Supporting trainees returning to practice following a prolonged ...

ISSN 0959-2962 No. 331

FEBRUARY 2015

THE NEWSLETTER OF THE

ASSOCIATION OF ANAESTHETISTS OF GREAT BRITAIN

AND IRELAND NEWSANAESTHESIA

INSIDE THIS ISSUE:

Supporting Trainees Returning to Practice Following a Prolonged Absence

The UK Global Anaesthesia Collaboration: The Big Launch

Safety Matters

Anaesthesia News February 2015 • Issue 331 3

16

Contents03 Editorial 05 President's Report 07 ‘John Snow Anaesthesia’ intercalated BSc funded by AAGBI/Anaesthesia 09 The Lifeboxes for Rio Lump Sum Legacy – an appeal to retiring anaesthetists 10 The UK Global Anaesthesia Collaboration: The Big Launch 14 Supporting Trainees Returning to Practice Following a Prolonged Absence 17 Jungle extreme running: from the Andes to the Amazon 20 The role of the trainee educational lead

22 Safety matters 25 Your Letters 27 Anaesthesia Digested 28 Particles

07

09

17

10

The Association of Anaesthetists of Great Britain and Ireland21 Portland Place, London W1B 1PYTelephone: 020 7631 1650Fax: 020 7631 4352Email: [email protected]: www.aagbi.org

Anaesthesia NewsChair Editorial Board: Nancy RedfernEditors: Phil Bewley and Sally El-Ghazali (GAT), Nancy Redfern, Richard Griffiths, Sean Tighe, Tom Woodcock, Mike Nathanson, Rachel Collis, Upma Misra, Felicity Platt and Gerry KeenanAddress for all correspondence, advertising or submissions: Email: [email protected]: www.aagbi.org/publications/anaesthesia-news

Editorial Assistant: Rona GloagEmail: [email protected]

Design: Chris SteerAAGBI Website & Publications Officer Telephone: 020 7631 8803Email: [email protected]: Portland Print

Copyright 2015 The Association of Anaesthetists of Great Britain and Ireland

The Association cannot be responsible for the statements or views of the contributors. No part of this newsletter may be reproduced without prior permission.

Advertisements are accepted in good faith. Readers are reminded that Anaesthesia News cannot be held responsible in any way for the quality or correctness of products or services offered in advertisements. 3

Editorial

FUJIFILM SonoSite, Inc. the SonoSite logo and other trademarks not owned by third parties are registered and unregistered trademarks of FUJIFILM SonoSite, Inc. in various jurisdictions. All other trademarks are the property of their respective owners. ©2014 FUJIFILM SonoSite, Inc. All rights reserved.

One look and the difference is clear: X-Porte delivers a type of image clarity never before seen in point-of-care ultrasound systems.

X-Porte’s Extreme Definition Imaging (XDI) was specifically created to meet the challenge of unwanted phantom echoes from side-lobe beams. Using XDI proprietary beamforming technology, visual clutter is substantially reduced while significantly enhancing clarity.

• Onboard Education: Watch 3D learning animations concurrently with live scans for real-time comparisons and guidance.

• Fully customisable: Multi-gesture touch-screen interface. Sealed to facilitate cleaning and infection control.

• Industry-leading five-year warranty.

Learn more about X-Porte today by downloading our X-Porte iPad app. Or, better still, request a demonstration to experience X-Porte yourself. Email us at [email protected]

www.sonosite.co.uk/products/x-porte

X-Porte – The World’s First Ultrasound Kiosk

1928_X-Porte Full Page Ad AN June v2.indd 1 11/04/2014 14:37

20

Anaesthesia News is one means by which the AAGBI communicates with its members (and lest anyone forgets, we are a members’ association; you choose to join, not because you feel you have to, but because you see membership as a benefit). There is no shame in publicising our successes, and ‘safety’ can just about trump anything else – be it in the form of the work of our Safety Committee, our work with industry, our guidelines, our publications, or many other activities. This month we have added ‘Safety Matters’ – something that we hope will become a regular column. We have started with a selection of letters related to safety and an article about the Yellow Card system. In future issues we may feature the work of the Safety Committee or highlight important, recent safety notices.

Another success is our sponsorship of research within the UK and Ireland. Each year we award over £200,000 in grants or provide other support for research, audit and quality initiatives. In future months we will include articles highlighting projects supported by the AAGBI, and how the researchers used the money.

The AAGBI is also proud to support overseas work, but we are not the only ones doing this. With support from the AAGBI, Liz Shewry and Ollie Ross in Southampton have worked with the Tropical Health and Education Trust to produce an interactive map describing anaesthetic projects in all corners of the world, with details of how to contact the organisers. The amount of collaboration involving anaesthetists from the UK and Ireland is both astonishing and humbling.

Our own charitable appeal ‘Lifeboxes for Rio’ (http://www.aagbi.org/about-us/aagbi-fundraising/lifeboxes-rio) is gathering pace (no pun intended). Having such a concrete target is a real spur. Lots of ideas are being generated (and not just cycling!), so please consider raising money for this appeal if you are planning any events this year. Hilary Aitken has provided a suggestion for those nearing retirement (see page 9).

Mike NathansonAAGBI Council Member


IF SO, THE AAGBI SAS TRAVEL GRANT COULD PROVIDE YOU WITH A VALUABLE OPPORTUNITY

SAS PERSONAL DEVELOPMENT GRANT

For more details, and an application form, please visit: www.aagbi.org/research/awards/sas-grade-anaesthetists

Closing date for applications: Tuesday 31 March 2015

AN OPPORTUNITY FOR SAS DOCTORS WHO WANT TO:

· BROADEN AND EXPAND THEIR KNOWLEDGE

· LEARN ABOUT NEW INNOVATIVE WORK

· VISIT RECOGNISED CENTRES ANYWHERE IN THE WORLD

· NETWORK WITH EXPERTS IN THE FIELD

· BRING EXPERTISE BACK TO THEIR DEPARTMENT

· GAIN ON THE JOB TRAINING

AAGBI Members can enjoy a 30% discount on these titles, and the entire

anaesthesia collection, at www.cambridge.org/AAGBI

Anaesthesia Highlights from Cambridge University Press!

Georgiou, Thom

pson and Nickells

Applied A

natomy for A

naesth

esia and

Inten

sive Care

Applied Anatomy for Anaesthesia and Intensive Care is an invaluable tool for trainee and practising anaesthetists and intensive care physicians seeking to learn, revise and develop their anatomical knowledge and procedural skills

Concise textual descriptions of anatomy are integrated with descriptions of procedures that are frequently performed in anaesthesia and intensive care, e.g. nerve blocks, focused echo, lung ultrasound, vascular access procedures, front of neck airway access and chest drainage. The text is supported by over 200 high-quality, colour, anatomical illustrations, which are correlated with ultrasound, fi breoptic and radiological images, allowing the reader to easily interpret nerve block sonoanatomy, airway fi breoptic images and important features on CT and MRI scans.

