There have been reports of various complications [2], which have occurred whilst attempting to perform this procedure and this is reflected in the low level of confidence for performing this procedure independently in our survey. We recommend more training list opportunities, introduction of formal teaching sessions and workshops to improve competence

References 1. Pulliam CW Subclavian vein catheterization. American Journal of Surgery 1985; 149: 416–418. 2. Brooks AJ. Ultrasound guided insertion of subclavian venous access ports. Annals of the Royal College of Surgeons of England 2005; 85: 25–27.

178 Poor correlation between visual analogue score (VAS), subjective pain relief and patient satisfaction after lower segment caesarean section (LSCS) yet still achieving new audit standard M. Pachucki,1 P. Ricci,2 N. Wharton,1 L. Herbert,1 S. Grier,1 T. Knight1 and S. Moxham1 1 Bristol Royal Infirmary; 2University of Bristol

Pain relief post LSCS is paramount in improving patient experience and reducing morbidity. In 2009, when last audited, our department failed the standard of post LSCS pain relief defined at that time as pain scores on the visual analogue scale (VAS) of less than 3 for >90% women [1]. Since then, and following debate in the literature [2], a new standard has been established by the RCOA [3] recommending >95% women to be satisfied with analgesia on day 1 post caesarean section with no mention of pain scores. If not contraindicated, 100% must also receive SAB opioid and NSAIDs.

Methods We undertook a prospective audit of post LSCS pain relief and patients satisfaction in our institution. Our project was registered with the Audit Department with the data collection and patient follow-up over 2 days post op (July 2013). Total number of caesarean sections performed during the audit period was 86 with 100% capture on day 1 and 63% capture on day 2 (many patients are transferred to a district general hospital for follow-on care). We reviewed the anaesthetic record, drug chart and questionned the mothers re: pain, side effects and satisfaction using a standardized data collection proforma.

Results All women having a spinal anaesthetic received subarachnoid opiate and all women were prescribed and given a NSAID regularly (unless contraindicated). Antiemetics (100%) and antipruritics (97%) were more widely prescribed than in 2009 audit (41% and 33% respectively) but pruritus complaints were more prevalent (51% vs. 33% of respondents in 2013 and 2009 audits). Fortunately, incidence of pruritus, nausea and vomiting was significantly reduced by day 2 in our sample – to 10%, 4% and 0% respectively. We reached the recommended ‘satisfaction’ target on both days (>95% respondents satisfied or more than satisfied) despite the fact that majority assessed their pain as above 3 on VAS (see Table 1). Alarmingly, it transpired that a large number of women (51%) suffered from pruritus on day 1 but did not receive any treatment despite appropriate prescription. Table 1 Pain self assessment, VAS scores and patient satisfaction on Day 1 VAS 1-3

VAS 4-6

VAS 7-10

41%

46%

13%

Mild

Moderate

Severe

58%

34%

6%

Satisfied and very satisfied

Not satisfied

96%

4%

Discussion Audit recommendations have changed since 2006 with emphasis on ‘satisfaction with analgesia’ rather than pain score on VAS. Satisfaction with analgesia and assessment of pain with VAS score do not seem to go hand in hand (in our sample 33% patients with mild pain gave a score above 3 on VAS). Since our re-audit, a Naloxone prescription sticker has been routinely attached to patients’ drug chart acting as a reminder and encouraging the ward staff to use it for pruritus treatment.

References 1. The Royal College of Anaesthetists; ‘Raising the Standard: a compendium of audit recipes.’ 2nd Edition 2006 2. Noblet J, Plaat F. Raising the standard. . .to unachievable heights? Anaesthesia 2010; 65: 87–8. 3. The Royal College of Anaesthetists; ‘Raising the Standard: a compendium of audit recipes.’ 3rd Edition 2012.


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Modified surgical procedure assessment (SPA) score can predict cardiac intensive care unit (CICU) length of stay M. Pachucki and J. Hillier Bristol Royal Infirmary

Intensive care beds are scarce in the UK. Identifying ‘fast-track’ patients and differentiating them from ‘prolonged stay’ patients can improve bed utilisation and resource allocation. ‘Fast-track’ protocols can only be implemented if ‘fast-track’ patients are reliably identified prior to surgery. Surgical Procedure Assessment (SPA) score [1, 2] is a simple, intuitive and easy to calculate pre-operative score that integrates surgical complexity (1-3) with patient co-morbidity (A-B). It has been shown to predict ICU length of stay (LOS) better than other scoring systems (i.e. Parsonnet, Tu, CARE) but it is not used routinely in our institution.

Methods We analysed 100 consecutive admissions to our CICU during 3 weeks in July 2013 and compared the length of ICU stay (ICU LOS), readiness for step down to High Dependency Unit (HDU) care with SPA score and EUROSCORE. Using our electronic database (Innovian system) we ascertained the SPA score (modified for type of surgery performed at our institution) of 95 patients eligible for the study and matched it with the ICU LOS and readiness for step down to HDU. We also used the modified SPA score to bundle the patients into short, intermediate and long stay groups and analysed the strength of that correlation.

Audit of follow-up after obstetric anaesthesia V. Paul, R. Kayani and H. Kaskos Wexham Park Hospital, Slough

Obstetric patients may undergo a regional or general anaesthetic procedure for labour analgesia, operative delivery or other surgical procedures. These anaesthetic procedures are associated with well-documented complications. Some of these are amenable to treatment and disastrous consequences can be avoided with early recognition. Follow-up of patients also gives the anaesthetist an opportunity to dispel any myths in the patient’s mind regarding any post natal symptoms wrongly attributed to the anaesthetic. It is also a platform to assess patient satisfaction, review anaesthetic shortcomings and plan for improvement in delivery of care. The Royal College of Anaesthetists recommends that 100% of patients should be followed up after an anaesthetic intervention.

Methods Review of entries in the anaesthetic register on the labour ward. Total number of cases having an anaesthetic input reviewed. The different types of anaesthetic interventions were noted. The number of patients who were not followed up was assessed.

Results In the month of review 228 obstetric patients had anaesthetic procedures. There were 66 Spinals; 127 Epidurals; 8 CSEs; 3 GA; 24 Epidural top-ups. Of these 82 patients were not followed up. The follow-up rate was only 64%.

Discussion

Results Ninety five patients were eligible for the study with median age of 68 years and were predominantly male (81 vs. 14). Majority of operations (90%) were performed on patients without significant co-morbidities (groups 1A and 2A). In our sample there was a strong correlation between increasing modified SPA score and ICU LOS (r = 0,82) as well as HDU readiness (r = 0,81). Furthermore, there was an even stronger correlation of both ICU length of stay (r = 0,97) and HDU readiness (r = 0,96) once patients were bundled into short (SPA group 1A only), intermediate (1B, 2A) and long stay (2B, 3A) groups depending on their modified SPA score. In comparison, the correlation, albeit weaker, was also present between the rising EUROSCORE and ICU LOS (r = 0,89) and EUROSCORE and HDU readiness (r = 0,42).

The audit was presented at the monthly departmental audit meeting. The reasons for not meeting the recommended standards was discussed. The main reasons were identified as: anaesthetic factors and patient factors. Anaesthetic factors included:- 1) Locum anaesthetist, 2) Anaesthetist busy, and 3) Lack of motivation? Patient factors identified were:- 1) Quick discharge, 2) Patient not in bed, and 3) Difficulty in locating patient due to frequent rearrangement of beds and names being taken off the noticeboard because of visit from ‘Care Quality Commission’. Recommendations made were: 1) Labour Ward Anaesthetic Consultant to ensure follow-ups had been done, 2) Make anaesthetic follow-up part of discharge check list, 3) Better induction for locum doctors about local policies including follow-up of patients, and 4) Re-audit.

Discussion

References

In our small sample higher SPA score was associated with increased ICU LOS. Despite its drawbacks – as any prospective score it does not take into account intraoperative events or complications - we believe SPA score can act as an adjunct in identifying prolonged ICU stay patients pre-operatively and as such help in more informed resource allocation and provide an easier way of scheduling in future.

1. 2. 3. 4.

OAA/AAGBI Guidelines for Obstetric Anaesthetic Services 2013. RCOG Standards for Maternity Care June 2008. RCOA Guidelines for Provision of Anaesthesia Services 2013. RCOA Raising the Standard: a compendium of audit recipes 2012.

References 1. Wagener G, et al. The Surgical Procedure Assessment (SPA) score predicts intensive care unit length of stay after cardiac surgery. Journal of Thoracic Cardiovascular Surgery 2011 Aug; 142(2): 443–50. 2. O Panzer, Surgical Procedure Assessment score predicts ICU length of stay in cardiac surgical patients. Critical Care 2006, 10(Suppl 1): P410.

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Survey of awareness of sepsis among healthcare staff in maternity services at a district general hospital

Evaluation of the STOP-BANG screening tool in diagnosis of obstructive sleep apnoea in specialist weight management patients

V. Paul, R. Kayani and H. Kaskos Wexham Park Hospital, Slough

F. Pearson,1 A. Batterham2 and G. Danjoux1 1 South Tees Hospitals NHS Foundation Trust, Middlesbrough; 2Teesside University Health and Social Care Institute, Middlesbrough

Genital tract sepsis has risen to become the leading cause of direct maternal deaths in the UK according to the latest triennial report (2006-2008) from the Centre for Maternal and Child Enquiries (CMACE). This is on a background of overall reduction in maternal mortality with a decline in most of the other causes of direct maternal deaths. Early recognition, close monitoring, antibiotic administration and implementation of protocol driven goal-directed therapies have been documented and recommended to improve outcomes and decrease sepsisrelated mortality. All health care professionals who care for pregnant and recently delivered women should adhere to local infection control protocols and be aware of the signs and symptoms of sepsis in the women they care for and the need for urgent assessment and treatment.1

Methods Questionnaire devised and sent via ‘surveymonkey’ to all doctors in the obstetrics & gynaecology department (28) and to all anaesthetists involved with obstetrics (26). A paper form with slightly different questions was given by hand to midwives circulating through the labour ward.

Results 16 responses were received from doctors and 14 from midwives. Among midwives: 29% did not know what was SIRS but 100% said they knew what was sepsis, 79% did not know the commonest cause of sepsis, 93% said they knew what to do in the 1st hour of diagnosis but only 57% had heard of sepsis six. Among doctors: Only 75% knew that sepsis was the leading cause of maternal mortality, only 19% knew the commonest source of sepsis, 69% knew the commonest causative organism, only 44% correctly identified the criteria for SIRS, however 56% knew the number of factors required to proclaim SIRS, only 34% knew definition of sepsis but 94% claimed to know the difference between sepsis, severe sepsis and septic shock and only 50% had heard of sepsis six.

Obstructive sleep apnoea syndrome (OSAS) is associated with an increased risk of perioperative complications [1]. The prevalence of moderate to severe OSAS in obese individuals is approximately 50%, with >80% of patients remaining undiagnosed. The STOP-BANG questionnaire is an 8-item screening tool validated in identifying OSAS preoperatively [2]. STOP-BANG thresholds have not been investigated in patients presenting for bariatric surgical procedures. Our aim was to assess the validity of the STOP-BANG questionnaire in identifying moderate-severe OSAS in patients referred from Specialist Weight Management (SWM) services.

Methods Consecutive patients referred for assessment of sleep disordered breathing by SWM services from August to December 2012 were included. A modified STOPBANG score was calculated for each patient (Figure 1) followed by assessment by a sleep physician. Diagnosis and severity of OSAS was made based on routine clinical institutional practice.

Results 104 patients (53 male) were included in the analysis. Mean (SD) body mass index (BMI) and body mass were 43.9 (7.3) kg.m 2 and 126 (27.3) kg, respectively, with 55/104 (53%) suffering from moderate-severe OSAS. No patients with a STOP-BANG score < 3 suffered from moderate-severe OSAS. ROC curve analysis identified a STOP-BANG cut-point of ≥5 as having the highest sum of sensitivity and specificity with an AUC of 0.83 (95% CI, 0.75 to 0.91). The associated likelihood ratios revealed that this STOP-BANG threshold would identify 71% of individuals with moderate-severe OSAS and would miss 21% of such individuals.

Discussion There was a general lack of awareness of SIRS, sepsis, severe sepsis, septic shock and the elements of sepsis six across the board. However, there was good awareness of the importance of early antibiotic administration. Recommendations for improvement included presenting the findings of this survey at a multidisciplinary monthly audit meeting, publicizing local sepsis guidelines, circulating easy-to-understand poster on sepsis, highlighting sepsis in local educational meetings and repeating the survey after a period of implementation of the changes.

References 1. Cantwell, Roch. Clutton-Brock, Thomas, Cooper, Griselda. Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer–2006–08. British Journal of Obstetrics and Gynaecology 2011; 118(Suppl. 1), 1–20. 2. Dellinger, R. Phillip, Levy, Mitchell, Rhodes, Andrew, et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. Critical Care Medicine February 2013; 41(2): 580–637. 3. Pasupathy, D, Morgan, M, Plaat, FS, Langford KS. Green-top Guideline No. 64a 1st edition - ‘Bacterial Sepsis in Pregnancy’. Royal College of Obstetricians and Gynaecologists April 2012.

Figure 1 Modified STOP-BANG questionnaire

Discussion We found the STOP-BANG tool to be a useful adjunct to aid in diagnosis and exclusion of moderate-severe OSAS in our study population. This has led to a change in the referral process from SWM/bariatric services to our Sleep unit at a regional level. STOP-BANG scores are now routinely calculated for all patients by referring teams and incorporated into the recently introduced referral pathway.

References 1. Kaw R, Chung F, Pasupuleti V, Mehta J, Gay P, Hernandez A. Meta-analysis of the association between obstructive sleep apnoea and postoperative outcome. British Journal of Anaesthesia 2012; 109(6): 897–906. 2. Chung F, Yegneswaran B, Liao P et al. STOP Questionnaire: A Tool to Screen Patients for Obstructive Sleep Apnea. Anesthesiology 2008; 108:812–21.


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184

Unilateral hypoglossal and recurrent laryngeal nerve injury following shoulder replacement surgery

An audit too far? A pan-Scotland survey of audit practice amongst anaesthetic trainees A. Primrose1 and F. Harding2 Crosshouse Hospital, Kilmarnock; 2The Royal Infirmary, Edinburgh.

1

L. Perry, S. Oosthuysen and S. Brown Norfolk and Norwich University Hospital

An ASA 2 64 year old gentleman underwent left total shoulder replacement. Anaesthesia was performed with awake interscalene block and a subsequent general anaesthesia. The interscalene block was performed under ultrasound guidance with 30 ml of 0.375% L-Bupivacaine injected. General anaesthesia was induced with propofol and atracurium. A grade 1 laryngoscopy was obtained and uneventful intubation with size 8 armoured endotracheal tube. A modified deck chair position was employed. Five days post-surgery he presented with numbness to his tongue and dysphonia. Initial assessment suggested Tapia syndrome [1]. An MRI scan was normal and neurologists diagnosed isolated right hypoglossal nerve injury. By 6 weeks his symptoms had resolved.

Discussion Tapia’s syndrome is a rare complication with extracranial involvement of recurrent laryngeal and hypoglossal nerves. The anatomical course of the hypoglossal nerve passes through relatively protected tissues with the exception of close proximity to the hyoid bone [2]. Compression with laryngoscope blades, laryngeal masks and endotracheal tubes have been implicated in cases of hypoglossal injury [3]. Trauma from an interscalene block has been reported as a cause of Tapia’s syndrome [4]. However, in this case paralysis was on the contralateral side to the nerve blockade. Excessive head rotation may occur during positioning or head may be moved during surgery and this has been associated with such injuries [5]. The modified deck chair position used in our centre tends to extend and rotate neck, raising possibility of such a cause. Whilst this condition tends to settle with time it causes distress to patients whilst symptoms persist. It is better to minimise risk by monitoring the inflation pressure in the endotracheal tube cuff, restricting manipulation of neck during surgery and considering use of clear drapes to allow observation of neck in case of movement during surgery.

References 1. Boisseau N. et al. Tapia’s syndrome following shoulder surgery. British Journal of Anaesthesia 2002; 88: 869–870. 2. Haslam B. et al. Unilateral Hypoglossal Neuropraxia following endotracheal intubation for total shoulder arthroplasty. AANA Journal 2013; 81: 233–236. 3. Stewart A, Lindsay WA. Bilateral hypoglossal nerve injury following the use of the laryngeal mask airway. Anaesthesia 2002; 57: 264–265. 4. Johnson T. et al. Cranial Nerve X and XII paralysis (Tapia’s syndrome) after an interscalene brachial plexus block for a left shoulder Mumford Procedure. Anesthesiology 1990; 90: 311–2. 5. Rhee G, Cho N. Isolated unilateral hypoglossal nerve palsy after shoulder surgery in beach-chair position. Journal of Shoulder and Elbow Surgery 2008; 17: 28–3.

104

Audit is a requirement of training, and participation in audit is mandatory to gain certificate of completion of training (CCT) [1]. Trainees are expected to complete at least one audit per year, however as audit is a measurable quantity of training there may be a pressure to complete more. Growing emphasis is placed on patient safety and quality improvement and audit is a valuable tool to facilitate this. However, with audit as a necessity, there is a risk it may be used incorrectly. We sought to gain more information regarding the audit process amongst Scottish anaesthetic trainees.

Methods All anaesthetic trainees in Scotland were invited to complete a short survey via email. This consisted of ten questions relating to the audit process, the results of which were then compiled.

Results A total of 66 trainees participated in the survey. This included a mixture of training grades, with nearly 50% being ST5-7. Of the trainees, more than half (58%) had completed one audit or less in the preceding twelve months and 64% of those surveyed had not completed an audit loop. Eighty percent of trainees had not received information regarding their audit lead at induction and many were not aware who the departmental lead was within their instituition (60%). The main reason for involvement in audit was as a requirement for their annual review of competence and to enhance their curriculum vitae (CV.) Only 12% participated in audit to enhance patient safety and 8% for quality improvement. The main barriers to completing audit involved changing rotations (64%) and a lack of support with audit ideas (77%). Lack of time due to clinical commitments also featured highly (73%). Questions in relation to making the audit process easier illustrated that an up to date list of departmental audits and a mentor system would be greatly beneficial. Of concern, more than 50% of trainees felt their training did not benefit from conducting audits.

Discussion Audit is a valuable tool, and if used correctly can help lead advances in patient care. However with a large emphasis put on audit in our training, danger exists that this may drive poor quality audit. This survey illustrates there are clear barriers to completing audit within current training and trainees feel under pressure and under supported in the process. Changing rotations and rota demands make completing the audit cycle difficult. Worryingly this compulsory part of the curriculum is viewed by more than 50% of the training body as non-beneficial. Solutions that help ensure high quality audit and facilitate the process, include a locally established audit data base with mentorship from consultants and senior trainees

References 1. CCT in Anaesthetics: Teaching and training, academic and research (including audit), quality improvement, and management for anaesthesia, critical care and pain medicine. 2nd edn. The Royal College of Anaesthetists; August 2010. Version 1.5. Available from http://www.rcoa.ac.uk/system/files/ TRG-CCT-ANNEXG.pdf (accessed March 2014)


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Audit on lower limb arthroplasties nephrotoxic drug usage

Emphysematous pyelonephritis I. Qazi1 and S. Shanbhag2 1 Birmingham Heartlands Hospital; 2Walsall Healthcare NHS trust

I. Qazi,1 M. Prasanna2 and S. Shanbhag2 1 Birmingham Heartlands Hospital; 2Walsall Healthcare NHS trust •

EPN is a severe necrotising infection of the renal parenchyma that causes gas accumulation in the tissues. It often has a fulminating course, and can be fatal if not recognized and treated promptly [1]. The first case of pneumaturia was reported in 1898; since then, approximately 200 cases of EPN have been reported.

Tranexamic Acid administration is currently a part of the Enhanced Recovery Protocol in Hip and Knee Arthroplasties (THRs and TKRs)[1]. The aim of it’s use is to minimise peri-operative blood loss and potentially reduce the requirement of peri-operative blood transfusions[1-3].

•

Methods •

Pre-operative assessment data collected from Anaesthetic assessment records, T & O clinics and GP letters, for patients undergoing lower limb joint replacement surgeries. Pre-operative and post-operative blood investigations noted. Administration of peri-operative Tranexamic Acid, Gentamicin and potential nephrotoxic drugs recorded. Peri-operative blood/blood product transfusion noted. Details of any significant post-operative events or complications noted.

• • • •

Results PATIENT DEMOGRAPHICS No. of patients audited Male patients —25 Female patients—25 Average (Median) age of patients (in years) Male patients—74 Female patients—71 TYPE OF JOINT REPLACEMENT SURGERY TKR—27 THR—18 Revision THR—4 Revision TKR—1 AVERAGE (MEDIAN) LENGTH OF STAY (IN DAYS) TKR—5 THR—8 Revision THR—23.5 Revision TKR—11 PERI-OPERATIVE RENAL DYSFUNCTION

• • •

Description A 56 year-old Caucasian male, was admitted to A&E with h/o severe abdominal pain, vomiting and collapse. He had been on treatment for a UTI. PMH- T2DM, PVD & HT. He was found to be in septic shock on clinical assessment and was subsequently intubated and ventilated due to a reduced GCS and progressive hypoxia. A CT abdomen revealed extensive gas within the left renal bed and with the renal parenchyma. Left kidney measured 11.3 cm c.f, right kidney 6.9 cm.

ITU management Severe sepsis leading to MOF with severe metabolic and lactic acidosis. Clinical deterioration despite fluid resuscitation, antibiotics and vasopressor therapy. Worsening metabolic acidosis with acute renal failure required urgent CVVHDF therapy. Initial improvement was followed by rapid increase in vasopressor therapy and cardiac arrhythmias. The patient eventually died following cardiac arrest on D3.

