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dioxide could be saved by changing activities related to the packaging of medical equipment alone. We need many more studies like this one, so that we can better focus both our use of limited resources, and our attention on things that really matter for the provision of high quality and sustainable patient care. E. Lear M. Davies Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.

References 1. McGain F, Algie CM, OToole J, et al. The microbiological and sustainability effects of washing anaesthesia breathing circuits less frequently. Anaesthesia 2014; 69: 337–42. 2. NHS Sustainable Development Unit. NHS Carbon Reduction Strategy for England: Saving Carbon, Improving Health. 2009. http://www.sduhealth.org.uk/documents /publications/1237308334_qylG_saving_ carbon,_improving_health_nhs_carbon_ reducti.pdf (accessed 03/04/2014). 3. NHS Sustainable Development Unit. Update: NHS Carbon Reduction Strategy for England: Saving Carbon, Improving Health. 2010. http://www.sduhealth. org.uk/documents/publications/126469 3931_kxQz_update_-_nhs_carbon_reduc tion_strategy.pdf (accessed 03/04/2014). doi:10.1111/anae.12733

Training anaesthetists about quality improvement Murray is to be commended on his work improving outcomes after 796

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emergency laparotomy [1]. As he comments, the initiatives described come not before time, as it is well known to most anaesthetists that this group of patients receive poorer care compared with patients undergoing similar elective procedures. An important point raised concerns the need to employ the right tools and techniques in order to implement the results of any (national) audit. Murray rightly extols the importance of quality improvement science in achieving change by using series of small changemeasurement cycles, as has now been well proven in medicine, as in other industries [2, 3]. We recently conducted a workshop for anaesthetists about the use of driver diagrams to plan quality improvement. Our worked example happened to be based on the National Emergency Laparotomy Audit and, anecdotally, it was clear to us that very few senior colleagues are equipped to be able to lead or take part in quality improvement activity, in contrast to more junior colleagues who are now required to complete a quality improvement project as part of their Foundation Year competencies [4]. In our opinion, there is an urgent need to train more senior clinicians in quality improvement science, rather than allow a further 20 years to pass without significant improvements in care. This will require a modest investment in time and resource, although much is available free online. Quality improvement workshops are now being organised via the Royal College of Anaesthetists, but we would also like to direct clinicians towards courses and tools

developed by the Institute for Health Improvement, BMJ Quality and the Health Foundation. M. Wittenberg National Medical Director’s Clinical Fellow, NHS England and British Medical Journal, London, UK Email: [email protected] J. Leitch Quality Unit, Scottish Government, Scotland, UK No external funding and no competing interest declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.

References 1. Murray D. Improving outcomes following emergency laparotomy. Anaesthesia 2014; 69: 300–5. 2. Farrell C, Hill D. Time for change: traditional audit or continuous improvement? Anaesthesia 2012; 67: 699–702. 3. Peden CJ, Rooney KD. The Science of Improvement as it relates to quality and safety in the ICU. Journal of the Intensive Care Society 2009; 10: 260–5. 4. Academy of Medical Royal Colleges. The UK Foundation Programme Curriculum. http://www.foundationprogramme.nhs. uk/download.asp?file=FP_Curriculum_ 2012_WEB_FINAL.PDF (accessed 09/04/ 2014). doi:10.1111/anae.12745

Use of intramuscular morphine in trauma patients The primary pharmacological choice of analgesia for management of moderate to severe pain on the battlefield remains intramuscular (i.m.) morphine. Current UK Armed Forces policy ensures that