Useful mnemonics and easily reproducible sketch diagrams make this an essential resource for anyone studying towards postgraduate examinations in anaesthesia and intensive care medicine.

Other titles of interest:

www.frcaq.comThousands of SBA and MTF MCQs for the Primary and Final FRCA examinations.

Physics, Pharmacology and Physiology for Anaesthetists, Second EditionMatthew Cross and Emma Plunkett (ISBN 9781107615885)

Essential Equations for AnaesthesiaEdward Gilbert and Marc Wittenberg (ISBN 9781107636606)

Applied Anatomy for Anaesthesia and

Intensive Care

Andy Georgiou Chris Thompson

James Nickells

Andy Georgiou FRCA DICM EDIC FFICM, Consultant in Anaesthesia and Intensive Care Medicine, Royal United Hospital Bath NHS Trust, Bath, UK.

Chris Thompson FRCA EDRA, Consultant in Anaesthesia, North Bristol NHS Trust, Bristol, UK.

James Nickells FRCA, Consultant in Anaesthesia, North Bristol NHS Trust, Bristol, UK.

Geo

rgio

u 9781107401372 C

over. C

M Y

K

JAMES ARMSTRONG HANNAH KING

PAEDsManual

PAEDIATRIC ANAESTHETIC EMERGENCY DATA MANUAL

Basic Physiology for AnaesthetistsDavid Chambers, Christopher Huang

and Gareth Matthews

Fuller, Granton

and McC

onachieH

andbook of ICU

Therapy

This popular handbook provides a practical guide to managing common and important problems in the critically ill patient, as well as sufficient background information to enable understanding of the principles and rationale behind the therapy without overloading the reader with detailed basic science.

Fully updated throughout, this third edition of Handbook of ICU Therapy includes new chapters on coagulation problems in the critically ill, airway management, electrolyte and metabolic acid–base problems, optimizing antimicrobial therapy, chronic critical illness, recognizing and responding to the deteriorating patient, ICU rehabilitation, palliative care, neurotrauma, the comatose patient, the obstetric patient, endocrine problems, and care of organ donors. Authored by senior clinicians from both sides of the Atlantic, chapters retain the easy-to-read format of previous editions.

Aimed particularly at residents and trainees starting out in the ICU or preparing for postgraduate examinations, this handbook also serves as a valuable refresher for established intensivists, anesthesiologists and surgeons.

John Fuller is Professor, Department of Anaesthesia and Perioperative Medicine, and Division of Critical Care (Department of Medicine), Western University, London, Ontario, Canada.

Jeff Granton is Associate Professor, Department of Anaesthesia and Perioperative Medicine, and Division of Critical Care (Department of Medicine), Western University, London, Ontario, Canada.

Ian McConachie is Associate Professor, Department of Anaesthesia and Perioperative Medicine, and Division of Critical Care (Department of Medicine), Western University, London, Ontario, Canada.

Reviews of previous editions:

“…the book focuses on the current state of evidence-based practice … provides a practical, concise reference for the trainee in critical care medicine.”Anesthesia and Analgesia

“…the book provides a broad discussion of the basics of ICU care, including excellent review chapters … Its most distinguishing features are detailed chapters about specific patient populations encountered in the ICU … it fills a niche for readers who do not want to delve into a full textbook of critical care but prefer more detail than the average ready reference.”Respiratory Care

Cover Design and illustration by Zoe Naylor

9781107641907 Fuller, G

ranto

n an

d M

cCo

nach

ie PB C

M Y

K

ICU TherapyHandbook of

Edited by John Fuller, Jeff Granton and Ian McConachie

THIrD EDITIoN

THIrD EDITIoN

Multiple True False Questions

for the Final FFICM

Multiple True False Q

uestions for the Final FFICM

Emma BellchambersKeith DaviesAbigail Ford

Benjamin Walton

Bellchambers, D

avies, Ford and W

alton

Following the introduction in 2013 of the FFICM exam for trainees in intensive care,

this book provides candidates with practice materials for the MCQ section. Written

by a team of specialists in intensive care medicine, including senior trainees who

have recently passed the new exam and authors of the popular FRCAQ website

(frcaq.com), the book contains 270 multiple true false questions that cover the

breadth of the current Faculty of Intensive Care Medicine curriculum. These are

presented as three 90-question practice papers, providing candidates with a faithful

simulation of the style, standard and format of the questions they will encounter.

With short and long explanations for each question, presented with up-to-date

references for extended reading, this book is both an ideal tool for in-depth exam

preparation and an excellent resource for practising consultants in intensive care

medicine. It is also suitable for candidates taking the EDIC and other intensive care

exams worldwide.

Emma Bellchambers BMedSci, BMBS, MRCP, FRCA is Specialty Trainee in Anaesthesia

and Intensive Care Medicine, Severn Deanery, Bristol, UK.

Keith Davies MA, MBBS, FRCA, FFICM is Specialty Trainee in Anaesthesia and

Intensive Care Medicine, Severn Deanery, Bristol, UK.

Abigail Ford BSc (Med Sci), MBChB, MRCP, FRCA is Specialty Trainee in Anaesthesia

and Intensive Care Medicine, Severn Deanery, Bristol, UK.

Benjamin Walton MBChB, MRCP, FRCA, FFICM is Consultant in Critical Care and

Anaesthesia, North Bristol NHS Trust, Bristol, UK.

OTHER TITLES OF INTEREST:

Pharmacology for Anaesthesia and Intensive Care, Fourth Edition

T. E. Peck and S. A. Hill (ISBN 9781107657267)

Applied Anatomy for Anaesthesia and Intensive Care

Andy Georgiou, Chris Thompson and James Nickells (ISBN 9781107401372)

Handbook of ICU Therapy, Third Edition

Edited by John Fuller, Jeff Granton and Ian McConachie (ISBN 9781107641907)

Cover designed by Hart McLeod Ltd

Cover illustration: © toei/iStockphoto

9781

1076

553

17 B

ELL

CH

AM

BE

RS

ET

AL

– M

ULT

IPLE

TR

UE

FA

LSE

QU

ES

TIO

NS

FO

R T

HE

FIN

AL

FFIC

M C

OV

ER

C M

Y K

MCCO

NACH

IEA

NESTH

ESIA and PER

IOPER

ATIV

E CA

RE

of the HIG

H-R

ISK PA

TIENT

The fully updated third edition of this popular handbook provides a concise summary of perioperative management of high-risk surgical patients.