25 out of the 50 patients audited had pre-existing Renal Dysfunction. Average Sr. Creatinine in these patients- 114 lmol/L 3 patients with previously normal renal function developed ARF post-operatively.

PERI-OPERATIVE TRANEXAMIC ACID ADMINISTRATION

•

12 out of the 29 pts. who received Tranexamic acid had significant risk factors, & there was no or poor consideration of its dose reduction & or avoidance.

PERI-OPERATIVE HAEMOGLOBIN LEVELS Female

Male

Discussion The clinical features of EPN are Fever (79%), Abdominal or flank pain (71%), Acute renal impairment (35%), Shock (29%), Altered sensorium (19%), Nausea and vomiting (17%), Dyspnea (13%) [2–3].

Peri-operative hemoglobin (HB)

patients

patients

Average (Median) pre-operative HB (in g/dl)

12.7

13.6

Average (Median) post-operative HB (in g/dl)

10.0

11.1

Average (Median) drop in HB (g/dl) in patients

2.55

2.1

Pathogens associated: Escherichia coli (66%), Klebsiella (26%) Others-Proteus, Pseudomonas, Streptococcus,Clostridium and Candida species. Recently, Entamoeba histolytica and Aspergillus fumigatus. Mixed acid fermentation is the mechanism of gas production & is secondary to rapid tissue catabolism and impaired transport of the end products at the inflammatory site [4].

2.6

2.3

EPN Staging

EPN- etiopathology

who received Tranexamic Acid Average (Median) drop in HB (g/dl) in patients who did not receive Tranexamic Acid

Discussion

• • • • • •

Poor prediction of high risk factors and peri-operative outcomes. Poor to no consideration of dose reduction and or avoidance of Tranexamic acid in patients with significant Risk factors. Lack of uniformity in dose reduction of Gentamicin &/ tranexamic acid in pts. with preop. Renal dysfunction. Surgical prophylaxis Policy with regards to IV Gentamicin administration not being adhered to. Lack of comprehensiveness in anaesthetic pre-operative assessments. Patient co-morbidities overlooked during pre-op. assessments by T & O.

Audit Recommendations

• • • •

To organise a joint multi-disciplinary meeting to highlight & discuss the findings of this Audit. Revision of the current Tranexamic acid protocol in light of the audit findings and in keeping with current evidence based practice. Improvement in the quality of pre-operative assessments for Hip and Knee Arthroplasties, to further enhance patient care and peri-operative outcomes To do a re-audit after implementation of current recommendations, to consistently and continually improve patient care.

References 1. E. Ortmann, M.W. Besser and A. A. Klein. Antifibrinolytic agents in current anaesthetic practice. British Journal of Anaesthesia 2013 Oct; 111(4): 549–63. 2. Alshryda S, Sarda P, Sukeik M, Nargol A, Blenkinsopp J, Mason JM. Tranexamic acid in total knee replacement: a systematic review and meta-analysis. The Journal of Bone and Joint Surgery. 2011 Dec; 93(12): 1577–85. 3. Zhou XD, Tao LJ, Li J, Wu LD. Do we really need tranexamic acid in total hip arthroplasty? A meta-analysis of nineteen randomized controlled trials. Archives of Orthopaedic and Trauma surgery 2013 Jul; 133(7): 1017–27.

Class Class Class Class Class

1: Gas confined to the collecting system. 2: Gas confined to the renal parenchyma alone. 3A: Perinephric extension of gas or abscess. 3B: Extension of gas beyond the Gerota fascia. 4: Bilateral EPN or EPN in a solitary kidney.

EPN Treatment Conservative treatment measures include prompt hydration, fluid resuscitation, systemic antibiotics, relief of obstruction with percutaneous drainage or stent placement and rapid control of diabetes, if present.

EPN-Surgical treatment: Nephrectomy is indicated as follows:

• • • • •

Treatment of choice for most patients. No access to percutaneous drainage or internal stenting (after patient stabilisation). Gas in the renal parenchyma or ‘‘dry-type’’ EPN. Class 3 and class 4 EPN. Possibly bilateral nephrectomy in patients with bilateral EPN.

References 1. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Archives of Internal Medicine 2000; 160(6): 797–805. 2. Tang HJ, Li CM, Yen MY, et al. Clinical characteristics of emphysematous pyelonephritis. Journal of Microbiology, Immunology and Infection 2001; 34(2): 125–30.13. 3. Pontin AR, Barnes RD, Joffe J, Kahn D. Emphysematous pyelonephritis in diabetic patients. British Journal of Urology 1995; 75(1): 71–4. 4. Huang JJ, Chen KW, Ruaan MK. Mixed acid fermentation of glucose as a mechanism of emphysematous urinary tract infection. The Journal of Urology 1991; 146(1): 148–51.


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An audit on preoperative fasting in elective adult surgical patients V. Ragothaman1 and K. Wilkinson2 1 Russells Hall Hospital, DGOH NHS Trust, Dudley, UK; 2Nobles Hospital, Isle of Man

Does the bike predict the ride? Cardiopulmonary exercise testing for elective open abdominal aortic aneurysm repair – a retrospective analysis G. Randhawa,1 R. Adair1 and H. Buglass2 Leeds Teaching Hospitals NHS Trust; 2Pinderfields General Hospital

1

Patients undergoing General Anaesthesia (GA) are usually fasted from midnight to prevent aspiration. The RCOA standards state that all elective patients, should be allowed to have clear fluids, until 2 hours before induction of anaesthesia.

Methods 40 patients were questioned preoperatively for intake of clear fluids over a 2 week period. Data were collected about the type of clear fluids and fasting times. Reasons for failure to comply with were documented.

Results Nearly half of all patients, did not have clear fluids 2 hrs before GA. Around 85% had water and the rest had black tea. The most common (52%) reason for failure was that, patient was not given specific information about fluid intake preop. The other major factor (30%) was patient noncompliance, despite information on the leaflet. A very few percentage was due to nurses being unaware of policy and also patient being denied fluid.

The aim of this study was to determine whether pre-operative cardiopulmonary exercise testing (CPET) predicts complications or 30-day mortality following elective open abdominal aortic aneurysm (AAA) repair.

Methods From January 2007, all patients presenting to a single vascular unit with a large (≥5.5 cm) AAA were referred for CPET using the Ergolineâ stationary bicycle and CareFusion Vmaxâ system. Anaerobic threshold (AT), peak oxygen consumption and ventilatory equivalents for oxygen and carbon dioxide were recorded on a prospective database, with patient demographics and comorbidities. These data were retrospectively analysed for all patients who had undergone elective open AAA repair by January 2012. Hospital records were used to determine mortality data and complication rates (defined using the Clavien-Dindo System [1]). Univariate (Pearson v² test) and multivariate (Cox regression) analyses were then performed to determine whether age, gender, comorbidities or CPET parameters correlated with post-operative complications or 30-day mortality.

Results Of the 210 patients undergoing CPET during the study period, 78 went on to have elective open AAA repair by the time of analysis. In the operated group, the median AT was 9.6 ml/kg/min (IQR 8.8-12.4), and 30-day mortality was 7.6%. The incidence of serious complications (Clavien-Dindo Grade III or IV) was 12.8%. Neither 30-day mortality nor complications were predicted by any of the CPET derived variables. The only variable which independently predicted 30-day mortality on univariate analysis was patient age over 75 (p = 0.001). Age over 75 and presence of hypertension approached significance in relation to incidence of serious complications (p = 0.076 and p = 0.055 respectively). However none of these variables reached statistical significance on multivariate analysis.

Discussion

Discussion Clear fluids reduces anxiety and postoperative nausea and vomiting [1,2]. Evidence shows no difference in PH or gastric volume when clear fluids were given 2 hours before GA [3]. Although local trust guidelines are in place, staff across trust are unaware of the starvation for fluids. Patients were being given information about starvation times on the surgical leaflet, but not adequate information, on the intake of nature and duration for clear fluids. We recommended more education of staff and specific and appropriate information for patients on the leaflet and reaudit again to complete the cycle

References 1. Read MS, Vaughan RS. Allowing pre-operative patients to drink: effects on patients safety and comfort of unlimited oral water until 2 hours before anaesthesia. Acta Anaesthesiolica Scandinavica 1991; 35: 591–595. 2. Smith AF, Vallance H, Slater RM. Shorter preoperative fluid fasts reduce postoperative emesis. BMJ 1997; 314: 1486. 3. Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database of Systematic Reviews 2003; (4): CD004423.

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Abdominal aortic aneurysm repair is a high risk surgical procedure [2]. Attempts should be made to quantify individual patients’ risk in order to facilitate informed consent and to plan peri-operative care. However, the optimal strategy for risk assessment remains unclear. In keeping with current literature [3], this study does not support the use of CPET as an isolated tool for predicting mortality or serious complications in patients undergoing elective open AAA repair. Despite a lack of evidence to validate the use of CPET for risk stratification in major vascular surgery [3], over 70% of UK anaesthetic departments with access to CPET use it for pre-assessment in this group [4]. This highlights a need for refinement of CPET use, or development of more reliable objective tools for risk stratification.

References 1. Dindo D, Demartines N, Clavien P. Classification of Surgical Complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Annals of Surgery 2004; 2: 205–213. 2. Tendera M, Aboyans V, Bartelink M, et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases. European Heart Journal 2011; 32(22): 2851–2906. 3. Young E, Karthikesalingam A, Huddart S et al. A Systematic Review of the Role of Cardiopulmonary Exercise Testing in Vascular Surgery. European Journal of Vascular and Endovascular Surgery 2012; 44: 64–71. 4. Huddart S, Young E, Padhu P. A national survey of CPET practice in the UK. In: 4th National perioperative CPET meeting. London: 2011.


190 Temperature monitoring during caesarean section

WITHDRAWN

C. Rimmer and Z. Arfeen City Hospitals Sunderland NHS Foundation Trust

Inadvertent perioperative hypothermia is a common complication of operative procedures, and has been associated with adverse outcomes for patients. In 2008 the National Institute for Clinical Excellence developed its guideline on managing inadvertent perioperative hypothermia. The aim of the audit was to assess the management of inadvertent perioperative hypothermia in the population presenting for the operative procedure of caesarean section.

Methods A data collection exercise was carried out over a four month period for all patients undergoing caesarean section in the maternity theatre. The data recorded included the timing of the operation, the urgency of the operation, the ASA grade and the anaesthetic technique. The measuring of and documenting of temperature and the use of warming measures was established for the preoperative, intra-operative and postoperative periods. In addition risk factors for inadvertent hypothermia were identified.

Results In total 62 data collection sheets were collected during this period. The preoperative temperature was documented in 50 cases (80%). The temperature was recorded on the preoperative checklist in 52 cases (87%). Temperature was recorded before induction of anaesthesia in 17 cases (28%). Temperature was recorded every 30 minutes intra-operatively in 7 cases (15%). Temperature was recorded on admission to recovery in 52 cases (84%). In 7 cases the temperature was recorded in recovery as below 36°c (14%), and in all these cases forced air warming was initiated in the recovery area. The temperature was recorded on discharge from recovery in 44 cases (71%). Table of temperatures recorded Median (°c)

Range (°c)

Preoperatively

36.7

35.5–37.9

Intra-operatively

36.9

36.1–38.2

Recovery Admission

36.4

35.4–38.4

Recovery Discharge

36.6

36–37.4

Discussion In our hospital, temperature monitoring for caesarean section patients in the preoperative period and in the recovery period is relatively good, conforming to the NICE guidelines in the majority of cases. Temperatures are being recorded prior to the patients coming to theatre, and on admission and discharge from recovery. Warming measures are being routinely utilised in the recovery area if appropriate. Pre-induction and intraoperative temperature recording is not being carried out routinely in this patient group, and warming measures are not being routinely utilised intra-operatively. This may reflect a lack of availability of temperature measuring equipment and active warming equipment in the theatre itself, or that other aspects of intra-operative care are being prioritised. Active warming would only have been indicated in a very small number of these cases, highlighting that inadvertent perioperative hypothermia is not a significant problem for this patient population.

References 1. Schmied H, Reiter A, Kurz A, Sessler DI, Kozek S. Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty. The Lancet 1996; 347(8997): 289–292. 2. Doufas AG. Consequences of inadvertent perioperative Hypothermia. Best Practice & Research Clinical Anaesthesiology 2003; 17(4): 535–549. 3. Inadvertant Perioperative Hypothermia – the management of inadvertent perioperative hypothermia in adults, National Institute of Clinical Excellence Clinical Guideline number 65, 2008


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Trainee contributions to articles published in Anaesthesia: a UK trainee perspective A. Rivers, H. Laycock and S. Yentis Chelsea and Westminster Hospital

Trainees may be motivated to publish journal articles to promote academic work, advance the specialty, or enhance their curriculum vitae [1]. It is unclear whether a reduction in training time following Modernising Medical Careers (MMC) in 2007 and the European Working Time Directive (EWTD), fully implemented in 2009, has hindered trainee contributions to medical research/publishing. We investigated whether the proportion of articles by UK trainees and medical students in the journal Anaesthesia has changed since 2005.

Methods All original articles published in Anaesthesia in 2005, 2007, 2009, 2011 and 2013 were reviewed online and evaluated for: i) the authors’ country of work; ii) the first author’s designation; and iii) presence of trainees (defined as registrars, specialist registrars, senior house officers, pre-registration house officers, foundation year doctors, medical students, specialist trainees, clinical research fellows, fellows, residents and senior residents) within the authorship. All data were collected and analysed using Microsoft Excel.

Results 460 articles were reviewed (80-104 per year); 184 were from the UK (27-47 per year). The authors’ grades were missing from 29 (0-11 per year). Trends in UK publications are shown in Fig. 1. A higher proportion of UK papers had a trainee as an author (mean (SD) 66 (9)%) compared with non-UK papers (48 (6)%; p = 0.006, unpaired t-test).

Application of cricoid force for rapid sequence induction and intubation: an audit of knowledge and practice in ITU nurses, operating department assistants and anaesthetic trainees S. Saha and J. Kinnear Southend University Hospital The fourth national audit project into major airway complications identified aspiration as the commonest cause of death in anaesthesia events in the UK, accounting for 22% of all reported incidents.[1] Application of cricoid force (CF) is widely practiced in the UK to prevent this occurring during anaesthetic induction & intubation of the at risk patient. An understanding the principles and practice of the technique are vital to applying effective CF. The aim of the audit was to examine knowledge and practice of CF amongst operating department assistants (ODAs), ITU nurses and anaesthetic trainees.

Methods A questionnaire was designed with two parts. The first part was regarding training, experience and confidence in applying CF. The second part involved true/false multiple choice questions (MCQs) related to anatomy, indications and performance. Participants were also asked to identify the cricoid cartilage on a human neck. Questionnaires were distributed and anonymously returned during a 3 week period in July 2012 amongst ITU nurses, anaesthetic trainee doctors and ODAs at Southend University Hospital.

Results Thirty nine questionnaires (57%) were returned by ITU nurses, 12 (60%) by ODAs and 7 (63%) by trainee anaesthetists. Six (15%) ITU nurses, 10 (83%) ODAs and 2 (28%) trainee anaesthetists had received formal training in CF. MCQs related to anatomy and indications for CF were answered correctly by more than 90% of all participants. Fifty one percent of ITU nurses and 75% of ODAs correctly answered MCQs related to timing CF should be initiated during rapid sequence induction, and 32% of ODAs and ITU nurses correctly answered MCQs related to indications for its release.

Figure 1. UK authorship of papers published in Anaesthesia as a percentage of all published papers.

Discussion Since 2005, there has been a decline in the proportion of papers in Anaesthesia originating in the UK; however, publications with trainee involvement do not appear to have fallen as rapidly, and have remained relatively static since 2007. Trainees from the UK were also better represented compared with non-UK trainees. While concerns regarding the effect of MMC, the EWTD and shift work on trainees’ involvement in non-clinical activities and on training have repeatedly been raised [2, 3], our data do not suggest that these factors had a major impact on trainee involvement in anaesthesia research. Amongst the limitations of our study are the inclusion of papers from only a single UK journal and the fact that we did not evaluate abstracts presented at meetings or other output of research in anaesthesia.

Acknowledgements HL is Trainee Fellow and SMY is Editor-in-Chief of Anaesthesia.

References 1. Duffet R. Publications by junior doctors: why do they do it? Psychiatric Bulletin 1994; 18: 553–4. 2. Tait MJ, Fellows GA, Pushpananthan S, Sergides Y, Papadopoulous MC, Bell BA. Current neurosurgical trainees’ perception of the European Working Time Directive and shift work. British Journal of Neurosurgery 2008; 22: 22–31. 3. Fizgerald JEF, Caesar BC. The European Working Time Directive: a practical review for surgical trainees. International Journal of Surgery 2011; 10: 399–403.

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Discussion Formal training was not mandatory for the participants in this audit despite CF being considered a core skill for those involved in airway management. Only approximately a third of ITU nurses identified and were confident to apply CF, and a third of ODAs unable to identify the cricoid cartilage. All groups had an understanding of relevant anatomy and the indications for CF. ITU nurses and ODAs performed less strongly on timing of CF application and release. An overall good performance by anaesthetic trainees reflects that rapid sequence induction & intubation is a core competency. Based on this work, training in CF has been incorporated into the ITU nursing and ODA educational programme.

Reference 1. Cook TM, Woodall N, Frerk C et al. Major complications of airway management in the UK: resultsof the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia. British Journal Of Anaesthesia 2011; 106: 617–31.


194

Uterotonic use following caesarean sections: an audit of practice following the introduction of a new guideline 1

2

3

2

S. Saha, R. West, S. Saha and J. Mukherjee 1 The Royal Free Hospital; 2Barnet General Hospital; 3The Royal London Hospital

Previously our hospital had no prescribing guideline for uterotonics for caesarean sections. As it was felt there was a large variation in practice, a survey was performed to assess this. The results of the survey demonstrated inconsistent prescribing both in terms of type of drug and route of administration. In particular there was found to be a high use of syntometrine IM, both with and without a previous dose of syntocin as well as non-standard dosage and routes of administration of other uterotonics. Following the survey a guideline was introduced for uterotonic prescribing following caesarean sections. This consisted of a stepwise approach starting with an intravenous (IV) 5unit syntocin bolus followed if needed by a syntocin infusion, +/ - ergometrine intramuscular (IM), +/ - prostaglandins (not intrauterine). An audit was performed to assess its impact.

Methods Over an eight week period, the attending obstetric anaesthetists were requested to complete proforma for each caesarean section performed. Data collected included grade of delivery, uterotonics administered and by which route.

Results The initial survey collected data from 94 caesarean sections. Thirty one used IM syntometrine of which 14 mothers received it as first line and 17 following 5units of IV syntocin. Also from this group two patients received intrauterine carboprost. One received a 10unit bolus of syntocin. In the audit following the introduction of the guideline data from 57 caesarean sections was collected. Fourteen did not follow the guideline, however eight of these were due to unintentional non-guideline doses for the initial IV syntocin bolus. Four were given IM syntometrine and one was given a 10unit bolus of syntocin intentionally.

Discussion The introduction of the guideline for uterotonic use following caesarean section has resulted in reduced prescription variability. The reduced IM syntometrine usage has resulted in a drop in the number of IM injections, doses of ergometrine and total dose of syntocin given (as it was frequently given following an IV syntocin bolus). In addition the guideline helps clarify that alternative dosing or routes of administration should only be used in exceptional circumstances (such as an additional IV bolus of syntocin or intrauterine carboprost). The unintentional non -guideline doses for the IV bolus of syntocin seen following introduction of the guideline is a specific area for improvement with simplification and formatting changes to the guideline poster being considered. However overall we feel that the logical stepwise approach of the guideline has helped improve teamwork, communication and uterotonic prescribing.

Reference 1. Saha S, West R, Mukherjee J. A survey of uterotonic use for caesarean sections at a district general hospital. OAA Liverpool. 2012.

Morbidly obese obstetric patient for LSCS should regional always be the first option? A. Sajayan and M. Nejdlova Birmingham Heartlands Hospital

Obstetric anaesthetists tend to prefer regional anaesthesia over GA based on several factors including maternal satisfaction, proven safety records and better pain relief [1]. Morbid obesity can be challenging to us whichever mode of anaesthesia we plan. Regional anaesthesia may not always be the most suitable option in morbidly obese obstetric patients and the outcome, maternal satisfaction and surgical conditions could be equal or better with general anaesthesia.

Description 23 year old primipara with a booking BMI of 63.7 was scheduled for an elective caesarean section. She was seen in the preoperative assessment clinic and was explained about the anaesthetic options and was planned for a regional technique. She was seen in the admission lounge by the anaesthetic consultant and was briefed about spinal/CSE technique and the possibility of converting to a general anaesthetic if the technique is difficult or the procedure takes longer than expected. In theatre, ultrasonography was used to estimate the depth of the space and to find out the land marks. Spinal and CSE was attempted multiple times using different length needles by two anaesthetists, a senior registrar and a Consultant, with a combined anaesthetic experience of more than 30 years. After one hour and fifteen minutes of repeated attempts, decision was taken to give a GA after discussing with the patient. Intubation was easy with a grade I view and the operation was uneventful. General anaesthesia provided the surgeon with a better operating condition especially when the retractors were used.

Discussion Anaesthetic management of obese parturients could be challenging which ever mode of anaesthesia is chosen. Traditional teaching is to avoid general anaesthesia in obese patients if possible. A UK study of more than 1400 caesarean sections found no differences between obese and non-obese parturient in rate of caesarean deliveries, co-morbidities, indications for delivery or anaesthesia complications [2]. There is no evidence that difficulty in intubation in non-obstetric population is related to high BMI. The incidence of increased BMI in obstetric poplation is ever increasing and anaesthetists should be able to cope with different anaesthetic options in an emergency situation. The experience will only be gained by doing more general anaesthesia in elective situations where appropriate supervision is available.