© 2014 The Association of Anaesthetists of Great Britain and Ireland

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all deployed personnel are issued two 10-mg morphine autojects for i.m. self-administration or to be given via buddy-aid [1]. In 2009, Smith et al. [2] published the results of a questionnaire sent to 122 UK and US medical personnel exploring their clinical opinion of current battlefield analgesia. All personnel responded; 52% disagreed that i.m. morphine had the ideal properties for managing severe pain in the pre-hospital environment. Over 50% of respondents with operational experience reported multiple instances of inadequate analgesia from i.m. morphine. During periods of shock, i.m. morphine may not reach the systemic circulation until adequate perfusion is restored, potentially leading to late boluses after administration. In such cases, i.m. morphine is used cautiously [3] for historical fear of ‘delayed morphine poisoning’ among battle casualties [4]. We conducted an internetbased questionnaire survey among physicians in anaesthesia and emergency medicine with experience of resuscitating trauma cases in a field hospital over the last 10 years, in order to determine current attitudes towards, and problems arising from, the use of i.m. morphine in the battlefield. We received 68 responses, all from UK physicians, 49 (72%) of who were anaesthetists and 19 (28%) emergency medicine specialists; 45 (66%) replies were from consultants. We were not able to determine a denominator for the questionnaires received. Respondents were deployed for 627 months, recording a total of

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9411 patient episodes. The actual number of casualty resuscitations experienced is unknown because duplication of care could not be accounted for in our survey. Eight (12%) respondents supplied logbook data, the remaining 60 (88%) providing best estimates. Ten (14%) respondents had observed complications attributable to i.m. morphine following resuscitation, all of which were secondary to inadequate analgesia rather than opioid side-effects. Thirty-nine (57%) respondents recalled being taught to avoid i.m. morphine in shocked patients. Battlefield Advanced Trauma Life Support prioritises the management of catastrophic haemorrhage, with analgesia given towards the end of the primary survey once bleeding is controlled. Our survey suggests that conservation of circulating volume appears to avoid late reperfusion opioid side-effects, potentially enabling a safe increased administration of opioid analgesia to wounded soldiers. Further evaluation is needed before adjusting clinical practice, however. An experimental model combining microdialysis sampling with lower body negative pressure to simulate various stages of haemorrhage may help clarify the pharmacokinetics of battlefield i.m. morphine [5]. C. P. Jones Liverpool Heart and Chest Hospital, Liverpool, England Email: [email protected] R. Chauhan University Hospital Coventry, Coventry, England D. Aldington Royal Hampshire County Hospital, Winchester, England

© 2014 The Association of Anaesthetists of Great Britain and Ireland

No external funding and no competing interests declared. The authors would like to thank their colleagues within the Defence Medical Services, without whom this survey could not have been completed.

References 1. Gaunt C, Gill J, Aldington D. British military use of morphine: a historical review. Journal of the Royal Army Medical Corps 2009; 155: 46–9. 2. Smith JE, Russell R, Mahoney PF, Hodgetts TJ. What is the ideal pre-hospital analgesic? – a questionnaire study. Journal of the Royal Army Medical Corps 2009; 155: 44–6. 3. Anon. Battlefield Advanced Trauma Life Support. Journal of the Royal Army Medical Corps 2003; 149: 297–302. 4. Beecher HK. Delayed morphine poisoning in battle casualties. Journal of the American Medical Association 1944; 124: 1193–4. 5. Cooke WH, Ryan KL, Convertino VA. Lower body negative pressure as a model to study progression to acute haemorrhagic shock in humans. Journal of Applied Physiology 2004; 96: 1249–61. doi:10.1111/anae.12737

Diclofenac sodium in Hartmanns solution In response to Madden’s letter about intravenous diclofenac [1], we wish to inform readers that we have undertaken stability testing of 375 mg diclofenac sodium (Voltarolâ, Novartis Pharmaceuticals UK Ltd, Camberley, UK) in 500 ml Hartmann’s solution (MacoPharma (UK) Ltd, Twickenham, UK), which represents the maximum concentration (75 mg.100 ml 1) in the Novartis Summary of Product Characteristics [2]. Novartis recommends diluting diclofenac in sodium chloride 0.9%, or glucose 5% if buffered with 0.5 mmol sodium bicarbonate. The smallest volume of sodium bicarbonate 4.2% or 797

Use of intramuscular morphine in trauma patients.

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