Written by an international group of senior clinicians, chapters retain the practical nature of previous editions, with concise text in a bulleted format, offering rapid access to key facts and advice. Several new chapters cover topics including: anesthetic mortality; cardiopulmonary exercise testing; perioperative optimization; obstructive sleep apnea and obesity hypoventilation syndrome; smoking, alcohol, and recreational drug abuse; intraoperative ventilatory management; the role of simulation in managing the high-risk patient; anesthesia, surgery, and palliative care; anesthesia and cancer surgery; neurotrauma and other high-risk neuro cases; anesthesia for end-stage renal and liver disease; and transplant patients.

Essential reading for trainee anesthesiologists managing seriously ill patients during surgery or studying for postgraduate examinations, this is also a valuable refresher for anesthesiologists and intensivists looking for an update on the latest evidence-based care.

Ian McConachie is Associate Professor for Anesthesia and Perioperative Medicine at the Western University, London, ON, Canada.

Other titles of interest:

Anesthetic Management of the Obese Surgical PatientJay B. Brodsky and Hendrikus J. M. Lemmens (ISBN 9781107603332)

Handbook of ICU Therapy, Third Edition Edited by John Fuller, Jeff Granton, and Ian McConachie (ISBN 9781107641907)

Handbook of Critical Incidents and Essential Topics in Pediatric AnesthesiologyEdited by David A. Young and Olutoyin A. Olutoye (ISBN 9781107687585)

Essentials of Trauma AnesthesiaEdited by Albert J. Varon and Charles Smith (ISBN 9781107602564)

9781107690578 McC

on

achie PB

C M

Y K

EDITED BY IAN MCCONACHIE

ANESTHESIA and PERIOPERATIVE CARE of the HIGH-RISK PATIENT

THIRD EDITIONReviews of the previous editions:

“McConachie et al. meet their goals of providing practical pearls on the care of high-risk surgical patients…a cost-effective, helpful addition to any student’s, trainee’s or practitioner’s library.”Anesthesiology

“A common sense approach to contentious areas of perioperative care…its ordered no nonsense style provides a clear overview to consolidate knowledge.”Anaesthesia

“This book could be placed on every desk in the hospital and would be a valuable resource in the hands of the junior as well as the more experienced anesthetist.”Critical Care

Anaesthesia ad 124x180 Nov14 v2.indd 1 01/12/2014 10:35

Advance Notice of 2015 BADS

ASM18 & 19 June 2015

English Riviera Centre Torquay, Devon

Call for Abstracts The Association will be accepting abstracts for this meeting via the BADS website from 1 January 2015.

Enquiries to: [email protected]

www.bads.co.uk

Mul%disciplinary Mee%ng | Lectures | Workshops | Joint & Satellite Sessions | Poster & Oral Presenta%on Compe%%on

Sessions Include: Pushing the boundaries for day surgery urology Applying Human Factors to theatre team work Running a Regional Anaesthe%c Day Surgery Service Day Surgery performance across the UK

Call for Abstracts The Associa+on will be accep+ng abstracts for this mee+ng via the BADS website from 1 January 2015

10 CPD points Book your study leave now

18 & 19 June 2015 English Riviera Centre Torquay, Devon

PRESIDENT'S REPORT


As well as longer days, the next few months see election season, with a general election in the UK, elections for new members of the GAT Committee and the AAGBI Board, along with election of my successor as President, and the next Honorary Secretary of the AAGBI. All of us will be able to participate in at least one of those votes, and we will all be affected to a greater or lesser degree by the outcomes.

My report this month may read more as a valedictory – nothing could be further from the truth. Rather I'm writing it at the end of ten days leave, when I have slept, read and cogitated, rather than my usual last minute, late at night, between on calls approach. Shortly before I went on leave I had a letter from the pension people confirming that my normal pensionable age has been pushed back seven years, giving me potentially a longer consultant career after my term as President than before. When I first stood for Council in 2006 I said I would have to live with the aftermath of decisions I made – I had no idea then how long that would apply! I should add, of course, that the thoughts in my report are my own and many may disagree with my conclusions – let me know!

Although the AAGBI now effectively interacts with five health systems, the main challenges facing each are similar – limited financial resource, ageing populations with comorbidities dominated by obesity and diabetes, with healthcare hugely dominated by hospitals, and primary and social care suffering even more from underfunding. There seems to be little doubt that relative spending should move out of hospitals and into primary care. Perhaps in future patient choice should be less about 'which hospital should I go to?' and more about 'why do I have to go to hospital at all?'

What does this mean for anaesthesia? There is no evidence that there will be less need for our services in future, quite the contrary, and almost all of what we do

will remain hospital-based. But in some places training posts in anaesthesia are being re-directed to primary care, with huge cost and time implications for those left trying to deliver a safe service. There is growing evidence however that not every hospital can or should do everything. Outcomes for specialist centres in cancer, vascular surgery stroke and trauma care clearly demonstrate their advantages, but at the cost of increased travel time and possible hospital closures or downgrading of services such as Emergency Departments. We know this as doctors (where would you want your oesophagectomy or aneurysm treated?) and so do political leaders, but no MP, MSP, AM, MLA, or TD was ever elected supporting closure of their local hospital.

A statutory Duty of Candour has been introduced in England, which applies only after harm has occurred; if we are to be truly candid with our patients should we not be more, publicly, honest about the future of secondary and tertiary care? There is a dilemma here for a membership organisation such as the AAGBI, as reorganisation of services is as emotive an issue for its members, the men and women delivering anaesthesia, critical care and pain medicine in hospitals of all sizes thought the UK and Ireland, as it is for our patients or politicians. Striking the right balance will be a challenge for the AAGBI Board, me and my successor(s), regardless of which party or, as seems more likely, parties are in power next year.

It would be easy to rest safe in the knowledge that the need for anaesthetists will not diminish, and we're reasonable safe in our operating theatres and ICUs, but we are not unaffected by the changing economics of healthcare – which other departments are being asked to replace 20 year old drugs (sevoflurane and desflurane) with 40 year old drugs (isoflurane) to save money? Try telling that to an 'Ologist or Minimally Invasive surgeon! We know that anaesthesia in the

With Christmas, New Year and another truly excellent WSM London receding in the rear view mirror, we can begin to look forward to longer days. Almost 20 years ago one of my (now long retired) consultants told me that Valentine's Day was the first day you could go to the pub in daylight at 5pm. How much has changed in 20 years; most of us dream of finishing at 5pm, and the pub seems a much rarer destination after work than it once was.