References 1. Adams JP and Murphy PG. Obesity in Anaesthesia and Intensive care. British Journal of Anaesthesia 2000; 85(1): 91–108. 2. Bamgbade OA, Khalaf WM, Obstetric anaesthesia outcome in obese and nonobese parturients undergoing caesarean delivery: an observational study. International Journal of Obstetric Anaesthesia 2009 Jul; 18(3): 221–5. 3. Ezri T, Medalion B, Weisenberg M, Szmuk P, Warters RD, Charuzi I. Increased body mass index per se is not a predictor of difficult laryngoscopy. Canadian Journal of Anaesthesia 2003 Feb; 50(2): 179–83.


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Acute fatty liver of pregnancy-need for high index of suspicion A. Sajayan, M. Nejdlova and M. Benham Birmingham Heartlands Hospital

Acute fatty liver of pregnancy is rare but serious condition that warrants high index of suspicion, early intervention & support. History & clinical presentation can be misleading causing delays in diagnosis.

Description A 17 yr old girl presented complaining of general body ache, chills, thirst, abdominal pain,vomiting and diarrhoea for a week.She was on holiday to the Canary Islands just before this. On examination, she was afebrile, jaundiced, tachycardic with a BP of 140/100 and normal respiratory rate. Her pregnancy test was positive and she was unaware of the pregnancy. She was started on oral labetolol and a scan was done to assess the pregnancy which suggested the gestation of more than 36 weeks. The membranes were spontaneously ruptured at unknown time.She was very dry at that point with shut down periphery and tachycardia .Bloods sent for full blood count, liver function tests, group & save, hepatitis screen and blood culture. Fluid resuscitation was commenced. The d/d was infective hepatitis or chorioamnionitis. The blood showed deranged liver function with high ALP, bilrubin and clotting screen slightly above normal limits. She gradually became more tachycardic and febrile and CTG was suspicious. A decision was made for caesarean section under GA and two units of FFP were given perioperatively along with two more litres of crystalloid. Operation was uneventful except for persistent tachycardia in the region of 120/min. She was kept in the HDU postoperatively and at the multi-disciplinary ward rounds afterwards, the d/d was HELLP, Chorioamnionitis, Gastroenteritis and Infective hepatitis mainly prompted by the history and presentation. Further investigations done next day included Ammonia, CMV, EBV, Haptoglobin, LDH, ANA, alpha1 AT which were normal & liver ultrasound which showed increased echogenicity.Her symptoms gradually improved and the blood results got gradually better after the second day. She was discharged after a week with a diagnosis of acute fatty liver of pregnancy based on the Swansea criteria.

Discussion The incidence of AFLP is between 1:700- 1:15,000 with a maternal mortality of 18% mainly secondary to DIC & infection. Symptoms are non specific and include nausea, vomiting, abdominal pain, jaundice and fever. History & presentation can be misleading and this can lead to increased morbidity and mortality. High ALT, AST, ALP, Bilirubin, WCC and low fibrinogen and deranged coagulation can present. Ultrasound of liver might show increased echogenicity and micro-vesicular steatosis. Swansea criteria can be used to aid diagnosis and 6 or more parameters are diagnostic. Management is mainly supportive with early delivery.

Are we achieving the principles of enhanced recovery in patients undergoing elective Lower Segment Caesarean Section (LSCS)? V. Salota,1 V. Uzkalniene,2 R. Salota,3 C. Roulson2 and M. Agarwal2 1 Guy’s and St Thomas’ NHS Foundation trust, London, UK; 2University Hospital Lewisham, London; 3St Helier Hospital, Carshalton, Surrey

Enhanced recovery is a model of care which reduces the physiological stress response and organ dysfunction caused by elective surgery. It enables patients to recover more quickly and be discharged from hospital sooner resulting in benefits to both patients and staff [1]. This model has been used with success in different surgical specialities however, in obstetrics this is still a new frontier. The aim was to audit the current practice for patients undergoing elective LSCS and utilise the findings to develop an enhanced recovery protocol.

Methods The study was approved by the hospital audit committee. A questionnaire was formulated to follow up patients undergoing neuraxial blocks for elective LSCS which included patient’s level of satisfaction for pain relief and time for pre and post-operative fasting, post-operative urinary catheter removal, mobilisation and discharge. The data was collected, analysed and results were compared with the principles laid down by NHS Enhanced Recovery Partnership Programme (ERPP) for obstetrics [2]. Mean and 2 standard deviation (SD) was calculated.

Results 23 patients were followed up and the results are shown as mean and 2SD of the findings in Table 1. Level of satisfaction for pain relief was moderate in 22%, good in 56% and excellent in 22% patients. 67% of patients were discharged from hospital three or more days after the operation. 9% patients achieved recommended pre-operative fasting time for clear fluid while none achieved recommended time for pre-operative food and urinary catheter removal.

Table 1 Mean and 2 SD of the findings from the current practice.

Mean Questions Pre-op fasting time for clear fluid Pre-op fasting time

(hours) 5.87 13.0

2SD 1.14–10.60 9.11–17.06

Recomm-

Patients that

endation

achieved recom-

by ERPP

mended time by

(hours)

ERPP (%)

02

09

06

00

for food Post-op fasting time

1.24

( 1.60)– 4.07

As tolerated

–

for clear fluid Post-op fasting time

5.02

0.18–9.86

As tolerated

–

18.72

12.69–24.75

12

18.37

11.78–24.96

As tolerated

for food Removal of urinary

00

catheter First mobilisation of patient

–

References 1. Gregory TL, Hughes S, Coleman MA, De Silva A. Acute fatty liver of pregnancy; three cases and discussion of analgesia and anaesthesia. International Journal of Obstetric Anesthesia April 2007; 16(2): 175–9. 2. Rajasri AG, Srestha R, Mitchell J. Acute fatty liver of pregnancy (AFLP)–an overview. Journal of Obstetrics & Gynaecology April 2007; 27(3): 237–40 3. Ko H, Yoshida EM Acute fatty liver of pregnancy. Canadian Journal of Gastroenterology January 2006; 20(1): 25–30.

Discussion Majority of patients fasted much longer than the ERPP2 and AAGBI recommendations3 with delayed urinary catheter removal and mobilisation. All these factors can potentially lead to stressed mother during peri-operative period which increases the risk of stress disorder, postpartum depression and dysfunctional parenting. Delayed discharge has both psychological and financial implications.Our results identified areas where improvement is required in order to achieve compliance to the generic elements of ERPP. Based on the findings we recommend greater emphasis on fasting guidelines and importance of early urinary catheter removal as it delays patient mobilisation. These can be achieved by greater patient involvement and re-educating midwives and theatre staff about the importance of generic elements of ERPP in the patient outcome. Regular patient feedback would help to improve their level of satisfaction. A local enhanced recovery protocol needs to be developed and re-audit to evaluate the progress.

References 1. Wilmore D, Sawyer F, Kehlet K. Management of Patients in Fast Track Surgery. British Medical Journal 2001; 322(7248): 473–476. 2. NHS Enhanced Recovery Partnership Programme. Fulfilling the potential: a better journey for patient and a better deal for the NHS. http://www. improvement.nhs.uk/documents/er_better_journey.pdf. 3. Royal College of Nursing. Perioperative fasting in adults and children. An RCN guideline for the multidisciplinary team. London: RCN, 2005.

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Uptake of influenza vaccine by hospital clinical staff

Northern deanery primary FRCA trainee survey – listening to trainees really does work

Y. Samaroo, Z. Pullen and S. Yentis Chelsea and Westminister Hospital

T. Sams, S. Mowat and C. Dickson Newcastle-upon-Tyne Hospitals NHS Foundation Trust

Influenza (flu) epidemics occur frequently, vary in their severity and can affect all populations. Healthcare workers are included in high-risk groups identified by the World Health Organization (WHO) as warranting annual influenza vaccination [1]. During the 2012-13 flu vaccination campaign, the Department of Health, NHS England and Public Health England set a national target that 70% of healthcare workers should receive the flu vaccination. Despite this, the national uptake of vaccination for this group during this period was 45.6%, similar to the previous year. The national target for 2013-14 is set at 75%, in keeping with international targets [2, 3]. We examined the uptake of flu vaccine in different staffing groups in our Trust over the latest ‘flu period’.

Pass rates for the primary FRCA have been falling with concerns raised over the amount of competencies and revision required during core training to pass the primary FRCA and gain an ST3 post [1]. Our survey in 2011 [2] obtained a consensus on local revision practices and feedback for our local primary FRCA course. Forty five of the fifty six (80%) trainees who responded recommended making the course more exam relevant and to involve senior trainees more. As a result trainees organised free MCQ, Viva and OSCE days and the local primary FRCA course became more exam orientated. A repeat survey was carried out in 2013 to assess revision practice and the impact on satisfaction and exam pass rates for trainees in our region.

Methods

Methods

As part of its routine monitoring activity, weekly staff vaccination figures have been compiled and presented anonymously to the Trust’s Operations Office since Oct. 2013. From these figures, we calculated the proportion of staff vaccinated within each staffing group (excluding Bank nursing/midwifery staff). The groups included in the analysis were chosen according their frequency of interaction with anaesthetists. The Trust’s Research & Development department and Operations Office approved release and presentation of these data.

A 12 question internet based survey was sent by email from the authors to all CT2, CT2+ and ST3 trainees in August 2013. Exam pass rates were calculated from the Northern School of Anaesthesia’s anonymised data.

Results Vaccination figures for five medical (black) and four non-medical (grey) staff groups are shown in Fig. 1. 60%

50%

40%

30%

20%

10%

Anaesthetic trainees

Anaesthetic consultants

Emergency medicine

Obstetricians

Surgeons

ICU nurses

Midwives

Theatre nurses/ODPs

NICU nurses

14

14 1/ /0 31

1/ /0 24

20

14

20

14

20 1/ /0 17

10

/0

1/

20 1/ /0 03

20

14

13

13

20 /1

27

2/ /1 20

2/

20

13

13

20

20

2/ /1

06

/1

2/

20 29

/1

1/

1/ /1 22

13

13

13

13

20

13

20

15

/1

1/

20 08

/1

1/

1/ /1

/1 25

01

0/

20

20

13

13

0%

Discussion Overall, there was a lower uptake of vaccination amongst non-medical staff compared with medical. Most vaccination was within the first month of the vaccination campaign for most groups, reaching a plateau at ~6 weeks. ICU Nurses were the most likely non-medical group to be vaccinated, perhaps reflecting their greater exposure to patients with severe complications of flu. Amongst doctors, surgeons were the least likely to be vaccinated. It is reassuring that consultant and trainee anaesthetists were equally likely to be vaccinated, although disappointing that only half had been within the 14-week study period. Neither the Trust nor any individual group had achieved the national target of 75% by the end of January. These and national figures mirror a universally low (< 50%) uptake of annual flu vaccination by healthcare workers worldwide [4]. Further work is required to explore the barriers to increasing uptake of flu vaccine by frontline staff.

Results The questionnaire was sent to 38 trainees of whom 28 (73.6%) replied. Trainees first sat the exam a median of 10 months after starting training (inter-quartile range (IQR) 7-10) and revised for a median of six months (IQR 4-6) spending a median 15 hours a week revising (IQR 12-20). In 2011 these figures were 6 months (IQR 4-6) and 15 hours a week (IQR 10-20) respectively. Trainees were asked to assess our regional teaching course and the new free teaching days using an 11 point numerical rating scale over five domains. The regional course received improved feedback across all domains with a mean overall rating of 5.2 (standard deviation (SD) 1.7), with variety of topics scoring highest at 7.1 (SD 1.3) and exam relevance 6.8 (SD 1.6). The new free training days received excellent feedback with an overall score of 8.6 (SD 1.1), with value for money scoring highest at 9.1 (SD 1.2) and exam relevance 8.9 (SD 1.2). Exam pass rates for the primary MCQ in the two years preceding these changes were 41.7% and 50%. In the two years following the improvements pass rates were 78.4% and 80% (p < 0.0001). In the primary OSCE / Viva the pass rates for the two preceding years were 57.1% and 61.5%. In the two years following the improvements they were 70.6% and 82.5% (p < 0.026).

Discussion Trainees in our region are taking the exam and revising for the same amount of time now as their predecessors. Having surveyed trainees in 2011, listened to their feedback and made improvements we have managed to significantly increase trainee satisfaction and our pass rates in all sections of the primary FRCA, contradicting national trends [1]. These results are relevant to any region as significant improvements in pass rates could be possible with the introduction of a similar process.

References 1. McCahon R, Joannides C. Is all well with training in anaesthesia? Bulletin of the Royal College of Anaesthetists 2012; 76: 16–18. 2. Sams T, Dickson C. Northern deanery primary FRCA survey. Anaesthesia 2013; 68: 987–993.

References 1. WHO. Seasonal Influenza Factsheet No. 211, March 2014. http://www.who. int/mediacentre/factsheets/fs211/en/.* 2. Brown C, Jorgensen P. Seasonal influenza vaccination in the WHO European Region & updated WHO recommendations, 2012. http://ecdc.europa.eu/en/ press/events/Documents/ECDC-WHO-influenza-meeting-Brown-3.pdf.* 3. Hakin B, Cosford P, Harvey F. The Flu Immunisation Programme 2013–2014. www. gov.uk/government/organisations/public-health-england/series/immunisation.* 4. Hooper CR, Breathnach A, Iqbal R. Is there a case for mandating influenza vaccination in healthcare workers? Anaesthesia 2014; 69: 95–100. *all accessed 14/03/2014. © 2014 The Authors. Anaesthesia © 2014 The Association of Anaesthetists of Great Britain and Ireland

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Electronic prescribing – does it affect drug administration and patient satisfaction? A. Sharma and A. Troy Countess of Chester Hospital NHS Foundation Trust, Chester, UK

Strategies to improve the remifentanil patient controlled analgesia service on delivery suite at our hospital P. Shorrock and S. Smith University Hospital South Manchester

A great deal of research has been undertaken comparing medication error rates between electronic and paper prescribing. There has however, been much less investigation of the effect of electronic prescribing on drug administration – such as ‘as required’ (PRN) analgesia – and the impact that this may have on patient satisfaction. Concerns have been raised, particularly in the period immediately following the initiation of an electronic prescribing system with regards to areas such as change management, loss of productivity and the impact of information technology requirements [1]. We audited patient satisfaction and adminsitraction of PRN analgesia before and after electronic prescribing was initiated in our maternity unit.

Remifentanil has been shown to be safe and effective in labour analgesia. Its rapid onset of action is suited to patient controlled analgesia (PCA) and its rapid offset of action is attractive with regard to side effects. We noted a low rate of remifentanil PCAs on our delivery suite and anecdotal discussion with midwifery staff revealed that some had less than satisfactory experiences caring for women using remifentanil. Consequently we undertook a review of our service and implemented a number of improvement strategies.

Methods

Following Trust audit departmental approval, all patients having a caesarean section were audited for one month before and one month after EMAR electronic prescibing was initiated on the post-natal ward. Data collected include worst pain scores on movement (VAS 0-10), post-operative morphine consumption, and patient satisfaction with post-operative analgesia using a four point verbal descriptor score.

A prospective audit was undertaken to identify the number of remifentanil PCAs used for labour analgesia over a 4 week period. Indication for PCA, objective effectiveness of analgesia and whether an epidural was sited at a later date were noted. A survey was sent to delivery suite midwifery staff to canvas opinion and training status regarding remifentanil PCAs. Finally we liaised with other obstetric anaesthetic departments within our region regarding their remifentanil PCA rate and satisfaction of staff.

Results

Results

Methods

A total of 106 patients had caesarean sections over the two month period, 53 before e-prescribing and 53 after e-prescribing. In each group, 50 (94%) patients stated that they were either satisfied or very satisfied with post-operative analgesia. Modal pain score was 5/10 in each group. Both groups had a mean morphine consumption of 17 mg in the 24 hours following surgery. Patient satisfaction scores remained high despite higher than recommended pain scores [2].

Discussion In this audit, electronic prescribing had no effect on patient satisfaction with analgesia, post-operative pain or total PRN morphine administration. These results somewhat allay concerns that ‘change management’ (and electronic prescribing in itself) may impact availability of PRN medications.

References 1. Halamka J, Aranow M, Ascernzo C et al. E-prescribing collaboration in Massachusetts: early experiences from regional prescribing projects. Journal of the American Medical Informatics Association 2006; 13: 239–244. 2. National Institute for Health and Clinical Excellence. Caesarean section: NICE guideline CG132. 2011; 45–6.

6 Remifentanil PCAs were prescribed over the audit period. 2 of these were indicated by anaesthetic advice the other 4 had a contraindication to epidural. 3 women needed supplementary oxygen. All 6 of the PCAs were felt objectively to be effective and no epidurals were sited at a later stage. 37 completed midwifery surveys were returned. 31(84%) stated they had received no formal remifentanil PCA training. 12(33%) had never cared for a labouring woman with a remifentanil PCA. 22(62%) stated they had been involved in cases where the woman had expressed interest in a remifentanil PCA herself. 20(54%) expressed a lack of confidence with regard to remifentanil PCA management.

Discussion The remifentanil PCA rate on our unit is low. A gap in formal midwifery training coupled with an element under-confidence appear to be factorial in our low rate. Consequently our review has led to a number of changes to ensure that women on our unit receive adequate choice regarding their labour analgesia. We have forged links with senior midwives and anaesthetists from a local trust to learn from their remifentanil experiences and we now have a remifentanil PCA lead midwife. We have established training for midwifery staff. Our remifentanil PCA guideline has been updated with a number of amendments; including the necessity for appropriate training and an increase in lock-out time. We are in the process of creating an integrated database for anaesthetic obstetric interventions including remifentantil PCA so a robust follow up service can be obtained. Once training is complete we intend to repeat the prospective audit and survey.

References 1. Blair J, Hill D, Fee J. Patient controlled analgesia for labour using remifentanil: a feasibility study. British Journal of Anaesthesia 2001; 87(3): 415–420 2. Volikas I, Butwick A, Wilkinson C, Pleming A, Nicholson G. Maternal and neonatal side-effects of remifentanil patient-controlled analgesia in labour. British Journal of Anaesthesia 2005; 95(4): 504–9 3. Evron S, Glezerman O, Sadan O, Boaz M, Ezri T. Remifentanil: A novel systemic analgesic for labor pain. Anesthesia and Analgesia 2005; 100(1): 233–8

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CPR in the prone position: a systematic review and guidelines for its application

Peri-operative temperature control in children: an audit

A. Simpson Royal Infirmary of Edinburgh

A. Singh, S. Agarwal and B. Lambert Birmingham Children’s Hospital

Intra-operative cardiac arrest in the prone position is rare but presents several unique challenges in the delivery of cardiopulmonary resuscitation (CPR) [1]. In this situation turning the patient supine prior to commencing CPR may incur significant delay in treatment [2] and additional risk to the patient [3]. Performing CPR in the prone position may therefore be preferable. The purpose of this review is to establish the viability of such a technique and to provide appropriate guidelines on the performance of prone CPR.

Thermoregulation is known to be disrupted in the peri-operative period, with the paediatric population particularly at risk. Hypothermia is associated with shivering and increased oxygen consumption, decrease in platelet function, blood loss, risk of surgical wound infection and impairment of drug metabolism. The Association of Anaesthetists advises that body temperature monitoring must be available in paediatrics and used when appropriate 100% children in the recovery area should have tympanic (or axillary) temperature in the range 36° 37°C. In our centre inditherm mattress and forced air blowers are used as warming methods for most of the procedures. This audit aimed to establish whether warming techniques are being used effectively in children and whether appropriate intra-operative monitoring is being used.

Methods A systematic review of the available literature was performed to identify previous work in this area. Pubmed was searched using the following search terms: ‘‘CPR prone’’, ‘‘cardiopulmonary resuscitation prone’’, ‘‘cardiac arrest prone’’, ‘‘cardioversion prone’’, ‘‘cardiac arrest pins’’, ‘‘CPR pins’’, ‘‘cardiac arrest Mayfield’’ and ‘‘CPR Mayfield’’. All languages were included. All retrieved articles as of January 2014 were assessed by title for relevance. Full text of relevant articles were then assessed against inclusion criteria. In addition, the references of all retrieved relevant papers were examined to identify further relevant work.

Results The available literature on CPR in the prone position is scant. Indeed, the majority of the published work are case reports. Nevertheless, the available research has demonstrated that CPR in the prone position can be successful, especially in certain clinical circumstances. Based on the existing research and the techniques which have been successfully employed, we propose guidelines for the performance of prone CPR when indicated. These recommendations address indications, cardiac compressions and hand position, application of counter-pressure on the sternum, airway management, defibrillator pad position, and management of the patient with head fixation (Mayfield) pins in-situ.

Discussion Whilst supine CPR remains the gold standard, prone CPR represents a viable alternative in certain situations. It should be considered for patients who suffer cardiac arrest in the prone position where turning the patient into the supine position would present a time delay or additional risk to the patient, particularly if the head is secured in Mayfield pins. It may be appropriate to turn the patient into the supine position for ongoing management of the arrest if prone CPR is unsuccessful and staff and resources are available to facilitate this change in position. As noted by previous authors, further quality research into CPR in the prone position is recommended.

References 1. Brown J, Rogers J, Soar J. Cardiac arrest during surgery and ventilation in the prone position: a case report and systematic review. Resuscitation 2001; 50: 233–8. 2. Atkinson MC. The efficacy of cardiopulmonary resuscitation in the prone position. Critical Care and Resuscitation 2000; 2: 188–90. 3. Miranda CC, Newton MC. Successful defibrillation in the prone position. British Journal of Anaesthesia 2001; 87: 937–8.

Methods Proforma was prepared to collect data. Data was collected prospectively over a period of 2 months from patients care plan, PEWS charts and anaesthetic charts. The prospectively collected data was analysed.

Results Data from 85 cases was analysed. Sex distribution was equal and more than half (53%) were below 5 years old. Weight range was between 4 to 82 kg with 56.04% of cases below 20 kg. More than half of the surgical procedures were ENT, Plastics, urology and general surgery. Most of the procedures (87%) had duration of less than 1 hour. In only 70.06% of cases temperature was between 36°-37° in recovery. In 30.05% of cases pre operative temperature was less than 36°. Only 5.9% of cases had intra op temperature monitoring. In recovery 10.6% cases had no temperature documentation.

Discussion Peri-operative temperature control in children undergoing day case surgery at our centre falls short of proposed standards. The rigorous standards can only be met through more aggressive peri operative temperature management. Temperature should be monitored in all children and appropriate warming methods should be used intraoperatively. We recommended that every effort should be made to keep children warm pre-operatively, documentation should be improved and reaudit to evaluate any improvement. Care should be taken not to over warm when using warming methods.

References 1. Recommendations for standards of monitoring during anaesthesia and recovery. London: AAGBI, 2007 (http://www.aagbi.org/pdf/Absolute.pdf). 2. Leslie K, Sessler DI. Perioperative hypothermia in the high-risk surgical patient (Review). Best practice and research. Clinical Anaesthesiology 2003; 17(4): 485–498. 3. Adamsons K Jr, Gandy GM, James LS. The influence of thermal factors upon oxygen consumption of the new born infant. Journal of Pediatrics 1965; 66: 495–508. 4. Valeric R et al. Hypothermia-induced reversible platelet dysfunction. Annals of Surgery 1987; 205: 175–181. 5. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical- wound infection and shorten hospitalization. New England Journal of Medicine 1996; 334: 1209–1215.


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The management of emergency caesarean section necessitated by Thrombotic Thrombocytopaenic Purpura (TTP) presenting in the third trimester

WITHDRAWN

N. Singh1 and K. Blyth2 University Hospitals Birmingham NHS Foundation Trust; 2Birmingham Women’s Hospital NHS Foundation Trust

1

We report the multi-specialty management of this rare condition presenting acutely in the 3rd trimester to achieve the successful treatment of the parturient and the delivery of a healthy fetus. TTP is an autoimmune condition characterised by microangiopathic haemolytic anaemia. The formation of multiple thrombi results in platelet consumption and potentially fatal clinical features including confusion or coma and renal failure. Ultra large von Willebrand Factor molecules (ULvWF) are found and these cannot be broken down due to a deficiency in vWF cleaving protease (ADAMTS13) caused by ADAMTS13 specific autoantibodies [1].

Description A 30 year-old primiparous lady presented to Birmingham Women’s Hospital (BWH) at 32 weeks gestation with lethargy and shortness of breath in April 2013. Investigations revealed worsening type 1 respiratory failure attributed to pulmonary congestion. Her past medical history included a tentative diagnosis of an undefined connective tissue disease on account of an episode of atypical haemolytic uraemic syndrome successfully treated with steroids in 2010. Blood tests on admission showed a severe anaemia and thrombocytopaenia (haemaglobin of 58 g/L, platelet count of 5 9 109/L). A diagnosis of acquired TTP was established by way of serology revealing low levels of ADAMTS13. Upon review by multiple specialties it was decided that delivery by emergency caesarean section at the Queen Elizabeth Hospital Birmingham (QEHB, nearest centre with necessary specialties including intensive care) would be prudent for both mother and fetus.

Discussion Pre-operative care included treatment with plasmapheresis and steroids followed by transfer to the QEHB intensive care unit for further pre-optimisation including the insertion of invasive lines (including a vascath), radiologically sited internal iliac balloons and correction of coagulopathy. Intra-operatively, the focus of attention was the prevention of and preparedness for major haemorrhage achieved by several means including thromboeslastography directed blood product therapy and the use of cell salvage. Post-operatively, ensuing renal failure warranted a period of continuous veno-venous haemo-filtration and eventual transfer back to obstetric high dependency care at BWH. The care of this critically unwell parturient necessitated the coordinated efforts of multiple specialties; obstetricians and anaesthetists as well as the specialist advice of nephrologists, haematologists, intensivists, radiologists and neoantologists. We would like to highlight the main clinical challenges encountered peri-operatively as well as the complicated logistics surrounding this case.

Reference 1. Roberts D. Haematology – thrombotic thrombocytopaenic purpura. GP online, October 2011, accessed online (March 2014): http://www.gponline.com/ Clinical/article/1097716/haematology-thrombotic-thrombocytopenic-purpura/

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Consent for prone positioning – a project M. Smith and P. Klepsch North Bristol NHS Trust

Our project involves performing a national survey of practice regarding discussion of risks of prone positioning followed by a local improvement project consisting of: an information video for patients, a written patient information leaflet, and a prone position risks sticker for anaesthetic charts.

Methods Using a ‘Survey Monkey’ questionnaire we designed a ten question survey and sent it out to 65 anaesthetic departments in England, list of which we received from United Kingdom Spinal Societies Board.

Results We received 626 responses from 62 Hospitals, 72% from Consultants, and the rest from Trainees and SAS grade doctors. 589 (94%) of them were anaesthetists, 31 (5%) orthopaedic surgeons and 6 (1%) neurosurgeons. 319 (51%) responders routinely explained the risks of prone positioning to the patients, but only 197 (32%) documented the discussion. Departments which had allocated space on the anaesthetic charts were more likely to document the risks 38% vs 29% (p value = 0.029). Most commonly quoted risks were: facial swelling 305 (84%), redness over pressure points 225 (62%) and peripheral nerve damage 156 (43%). Risk of visual loss was quoted by 126 (35%) responders. One or more complication in their patients was remembered by 178 (32%) responders. Question 9 regarding responsibility unfortunatelly had faulty logic as it didn’t allow two answers to be selected, 94 (15%) felt it is a surgical resposibility to explain positioning risks, 165 (27.5%) anaesthetist’s and 340 (57%) didn’t know, however 96 (15% of 626) left a comment saying it is a joint responsibility.

Discussion Prone position has been quoted as high risk in many publications [1]. The practice of explaining and documenting risks of prone position to patients appears inconsistent across England. There are no national guidelines on how much to disclose and who should take the responsibility. In a survey of patients’ opinion in the USA at least 80% of patients prefered full disclosure of the risk of postoperative visual loss during spinal surgery in prone position [2]. In our hospital we are in a process of designing an information leaflet and a video in an attempt to improve and standardise information given to our patients. We are also creating a sticker for anaesthetic notes to improve documentation of the risks. We feel that a national consensus between specialist societies is needed to help professionals in deciding what risks to discuss and document in relation to prone positioning.

Acknowledgements We would like to thank our departmental secretaries Jean Moon and Andrea Giambarresi for phoning all anaesthetic departments and obtaining their email addresses.

References 1. H. Edgcombe, K. Carter and S. Yarrow. Anaesthesia in the prone position. British Journal of Anaesthesia 2008; 100(2): 165–83. 2. Corda DM, Dexter F, Pasternak JJ, Trentman TL, Nottmeier EW, Brull SJ. Patients’ Perspective on Full Disclosure and Informed Consent Regarding Postoperative Visual Loss Associated With Spinal Surgery in the Prone Position. Mayo Clinic Proceedings. Sep 2011; 86(9): 865–868.

206 ‘‘How safe are your labels?’’ An audit into the inter-theatre variability of anaesthetic drug labels M. Smith and L. Sharp Nottingham University Hospitals

Patient safety is under increased scrutiny. An area often overlooked is the provision of appropriate labels for anaesthetic drugs in theatre. Whilst anaesthetists routinely label their drugs, anecdotal evidence shows that the labels are often provided in an ad-hoc and disorganised way. There have been a number of serious untoward incidents in our trust directly relating to mis-labelling of drugs so in order to address this an audit was undertaken to assess the access to anaesthetic drug labels and inter-theatre variability in one centre.

Methods An inventory was carried out of all anaesthetic labels in all theatres at a large university teaching hospital. This was analysed to quantify what was provided, how it was presented, and to assess for any duplications or incorrect nomenclature, in accordance with the AAGBI guidelines on Anaesthetic Drug Labelling Clinical review: Renal tubular acidosis [1, 2]. Based on this, a proposed minimum selection of labels was set as a standard.

Results We ascertained existence of a wide variation in the availability of anaesthetic labels across all theatres. The labels were presented in disorganised fashion with duplications cluttering the clinical environment; important omissions, such as suxamethonium labels only being present in 85% of theatres; presence of inappropriate labels for the environment e.g etomidate in daycase. We also noted several incidences of similarly coloured labels from drugs with very different classes of drug mixed together. Despite the AAGBI’s [2] proposal for updated standard nomenclature of anaesthetic drugs in the UK we found many examples of old stickers remaining in circulation – e.g glycopyrronium where 88% of labels were incorrect.

Discussion The results suggest that the provision of stickers could be improved and in certain instances we found genuine risks to patients. Whilst a lone worker may be able to compensate by using incorrect labels this is not conducive to safe handover or efficient management of an emergency situation. The presentation and organisation of the labels may also have serious implications for their use. In an attempt to improve the provision of labels we propose a cheap and efficient solution to ensure the safe and organised storage and dispensing of anaesthetic labels to prevent potential labelling errors, which can have serious implications for patients.

References 1. Recommendations for anaesthetic drug labelling (http://www.aagbi.org/ sites/default/files/syringelabels03.pdf). 2. Syringe labelling in critical care areas June 2004 Update (http://www.aagbi. org/sites/default/files/syringelabels(june)04.pdf).


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A rare cause for a rapidly progressive neurological condition

Emergency anaesthetic management of an adult patient with Poland-Moebius syndrome

M. Smith, B. Evans and G. Wilbourn United Lincolnshire Hospitals

F. Stonley1 and S. Yeo2 1 Sandwell & West Birmingham NHS Trust; 2Wye Valley NHS Trust

Description In this report we present a case of a 29 year old woman with a background of intravenous drug use who presented with a progressive neurological condition ultimately requiring level 3 organ support. The patient initially presented to ENT with a sore throat and dysphagia which had progressed over several days. She also had ptosis and diplopia and profound muscle weakness in her limbs. In addition to her neurological conditions she had multiple leg wounds, which required extensive surgical debridement, and Clostridium Botulism was isolated as a causative organism. Our patient remained ventilated following surgery but only required respiratory support for 72 hours before being extubated and making a good recovery.

Discussion Clostridium Botulinum is a naturally occurring Gram positive organism which occurs in soil, dust and aquatic sediments. The incidence of wound colonisation is increasing since it was first described in 2000, and is found exclusively in the intravenous drug using population due to a practice known as skin popping, which involves the injection of heroin, often dissolved in citric acid, directly into muscle or under the skin, which provides optimum conditions for bacterial growth. Botulism presents to a range of specialities including ENT and ophthalmology with a variety of symptoms. Classically patients present afebrile with a sore throat, dysphagia and range of cranial nerve signs including diplopia, blurred vision, ptosis, nystagmus. This is then followed by weakness in the neck and arms, ultimately progressing onto a weakness of respiratory muscles and a respiratory failure. Due to the difficulty in isolating a causative organism the diagnosis should be made on clinical grounds and this can be difficult due to the rarity of the condition combined with its similar clinical presentation to several other progressive neurological conditions. The management consists of early wound debridement and supportive care. There is an antitoxin available and this can be used in conjunction with benzyl penicillin and metronidazole to remove any circulating toxin and treat the causative organism. Weaning from respiratory support can be a prolonged process requiring an extended period of rehabilitation but most patients have good ventilatory muscle strength by one year. With the incidence Clostridium Botulinum increasing in the UK it is an important addition to our armoury of differential diagnoses in patients with new onset neurological symptoms and a background of intravenous substance abuse.

References 1. Wenham, T, Cohen, A.Contin Educ Anaesth Crit Care Pain 2008; 8(1): 21–25. 2. Wound botulism in people who inject drugs: suspected and confirmed cases reported to Public Health England, England and Wales: 2000–2013, Shooting Up Report, HPA Website. 3. Health Protection Agency Botulism Duty Doctor Protocol (January 2013). 4. Brett MM, Hallas G, Mpamugo O. Wound botulism in UK and Ireland. J Med Microbiol 2004; 53: 555–61. 5. Wilcox PG, Morrison NJ, Purdy RL. Recovery of the ventilatory and upper airway muscles and exercise performance after type A botulism. Chest 1990; 98: 620–6.

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We present a case of a profoundly shocked patient with a rare and complex syndrome, requiring emergency laparotomy. We report the successful anaesthetic and intensive care management of this patient, and discuss the options available to all anaesthetists working in non-specialised centres.

Description A 25 year old female with Poland-Moebius Syndrome presented out of hours to a small district general hospital Emergency Department. She was pregnant at 15 weeks gestation, and presented with acute onset abdominal pain and profound hypotension. FAST scan revealed intra-abdominal fluid. Antenatal ultrasound had previously confirmed an intrauterine pregnancy. Rapid examination revealed a predicted difficult intubation and poor IV access. From her history her cardiorespiratory function was presumed to be suboptimal, but to an unknown extent. Emergency exploratory laparotomy was performed, which revealed a uterine rupture, secondary to a previously undiagnosed bicornuate uterus.

Discussion Poland-Moebius Syndrome is an oromandibular-limb hypogenesis syndrome, first described in 1888. Our patient had a right sided facial nerve paresis, bilateral hearing loss, retrognathia, limited mouth opening, absent right pectoralis muscle, reported hypoplastic right lung, absent right radius and anomalies to the right hand. This presented challenges to the anaesthetist in respect of a potentially difficult intubation and ventilation, poor intravenous access, and an unquantified cardiorespiratory function. Tracheal intubation, though difficult, was achieved with standard intubating adjuncts. Performing a surgical cricothyroidotomy had been predicted to be straightforward, and was planned for. Ventilation was not difficult, but extubation and subsequent oxygenation were complicated by copious secretions. We were successful in obtaining IV access, but there are no contraindications to IO access. Some reports suggest avoiding succinylcholine in patients with Poland-Moebius syndrome; we used it without complication. In summary, standard techniques and algorithms were successfully used, available to all anaesthetists in the emergency situation.

References €bius PJ. Ueder angeborenen doppelseitge abducens-facialis lahmung. Mo Munchener Medizinische Wochenschrift 1888; 35: 91–94. Ames WA, Shichor TM, Speakman M, Zuker RM, McCaul C. Anesthetic management of children with Moebius sequence. Canadian Journal of Anesthesia 2005; 52(8): 837–844. Ferguson S. Moebius syndrome: a review of the anaesthetic implications. Paediatric Anaesthesia 1996; 6(1): 51–564. Krajcirik WJ, Azar I, Opperman S, Lear E. Anaesthetic management of a patient with Moebius syndrome. Anesthesia & Analgesia 1985; 64: 371–372. €bius syndrome. Journal of Gondipalli P, Tobias JD. Anesthetic implications of Mo Clinical Anesthesia 2006; 18: 55–59.


Regional anaesthesia has multiple benefits for open reduction and internal fixation of wrist fractures – but not at the weekend J. Strachan,1 V. Athanassoglou1 and C. Morris2 1 Oxford University Hospitals NHS Trust, Oxford; 2Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust

210 Emergency anaesthetic management in a child with Glutaric Aciduria Type1 D. Subramani1 and V. Gopinathan2 1 Nottingham University Hospitals NHS Trust; 2Sherwood Forest Hospitals NHS Trust

Description Methods We performed a retrospective case notes audit of all patients over one year who received an internal fixation of a wrist fracture and considered day and time of surgery, anaesthetic and analgesic technique, duration of case, intraoperative opioid use, post operative pain score, rescue analgesia, post operative nausea and vomiting (PONV) and time to discharge.

Results There were 117 patients included in the audit. Approximately 75% less cases received regional anaesthesia at weekends compared with cases midweek. The overall rate of regional anaesthesia was lower than expected (only 22% of all cases). PONV was reduced in the group of patients that received regional anaesthesia and there was no association between receiving a nerve block and an increased overall duration of case. The amount of intraoperative morphine, pain scores in recovery and the amount of morphine given in recovery were similar between the two groups. Additionally, severe pain was seen in recovery in those patients whose anaesthetic included neither a nerve block or strong opioid.

A 3 year old child known to have Glutaric Aciduria Type1 presented to emergency department with seizures. Her seizures were initially controlled with benzodiazepines and she was admitted to the ward for further management. Whilst in the ward she had a recurrence of seizure and needed an urgent CT scan to rule out any intracranial pathology. She was not fasted prior to the event and was on her emergency feeding regime to avoid catabolic state. She was maintaining her airway during the post-ictal period. A 22G cannula had been inserted and 10% dextrose with 0.45% normal saline was administered. Her arterial blood gas was normal apart from a raised lactate. The child received a rapid sequence induction with propofol (5 mg/kg) and rocuronium (0.6 mg/kg). The airway was secured with an uncuffed 5.0 mm endotracheal tube and a nasogastric tube was inserted. Anaesthesia was maintained with propofol infusion (10 mg/kg/hr) for the transfer to CT scan. Ondansetron (0.15 mg/kg) was administered for anti-emetic prophylaxis and her temperature was monitored throughout. She was extubated uneventfully after the scan and was transferred back to the ward.

Discussion

There is evidence that regional techniques offer benefits for patients undergoing surgery for wrist fractures [1]. In our institution there are several potential reasons for the reduced rate of regional anaesthesia at weekends. Weekday trauma lists are largely run by dedicated consultant trauma anaesthetists. Weekend trauma lists are delivered by junior anaesthetists, but usually with immediately available consultant supervision. Many junior trainees, and the majority of general on call consultants may not be confident performing upper limb nerve blocks. Midweek wrist trauma is often operated on by specialist upper limb trauma surgeons, who are supportive of regional anaesthetic techniques. Weekend operating is often by registrars or non specialist consultants. There may be unfounded fears amongst some surgeons regarding the risk of unrecognised compartment syndrome. Also some may believe that regional anaesthesia adds unacceptable time delays to operating lists. We therefore plan to organise upper limb surgery into more dedicated lists with a specialist surgeon and anaesthetist and re audit our progress next year.

Glutaric Aciduria is a rare inborn error of metabolism that results from a deficiency of glutaryl –CoA dehydrogenase. It is an autosomal recessive mitochondrial disorder and presents in early childhood. The most common presenting symptoms are macrocephaly, hypotonia or diffuse rigidity, encephalopathy, seizure and dystonic movements. Patients are prone to develop acute neurologic crisis typically precipitated by infection or physiological stress. Metabolic manifestations such as metabolic acidosis and hypoglycaemia are rarely present except in acute phases. Anaesthesia management should consider the possibility of pulmonary aspiration, prolonged responses to non-depolarising muscle relaxants and hyperkalemic responses to succinylcholine. In our case as the child was not fasted, appropriate measure to avoid aspiration were taken. This includes use of H2 blockers and rapid sequence induction with cricoid pressure. Continuous monitoring of neuromuscular blockade and administration of small doses of neromuscular blocking drugs are important. Propofol can be used in patients with Glutaric Aciduria type1 for procedures of shorter duration but we have to be aware that propfol infusion can lead to severe metabolic acidosis in some mitochondrial disorders.

Reference

References

Discussion

1. Egol KA, Soojian MG, Walsh M, Katz J, Rosenberg AD, Paksima N. Regional anesthesia improves outcome after distal radius fracture fixation over general anesthesia. Journal of Orthopaedic Trauma 2012 Sep; 26(9): 545–9.

Hernandez-Palazon J, Sanchez-Rodenas L, Martinez-Lage JF, Collado IC. Anesthetic management in two siblings with glutaric aciduria type 1. Paediatric Anaesthesia 2006 Feb; 16(2): 188–91. Goktas U, Kati I, Aytekin OC. Management of outpatient anaesthesia in an unusually case with glutaric aciduria type-1. Paediatric Anaesthesia 2009 Jun; 19(6): 632–3. Adelais G. Tsiotou, Anna Malisiova, Nikolaos Bouzelos, Dimitrios Velegrakis. The child with glutaric aciduria type I: Anaesthetic and Perioperative Management. Journal of Anaesthesia 2011; 25(2): 301–304.


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Audit of unplanned admissions following day case laparoscopic cholecystectomy: a 3 year review D. Subramani, T. Fletcher and J. Ward Nottingham University Hospitals NHS Trust

Methods We conducted a retrospective analysis of all consecutive patients admitted from the day case unit to the Trust hospital from July 2011 to July 2013 following Laparoscopic Cholecystectomy surgery. Data was collected from the admission details completed by day unit staff prior to each transfer. It was analysed for the reasons for admission: and we attributed these causes to ‘‘surgical’’, ‘‘anaesthetic’’ or any ‘‘other’’ reasons. Data was collected, handled and analysed by the hospital clinical governance team, with all patient data anonymised and complying with information governance practice.

Results There were 618 day case laparoscopic cholecystectomies performed over this 3 year period from July 2011 to July 2013. Out of these 40 patients (6.4%) were admitted, 21 patients (52.5%) were admitted due to anaesthetic reasons and 18 patients (45%) were admitted due to surgical reasons. One patient (7.5%) suffered both an anaesthetic and surgical complication. Admission rates (6.4%) were lower compared to our results with our previous audit (Jan 2010 to Dec 2011 - 8.6%). Surgeons with regular day surgery lists, and who undertake larger volumes of this type of work were found to have lower admission rates.