I was awarded the John Snow iBSc award by the AAGBI/Anaesthesia to support me during my intercalated Masters of Research degree in 2013/2014. The project title was ‘Neurophysiological correlates of consistent placebo analgesic responses’. After completing my project, I was given the opportunity to present the results at the Royal College of Anaesthetists Annual Winter Research meeting - an inspiring experience, from which I learnt a lot. The high quality of projects presented and the intense questions

highlighted the high standards required in research and the need for critical analysis when interpreting results.

My project was around pain and the placebo effect, supervised by Professor Anthony Jones of the Human Pain Research Group at the University of Manchester. I wanted to research placebo analgesia as I have long been interested in the neuroscience of pain and the influence of the brain’s endogenous analgesic mechanisms on the pain experience. This field of research is one that has grown significantly over the past decade and has provided evidence that is of interest to many anaesthetists. In particular, recent evidence suggests a significant proportion of the analgesic effect of drugs prescribed may result from the endogenous mechanisms activated by expectation of pain relief. A better understanding of these mechanisms may contribute to a better understanding of an individual’s treatment response when managing pain.

We aimed to answer two main questions surrounding placebo analgesic responses. The first was an investigation into the

influence of context and treatment modality on the placebo response. We examined whether topical placebo gels induce a greater placebo response than oral placebo tablets in response to experimental pain. There has been an increase in the use of topical analgesics over recent years; however, a study performing a direct comparison between placebo responses to topical and oral placebos in an experimental setting had not been performed prior to our study. Our second question was whether certain individuals respond consistently to different placebo modalities, investigating the influence of individual traits in placebo response. This question was generated by studies that suggested individual traits (such as personality and genotype) might determine the placebo response. Are certain individuals consistent ‘placebo responders’? If so, these trait characteristics should result in relatively consistent placebo responses despite changes in the contextual delivery of a placebo. In order to investigate this we performed a randomised controlled cross-over study comparing individual responses to both gel and tablet placebos in response to experimental pain over two experimental sessions and recorded brain activity throughout using EEG.

Our final results identified that placebo gels induce a greater reduction in experimental pain, than placebo tablets. We established that this effect was not a result of physical effects of gel application through our analysis of responses in the control group in our study. This effect was found to be associated with a greater expectation of pain relief and we believe the site-specific nature of the gel application may have interacted with expectation to increase placebo response. Furthermore, a strong correlation between treatment responses across different treatment modalities was not identified. Hence there is little evidence for the concept of individual traits that determine placebo responses

‘John Snow Anaesthesia’ intercalated BSc funded by AAGBI/Anaesthesia

In 2013 the NIAA made seven ‘John Snow Anaesthesia’ awards to support intercalated BSc medical students (http://www.niaa.org.uk/article.php?newsid=1124#pt). In a competitive process AABGI/Anaesthesia funded two of these. This report is from one recipient who was awarded £2000.

John Snow

Matthew Leung

www.gatasm.org

• Greateducationalprogrammeincludinglectures,

problembasedlearningandworkshops

• FunsocialeventsincludingtheAnnualDinner&Dance

• Professionaldevelopmentopportunitiesincluding

mentoring,consultantinterview,postersandprizes

• Parent&babyroomwithlivestreamingof

conferencelectures

MANCHESTERRENOLD BUILDING, UNIVERSITY OF MANCHESTER

ANNUAL SCIENTIFIC MEETING

17-19 JUNE 2015BOOK YOUR STUDY LEAVE NOW!

developed world is safe, in terms of direct mortality, compared with 30 or 40 years ago, and certainly compared with the developing world. That improved safety is, in part, a result of the work of the AAGBI and other organisations in promoting better standards. We have in the past, though, been rather inward looking, which goes a long way to explain why despite representing the largest single specialty in hospital medicine, our influence can seem so limited.

That began to change with what became NCEPOD, and recent projects looking at outcomes from hip fracture and emergency laparotomy must be the way forward. It is no longer enough to be outstanding clinicians in the operating theatre or ICU; we must extend that excellence into the whole peri-operative journey. The RCoA's focus on peri-operative medicine, with its Stakeholder event in late January, is to be applauded and encouraged. I know there are already many good local examples of this in practice, and we are keen to hear of your successes. My distinguished predecessor, Peter Baskett, has often been quoted as saying anaesthetists cannot hope for greater influence while remaining shackled to their anaesthetic machines, and his words have never been truer.

So for those considering election to GAT, the AAGBI Board, Honorary Secretary or as my successor, there will be many challenges ahead. Some are obvious to us now and other have yet to emerge. An immediate challenge for all of them will be time. Despite high level support from the top of the NHS, including all the Chief Medical Officers, few hospitals recognise the importance to the whole healthcare system of work for the AAGBI, RCoA or specialist societies. Or if they recognise its importance, this is not matched with the allocation of time in job plans (another change from 20 years ago) I am fortunate to live and work within 25 minutes walk of 21 Portland Place, making it easier to combine a full-time clinical post with my role at AAGBI; few future candidates are likely to share my advantage. With the demise or withering (depending where you work) of Clinical Excellence Awards, some of the other incentives to election are disappearing. The AAGBI is already considering the need to reimburse employers for the time of Officers and Board Members. There are no immediate plans for this, but it seems prudent to assess the impact on our finances and activity sooner rather than later.

So do engage with some or all of the upcoming elections. If you're not standing or canvassing, at least vote. Apathy was never the solution.

Andrew Hartle President, AAGBI

Anaesthesia News is the official magazine of the Association of Anaesthetists of Great Britain & Ireland.

Anaesthesia News now reaches over 10,500 anaesthetists every month and is a great way of advertising your course, meeting, seminar or product.

For further information on advertising

Dr Les GemmellImmediate Past Honorary Secretary

21 Portland Place, London W1B 1PYT: +44 (0)20 7631 1650F: +44 (0)20 7631 4352E: [email protected]

W: www.aagbi.org

Tel: 020 7631 8803or email Chris Steer: [email protected]

www.aagbi.org/publications

CALL NOW FOR A MEDIA

PACK

AN

AES

THES

IA N

EWS

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

6


across different treatment modalities and situations. Together, our results highlight an important message, that the contextual influence of treatment delivery is important in determining analgesic outcome. This simple yet important study provides further evidence of the importance of psychological mechanisms underlying the management of pain.

The next step in this research will be to determine a source localisation of the EEG data collected, with the aim of identifying possible neurophysiological correlates of the data. Other members of the team will be helping with this as I have re-entered my clinical studies, and we aim to publish the results next year. I will continue with my fourth year at medical school and will try to conduct a smaller research project on chronic pain as part of the compulsory research project block at the end of the year. I also hope to apply for an academic foundation track post as I have thoroughly enjoyed my year of research and would like to pursue a career in academic medicine.

I would like to thank the AAGBI/Anaesthesia for the John Snow award as the support it provided helped ease the financial burden of doing an extra year of study (particularly a Master’s degree), enabling me to fully focus on my research.

Matthew LeungMedical student, University of Manchester

The 15th of November 2016 is a date that has been circled in red ink in my mental diary for some years now. It’s my 58th birthday and, sometime around that date, I will be in receipt of a large lump sum from the Scottish Public Pension Agency, because that’s the date I have selected to retire.

I am pledging that at that time I will donate the equivalent of at least one Lifebox (£160) to the AAGBI’s appeal, and call on retiring AAGBI members between now and then to do the same. This can be retrospective – if you have received a lump sum since September 2014 (AAGBI appeal launch), you can join in. You don’t need to bake cakes or go on a cycle ride – simply donate.

Every year 75–100 AAGBI members retire. I would like as many Lifeboxes as possible to be donated by retiring or recently retired anaesthetists before I go in November 2016. This is the chance for us oldies to leave a lasting legacy for anaesthesia worldwide.

Why should we do this?

• Our generation has had the benefit of a higher final salary than previous generations, and will be the last to benefit from an automatic lump sum. Relative to the size of most of our lump sums, £160 is petty cash.

• We are also the last generation to remember what it’s like to deliver anaesthesia without pulse oximetry. Remember the days when you had to decide if a patient was looking ‘a bit dusky’? (Somehow, the word ‘blue’ didn’t pass anyone’s lips). Throughout the world, many anaesthesia providers are still in this position. We can help them.

• There are quite a lot of us – the recruitment bulge of the 1990s is approaching retirement, so we can provide a lot of Lump Sum Lifeboxes.

• We have had a career which is rewarding – in every sense – and as we step away from clinical practice, it’s time to give something back.

• Once you have retired, the AAGBI offers 3 retired subscription rates, £38, £23 or £0 to move onto. There’s more than £160 right there.

I know I’m getting older because the AAGBI Presidents are starting to look young, and I’m starting to reflect on my career in preparation for leaving it behind. I can’t think of a better gesture to underline all that anaesthesia (and the AAGBI) has done for me than this small gesture to the anaesthetic community in the wider world.

I’d like to invite others in my fortunate position to do the same.

Hilary AitkenConsultant Anaesthetist, Paisley

AAGBI Foundation: Registered as a charity in England & Wales no. 293575 and in Scotland no. SC040697Lifebox: Registered as a charity in England & Wales (1143018)

Lifebox makes surgery safer in low-resource countries where the risk of dying from anaesthesia is as high as 1 in 133.

www.lifebox.orgDonate now: https://mydonate.bt.com/events lifeboxes4rio/182427

The Lifeboxes for Rio Lump Sum Legacy – an appeal to retiring anaesthetists

www.aagbi.org/lifeboxesforrio

SAS Simulation Training Thursday 26 February 2015or Thursday 12 March 2015

Venue: Centre For Clinical PracticeChelsea and Westminster Hospital369 Fulham Road | London | SW10 9NH

This course is specially designed for the needs of SAS anaesthetists. The content will be based on Anaesthesia Crisis Resource Management (ACRM). This course aims to train anaesthetists to avoid and deal with crisis situations. The main focus is on teamwork and human factors. Useful practical points will also be covered. The setting is a simulated theatre using an advanced simulation manikin with realistic physical and physiological signs.

Delegate registration fees: £240 per candidate Spaces are limited. To book please contact: [email protected]

(CPD points applied for)

2 x one day training courses

Ultrasound for Peripheral Nerve Block Workshops2015

Thursday 30th April 2015Thursday 26th November 2015

B. Braun Business Centre, Thorncliffe Park, Sheffield, S35 2PW

For more information or to register please contact a member of the events team:

Tel: 0114 225 9057 or 0114 225 9035/36 Email: [email protected] Web: www.aesculap-academia.co.uk

The programme will focus on peripheral nerve blocks for the upper and lower limb. Each workshop will be practicalbased with an introductory lecture to the upper and lower limb. The practical sessions will include surface anatomy,needling techniques, nerve mapping and ultrasound guided nerve blocks.

Registration DetailsThe course fee of £165.00 (inc. VAT at 20%) includes:• Delegate Pack• Certificate of Attendance• CPD Points Applied for• One Day of Education• Lunch and Refreshments

Follow us on Twitter @academia_uk #RegionalAnaesthesia

The UK Global Anaesthesia Collaboration:

The Big Launch

Many UK-based anaesthetists are currently working on collaborative anaesthetic projects in the resource-poor environment. Projects with the same aims of improving safe anaesthetic delivery by using educational resources and programmes, could be geographically close but neither knew of each other’s existence. In 2012 we became concerned that there was a lack of information to alert fellow anaesthetists to these projects. Reports of partnerships in neighbouring towns but unknown to each other were prolific. As overseas partnership work continues to grow it made not only sense but seemed vital to increase the collaboration between projects and we set out to develop a way to share knowledge between projects, as well as sharing experience.

The project aims were:

• optimise project coordination locally with overseas partners and within the UK

• provide mentoring expertise and resources for all to share• provide a contact point for future partners• continue the ‘professionalisation’ of UK-overseas

anaesthesia links

After an original draft survey was sent out we realised that to deliver our aim we needed to involve as many UK anaesthetists as possible. A partnership was developed between us, the AAGBI and THET, since when the project has grown dramatically in size. As a group we decided to focus our work on three project outputs:

a comprehensive survey and 'map' of current UK overseas/developing world anaesthetic projects; a pool of experts and a pool of possible mentors; and, an online library of educational resources. In addition we wished to develop joint AAGBI/THET Good Practice Guidelines, a national group providing advice to such projects, and develop a new network for future collaboration.

Together with a working group from the AAGBI International Relations Committee and THET, a comprehensive survey tool was created. Emails inviting participation were sent to all AAGBI members, AAGBI Linkmen and known anaesthesia links on the THET database, and to individuals and groups known to be involved in overseas work. The survey was administered by Enventure on behalf of the AAGBI and THET. We included the following survey questions:

• information regarding the respondent profile• details of each individual project• details of local anaesthetic services and individuals involved

for each project• collaborations with UK groups, for example AAGBI and the

Department for International Development• collaborations with others specialities, for example

obstetrics, paediatrics• resources used by projects, for example Lifebox, lectures• project tools, for example planning tools, theory of change• funding and leave for UK-based volunteers

The 'Survey of Global Anaesthesia Collaboration' closed in November 2013 and a database was created. In the survey, 210 projects were reported – mostly from English-speaking and Commonwealth countries. A detailed analysis of the data collected will be published in the near future.