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Use of a massive haemorrhage protocol in a UK district general hospital is associated with an improvement in mortality B. Taylor,1 L. Lambert2 and A. Windsor2 1 New Cross Hospital, Wolverhampton; 2Royal Shrewsbury Hospital

Day case laparoscopic cholecystectomy is a safe alternative to planned overnight admission, with no difference in morbidity, re-admission rate, pain, postoperative quality of life, patient satisfaction or time to return to work. With the increasing numbers of these cases being performed as day surgery, it is important to ensure that there is no increase in unplanned admissions. Admissions are reported at being between 5 and 31% and at our unit admission rates were at 8.6% from a previous audit. We aimed to audit our current admissions following day case laparoscopic cholecystectomy over a three year period, to see whether we can improve the services with changes in clinical strategies. In addition to identifying reasons for failed day case discharges.

Massive haemorrhage is associated with significant morbidity and mortality. In the context of major trauma managed in a large centre, the use of a massive haemorrhage protocol emphasizing early haemostatic resuscitation reduces mortality (1). However, it is not clear if these models are effective in non-trauma patients (2). There is some concern that these protocols may increase the wastage of blood products which might be a concern in smaller hospitals. (3) We aimed to audit the activation of and compliance with a massive haemorrhage protocol in a UK district general hospital. To assess if compliance with the protocol resulted in a difference in mortality, morbidity, length of ICU stay, or use of blood products.

Methods Retrospective audit over 12 months analyzing the case notes of all patients who had suffered a massive haemorrhage against a massive haemorrhage protocol which emphasizes early haemostatic resuscitation.

Results The protocol was activated in 9 patients, but unfortunately notes were unavailable for one as he was undergoing outpatient treatment. A further 9 patients were identified as having had a massive transfusion, without activation of the protocol, from blood bank data as having been issued emergency uncrossmatched group O blood, or having had more than 10 units of any blood products in a 24 hour period. Where a massive haemorrhage protocol was used, 1/8 patients (12.5%) died. Where a major transfusion was conducted without activation of the protocol, 7/9 patients died (77.8%). This finding was statistically significant (p = 0.0152) using a 2-tailed fishers exact test. Fewer units of red cells (p = 0.0011) and FFP (p = 0.0034) were used in patients managed according to the protocol, but there was no difference in the use of platelets or cryoprecipitate. Two patients in the group where the protocol had not been activated were given cryoprecipitate despite normal fibrinogen levels, and a further two in this group were not given cryoprecipitate despite fibrinogen levels under 1 g/l

Discussion

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Use of a massive haemorrhage protocol which focuses on rapid haemorrhage control, haemostatic resuscitation and early use of blood is associated with a lower mortality than management of major bleeds without the protocol. This appears to apply in predominantly nontrauma patients in a non-specialist centre. This was a retrospective audit, and the group in whom the protocol was not activated had a higher expected mortality, therefore the results warrant further research

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1. Khan S, et al. A major haemorrhage protocol improves the delivery of blood component therapy and reduces waste in trauma massive transfusion. Injury 2013; 44(5): 587–92. 2. Pacheco LD, et al. The role of massive transusion protocols in obstetrics. American Journal of Perinatology 2013; 30: 1–4. 3. Sinha R, Roxby D. Change in transfusion practice in massively bleeding patients. Transfusion and Apheresis Science 2011; 45(2): 171–4.

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Figure 1 Percentage of admissions for each surgical team

Discussion Unplanned admissions following day surgery not only reflects the quality of clinical work undertaken, but is also influenced by the choice of surgical procedure performed, the effectiveness of pre-assessment and, to some extent on the local protocol/guidelines for addressing postoperative recovery issues. The most common factors for unplanned admission are ‘surgical’ observations, pain and PONV. Careful selection of patients, increased use of local anaesthetic (and perhaps regional) techniques, and more aggressive control over pain and PONV may help reduce these admission rates even further.

References 1. K. S. Gurusamy, S. Junnarkar, M. Farouk, and B.R. Davidson. Day-case versus overnight stay in laparoscopic cholecystectomy. Cochrane Database of Systematic Reviews 2008; (1): CD006798. 2. British Association of Day Surgery (BADS). Directory of recommended day and short stay surgical procedures, 3rd edn. 2009. 3. Lower J. 2011.A service evaluation of day surgery laparoscopic cholecystectomy. Internal Service Evaluation. Nottingham University Hospitals. 4. Jacob A. Akoh, Will A. Watson, Thomas P. Bourne. Day case laparoscopic cholecystectomy: Reducing the admission rate. International Journal of Surgery 9(1): 63–67.

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A rare cause of post-partum haemorrhage. The diagnostic role of the anaesthetist on labour ward N. Ungureanu and R. Somaiya George Eliot Hospital NHS Trust Nuneaton

The rupture of unscarred uteri is rare and doctors should have a high index of suspicion regarding the possible occurrence of this life threatening event. A literature search revealed a very low incidence of this type of uterine rupture (0.0033% of deliveries).The risk factors associated with such an event are augmentation of labour, grand multiparity, instrumental deliveries and congenital uterine anomalies, but none of these were present in this case.

Description The anaesthetist was called to attend a 34 year old lady that had a vaginal delivery complicated by shoulder dystocia, 20 minutes before. The baby was delivered within 3 minutes. At the time of delivery the patient was Term+ 10/ 40 and had a previous normal vaginal delivery 3 years before. She had a working epidural, but required top-up boluses for breakthrough pain in the left flank during the day. On arrival, the anaesthetist found the patient was in shock with a CR of 4 sec. She was having a 2nd degree tear repair and the estimated blood loss was 400 mls. A second large bore cannula was immediately inserted and fluid resuscitation was started simultaneously. A venous blood gas was sent at the same time and the PCEA was disconnected. On examination, the patient was clammy, complaining of mild left sided abdominal pain and had guarding on deep palpation on the same side despite a good bilateral T6 to L1 sensory epidural block.The VBG showed metabolic acidosis (PH = 7.28) with a lactate of 3.8, a BE of - 8.1 and an Hb of 67 g/l. The possibility of a uterine rupture was then raised and the obstetric registrar was asked to perform an urgent abdominal USS that revealed a large haemoperitoneum. The patient was immediately transferred to theatre and had a laparotomy under a general anaesthetic. The operative finding was a posterior uterine wall rupture. The rupture was closed with haemostatic sutures in two layers and the uterus was salvaged. The estimated total blood loss was 4000 mls.

Discussion The case highlights the importance of considering the possibility of uterine rupture after vaginal deliveries in patients with unscarred uteri. The presence of a working epidural complicated the clinical picture and assessment. A ruptured uterus before the second stage of labour is improbable and an even rarer event, but it was also a possibility in this case.The patient complained of breakthrough left upper quadrant and left flank pain for 2-3 hours before the delivery although she had a reasonable level of epidural block on that side. Junior doctors in both Anaesthetics and Obstetrics should be aware of these rare events and work as a team towards reaching a diagnosis.

References €lmezoglu,SYSTEMATIC REVIEW: 1. G. Justus Hofmeyr, Lale Say and A. Metin Gu WHO systematic review of maternal mortality and morbidity: the prevalence of uterine rupture. An International Journal of Obstetrics & Gynaecology 2005; 112(9): 1221–1228. 2. David A. Miller, T. Murphy Goodwin,Robert B. Gherman et al, Intrapartum rupture of the unscarred uterus. Obstetrics and Gynaecology 1997; 89(5 Part 1): 671–673.

214 Severe metabolic acidosis and chronic constipation. A diagnostic dilemma N. Ungureanu and M. Bryant George Eliot Hospital NHS Trust Nuneaton

Normal anion gap metabolic acidosis can pose diagnostic difficulties in patients with multi-organ failure admitted to ICU. Our patient was investigated since childhood for severe chronic constipation and a possible variant of Hirschprung’s disease (not confirmed by bowel biopsy) and was admitted to ICU after becoming acutely ill with sepsis and severe metabolic acidosis. The acute episode was treated over a few weeks, the acidosis was finally corrected after starting sodium bicarbonate treatment and the diagnosis of type 2 proximal renal tubular acidosis secondary to possible Fanconi’s syndrome (family history present) was considered after input from a national renal tubular acidosis specialist was sought.

Description We present the case of a 17-year old girl with long term severe constipation that was admitted into our hospital ICU with severe metabolic acidosis (pH 7.13, BE -22.3, HCO3 4.3, Lac 3.0, Cl 96), as well as severe sepsis, acute kidney injury and diarrhoea,followed by multi-organ failure. The patient was initially extremely ill and received multiple organ support (renal, cardiac and respiratory). After the initial stabilisation, she had a CT abdomen that showed a hugely dilated rectum. A PR manual evacuation of faeces was performed and a bowel perforation was ruled out. The initial sources of sepsis were thought to be the bowel translocation due to faecal impaction and a community acquired pneumonia. Broad spectrum antibiotics and antivirals were started and she recovered well enough to be discharged to a medical ward after a few days. The patient was readmitted to ICU soon after her severe metabolic acidosis reoccurred. She was again managed with renal replacement therapy and was referred to the renal team for the first time 14 days after her initial ICU admission. The treatment with sodium bicarbonate 2 g QDS was started at this stage, the metabolic acidosis was corrected and the patient was discharged home 1 month after her initial admission.

Discussion Persistent and reoccurring severe metabolic acidosis should prompt intensivists to consider less common pathologies and involve renal physicians early in the diagnosis and specialist treatment of these patients. This patient suffered for years from severe chronic constipation that was most probably a consequence of her persistent metabolic disturbance and dehydration induced by a type 2 proximal renal tubular acidosis.The patient’s constipation resolved, she regained 20 kg in weight and was able again to live a normal life. We are awaiting confirmation of her final diagnosis from the renal tubular acidosis specialist in London.

References 1. Troels Ring, Sebastian Frische and Soren Nielsen. Clinical review: Renal tubular acidosis – a physicochemical approach. Critical Care 2005; 9: 573–580. 2. Sahar Fathallah-Shaykh, Adrian Spitzer, Fanconi Syndrome, Emedicine, http:// emedicine.medscape.com/article/981774-overview.


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Anaesthetic non-touch technique for butterfly children C. Wai1 and T. Raghavendra2 North Western Deanery; 2Central Manchester Foundation Trust

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Epidermolysis Bullosa (EB) is a group of rare, genetically determined condition characterised by excessive fragility of the skin and mucosa to separate from the underlying tissues after trauma or friction leading to blistering and subsequent scarring [1–4].

Description We described the anaesthetic management of a 4 year old girl with DowlingMeara type Epidermolysis Bullosa Simplex (DM-EBS) who underwent dental restoration and multiple teeth extractions. She had a previous history of significant scald injury requiring repeated general anaesthesia. She developed blisters from her previous intubations but they were straightforward. On examination, patient had active blisters on her palms, elbows and lower limbs, with scarring of her previous blisters sites. Equipments that would be in direct contact with the patient were identified and specialised dressings were attached to these. Patient was very cooperative and inhalational induction was performed as difficult intravenous access was predicted. Our main concern was the formation of blisters with any mild contact. As soon as she was asleep, intravenous access was secured using Mepitel and a bandage. Monitoring equipments which were specially prepared were attached to patient. A Size 2 laryngeal mask airway (LMA) which was a size smaller for the patient was utilised and precautions were taken to avoid rotational movement within the oral cavity. The patient’s eyes were lubricated with paraffin based ointment and she was operated on the transfer trolley to avoid unnecessary movements. The airway was left unsecured and the dentist utilised ample amount of petroleum jelly throughout the procedure to reduce blistering of her mucous membranes. Anaesthesia was maintained with oxygen, air and sevoflurane. Upon emergence, the LMA was deflated prior to removal. No new blisters were noted postoperatively and she was discharged home a few hours later.

H. Waqar-Uddin and D. Haley Royal Blackburn Hospital

Ventilator-Associated Pneumonia (VAP) is defined as hospital acquired pneumonia in mechanically ventilated patients occurring 48 hours or more after tracheal intubation. Responsible for almost 25% of ICU infections, VAP results in increased length of ICU and hospital stay, with associated mortality as high as 50% [1]. Substantial evidence suggests that introduction of a ‘VAP Care Bundle’ reduces the risk of developing VAP [2]. Our initial audit showed reasonable compliance with delivery of components of the care bundle but poor documentation of both the VAP care bundle and the Clinical Pulmonary Infection Score (CPIS). We reaudited both the use of the VAP care bundle and CPIS after staff education and changes to the format of patients’ charts.

Methods We examined the daily use of both the Department of Health endorsed VAP Care Bundle and Clinical Pulmonary Infection Score (CPIS) in ICU patients. Forty separate patient episodes were assessed to determine the delivery rate of each Care Bundle element, through assessment of the patients and their clinical notes. Documentation of Care Bundle delivery and CPIS completion was also assessed.

Results Full compliance with delivery of all aspects of the VAP care bundle occurred in 85% of cases. The prescription of appropriate GI prophylaxis was the only aspect that was not performed universally. Documentation of the VAP bundle also improved from 50% in the previous audit to 70%. However, use of CPI scores, which was previously poor at 30%, was even worse at only 20%.

Discussion

Discussion Epidermolysis Bullosa Simplex is an autosomal dominant subtype of EB due to mutation in the keratin 5 or 14 gene with the DM type being the most severe form [2, 4]. Incidence of EB is thought to be 1 in 17000 births with EBS making up 70% of the cases [3]. DM-EBS is characterised by generalised intraepidermal blistering which tends to occur in clusters [2]. This is due to an abnormality of the keratin-filament network which leads to impaired resistance of basal epidermal cells to external shearing forces [4]. Patients with this condition can prove to be a challenge. Whilst anaesthesia may be uneventful, meticulous care has to be taken to avoid exacerbating the condition and a non-touch technique such as the one employed in this case would be recommended.

References 1. Ames W, Mayou B, Williams K. Anaesthetic management of epidermolysis bullosa. British Journal of Anaesthesia 1999; 82: 746–51. 2. The Dystrophic Epidermolysis Bullosa Research Association of America. EB Simplex 2014 http://www.debra.org/simplex (accessed 17/03/14). 3. DEBRA. What is EB 2014 https://www.debra.org.uk/article-what-is-eb.html (accessed 17/03/14). 4. Ishida-Yamamoto A, McGrath J, Chapman S, Leigh I, Lane E, & Eady R. Epidermolysis bullosa simplex (Dowling-Meara type) is a genetic disease characterized by an abnormal keratin-filament network involving keratins K5 and K14. Journal of Investigative Dermatology 1991; 97(6): 959–68.

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Re-audit of compliance and documentation of the department of health endorsed Ventilator Associated Pneumonia care bundle and Clinical Pulmonary Infection Scores in ICU

The use of care bundles to improve aspects of patient care has increased, especially in the ICU environment. Many aspects of the bundles are evidence based and could result in improved patient outcomes. However, ensuring universal delivery of the bundles is a challenge. In our audit, the care bundle was delivered almost universally except for the prescription of GI prophylaxis. This suggests an educational deficiency which could be remedied with appropriate staff training. Documentation of the delivery of the VAP bundle, done by the nursing staff, improved from 50% to 70% in the re-audit. However, documentation of the CPI scores which is done by the medical staff was worse, falling from 30% to 20%. This may be related to regular rotation of junior doctors who are unfamiliar with protocols in a new hospital. However, VAP bundles and CPIS are well established aspects of ICU care so these poor results cannot be entirely explained by this effect. Controversy exists over the utility of CPI scores in diagnosing VAPs [3]. Failure to use and document the CPI scores may reflect a lack of trust in their specificity in the diagnosis of VAP.

References 1. Chastre J, Fagon JY. Ventilator-associated pneumonia. American Journal of Respiratory and Critical Care Medicine 2002; 165: 867–903 2. Masterton RG, Galloway A, French G, et al. Guidelines for the management of hospital-acquired pneumonia in the UK: report of the working party on hospital-acquired pneumonia of the British Society for Antimicrobial Chemotherapy. Journal of Antimicrobial Chemotherapy 2008; 62: 5–34. 3. Zilberberg MD, Shorr AF. Ventilator-associated pneumonia: the clinical pulmonary infection score as a surrogate for diagnostics and outcome. Clinical Infectious Diseases 2010 Aug 1; 51–52.


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Evidence-based prescribing of renal replacement therapy in the intensive care unit

Needle phobia in pregnancy – a review of a specialist clinic

H. Waqar-Uddin,1 S. Mousdale1 and D. Cottle2 1 Royal Blackburn Hospital; 2Lancashire Teaching Hospitals NHS Trust

K. Whitehouse and J. Morch-Siddall Royal Victoria Infirmary, Newcastle upon Tyne

Research suggests that there is no benefit in using doses of renal replacement therapy (RRT), expressed as effluent flow rate, higher than 25 ml/kg/hr [1]. Our institution uses the Prismaflex machine to provide RRT as continuous venovenous haemodiafiltration (CVVHDF). Certain parameters are entered to set up the machine, including blood flow rate, pre-filter fluid input rate, replacement fluid rate, dialysate rate and fluid removal. Taking these variables and calculating an effluent flow rate in ml/kg/hr is complex and, anecdotally, wide ranges of RRT were being delivered. There was also a communication issue between the medical staff prescribing the RRT and the nursing staff setting up the device. Inappropriate doses of RRT lead to multiple problems including poor solute clearance, cardiovascular instability and decreased filter lifespan. Unnecessarily large doses are also financially wasteful in terms of consumables. We have introduced a novel excel-based calculator in an attempt to standardise the prescribing of RRT. The calculator requires the physician to specify the patient’s weight, haematocrit and potassium level and produces the appropriate parameters listed above to give an effluent flow rate of 25 ml/kg/hr. As well as standardising the dose of RRT, it provides the nursing staff with the correct variables to programme the Prismaflex in a user-friendly format. In this study, our aim was to assess the prescribing and delivery of RRT prior to introduction of the calculator.

7.2% of pregnant women suffer from needle phobia [1]. These women are at high risk of serious morbidity and mortality; they are less likely to attend antenatal appointments, testing and comply with venous thrombo-embolism prophylaxis. The minimum antenatal data set required at booking in the UK specifies needle phobia should be identified [2]. A recent enquiry into maternal deaths in the UK [3] identifies needle phobia as a risk factor for maternal deaths. In recognition of this risk a clinic was established to treat these women using progressive desensitisation under hypnosis.

Methods The Prismaflex machines have memory cards which record the episodes of RRT that are delivered by that machine. We retrieved these memory cards and analysed the data within them from RRT episodes prior to introduction of the calculator. The data included the delivered effluent flow rates, the ‘downtime’ between episodes and the cause of the RRT being stopped e.g. the filter clotted.

Results We identified a total of 76 episodes of RRT on the data cards between 2007 and 2012. The mean time of each episode of RRT was 12.8 hours. The mean ‘downtime’ during each episode was 0.75 hours. The mean effluent flow rate was 42.9 ml/kg/hr. It was not possible in all instances to conclude why the filter was stopped.

Discussion This study demonstrates a huge variation in the doses of RRT prescribed before the introduction of the calculator. In addition, the episodes of renal replacement therapy were often interrupted because of line related problems or the filter clotting. Both these issues are potentially attributable to inappropriate doses of RRT. In the majority of the episodes of RRT, the delivered dose was significantly higher than the optimum 25 ml/kg/hr.

Reference 1. Bellomo R, Cass A, Cole L et al. Intensity of Continuous Renal-Replacement Therapy in Critically ill Patients. The RENAL study. New England Journal of Medicine 2009; 361(17): 1627–1638.

Methods 6 months after the clinic started a retrospective audit was undertaken. The notes of all women referred were reviewed. The data acquired included details of the phobia, treatment received and pregnancy outcomes.

Results 24 patients were referred over a 6 month period (6 women did not attend). The mean gestation at referral to the clinic was 16.9 weeks. Only 17% of women were asked about needle phobia at their first ante-natal encounter. The women referred displayed a range of phobias aswell as needle phobia, including fear of hospitals and labour. The nature of the phobias were mixed (41% vagal, 41% sympathetic, 12% mixed with 6% presenting with anxiety not phobia). Of the phobic women, 50% had a moderate phobia and 50% a severe phobia. Women were seen an average of 2.75 times before delivery. So far 21 women have delivered, 1 at a different hospital. There was no morbidity or mortality associated with delivery, 18 of 19 women who needed a cannula were able to have one and 8 out of 9 patients who needed subcutaneous low molecular weight heparin (LMWH) accepted this.

Discussion One of the most significant findings of this review was the failure to identify women with needle phobia at their first antenatal encounter (only 17% of the women who were referred were asked at this stage). An average course of hypnotherapy treatment for needle phobia takes 3 sessions for vagal phobia and 6 sessions for sympathetic phobia. Women were referred on average 23.1 weeks before their due date; identifying and referring women earlier would increase the time available for treatment. It is very likely that there are needle phobic women who have been missed by this referral process. We are developing a new referral pathway for needle phobic women and are planning a re-audit once this is in place. The clinic has made a positive difference to the women treated, with the majority of women being able to deal with their phobias to an extent where they were able to receive treatment (the exceptions being one woman who refused a LMWH injection and one who refused a cannula).

References 1. Lilliecreutz C, Josefsson A. Prevalence of blood and injection phobia among pregnant women. Acta Obstetricia Et Gynecologica Scandinavica 2008; 87: 1276–1279. 2. NHS(2013).Clinical Negligence Scheme for Trusts requirements. Available: http://www.nhsla.com/. Last accessed 02/02/2014. 3. Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. British Journal of Obstetrics and Gynaecology 2011; 118(Suppl. 1): 1–203.


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A baseline audit to investigate areas of improvement for an enhanced recovery in obstetrics protocol

An audit to evaluate post operative analgesia for tonsillectomy in children following an MHRA alert

V. Williams and V. Gudimetla Leighton Hospital, Mid Cheshire Hospital Foundation Trust

V. Williams, L. Wilson and M. Greene Leighton Hospital, Mid Cheshire Hospital Foundation Trust

Enhanced recovery in colorectal and orthopaedic surgery is well established in our hospital and throughout the country. It has been accredited with improved outcomes and reduced inpatient stays [1]. However, this has not been extrapolated to the obstetric population across the country. We are planning to adopt an enhanced recovery policy for elective caesarean section (CS) to allow our new mothers to recover quickly and go home sooner, from as early as the day following surgery. Therefore a baseline audit was undertaken to investigate areas that could be improved.

Codeine is a mild opioid that has been used for may years for moderate pain relief in adults and children. However, in July 2013 a medicines and healthcare products regulatory agency (MHRA) alert was published advising against the use of codeine in any child under the age of 12; furthermore, contraindicating codeine administration for children under the age of 18 who undergo tonsillectomy +/- adenoidectomy for obstructive sleep apnoea [1]. This review was triggered by concerns of an increased risk of morphine toxicity when susceptible children receive codeine for pain relief after surgery following the reporting of three fatalities and one life threatening case of respiratory depression in children [2, 3]. Therefore an audit was performed to assess knowledge of the MHRA alert and to ensure codeine was not being prescribed for children undergoing these procedures.

Methods The project was registered with the hospital audit department. Data were collected from 1st to 31st October 2013. All elective caesarean sections performed during this time period were included. Data was gathered about length of stay, fasting times and timescales for mobilisation, removal of the urinary catheter and discharge home. The quality indicators used were based on the NHS enhanced recovery partnership document [2].

Results There were 24 patients who underwent elective CS during the time period. The average fasting time was 14 hours for solid diet and 9 hours for oral fluids. All of the patients had a spinal with heavy bupivacaine and intrathecal diamorphine. Average time to oral fluid intake post surgery was 125 minutes and 217 minutes for diet. Time to urinary catheter removal was on average 21 hours, ranging from 17-35 hours. Time to mobilisation was 22.4 hours. Average time to discharge from time of CS was 50.3 hours. Three patients had a prolonged stay of 98-174 hours. Reasons for delayed discharge (after 48 hours) included bladder injury or more commonly, neonatal admission to the special care baby unit.

Discussion We consider this a very important audit to improve perioperative care of CS patients. The vast majority of resources in a typical obstetric unit are utilised for CNST compliance thereby restricting the time and personnel to carry out audits like ours. Areas that we going to focus on will be minimising fasting times, with better patient education and the introduction of high energy drinks two hours prior to surgery. Time to removal of the urinary catheter will be reduced to a maximum of 12 hours unless contraindicated, and patients will be encouraged to mobilise on the evening post surgery. A standardised analgesic regimen will be instituted including patient controlled oral analgesia on the post natal ward. We believe that the introduction of an enhanced recovery programme for obstetrics will improve patient satisfaction and patient flow. By allowing mothers to return to their normal environment sooner, we may reduce their risk of morbidity.

References 1. Kehlet H. Fast-track colorectal surgery. Lancet 2008; 371:791–3. 2. NHS enhanced recovery partnership. Fulfilling the potential: a better journey for patients and a better deal for the NHS. http://www.improvement.nhs.uk/ documents/er_better_journey.pdf.

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Methods Approval was gained from the hospital audit department. A data collection form was used to gather information about patient age, procedure performed, postoperative analgesia prescribed and administered and delayed discharge data.

Results A total of 28 patients were identified from 1st July to 31st October 2013 inclusive. Obstructive sleep apnoea and snoring collectively accounted for more than half of the indications for tonsillectomy. All patients were prescribed paracetamol and 79% were prescribed ibuprofen. Eleven patients, 39%, were prescribed codeine, but only two patients had codeine administered. Eight of the eleven patients were less than 12 years old. There were four delayed discharges, one of which was for apnoeic episodes, this patient was prescribed codeine but did not receive any on the paediatric ward.

Discussion Over a third of children less than 18 years of age were prescribed codeine for post tonsillectomy analgesia. This is contrary to MHRA advice and hence this audit has highlighted a lack of cascade of MHRA alerts within the department. The results of this audit have been presented to the anaesthetic department and advice given regarding the MHRA alert. Ways of ensuring MHRA alerts are made available to all consultant anaesthetists are being explored. Possible solutions to this problem are for the pharmacy department or the lead clinician to have responsibility to cascade appropriate alerts to the anaestheic department. The department will be re-audited in six months time to assess if there has been any change following the results and recommendations from this audit.

References 1. MHRA Drug Safety Update. Codeine for analgesia: Restricted use in children because of reports of morphine toxicity. July 2013. http://www.mhra.gov.uk/ Safetyinformation/drugsafetyupdate/CON296400. 2. Ciszkowski C, Phillips M, Lauwers A, Koren G. Codeine, Ultrarapid-Metabolism Genotype, and Postoperative Death. New England Journal of Medicine 2009; 361: 827–8. 3. Kelly LE, Rieder M, van dan Anker J et al. More Codeine Fatalities After Tonsillectomy in North American Children. Pediatrics 2012; 129: 1343–7.


Exercise at altitude and predicting AMS: can a lack of recovery of heart rate and oxygen saturation levels following a two minute cardiovascular stress test at altitude be used to predict the likelihood of developing AMS? C. Williams,1 D. Nilssen,2 M. Jacobsen,2 P. Hertz2 and L. Freer3 1 Anaesthetic Department, Morriston Hospital, Swansea; 2Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; 3Everest ER, Everest Base Camp, Nepal

Acute mountain sickness (AMS) is a common problem at high altitude, affecting 42% of those ascending to 3000 metres or above [1]. AMS may progress rapidly with fatal results if the acclimatisation process fails or symptoms are neglected and the ascent continues.

Methods A prospective study was carried out on 33 volunteers during an expedition to Everest Base Camp during October 2013. All volunteers were healthy and gave informed consent to participate in the study. The study was carried out at Khumjung, a small village in the Solokhumbu region of North-Eastern Nepal at an altitude of 3970 metres. Heart rate and oxygen saturations were measured following five minutes of rest. Subjects then exercised at maximal effort for two minutes. Following this, heart rate and oxygen saturations were measured immediately after exercise, and at one minute, two minutes and five minutes after cessation of activity. Volunteers were assessed during further ascent for symptoms of AMS using the Lake Louise criteria [2].

Results Desaturation following exercise was seen in all volunteers. Subjects taking acetazolamide as AMS prophylaxis showed a marked deterioration in oxygen saturation levels following exercise with a maximum decrease in oxygen saturations of 34% and a slower recovery to base-line values. The maximal increase in heart rate was seen at one minute post exercise. 54% of subjects had a heart rate within ten beats per minute of base-line at five minutes post exercise. 21% had a heart rate of 30 beats per minute or faster than the base-line measurements. Subjects who developed symptoms of AMS as defined by the Lake Louise consensus criteria showed slower recovery of heart rate and oxygen saturations back to pre-exercise measurements at 5 minutes after exercise.

Discussion The mainstay of AMS treatment in the field is descent with medical treatment and oxygen substitution used to facilitate this. Prevention is the safest and the most efficient method of care. Being able to identify those at risk of developing AMS could help reduce, and even prevent, the development of serious problems as well as identifying those who may benefit from prophylactic treatment. Recent as yet unpublished research has shown that although acetazolamide gives higher oxygen saturations at rest, it compromises exercise at altitude with a bigger fall in oxygen saturations and an increased perception of difficulty in exercise [3]. The ability to measure heart rate and oxygen saturations is possible with small hand held pulse oximeters and could provide a low-cost non-invasive test to predict those at risk of AMS. Further studies are now needed in a larger groups of subjects.

222 Audit of implementation of the AAGBI checking anaesthetic equipment 2012 guideline C. Wilson and I. Walker Great Ormond Street Hospital NHS Foundation Trust

The use of an anaesthetic equipment checklist reduces the risk of perioperative morbidity and mortality [1]. The AAGBI Checking Anaesthetic Equipment 2012 guideline has been designed in a new ‘read and do’ checklist format to reflect incidents reported nationally [2]. We conducted an audit using electronic voting pads to find out if this checklist was available for use and being used in our hospital, and re-audited after a short, targeted educational programme.

Methods All areas performing anaesthesia were visited to identify whether the 2012 AAGBI equipment checklist was available, and whether key backup safety equipment, highlighted in the checklist, was also present (self-inflating bags and a full oxygen cylinder). The audit standard was that 100% of areas should have the checklist and backup equipment immediately available. We asked all anaesthetists who attended the monthly departmental audit meeting to participate in a survey using voting keypads. Participants were asked if they were aware of the checklist, and whether they used it in their daily practice. We explained the background to the latest checklist with a video demonstration, and then asked whether we had influenced their practice.

Results Eighteen of the 39 areas (46%) in the initial audit had the checklist available. All areas had a full oxygen cylinder on the machine. Adult and paediatric selfinflating bags were present in 87% of the areas. On re-audit all areas had both the checklist and emergency equipment available for use. Twenty anaesthetists took part in the departmental meeting and survey using voting keypads. Nineteen responses were complete and therefore analysed (11 consultant anaesthetists, 8 senior registrars). Twelve anaesthetists (61%) had seen the checklist previously and one anaesthetist (5%) reported using it routinely. Following our educational session 14 anaesthetists (74%) stated that they would use the checklist in their future practice.

Discussion Prior to this audit compliance with the AAGBI equipment checklist, published in 2012, was low. The checklist itself was present in less than half of anaesthetic areas, self-inflating bags were not present in all the areas, and only one anaesthetist reporting that they used the checklist routinely. Intention to use the checklist was improved after training. This audit highlights the importance of local implementation of new guidelines. Further audit and training is planned to ensure that change of practice is sustained. Electronic voting devices were a powerful survey tool in the setting of a departmental meeting. A very high response rate was achieved and anonymity of the responders was maintained.

References 1. Arbous M, Moursing A, van Kleef M et al. Impact of Anaesthesia Management Characteristics on Severe Morbidity and Mortality. Anesthesiology 2005; 102: 257–68. 2. Hartle A, Anderson E, Bythell V et al. Checking Anaesthetic Equipment 2012. Anaesthesia 2012; 67: 660–668.

References 1. Imray C, Booth A, Wright A, Bradwell A. Acute altitude illness. British Medical Journal 2011; 343: 411–7. 2. Hackett PH, Oelz O. The Lake Louise consensus on the definition and quantification of altitude illness. In: Sutton J, Coates G, Houston C, eds. Hypoxia Mountain Medicine. Burlington, VT: Queens City Printers: 327–30. 3. Bradwell A. Adverse effect of acetazolamide on exercise at altitude (3459 m). Oral presentation at Birmingham Medical Research Expeditionary Society Altitude Research Conference. 22nd November 2013.


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Costs incurred by anaesthetic trainees and students presenting posters at the 2014 AAGBI Winter Scientific Meeting H. Wordsworth, H. Laycock and S. Yentis Chelsea and Westminster NHS Trust

Presentation of posters at medical conferences is an important part of academic/professional activity. The AAGBI has three meetings each year at which posters may be presented. We investigated the arrangements for funding of such presentations by trainees.

Methods All UK/Irish trainees or medical students presenting posters at the 2014 AAGBI Winter Scientific Meeting (WSM) were approached in person during the meeting, or by email afterwards if they could not be found. Those consenting to take part were asked what training position they currently held, and how their poster production costs and conference attendance fee were funded.

Results During the WSM two posters were withdrawn and eight were not displayed. Of the remaining 87, 61 (70%) were confirmed as presented by UK/Irish trainees and 59 (97%) consented to take part in the survey (47 at the WSM and 12 by email). Three of the remaining 26 abstracts were authored by non-UK/Irish doctors or non-trainees and there was no information for 23. All three questions were answered by 55/59 participants (93%). Those presenting were Specialist Trainees 3 + (40; 65%), Core Trainees (8; 13%), Clinical Fellows (7; 12%), Foundation Year doctors (4; 7%) or medical students (2; 3%). Most were self-funded (Table 1). Table 1 Funding source for poster production and conference attendance (n = 55). Poster production

Conference attendance

Self-funded

38 (69%)

41 (75%)

Funded by department

16 (29%)

14 (25%)

Funded by study budget

1 (2%)

Medications advice: a completed audit cycle after introducing a clinical guideline M. Worrall, R. Sinclair and M. Patel Royal Victoria Infirmary, Newcastle

In 2011 an audit was performed to ascertain whether appropriate advice was given to patients to ensure they took the ‘correct’ prescribed medications before elective general surgery. The results of this snapshot audit revealed that 19% of prescriptions were inappropriately managed on the day of surgery: there was particular concern about antihypertensives and cardiac drugs. A clinical guideline was devised by the preassessment team and senior surgical pharmacist and a simple reference table produced for use on the wards and in the preasssessment clinic to advise on medication management preoperatively.

Methods In 2013 the audit loop was completed to review the impact the guideline had on pre-operative medication instructions and patient concordance. The audit standard, as previously, was ‘‘100% of patients should receive essential preoperative drugs on the day of surgery’’

Results The results of this repeat audit suggest that there have been some improvements in the ‘correct’ management of medications before elective surgery at the Royal Victoria Infirmary since the introduction of a clinical guideline. Importantly the number of patients who received advice on which medications to take or omit increased from 21% to 94% in 2011 and 2013 respectively (Table 1). Furthermore specific problem areas which were identified in the original audit have been addressed to some degree and fewer patients inadvertently received ACE inhibitors or AT2 receptor antagonists on the morning of surgery. There still appears to be some variation in practice regarding preoperative drug administration of PPIs and antiplatelet agents despite clear guidance from the preassessment team. It is likely that there will always be some individual clinician variation in opinion about the importance of some preoperative medications; indeed the guideline allows for variation according to specific clinical advice or special or atypical circumstances.

0 Number of patients

Discussion Trainees presented most of the posters at the 2014 WSM. Presenting at national meetings scores points for CT1 and ST3 interviews and is viewed favourably at fellow and consultant interviews. Audits, quality service projects and research form part of the Royal College of Anaesthetists Curriculum [1], and trainees are using conferences to promote their work and findings. However, the cost of presenting can be significant; for example, trainee attendance fees can be several hundred pounds (for WSM 2014 it was £369) and scientific poster production can cost up to £65 [2]. Anaesthetics was identified by the Junior Doctors Committee in 2011 as the most expensive speciality training, with estimated personal costs of ~£25K to complete CCT [3] (n.b. excluding the financial burden of presenting at meetings). Our results show that most of those presenting at WSM were indeed self-funded. This may be related to diminishing study budgets, or increasing willingness to spend personal funds on improving curricula vitae to compete in a hostile job market.

References 1. Royal College of Anaesthetists. 2010 CCT Curriculum. www.rcoa.ac.uk/ careers-training/training-anaesthesia/the-training-curriculum/CCT2010 (accessed 09/03/2014). 2. UCL Media Services. A guide to successful poster production. www.ucl.ac.uk/ mediares/downloads/poster_printing.pdf (accessed 09/03/2014). 3. Jaques H. Junior doctors spend £17 114 on postgraduate training. British Medical Journal Careers, 7 Oct 2011.

124

2011

2013

109

100

% (n) total medications taken appropriately

81 (504)

91 (203)

% (n) of patients who had been given preoperative

21 (23)

94 (94)

instructions/advice % (n) ACE inhibitors taken (correctly) on day of surgery

35 (12)

22 (2)

% (n) PPI and H2 antagonists taken (correctly) on day

83 (34)

74 (26)

of surgery % (n) antiplatelet medications taken on day of surgery

47 (9)

12 (2)

% (n) chronic pain medications taken (correctly) on day

65 (30)

100 (16)

of surgery

Discussion This audit cycle has shown the benefit of introducing a clinical guideline to advise on the appropriate management of drugs before elective surgery. A further audit cycle should be completed in the future to confirm adherence and review the guideline.

References 1. Castanheira L, Fresco P, Macedo AF. Guidelines for the management of chronic medication in the perioperative period: systematic review and formal consensus. Journal of Clinical Pharmacy and Therapeutics 2011; 36: 446–467. 2. Douketis JD,Spyropoulos AC, Spencer FA et al, Perioperative management of antithrombotic therapy. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141(2 suppl): e326S–e350S.


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Predicting difficult intubation in bariatric surgery: use of compound indices in the morbidly obese D. Wright,1 M. Hulgur,1 J. Walkington2 and P. Lanka1 1 Hull and East Yorkshire Hospitals NHS Trust; 2York Teaching Hospital NHS Trust Using obesity criteria for Asian populations (BMI¡ Y27.5), Kim et al [1] showed that neck circumference to thyromental distance ratio >5.0 was a more sensitive and specific predictor of difficult intubation than established measures. We investigated whether this and other compound indices could predict difficult intubation in the obese UK population.

Methods Ninety eight patients (65 female, 33 male) with a BMI≥35 undergoing laparoscopic gastric banding, were assessed pre-operatively using four measures: neck circumference (NC), neck circumference/thyromental distance ratio (NC/TM), height/thyromental distance ratio (H/TM) and sternomental distance x thyromental distance product (SMxTM). General anaesthesia was performed by one of two consultant anaesthetists using their standard technique. Modified Cormack and Lehane grade [2] was documented at laryngoscopy. We used 2 definitions of difficult intubation: grade 2b or higher and grade 3 or higher. Data was analysed using receiver operating characteristic (ROC) curves to determine cut off points, sensitivity, specificity and area under curve (AUC).

Results Mean BMI was 48.6 (SD 10.9). Thirty four patients were grade 2b+, 13 patients grade 3+. ROC curves showed that NC/TM was the most accurate measure (Fig. 1), with a clear cut-off, predicting both grade 2b+ (NC/TM>5.49, sensitivity 78%, specificity 64%, AUC 0.69) and grade 3+ (NC/TM>5.49, sensitivity 85%, specificity 53%, AUC 0.66). Other measures had less clear cut off points. NC showed poor accuracy for 2b+ (NC>43.5 cm, sensitivity 62%, specificity 53%, AUC 0.64) and moderate accuracy for 3+ (NC>44.6 cm, sensitivity 77%, specificity 58%, AUC 0.65). H/TM showed moderate accuracy for 2b+ (H/TM>20.06, sensitivity 76%, specificity 49%, AUC 0.63) and poor accuracy for 3+ (H/TM>20.09, sensitivity 69%, specificity 48%, AUC 0.6). SMxTM was the least accurate for 2b+ (SMxTMD143.3 cm, sensitivity 76%, specificity 44%, AUC 0.61) and 3+ (SMxTM5.49

Delirium in the intensive care unit J. Alfonso Newcastle University

Delirium is an acute state of confusion characterised by fluctuating mental state/level of consciousness. It is an important complication in patients in intensive care as it’s implicated in higher rates of morbidity and mortality [1], increased hospital duration of stay [2] and reduced quality of life post-discharge [3]. The aim of this audit is to improve the quality of care of our critical care patients by measuring how successful we are at regularly screening for delirium, and how successful we are at documenting it in medical notes. All patients should be screened daily and all cases of delirium should be documented, as per NICE and Intensive Care Society guidelines.

Methods Prospective point prevalence study. All eligible patients were screened for delirium using recognised tools, i.e. Richmond Agitation-Sedation Scale (RASS) and Confusion Assessment Method for the ICU (CAM-ICU), at the Intensive Therapy Unit at University Hospital North Durham (UHND). Data was collected within the period 8/1/13 – 2/2/13 and included other variables such as ventilation status, RRT/dialysis status and sedative regime at the time of screening. For patients testing positive for delirium, medical notes were referenced for evidence of documentation.

Results Variable

CAM-ICU +ve

CAM-ICU

ve

Mean Age (years)

73.4 (60–85)

65.6 (35–85)

Intubated/Ventilated (n = 14)

43%

57%

Not Intubated/Ventilated (n = 30)

23%

77%

62.5%

37.5%

Medical Admission (n = 21)

14%

86%

Surgical Admission (n = 23)

43%

57%

RRT/DIalysis (n = 8)

Sixty-two patients were seen, 36 male and 26 female. The 29% (n = 18) who scored RASS -4 or -5 were too heavily sedated to use CAM-ICU and therefore were not eligible for delirium screening. Of the 44 that were screened, 29.5% (n = 13) were CAM-ICU positive, and of those only one patient (6%) had it documented in their medical notes.

50

Discussion AUC 0.69

0 0

50

100

100% - Specificity % Figure 1 ROC curve, intubation grade ≥2b: Neck circumference to thyromental distance ratio (NC/TM)

Discussion NC/TM ratio is a simple test which may be used instead of complex scoring systems. Results are similar to Kim et al, with NC/TM the most accurate predictor of difficult intubation. A cut off of >5.49 was the same for predicting 2b+ and 3+, which may be due to the small number of grade 3+ intubations. This is higher than the Asian study and may reflect differences in body morphology and higher mean BMI in our study (48.6 vs 30.1). We included grade 2b, despite some not considering this difficult, as the higher incidence of difficult mask ventilation and desaturation in these patients renders any difficulty clinically relevant. Absence of blinding or protocolised anaesthesetia are limitations to this study

References 1. Kim WH, Ahn HJ, Lee CJ, Shin BS, Ko JS, Choi SJ, Ryu SA. Neck Circumference to thyromental distance ratio: a new predictor of difficult intubation in obese patients. British Journal of Anaesthesia 2011; 106: 743–8. 2. Yentis SM, Lee DJH. Evaluation of an improved scoring system for the grading of direct laryngoscopy. Anaesthesia 1998; 53: 1041–1044.