The original focus has been to get the information mapped in order to allow the collaborative process to begin. After a lot of discussion regarding various websites capable of hosting the map, the decision was made to go ahead with Google Maps. This a free site but surprisingly versatile and support is also provided for charities such as the AAGBI Foundation. Fantastic IT support from the AAGBI (Andrew Mortimore) has lead to the development of the map which is hosted on the AAGBI site and is freely

accessible to all (http://www.aagbi.org/international/thet). Each project has a ‘pin’ on the map based at the site of the collaborative work. The following information on each project is available by clicking on the ‘pin’:

• programme name/type/organisation • overseas programme director/contact person• UK contact details, UK lead, UK contact email addresses• key collaborations (overseas and UK)• specialities• project aim/purpose• project outputs• project activities • resources available to share (Y/N)

Over the last two years we have worked with the AAGBI and the Tropical Health and Education Trust (THET; www.thet.org) to produce a comprehensive 'map' of UK and overseas linked anaesthetic projects, a pool of experts and a virtual library of online educational resources. x

Anaesthesia News February 2015 • Issue 331 11 10 Anaesthesia News February 2015 • Issue 331

12 Anaesthesia News February 2015 • Issue 331

The map can also be ‘reversed’ so that one can look for a contact within their local area or hospital. The respondent’s hospital, name, project details and resources can be accessed via this route. This allows those starting out to know who to contact within their region or those already involved to obtain advice. An online form has been developed to allow new projects to be added.

Emails can be sent directly from the page to submit changes to details. We envisage the map to be an ongoing piece of work. It will only succeed if new projects are added as they develop and changes are made when required. We are relying on you to keep us updated.

Finally, a virtual online resource library using data from the survey has now been created. Links to common anaesthetic global medicine resources such as SAFE, Lifebox and Primary Trauma Course are available via the resource library. This library also allows the user to judge which resources may be of assistance and contact the individuals themselves. It is possible to filter the site according to the type of resource required (for example, ‘video’) or anaesthetic speciality (such as paediatrics). By sharing resources we hope to be able to increase collaboration and consistency. It also includes those very useful UK-based anaesthetic training courses for the resource-poor environment as well as details of UK meetings. Again please do add to this database of resources and email us via the weblink to update any details.

The online collaborative map is open access and fully supported by AAGBI, THET, RCoA, WFSA and the World Anaesthesia Society. We believe this project will help those already involved in overseas work as well as those interested in getting involved. We are grateful to all the participants and we hope future projects continue to be added to the database. Collaboration with other specialities (such as the Royal College of Surgeons) and other countries (via the World Federation of Society Anaesthesiologists) are in the pipeline to expand the map further. This is the only mapping project of overseas partnerships that we are aware of and has taken many months of hard work. We believe it demonstrates the commitment of the speciality to improving global anaesthesia. Please use the map and resource library and continue to add new projects. It will only work with your support.

Dr Liz Shewry and Dr Ollie RossConsultant AnaesthetistsShackleton Department of Anaesthesia, University Hospital Southampton

www.aagbi.org/international/thet12 Anaesthesia News February 2015 • Issue 331

A 2 day course aimed at ST3+, SAS and consultants seeking to update their skills in fibre optic intubation

Wednesday 22nd & Thursday 23rd April 2015Manikin Practice, Interactive Workshops, Lectures

and Asleep fibre optic intubation of a patient

Course fee £350RCOA CME approved 10 points

For more information contact:

Course secretary: Hazel Cherrie Telephone: 0131 242 3151

Email: [email protected]

www.anaes.med.ed.ac.uk/fibreoptic.htmlDepartment of Anaesthesia, Royal Infirmary

51 Little France Crescent, Edinburgh, EH16 4SA

Supported by

14 Anaesthesia News February 2015 • Issue 331 Anaesthesia News February 2015 • Issue 331 15

As a trainee, returning to practice following a prolonged absence from anaesthetics can be daunting especially with the prospect of solo lists and on-calls. This may apply regardless of whether you are returning to work from maternity leave, following a period of ill-health or have been pursuing other professional goals such as research or a period of Intensive Care Medicine training.

Supporting Trainees Returning to Practice Following a Prolonged Absence

The Academy of the Medical Royal Colleges (AoMRC) published guidance on returning to practice in 2012 (which included those returning to their usual practice after working in a different clinical field). The AoMRC was concerned that there was a perceived lack of guidance on supporting a return to practice, potentially compromising patient safety, and so established a working party to review this area.

The recommendations of the working party define a prolonged absence as more than three months and give examples of checklists which should be used pre- and post-absence to allow an individualised action plan to be formulated to support a doctors’ return to practice.1 The Royal College of Anaesthetists (RCoA) has subsequently updated its return to work guidance using the framework suggested by the AoMRC.2

The Wessex School of Anaesthesia have successfully introduced a return to work programme for those anaesthetists with no on-going health, conduct or capability issues who expect to return to

practice in a short period of time. You can read about it in a previous issue of Anaesthesia News3 and access examples of the paperwork used to support a successful return to work on the AAGBI website4

(flowchart, pre-absence and return to work forms).

Returning to work following maternity leaveMaternity leave is the most common reason for trainees to have a prolonged period of absence from training. Most will expect (or be expected) to return to practice within a short space of time. As this is a planned absence it is worth giving your return to work some thought even before you go off. In particular think about whether you plan to return to work less than full time (LTFT) as the application will take some time.

Think about the things you can do during your maternity leave to keep up to date. This may simply involve making the effort to do

some reading but you may also wish to attend some courses or meetings or take advantage of keeping in touch (KIT) days. You are contractually entitled to up to 10 KIT days during maternity leave. These must be agreed prospectively with your employer and can be used to have some supervised clinical time or to attend courses etc. appropriate to your stage of training. You will be paid at the basic daily rate for each KIT day taken.

Prior to your return to work it is important you make contact with your Training Programme Director and the College Tutor/Educational Supervisor at the hospital you will be working at to ensure your return is as smooth as possible. The level of support you will require will depend on various factors including length of absence and stage of training. It is useful to agree an appropriate period of supervised practice prior to returning to out of hours work. Identify your training needs early to ensure you receive the correct training placement. If you are returning to work LTFT it may take you longer than you expect to regain your clinical confidence – this is not unusual.

The Bulletin of the RCoA has published useful articles with advice on preparing for maternity leave5 and a personal view of returning to work following maternity leave.6

Returning to work following an illness or with a disabilityReturning to work following an illness or with a disability is more complex and trainees in this situation are likely to need much more support than those returning from maternity leave. The type of absence is likely to be unpredictable in its onset and length so early communication with your Training Programme Director and human resources officer is advisable.