Of those eligible for screening, 29.5% tested positive for delirium, and this is not routinely documented in the medical notes. Also noted that hypoactive delirium (RASS 0). Limitations to this study include small sample size, and variation in time of day screening was conducted. This audit was presented to the anaesthetic department at UHND, and recommendations were made re: enhanced vigilance in delirium screening and documentation, and including delirium screening pro forma in the ITU medical notes.

Ackowledgements Thank you to Dr Matthew Wayman and the anaesthetics department at UHND for helping me collect and process my data.

References 1. Balas MC, Happ MB, Yang W, Chelluri L, Richmond T. Outcomes Associated With Delirium in Older Patients in Surgical ICUs. Chest 2009; 135(1): 18–25. 2. Shehabi Y, Riker RR, Bokesch PM, et al. Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients. Critical Care Medicine 2010; 38(12): 2311–8. 3. Van Rompaey B, Schuurmans MJ, Shortridge-Baggett LM, Truijen S, Elseviers M, Bossaert L. Long term outcome after delirium in the intensive care unit. Journal of Clinical Nursing 2009; 18(23): 3349–57.


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Audit of adherence to antacid and fasting guidelines for elective caesarean section at The Royal Victoria Infirmary (RVI), Newcastle Upon Tyne, UK

The pre-operative anaesthetic visit: an audit of the quality of provision from the patient’s perspective, using RCOA guidelines in a university hospital

E. Barnard Newcastle University

A. Bell1 and R. Lakshmanan2 1 University of Birmingham Medical School; 2University Hospital Birmingham NHS Foundation Trust

Elective caesarean section under regional anaesthesia carries a 1% risk of conversion to general anaesthesia [1]. Pre-operative fasting and antacid prophylaxis guidelines aim to reduce the risk of maternal pulmonary aspiration associated with general anaesthesia. The Royal Collage of Nursing (RCN) guidelines state patients should be encouraged to consume clear fluids 2 hours prior to surgery [2].The aim of this audit was to investigate current practice regarding concordance with RCN fasting guidelines (6 hours for solids and 2 hours for clear fluids) (endorsed by Royal Collage of Anaesthetists and Royal Collage of Midwives) and the NICE guideline for caesarean section [3], which encompasses antacid prophylaxis.

Methods

Methods Recovery suite staff collected data using a proforma; the anaesthetic (regional /general, time anaesthetic delivered), antacid (whether prescribed/taken, type), fasting times (solid /clear fluid, how long patient told to fast for, how fasting information was delivered), patients’ feeling of hunger and thirst prior to operation and whether low urine output delayed recovery.

59 patients agreed to take part with 49 analysed after exclusions. All patients received a preoperative visit, but only 84% were seen by the same anaesthetist as delivered the anaesthesia. All pre-operative indicators of visit quality scored an average above 50% (Table 1). However, two individual scores were under 30% for A. and B. quality indicators respectively. Average scores of patient satisfaction for accuracy of pain and sickness expectation were 83.9% and 88.8% respectively. Two individual scores relating to pain expectation accuracy recorded below 30%. Overall satisfaction with the anaesthetic experience gave a 93.9% mean.

Results

Table 1 Average questionnaire responses.

The completion rate was 88% (36/41 patients). All mothers surveyed had a spinal anaesthetic for surgery, none of which were converted to a general anaesthetic. All mothers reported concordance with the fasting and antacid guidelines. The mean reported time without solids was 14 hours (SD 3) and without clear fluids was 12 hours (SD 3). None of the patients reported consuming clear fluids around 2 hours prior to anaesthetic. Ninety-four percent of mothers reported receiving written fasting instruction; however the duration mothers reported being told to fast for varied considerably. Mothers did not report a difference in fasting guidelines for solids of clear fluids. Low urine output delayed recovery in 12 patients; however there was no correlation between low urine output and time spent without solids or clear fluids

Discussion Mothers follow guidelines; however current Trust patient information, which state ‘‘nil by mouth from midnight’’, is not in line with RCN guidelines. Patient information should be changed in line with these guidelines, with particular emphasis on encouraging consumption of clear fluids the morning of surgery. Timely re-audit of the guidelines should include a question specifically on whether patients were encouraged to drink clear fluids on the morning of surgery.

A 2-part patient questionnaire was designed to evaluate the quality of anaesthetic visits on the Ambulatory Care Unit, University Hospital Birmingham (UHB). Pre-operatively patients completed the questionnaire after the visit, evaluating satisfaction with 6 key aspects [1]. Post-operatively patients scored satisfaction with the anaesthetic experience overall and on accuracy of post-operative pain and sickness expectation. Visual analogue scales, de-graduated to reduce bias, were used to quantify patient satisfaction, with additional constrained and free text responses. Data scores were individually analysed and, as a mean, compared to RCOA based targets for each criteria.

Results

Average (mean) patient Questionnaire statement (Quality indicator)

satisfaction

Part 1. Pre-operative A. Anaesthetist made the patient feel at ease

92.3%

B. Patient had trust and confidence in the anaesthetist

92.0%

C. Patient was made to feel comfortable to ask any questions

92.5%

D. Questions were answered fully and satisfactorily

94.3%

E. Anaesthetist spent enough time on the visit and was not

93.9%

rushed F. Adequate privacy for the visit

90.5%

Part 2. Post-operative G. Post-op pain was as the patient expected it would be

83.9%

H. Post-op sickness was as the patient expected it would be

88.8%

I. Overall satisfaction with the anaesthetic experience

93.9%

Acknowledgements

Discussion

Dr Nancy Redfern (Consultant Anaesthetist) Dr Val Bythell (Consultant Anaesthetist) Staff of the RVI Labour Ward.

The anaesthetic service at UHB Ambulatory Care met the RCOA target for completion of preoperative visits with all patients. However, only 84% could confirm they were seen by the same anaesthetist as delivered the anaesthesia, failing to meet a 100% target. Whilst further analysis showed this did not correlate with poor satisfaction of visit quality, this still requires improvement. It would be advisable to explore why this occurred, as the target is not relevant in ‘exceptional circumstances [1, 2]. All pre-operative indicators of visit quality surpassed the RCOA average target of 50%, as did post-operative satisfaction with pain and sickness expectation. A very positive overall satisfaction of 93.9% was recorded. A single patient scored under 30% satisfaction for both questionnaire statements A. and B. indicating cause for concern by RCOA standards [1]. This was an isolated event, with no free text clarification, possibly explained by anxiety, previous experience, or poor understanding of the question. Two individual patients also scored under 30% satisfaction relating to post-operative pain expectation, highlighting a cause for concern. Whilst again unexplained isolated events, it would be beneficial to attempt to investigate and address these identified issues in further studies.

References 1. Kinsella SM. The shock of the ‘Nuer’: the UK experience with new non-Luer neuraxial equipment and implications for obstetric anaesthesia. International Journal of Obstetric Anaesthetics 2013; 22(1): 1–5. 2. RCN Clinical Practice Guideline, Perioperative Fasting in Adults and Children; An RCN Guideline for the Multidisciplinary Team, full version published November 2005. 3. National Institute of Health and Clinical Excellence, NICE Guidelines; Caesarean Section, published November 2011.

References 1. White LA. The pre-operative visit. Raising the Standard: A Compendium of Audit Recipes, 3rd edn. RCOA, 2012; 76–77. 2. Pre-operative Assessment and Patient Preparation: The role of an anaesthetist; AAGBI safety guideline. January 2010; 2nd edn.

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An audit of pain at home after day case surgery in children

VA ECMO – useful for a short term weaning process off cardiopulmonary bypass?

N. Dalton1 and U. Misra2 Newcastle Medical School; 2Sunderland Royal Hospital

S. Doyle Newcastle University

Strong peri-operative analgesia may initially give effective pain control in children who have had day case surgery. However, as this analgesia wears off, these children may experience higher levels of pain at home away from a clinical environment. Furthermore, following the withdrawal of codeine as a post-operative analgesic in children under 12 years [1], parents are left with very little options in terms of further analgesia to administer should paracetamol and ibuprofen be insufficient.

Veno-arterial Extra Corporeal Membrane Oxygenation (VA ECMO) is used to provide circulatory support to patients with impaired cardiac function [1]. Right ventricle failure (RVF) is a common complication post heart transplant, particularly in patients with congenital heart diseases and longstanding pulmonary hypertension [3]. However, the use of VA ECMO as a short-term bridge used for weaning patients off Cardiopulmonary bypass (CPB), suffering from RVF, is not yet routine practice. It can however provide a potential bridge to recovery from intra theatre CPB in patients with RVF.

1

Methods Over a 3 week period, parents/guardians of children having day case surgery at Sunderland Royal Hospital were consented for participation in the audit. Three days following their child’s operation, the parent/guardian was contacted by telephone to complete a short questionnaire scoring various indicators of their child’s pain since the operation, and compared to the standards set out by the Royal College of Anaesthetists (RCOA) [2].

Results When measured against the RCOA standards the sample cohort of 60 cases failed on every domain: Table 1 Pain indicators measured in the sample cohort compared to RCOA standards.

RCOA Pain Indicator Severe pain on any day

RCOA

Cohort

Standard (%)

Results (%)

Description A 37-year-old male who underwent an orthotopic heart transplantation in February 2014 for transposition of his great arteries and a previous mustard procedure in 1977. An implantable cardiovertor defibrillator device was fitted in 2006. A left ventricle assist device was inserted for continued detoriation of ventricular function in 2012. During the heart transplantation excessive bleeding and persistent acidosis; CPB time was 430 minutes. After implantation, trans oesophageal echocardiogram showed a poor left and right ventricular function. Despite inotropic and vasopressor support with Adrenaline 5 mcg/min, Milrinone 1 mcg/kg/ min, and Vasopressin 0.02 units/min, the right ventricle was still showing moderately impaired function towards the end of the procedure and the decision was made to commence the patient on VA ECMO. The patient remained on VA ECMO for the following 2 days, in which his inotrope dependency decreased markedly, and the decision was made to gradually wean the ECMO and it was removed 2 days post transplant. Trans thoracic echocardiogram then showed good left ventricular function and moderately impaired right ventricular function. The patient has continued to do extremely well following decannulation and is progressing well.

0

8

Mild or nil pain by day 2

>90

75

Discussion

Mild or nil pain by day 3

100

90

Sleep returned to normal by day 3

100

88

Mood/Behaviour returned to normal by

100

88

This case demonstrates the interesting potential for the use of VA ECMO as a short-term weaning process following cardiopulmonary bypass in patients with right ventricular failure. It provides effective, temporary, cardio pulmonary support that can be initiated in a short amount of time and can improve outcomes. The decision and approach should be of multi disciplinary fashion to minimize potential complications such as limb ischaemia and major haemorrhage [2]. Initiation of VA ECMO within theatre in patients who are difficult to wean off bypass due to acute right ventricular failure may provide a useful and effective wean from bypass and further research would be interesting to improve safety.

day 3 Activity levels returned to normal by day 3

100

63

Seeking additional healthcare advice in

90% cases key observations (see Fig. 1) should be completed: every 15 minutes within the 1st hour, half hourly for hours 2–4, and hourly thereafter until discharged from the unit. To document whether obstetric recovery staff are trained to general recovery standards.

• •

Results

• • • • •

Within the 1st hour on the unit 63.8% cases met standards. Of the temperature measurements, 1.6% met criteria. Of ‘‘level of blockade’’ measurements, 7.6% met criteria. For hours 2–4 on the unit, 62.6% met criteria. Of the hourly readings, 64% met criteria for the remainder of their stay on the unit. Just 6.3% had urine output monitored hourly. Of the unit staff, 10.6% were trained to recovery standards. The majority (94.6%) of patients met discharge criteria before leaving the unit.

Figure 1. Demonstrates% attainment of standards for each observation(yellow = 1st hr, green = 2–4 hrs, red = remaining hrs). 100 90

Percentage done correctly (%)

80 70 60 50 40 30 20 10

e

ut Ur

in

e

ou

tp

nc

Lo ss od

Ba la id

Blo

Flu

Pa in Sc or e le ve lo fb lo ck ad e

od Pr es su Te re m pe ra tu re Co nc io us ne ss le ve l

Blo

at e

Ra te

yR

ar t

ira to r

02

Acknowledgements

He

on

0 Sa tu ra Ɵ

There was a significant variation in ventilator settings amongst different anaesthetic practitioners. A significant proportion of patients were being ventilated well above the proposed lung protective volumes and therefore potentially leading to ventilator associated lung injury. This may be due to the documentation and common use of the patient’s total body weight as opposed to their IBW. In addition many practitioners may not be fully aware of the benefits of using intra-operative lung-protective ventilation. It is proposed that the IBWs be calculated prior to surgery and documented in the pre-assessment booklets once the results are presented to the respective department. A 7 day follow up of the patients could be incorporated into a re-audit.

Re sp


231

ObservaƟons

I would like to thank Dr. Karuna Kotur and all the staff at the Freeman Hospital Central Operating Department in helping collect the data for this audit.

References 1. Futier E, Constantin J, Paugam-Burtz C et al. A trial of intraoperative low-tidalvolume ventilation in abdominal surgery. The New England Journal of Medicine 2013; 369: 428–437. 2. The Acute Resipiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The New England Journal of Medicine 2000; 342: 1301–1308.

Discussion Some of the reasons observation monitoring did not meet standards include: not all observations were done every time, and, often there was a delay from intended to actual discharge. Urine output documentation was very low, perhaps because the recovery chart does not provide space for documentation. Poor temperature documentation may be due to inconsistencies between different recovery protocols, but, as sepsis is one of the main causes of direct maternal death [2] it is crucial to monitor adequately. Appropriate training of staff should be a major focus on the unit, as well as increasing the frequency of observations. Particular emphasis should be placed on urine output, level of blockade, and temperature. A multidisciplinary maternity critical care group has been set up in Sunderland which is looking into improvement in care and delivery of this training to midwives.

Acknowledgements Dr Misra for help co-ordinating this audit.

References 1. Scholefield H, Fitzpatrick C, Jokinen M et al. Providing Equity of Critical and Maternity Care for the Critically Ill Pregnant or Recently Pregnant Woman. Royal College of Anaesthetists and Royal College of Obstetricians and Gynaecologists. 2011. 2. Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. An International Journal of Obstetrics and Gynaecology (BJOG) 2011; 118(Suppl. 1): 1–203. 3. Colvin JR, Peden CJ. Raising the standard: a compendium of audit recipes. Royal College of Anaesthetists 2012; 222–3.

128


Emergencies in the intra-operative period: a check and challenge audit for anaphylaxis and cardiac arrest S. Lonsdale,1 J. Ferns2 and A. Nazar2 St Bartholomew’s and the Royal London School of Medicine; 2Whipps Cross Hospital, Barts Health NHS trust

234 Effectiveness of pre-operative smoking cessation interventions for patients attending the anaesthetic pre-assessment clinic in Ninewells Hospital, Dundee.

1

Anaphylaxis during the intra-operative period is an uncommon, but dramatic event. Results from a French national survey on anaphylaxis during anaesthesia suggest that the incidence may be higher than previously estimated [1]. The Royal College of Anaesthetists recommend that all theatre staff should have a working knowledge of the guidelines for anaphylaxis [2, 3]. Following an in-theatre anaphylaxis and cardiac arrest in our hospital, an audit was conducted to determine the emergency protocol awareness of clinical staff working in theatre.

Methods

J. McBrien,1 M. Checketts2 and A. Radley3 University of Dundee; 2Department of Anaesthesia, Ninewells Hospital, Dundee; 3 Department of Public Health, NHS Tayside

1

Smoking is associated with an increased risk of anaesthetic and surgical complications1. Effective smoking cessation interventions should be carried out in the pre-operative period. We sought to investigate the effectiveness of the current smoking cessation interventions used with patients attending the Ninewells Hospital Anaesthetic Pre-Assessment Clinic (PAC). A comparison was made between the smoking cessation patterns of patients willing to attend a formal Smoking Cessation Programme (SCP) with those who did not wish to be referred.

Over a period of 5 days in February 2014, a clinical vignette was given to theatre staff in their place of work. The vignette concluded stating that anaphylaxis was suspected; respondents were asked to describe their actions to this and, in addition, their actions should a subsequent cardiac arrest occur. Successful identification of the main steps within the Resuscitation Council (UK) anaphylaxis algorithm [4] and cardiopulmonary resuscitation algorithm (5) were recorded using a standard proforma. Finally, participants were questioned on their knowledge of the location of (1) the guidelines for managing anaphylaxis and cardiac arrest (2) the crash trolley and (3) adrenaline.

Methods

Results

Results

A total of 45 clinical staff participated, including: 17 doctors (10 anaesthetists, 6 surgeons and 1 junior doctor) and 25 nursing and other staff (6 operating department practitioners, 7 recovery staff, 8 scrub nurses, 3 midwives, 1 sister and 3 medical students). All identified the need to call for help and 100% of doctors and 76% of nursing staff were aware of the basic protocol for managing anaphylaxis. All doctors demonstrated knowledge of the application of the ABCDE algorithm compared to 88% of nursing staff. Nursing staff were more aware of the need to retrieve the crash trolley in a cardiac arrest by a margin of 5.9% compared to doctors. Nursing staff were also more aware of the location of guidelines (84% vs 77%), the crash trolley (92% vs 47%) and adrenaline (88% vs 71%).

Discussion Nursing staff and doctors demonstrated inverse strengths with regard to their awareness of equipment location and emergency protocols. This pattern is likely to be multifactorial. A varied and often transient staff population, combined with the proximity of highly trained anaesthetists may reduce the sense of responsibility on the individual. As such emergencies are rare and clinical experience limited, novel ways of preparing are needed. Improved signage, emergency drills and improvement of both the initial induction to theatre and pre-operative briefing, are options to improve knowledge and optimize systems for emergency response.

References chot P, Auroy Y, Jougla E. Groupe d’Etudes des Re actions 1. Mertes PM, Alla F, Tre siques. ‘Anaphylaxis during anesthesia in France: Anaphylacto€ˇdes Peranesthe An 8-year national survey.’ The Journal of Allergy Clinical Immunology 2011; 128: 366–73. 2. Raising the Standard: A Compendium of Audit Recipes, 3rd edn. Royal College of Anaesthetists, 2012. 3. Guidelines for the Provision of Anaesthetic Services for Intra-operative Care. Royal College of Anaesthetists, 2014. 4. Emergency treatment of anaphylactic reactions: Guidelines for health care providers Resuscitation Council (UK) Revised 2012. 5. Resuscitation Guidelines 2010 Resuscitation Council (UK) 2010.

The smoking habits of patients who attended a SCP following referral from the Anaesthetic PAC between May 2011 and May 2013 were compared to smokers attending the Anaesthetic PAC between August and October 2013 who chose not to be referred to a SCP. Information was obtained from follow-up written questionnaires completed by those attending a SCP at one and 12 months after initial contact with a provider. Telephone questionnaires were conducted with patients from both groups.

In the two year period identified, only 43 smoking patients accepted referral to a SCP out of approximately 20000 attendances at the Anaesthetic PAC. The SCPs were provided by pharmacies in the local area. Of the 30/43 patients contactable at one month after contact with a SCP, 11 had not smoked in the two weeks prior to questioning. Three of these 11 patients had received financial incentives from the Quit4U Scheme. Only one patient out of those successfully contacted at 12 months follow-up had stopped smoking. Of the 30 patients contacted who chose not to be referred to a SCP, one stopped smoking before surgery, 13 reduced the number of cigarettes smoked and 16 did not change their smoking habits. 22/30 patients not referred to a SCP thought smoking would have no effect on the outcome of their surgery. 10/30 patients who declined referral were using electronic cigarettes at the time of telephone follow-up.

Discussion This service evaluation shows many ways in which smoking cessation prior to surgery could be improved. Patients should be informed with written documentation that smoking up to the time of surgery increases cardiac and pulmonary complications, impairs tissue healing and is associated with more infections [1]. SCPs should be run within the Anaesthetic Pre-Assessment system to enable continuous contact with patients seeking to stop smoking up to the time of surgery, and in the post-operative period, which patients value but which did not take place. Consideration should be given to using electronic cigarettes as a smoking cessation tool but are not currently offered by SCPs due to concerns over their safety [2].

References 1. Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet 2002; 359: 114–7. 2. Flouris AD, Oikonomou DN. Electronic cigarettes: miracle or menace? British Medical Journal 2010; 340: c311.


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An audit on the use and documentation of Intra-operative Fluid Management Technology (IOFMT) in the anaesthetic department H. Mulgrew University of Liverpool

Minimum standard monitoring during anaesthesia consists of pulse oximeter, 3 lead electrocardiogram and non-invasive blood pressure. Optimal fluid management is essential for good outcomes in patients undergoing major surgery [1]. New technologies for monitoring cardiac output are being commissioned that give a more accurate indicator of tissue perfusion; providing the information needed to give goal directed fluid therapy, which has been shown to improve patient outcomes [2, 3]. The two devices used in the trust are the CARDIO-Q Doppler Monitor, recommended by National Institute for Health and Care Excellence (NICE), and the LIDCO Arterial Pulse Waveform Analysis. The aim of this audit is to assess if IOFMT is being used for the procedures for which it is indicated.

Methods A random sample of 30 individual procedures in which IOFMT was indicated as per Commissioning for Quality and Innovation (CQUIN) guidance during September-November 2013 was identified. These were referenced against the anaesthetic charts to establish whether IOFMT was used. Weekend and emergency procedures were excluded from the sample. The standard for use of IOFMT for specified procedures or other relevant high risk surgery is 80%.

Results Of the random sample of 30 procedures dating from 01/09/13 to 15/11/13 for which IOFMT was indicated, 77% (n = 23) recorded that IOFMT was used. Out of these, the LIDCO system alone was used for 17% (n = 5) and CARDIO-Q alone was used for 43% (n = 13). Both CARDIO-Q and LIDCO systems were used together for 17% (n = 5) cases.

Discussion There are several reasons why the target was not quite reached. There is contention as to whether IOFMT should be used for laparoscopic procedures. It is suggested that a consensus is made locally to clarify this and communicated to all team members. These devices are relatively new and data from recent metaanalyses is conflicting as to whether patient outcomes are better when they are used [4]. However, better patient outcomes are more frequently reported in trials that report clinician ‘championing’ of equipment [4]. It may be that benefit is limited to cases where there is greater operator experience and clinical knowledge of device limitations. More work in the form of a local audit is needed to evaluate patient outcome in cases where IOFMT has been used. It would help also to seek clinician opinion in the form of survey to assess confidence in using the equipment, and to make training and education available where necessary. Re-audit is planned for May 2014.

Clinical audit on the peri-operative management of diabetes mellitus K. Pitrola and C. Stannard The Royal London Hospital, Barts & the London NHS trust

Diabetes mellitus is a common endocrine disorder faced in anaesthesia. The metabolic management of diabetes during the peri-operative period can be complicated by starvation times, the endocrine and the consequent metabolic response to surgery. Therefore, it is important to follow local trust guidelines in the peri-operative management of patients with diabetes in order to minimise complications. Bart’s and the London NHS trust currently lack these guidelines.

Methods The Association of Surgeons of Great Britain and Ireland (ASGBI) have published guidelines for ‘The peri-operative management of the adult patients with diabetes.’ We conducted an audit against the recommendations outlined in these guidelines. Adult elective patients admitted through day stay unit and selective wards during a 1 week period with type I or II diabetes were audited.

Results A total of 32 patients (31 patients with type II and 1 patient with type I) were identified during this period. 81% of patients had attended a pre-assessment clinic, of which only 2 patients did not have their diabetic medications documented. 46% of patients did not have a written plan for the peri-operative management of diabetes. 66% of patients were not scheduled in the first third of the list. Accounting for changes in the list order, 59% of patients were not operated on in the first third, despite fasting since early morning. Glycaemic control was observed by looking at HbA1c levels. 44% of patients had no record of their HbA1c in the last three months. Out of those that did, 2 patients’ HbA1c levels were above the recommended 68 mmol/L (8.5%). All but one patient had a documented pre-op BM recorded. For those patients in theatre for longer than 1 hour, only 40% had their BM recorded intraoperatively. 5 patients’ BM fell outside 5.5–11.1 mmol/L. But all but 1 was in range according to the Bart’s diabetic chart. No patients discharge was delayed by diabetes related problems. Excluding those on diet control, 12/28 patients did not receive instructions about their diabetic medication for discharge.

Discussion The overall management of patients with diabetes was good. Care should be taken when re-ordering patients with diabetes on the day of operation. Patients with diabetes should receive clearer plans for their diabetes medication upon discharge. Bart’s and the London NHS trust are currently developing guidelines for the peri-operative management of patients with diabetes. A re-audit cycle will be completed once these guidelines have been implemented.

Acknowledgements Many thanks to Dr. Corinne Stannard.

Reference

Acknowledgements Thanks to Anaesthetic department at Whiston Hospital, in particular Dr Waits and Dr Miller for their help with this audit.

M, Grimaud D. Diabetes mellitus: implications for the 1. Raucolles-Aime anaesthesiologist. Current Opinion in Anaesthesiology 1996; 9: 247–53.

References 1. Mythen G. Swart M. Acheson N et al. Perioperative fluid management: consensus statement from the enhanced recovery partnership. Perioperative Medicine Journal 2012; 1: 23. 2. Corcoran T Rhodes JE, Clarke S, Myles PS, Ho KM. Perioperative fluid management strategies in major surgery. Anesthesia and Analgesia 2012; 114(3): 640–51. 3. Gan T. Soppitt A. Maroof M, et al. Goal-directed Intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology 2002; 97(4): 820–6. 4. Srinivasa S. Lemanu D. Singh P et al. Systematic review and meta-analysis of oesophageal Doppler-guided fluid management in colorectal surgery. British Journal of Surgery 2013; 100: 1701–17087.

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Audit of anaesthetist induction and knowledge of location of emergency equipment on the RVI labour ward M. Poulsom Newcastle University

238 Improving compliance with the pre-theatre checklist to improve patient safety S. Puvaneswaralingam, E. Chin, J. Fleming and S. Hilton-Christie NHS Tayside

Obstetric anaesthetic emergencies may cause significant harm; necessary emergency equipment has to be easily locatable. Equipment location should be detailed during anaesthetist induction but a lot of information is given out at this time – how much do they recall?

Surgical checklists have been proven to improve patient safety [1]; however, the pre-theatre checklist in Ninewells Hospital, Dundee, was found to be inadequately completed in surgical wards. Our aim was to improve compliance with completion of the pre-theatre checklist in the Main Theatres and West Block Theatres, in Ninewells Hospital, by 10% in three weeks.

Methods

Methods

The aim was to audit practice regarding induction and anaesthetist knowledge of equipment location against national guidelines. Guidelines state that all anaesthetists working in obstetrics should have been inducted and should also be able to locate emergency equipment.1,2 The audit took place in the RVI Department of Anaesthesia between 20/02/2014 – 31/01/2014 and took the form of a questionnaire registered with Newcastle NHS Trust. The study group included 9 consultant obstetric anaesthetists and 21 trainees (CT2 – ST7) who had worked on the Labour Ward in the last 3 years. Data collected included induction status and confidence in knowledge of item location (using a visual analogue scale from ‘not confident’ to ‘completely confident’). Participants were then asked to mark the location of 7 items of emergency equipment onto a floor plan of the RVI Labour Ward, (items were those included in the unit induction).

Results The majority of anaesthetists had been inducted (73%). Inducted anaesthetists located more items correctly (59% items located compared to 39% of items in the non-inducted group). Only 1 anaesthetist could locate all the items. None of the items were locatable by everyone (Fig. 1). Overall the more confident the anaesthetist the more items they could locate, however 3 anesthetists marked € themselves as ‘‘completely confident’’ and could only locate ¡U1item.

Baseline data from 24 patients was collected over one week, with changes tested on 12 patients over two weeks, in the Main Theatres and West Block Theatres. Outcome measures assessed the number of fully completed checklists, process measures assessed the extent of completion of each checklist and balancing measures evaluated the effect on time taken to complete the checklist and staff satisfaction. Based on the baseline data, the first Plan-Do-Study-Act (PDSA) cycle tested a re-designed (different layout) checklist, and a second PDSA cycle tested a simplified (reduced content) checklist.

Results Percentage completion of the pre-theatre checklist increased to 88%, from an average baseline of 66%, following two tests of change (see Fig. 1). A redesigned checklist was better completed, with average percentage completion improving to 77% after the first test of change. Based on further comments from nursing staff and input from the entire Quality Improvement Team, the content of the checklist was reduced. Several items which were irrelevant to ward nursing staff, such as ward bed hydraulics and preparation of operation site, were removed from the checklist and percentage completion improved again achieving 88% compliance. 100 Nurse unaware checklist was double-sided on this occasion

90

Percentage completion of pre-theatre checklist (%)

80 Goal 70

Median

60 50 Baseline data PDSA 1 Re-designed checklist with input from Senior Clinical Nurse and baseline data

40 30 20

PDSA 2 Simplified checklist with input from the entire Quality Improvement Team

10 0

Figure 1. Knowledge of item location.

Discussion Neither of the audited standards were met. Only 73% of anaesthetists had been inducted, possibly due to time constraints. Inducted anaesthetists could locate more items supporting the use of induction to aid knowledge. Easily visible items (e.g. kept in corridor) were located more suggesting recall is better when using visual memory. Intralipid was the exception, as it was the most located item despite being kept in a cupboard; possibly as it is needed in a specific life threatening situation and so anaesthetists actively try to learn its location. Three € anaesthetists who were ‘completely confident’ could only locate ¡U1item implying that even if someone appears confident they may still need showing equipment location. The major limitation is that items may have changed location since anaesthetists were last on the Labour Ward.

Acknowledgements

4-2-14

5-2-14

6-2-14

12-2-14

14-2-14

18-2-14

19-2-14

21-2-14

Date Figure 1 Compliance with completing the pre-theatre checklist improved with a change in layout and a change in content.

Discussion The study showed that a change in layout and content of the pre-theatre checklist improved percentage completion by 22% and this was due to colour-coding, clearer wording and less items. Correct completion of the checklist improves patient flow through theatre, reduces workload of nursing staff and ensures patient safety.

Reference 1. Haynes AB, Weiser TG, Berry WR, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. The New England Journal of Medicine 2009; 360: 491–9.

I would like to thank the RVI Anaesthesia team for their help in completing this project.

References 1. Leedham J, Patel S. Anaesthetic emergencies ¨C drugs and equipment preparedness. The Royal College of Anaesthetists, Raising the Standard: a compendium of audit recipes 2012; 4.8: 150 2. Association of Anaesthetists of Great Britain and Ireland, Obstetric Anaesthetists¡¯ Association, OAA/AAGBI Guidelines for Obstetric Anaesthetic Services 2013; 6.


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Why send your ODPs out of the operating theatre when you most need them? An audit of blood gas analysis during surgery

Target setting of physiological variables within an ICU: Can our current management of severe traumatic brain injury be improved?

W. Rook and H. Johannsson Imperial College Healthcare NHS Trust

E. Smith,1 L. Li,2 F. Anderson2 and J. Joss2 1 University of Dundee; 2NHS Tayside

Methods An observational study was performed in the operating theatres of Imperial College Healthcare NHS Trust, London. Five major surgical procedures for which arterial lines were used were audited, focussing on the sampling and analysis of arterial blood gases. A standardised assessment form was used.

Results Two vascular procedures, two major abdominal procedures and one cardiac procedure were assessed. When asked, all the anaesthetists reported that a common indication for performing a blood gas analysis was an acute physiological change in the patient. In all cases, an anaesthetist drew the blood sample and gave it to the only Operating Department Practitioner (ODP) present in the theatre to transport and analyse. For all cases, the blood gas analysis machine was remote from the operating theatre, and the ODP had to leave the operating theatre to perform the analysis. Seventeen blood gas samples were sent during the five operations. The ODP was out of the operating theatre for a median [range] time of 292 [160–643] seconds. When asked who would do the blood gas analysis if the ODP were unavailable, anaesthetists’ replies included: ‘‘one of the scrub nurses’’, ‘‘a trainee’’ and ‘‘whoever else is around’’.

Discussion Blood gas samples are often taken and analysed when patients become physiologically unstable during major surgery, and yet the transport and analysis of these samples is usually the task of a key member of the theatre team who should be present in the theatre to assist the anaesthetist when the patient is unstable. In this small, observational study, blood gas machines were in the operating theatre suite but remote to the theatres themselves, and ODPs were sent out of the operating theatre for an average of almost 5 minutes at potentially critical times. If an ODP had not been available, another staff member who most likely was not appropriately trained in the use of the blood gas analysis may have been used, and this may have led to quality control problems and inaccuracy of the results. Near-patient testing is becoming increasingly common in medical care, and yet the current situation in many operating theatres seems to be that the machines that can provide safety-critical information during major surgery are not quite near enough. Consideration should be given to housing blood gas analysis machines in operating theatres that have a high major surgical caseload. Anaesthetists should think twice before sending a key member of their team out of the theatre for 5 minutes.

Traumatic brain injury (TBI) is the leading cause of death and disability in young adults in the developed world [1]. Whilst primary injury cannot be altered, targeted management to prevent secondary brain injury has led to a decline in mortality [1]. Control of physiological parameters is documented to reduce both morbidity and mortality [2, 3].

Methods Following Caldicott approval, we retrospectively audited the last 20 adult patients with severe TBI requiring intracranial pressure (ICP) monitoring. The aim of the audit was to assess the documentation of physiological parameter targets and adherence to them. Patients were identified using the intensive care unit (ICU) database. Data on basic demographics, clinical parameters and documentation of physiological targets within the first 72 hours of patient stay were collected. Targets assessed: mean arterial pressure (MAP), arterial pressure of oxygen (PaO2), arterial pressure of carbon dioxide (PaCO2), ICP, cranial perfusion pressure (CPP), and elevation of the head of the bed.

Results There were 14 male and 6 female patients admitted; the median age was 46.5 (17–79 years). Overall mortality was 45%. Table 1.1 summarises target documentation. All patients had 3 or more physiological targets set within the first 72 hours but only four of the cohort (20%) had all 6 targets set. MAP was the most poorly documented of targets, with 9 of 20 patients not having a documented MAP target within the first 72 hours. PaCO2 was a well documented target, with only one patient not having a documented target. ICP and CPP were both well documented (18 of 20 patients having a target in both instances), and all patients had either an ICP or CPP target set within the first 72 hours of stay. Table 1.1 Target setting within the cohort (n = 20) during the first 72 hours of stay. “x” targets documented

x=0

x=1

x=2

x=3

x=4

x=5

x=6

Patients with

0

0

0

1

6

9

4

“x” targets (out of 6) documented within the first 72 hours

Discussion We have demonstrated that we do not consistently document targets in our unit. Documentation varied from target to target and was better for CPP/ICP than for MAP. One explanation may be that there is a degree of overlap between control of parameters - for example MAP and CPP. With clearly documented targeting of physiological parameters we postulate that patient safety and outcome will be improved due to ‘‘breaches’’ in targets being promptly identified and appropriately managed. This audit has driven some quality improvement work and the development of a ‘‘target sticker’’ within the unit.

References 1. Dinsmore J. Traumatic brain injury: an evidence-based review of management. Continuing Education in Anaesthesia, Critical Care & Pain 2013; 13(6): 189– 195. 2. Schirmer-Mikalsen K, Vik A, Gisvold S, Skandsen T, Hynne H, Klepstad P. Severe head injury: control of physiological variables, organ failure and complications in the intensive care unit. Acta Anaesthesiologica Scandinavica 2007; 51(9): 1194–1201. 3. Balesteri M, Czosnyka M, Hutchinson P, Steiner L, Hiler M, Smielewski P, Pickard JD. Impact of intracranial pressure and cerebral perfusion pressure on severe disability and mortality after head injury. Neurocritical Care 2006; 4(1): 8–13.

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A snapshot survey to evaluate and facilitate the development of undergraduate education in anaesthetics at Worcestershire acute hospitals NHS trust H. Sooch,1 N. Singh2 and S. Millett2 1 University of Birmingham Medical School; 2Worcestershire Acute Hospitals NHS Trust

Undergraduate medical students from the University of Birmingham undertake a 2-week placement in anaesthetics at our trust. Teaching is primarily in theatre with some tutorials, across two sites, the main site and a satellite hospital. Our current teaching programme was evaluated with reference to the university curriculum. The overall objective of this work has been to enhance the teaching programme.

Methods Anaesthetists were surveyed to evaluate the educational usefulness of the theatre list they were undertaking. The survey recorded: surgical specialty, location, timing, caseload, complexity and the presence of a trainee or medical student. Respondents were asked which of the curriculum topics they would be most likely to discuss. Opportunities to observe advanced skills including; invasive monitoring, regional techniques, ASA III or greater patients etc. were also recorded. Opinions regarding the usefulness of observing non-technical skills and whether the presence of a trainee anaesthetist can facilitate teaching students were surveyed.

Results

Ge ne Number of respondents ranking topic in top 5 ra la na Re es gio th na es ia la na es th es Po ia stSa op fe us an eo alg Ad fl e s oc ia m al in an ist ra ae Ɵo sth n eƟ of cs bl No oo rm d pr al od ph Ri uc ys sk ts io so lo fa gic na al es ra th ng Pa es es ia Ɵe an nt Lim sw d su ith ita rg Ɵo er m y ed ns ica of ld m on iso ito rd Pr er rin es op g( Sp bl oo O2 ds ,N Pr Ox an IB ev yg P) d en en in Ɵo ve th n sƟ er an ga ap d Ɵo y( tre n in s at di m ca en Ɵo to ns fP ,e Pe ON qu riop ip V m er en aƟ t, ve ha flu za id rd m s) an ag em en t

Forty responses were collected (>50% from consultant anaesthetists). Of the total number of lists undertaken during the study period, greater than 50% were surveyed. Greater than 50% of surveyed lists did not have a regular anaesthetist and also did not have a trainee or a medical student present. Of all lists, 88% had 6 or fewer patients and 65% were perceived as low/moderate complexity. The majority of opinions collated regarding the usefulness of trainee anaesthetists in teaching and incorporating human factors awareness were positive. Across all respondents, a predilection for certain discussion topics was noted. Importantly, some topics were rarely discussed including hazards relating to: the use of local anaesthetics, administration of blood products and oxygen therapy (Fig. 1).

40 35 30 25 20 15 10 5 0

Figure 1: Topics most commonly discussed with medical students

Discussion This survey highlights tangible opportunities for the enhancement of undergraduate training in anaesthetics. The results suggest that lists, particularly at the satellite hospital, are somewhat under-utilised for teaching undergraduates. The lists are heterogeneous in terms of trainers, their complexity and opportunities for learning. We propose a timetable of rotation through different theatres at the two different sites to afford students a varied but structured programme of learning. The syllabus topics deserving more frequent discussion tend to be those less easily accessed in clinical practice and often relate to aspects of patient safety. To address these topics and to facilitate an awareness of human factors we hope to incorporate simulation based training as part of our programme.

Evaluating the long term effectiveness of airway and fluid management training in medical students C. Streeter, I. Reece and Z. Al-Hubeshy Leicester Medical School

Fluid management is one of the responsibilities of Foundation Year Doctors, however it is evident that many newly qualified doctors find this challenging and some consultants feel that junior doctors have received inadequate training [1]. Little research has been conducted to assess the effectiveness of fluid management training in students or doctors. Research shows that airway management is complex and can be unsuccessful in unskilled doctors [3]. Simulation training for airway management improve learners’ satisfaction, improve outcomes in comparison with no intervention and nonsimulation intervention, and improve knowledge retention [3]. Leicester Medical School’s surgical and anaesthetics society (SCRUBS) held a National Airway and Fluid Management Day earlier this year. The objectives were for students to appreciate the different airway and fluid types available, and be able to identify and use the relevant ones in different clinical scenarios.

Methods A pre-teaching questionnaire made up of eleven single best answer questions was given to all 42 students. Teaching was achieved by a series of lectures conducted by anaesthetic registrars in the morning, followed by simulation training in the afternoon. Afterwards a post-teaching questionnaire consisting of the same questions and feedback was given to all students. In order to determine if the knowledge gained from the day had been retained, we conducted a 6 week follow-up questionnaire that was distributed via email. The same questions were given, in order to directly compare results.

Results Completed pre and post-teaching questionnaires were received from 41 students; 32 students completed the 6 week follow-up questionnaire. The preteaching results mean score was 7.220 marks compared to 9.171 marks for the post-teaching results, and 8.512 marks for 6-week follow-up results. The data was analysed using a one way ANOVA test. There was a statistically significant improvement in marks immediately after teaching (mean difference of 1.951 P value

Abstracts of the AAGBI Annual Congress, 17-19 September 2014, Harrogate, UK.

Abstracts of the 2014 NATA Annual Meeting & Clinical Symposia, June 26-28, 2014, Indianapolis, Indiana.

Abstracts of the 2014 SGI 61st Annual Scientific Meeting, March 26-29, 2014, Florence Italy.

British Paediatric Neurology Association Abstracts of the 2014 Annual Meeting, 29-31 January 2014, Winchester, UK.

Abstracts of the XXXII Annual Scientific Meeting of the British Blood Transfusion Society, 24-26 September 2014, North Yorkshire, UK.

Abstracts of the British Society of Gastroenterology Annual General Meeting. June 16-19, 2014.

Abstracts of the 54th Annual Scientific Meeting of the British Society for Haematology, 28-30 April 2014, Birmingham, UK.

Abstracts of the 54th Annual Teratology Society Meeting, June 28-July 2, 2014, Bellevue, Washington.

Abstracts of the RACS Annual Scientific Congress and ANZCA Annual Scientific Meeting, 5-9 May 2014, Singapore.

Abstracts from the Annual Scientific Meeting of the BSGI, 24-25 April 2014, London, England.

Abstracts of the ESCP 9th Scientific and Annual Meeting, 24-26 September 2014, Barcelona, Spain.

Abstracts of the Hong Kong Urological Association Annual Scientific Meeting, November 9, 2014, Hong Kong.

Abstracts of the BSIR 2014 Annual Scientific Meeting, Liverpool, United Kingdom.

Abstracts of the EAO 23rd Annual Scientific Meeting, September 25-27, 2014, Rome, Italy.

Irish thoracic society annual scientific meeting 2014.

The College of Podiatry Annual Conference 2014: meeting abstracts.

2017 Canadian Society of Surgical Oncology Annual Scientific Meeting Abstracts

2017 Trauma Association of Canada Annual Scientific Meeting Abstracts.

2016 Canadian Society of Surgical Oncology Annual Scientific Meeting Abstracts.

2016 Trauma Association of Canada Annual Scientific Meeting Abstracts.

Highlights from the scientific and educational abstracts presented at the ASER 2014 Annual Scientific Meeting and Postgraduate Course.

Abstracts of the SIR 2014 Annual Scientific Meeting Program Convergence, 22–27 March 2014, San Diego, CA.

Abstracts of the 6th Annual Scientific Meeting of the British Obesity & Metabolic Surgery Society (BOMSS), 22-23 January 2015, Newcastle, UK.

Abstracts of the 56th Annual Meeting of the American Headache Society, June 26-29, 2014, Los Angeles, CA.