Occupational Health will deal with your situation in confidence and may be useful in helping to arrange an individually tailored return to work programme. If you have a chronic or relapsing illess, it is useful to make an appointment to see the Consultant Occupational Physician, who can help you to identify whether any work-related issues have an impact on your health and will act as an advocate for you in getting the appropriate 'reasonable adjustment', so you stay as well as possible. There have been several articles detailing a return to work following illness or disability through the eyes of those who have experienced it; Returning to work in a wheelchair;7 Returning to work – as a disabled anaesthetist;8 Returning to work – a personal view.9

Returning to work coursesA national multicentre (London, Bradford and Bournemouth) anaesthesia return to work course (GASagain) has been established which focuses on scenario based simulation and interactive tutorials. More information and future course dates can be found at www.gasagain.com. Some schools of anaesthesia are also beginning to run their own return to work courses, recognising the importance of supporting trainees resuming their anaesthesia training.

Your CCT dateThe RCoA will need to be informed of your intention to take maternity or any other leave. Your CCT date will be suspended until your actual return to work, allowing any unplanned extension to your leave to be factored in. Upon returning to work you must notify the RCoA Training Department of your return date, and whether you are returning on a LTFT basis, and a new CCT date will be calculated.

A recent position statement from the General Medical Council (GMC) provides guidance on the management of absences from training and their effect on a trainee's CCT date. From 1st April 2013 any trainee who has been absent for more than 14 days in any 12 month period (excluding annual leave or study leave) will have a review to decide whether a CCT date extension is required. This review of absence will occur at ARCP and Deaneries will administrate the process in consultation with the RCoA. Deaneries are expected to implement this guidance flexibly to reflect the nature of the absence, the timing and the effect of the absence on the individual’s competence.10

Historically three months of one maternity leave could be counted as exceptional leave without affecting a trainee's CCT date. Exceptional leave no longer exists; however, if a trainee can demonstrate that all the necessary competencies have been achieved then the RCoA may still allow some maternity leave (or other leave) to be 'counted' on an individualised basis.

Less Than Full Time TrainingFor those returning to work LTFT the AAGBI website11 and GAT Handbook12 provide some useful information on how to negotiate the logistical challenges that organising LTFT training may present. In addition the RCoA and the AAGBI are joining forces in hosting a 'Shape of LTFT Training 2015' day at the RCoA on 6th of May 2015. This will provide the opportunity for trainees, trainers and programme directors to learn how to get the most from, or develop their LTFT training programme. The format of the day will be a series of workshops addressing current LTFT issues including: returning to work, the organisation and practicalities of LTFT training, contract negotiations and maximising your retirement income, achieving your full potential during LTFT training and successfully securing a consultant post. There will also be a question and answer session with an LTFT expert panel. To register for this event go to http://www.rcoa.ac.uk/education-and-events/the-shape-of-ltft-2015.

References1. Return to practice guidance. The Academy of the Royal Medical Colleges, April 2012. http://www.

aomrc.org.uk/doc_view/9486-return-to-practice-guidance 2. Returning to work after a period of absence, The Royal College of Anaesthetists, May 2012. http://

www.rcoa.ac.uk/document-store/career-breaks-and-returning-work3. King W, Haigh F, Aarvold A, Hopkins D, Smith I. Returning to work the Wessex way, Anaesthesia News

June 2012: 299; 18-19. http://www.aagbi.org/sites/default/files/JuneAnaesthesiaNews_Web_0.pdf.4. AAGBI Trainee Updates: Returning to work after a prolonged period of absence. December 2012.

http://www.aagbi.org/professionals/trainees/gat-news5. Cullis K. Pregnancy and preparing for maternity leave. Bulletin of the Royal College of Anaesthetists

2011: 66; 12-14. http://www.rcoa.ac.uk/document-store/bulletin-66-march-2011. 6. Cullis K. Returning to work after maternity leave. Bulletin of the Royal College of Anaesthetists 2011:

65; 20-21. (http://www.rcoa.ac.uk/document-store/bulletin-65-january-2011).7. Rugen J. Returning to work in a wheelchair. Anaesthesia News October 2011: 291; 8-9. http://www.

aagbi.org/sites/default/files/October%20ANews%20Final_0.pdf.8. Fossati N. Returning to work – as a disabled anaesthetist. Bulletin of the Royal College of

Anaesthetists 2011: 66; 26-28. http://www.rcoa.ac.uk/document-store/bulletin-66-march-2011.9. Jobling L. Returning to work – a personal view. Bulletin of the Royal College of Anaesthetists 2011:

66; 29-31. http://www.rcoa.ac.uk/document-store/bulletin-66-march-2011.10. Position Statement: Time out of training. General Medical Council, November 2012. http://www.gmc-

uk.org/20121130_Time_out_of_Training_GMC_position_statement_Nov_2012.pdf.pdf_56438711.pdf

11. Gibb S, Carey S. Less than Full Time Training in Anaesthesia: An A to Z Guide, March 2013. http://www.aagbi.org/sites/default/files/A%20to%20Z%20Guide%20to%20LTFT%20%20Anaesthetic%20Training%20March%202013%20%282%29.pdf

12. GAT Handbook 2013-14. http://www.aagbi.org/sites/default/files/GAT%20Handbook%20Web.pdf

Article adapted from GAT Handbook chapter on 'Returning to Work Following a Prolonged Absence'. All websites accessed 10/12/2014.

Sarah GibbChair of GAT Committee


In medical training today we face many challenges, with increasingly complex and poorly patients, a faster pace of training, and more extracurricular requirements on top of the inevitable exams. At the same time, there seem to be fewer opportunities to do something exciting, new and refreshing within medicine. Sometimes you just need something a little different to reinvigorate and rejuvenate passions for day-to-day work...

Jungle extreme running: from the Andes to the Amazon

The Jungle Ultra in Peru (www.beyondtheultimate.co.uk) is a 230 km endurance challenge. Encompassing five stages, it is a 6-day event that runs from the cloud forest to the Amazon basin. The starting point is 10 500 ft above sea level, with the majority of the race run at temperatures of 25–30 0C and 100% humidity over tough jungle trails, mountain roads and village tracks. The race averages 30 km a day, with 90 km on the last stage over two days (there is a cut-off time at one checkpoint as, once night falls, there is a real danger of jaguar attacks). The racers and the medics have to be self-sufficient, carrying all food, clothing, medical kit and accommodation (usually a hammock).

The competitors are, on the whole, adventure seekers and, from anecdotal evidence, alpha type personalities. They are fully briefed on the dangers of the jungle and are aware of all the risks; from the possibility of life-threatening snake bites to fatal animal attacks from bears and jaguars. This is further compounded by the fact that medical evacuation could take up to 8 hr even if the

weather is good. However this all heightens the challenge. I joined a team of medics consisting of seven doctors (one supervised FY1, several expedition experienced medics, one anaesthetist and one medical registrar), a medical student, a nurse and a paramedic. Usually the only site we had to work was a flat patch of dirt where we set up a clinic, a couple of posts for setting up our accommodation and a hole in the ground for the bathroom. If we were lucky there was a rainwater system for a shower. Our medical kit compromised of three large holdalls with essential pieces of equipment including a rope, a knife and tarpaulins. As the week progressed we all became a little grubby and less fresh, but uniformly, so nobody ever quite noticed.

Medically the competitors kept us busy. Mostly we treated musculoskeletal injuries and gave out protective strapping, blister and foot care and some fluid resuscitation. The most dramatic situation required a cannula and a litre of fluid administered in the jungle on top of an ant nest, and a little anaesthetic help when


EDINBURGHSCOTLAND

SAVE THE DATE

A5_AC2015.indd 1 24/11/2014 12:17

The International Relations Committee (IRC) offers travel grants to members who are seeking funding to work, or to deliver educational training courses or conferences, in low and middle-income countries.

Please note that grants will not normally be considered for attendance at congresses or meetings of learned societies. Exceptionally, they may be granted for extension of travel in association with such a post or meeting. Applicants should indicate their level of experience and expected benefits to be gained from their visits, over and above the educational value to the applicants themselves.

TRAVEL GRANTS/IRC FUNDING

For further information and an application formplease visit our website:

http://www.aagbi.org/international/irc-fundingtravel-grantsor email [email protected]

or telephone 020 7631 1650 (option 3)

Closing date: 23 February 2015

RCOA SPRING SYMPOSIUM:PERIOPERATIVE MEDICINEThursday, 14 May and Friday, 15 May 2015The Royal College of Physicains, Edinburgh£390 (£295 for RCoA registered trainees)Event organiser: Dr B Shippey

2015’s Spring Symposium will be an informative and thought-provoking event, providing an opportunity for consultants and trainees to gain valuable insights into the current issues in anaesthesia followed by an evening social.

#RCoASS15

Sessions on the day include: ■ Assessment and

management of risk ■ High risk patients ■ Prevention of complications ■ Optimisation and

management of chronic morbidity

■ Perioperative medication ■ Postoperative care

The event will also include: ■ Workshops ■ Abstract competition ■ Trade exhibition ■ Social evening

■ Postoperative care

RCoA

EVENTSEVENT ONLINE SERVICESEVENT ONLINE SERVICES

[email protected] | 020 7092 1673 | www.rcoa.ac.uk/events

an-FEB14.indd 2 03/12/2014 15:40


Canadian Anesthesiologists’ Society www.cas.ca

SPECIAL DISCOUNT AVAILABLE TO

Association of Anaesthetists of Great Britain and Ireland

JUNE 19– 22, 2015

CAS ANNUAL MEETING 2015

OTTAWA

the medical registrar accidentally cannulated an artery. However the majority of the work that was required was the opposite of the values and philosophies we work with in the NHS. We spent 24 hr a day with the 30 runners and the 10 medics and we witnessed strong personalities become almost childlike, requiring mothering, being told when to eat, sleep and drink. Autonomy diminished through the week, and paternalism took over. Confidentiality evaporated as they all shared their war stories at dinner next to the medical area, which also became the focal point of every camp as the runners and medics became more of a family and instead of instinctively wanting to medicalise them, we moved to using every trick we knew to get them through the race. This included spending two consecutive nights in a tent with two racers, to get them up hourly to drink enough fluid so that I could safely allow them to race the next day.

As an anaesthetist, many questioned what I could offer to the team. After all, if intubation was required in the jungle environment, the patient would be likely to die. However despite being a CT3 junior in a hospital setting, I was the focal point for discussions with the group with all difficult cases. As the only anaesthetist in the group I was the only one among us who had the clinical skills to cannulate severely dehydrated competitors, effectively manage fluid resuscitation in water and salt depleted patients, understand the physiology of altitude, dehydration and salt control and, given I am an ACCS trainees, to fully embrace the minor injuries and musculoskeletal (team physiotherapist) role as well. The many arrests and trauma calls I had previously attended gave me the

confidence and ability to lead and delegate within this team, and manage what I actually considered ‘well’ patients in comparison, a view not necessarily shared by all the team members in some of the scenarios. My advice: every team in a wilderness medicine environment needs an anaesthetist.

What did I get from this experience? A realisation that basic medical intervention isn’t about sophisticated tests or measurements, but common sense and simple preventative and basic interventions. In addition, a sense of the art of medicine when assessments of our patients were ‘end of the bed’ judgements and interventions were basic, and, ultimately, a huge sense of pride when they crossed the finish line.

How did it differ from the NHS? Firstly, the torrential downpours. A month’s worth of rain came down, usually around 2 am, while we were all asleep in our hammocks; not a phenomenon often seen on a night shift on the obstetric or ICU unit. However, the main contrast was the freedom to spend time with our patients, get to know them, and almost instinctively know what they needed as we laid eyes on them, a luxury we don’t always have in the NHS. The whole experience was liberating and, with such a short time span, allowed an experience within the constraints of annual leave.

Gemma Claire Lee CT3 Anaesthetics, Hull Royal Infirmary

The Anaesthesia Heritage Centre is producing a series of four temporary exhibitions honouring the work of the doctors who gave anaesthesia and pain relief to wounded people during the First World War.

The four exhibitions, each lasting a year, will explore the development of anaesthesia and pain relief and how the status of anaesthesia changed during this time.

The first exhibition in 2014-2015 will look at Geoffrey Marshall versus Henry Boyle: who really developed the Boyle machine?

The Anaesthesia Heritage Centre invites you to a series of new exhibitions:

*

Visitor information:

The Anaesthesia Heritage Centre, AAGBI Foundation, 21 Portland Place, London W1B 1PY.

Registered as a charity in England & Wales no. 293575 and in Scotland no. SC040697

ANAESTHESIA HERITAGE CENTRE

Did you know that during the First World War• The first specialist military anaesthetic

posts were created.• An understanding developed of how to

anaesthetise wounded soldiers suffering from shock.

• The Boyle anaesthetic machine was developed which is still in use today.e

British soldiers bringing back the wounded

©IWM (Q 721) courtesy of the Imperial War Museum

Oral history interviews linking past to present are also featured. These living histories highlight how treating wounded people in wartime has led to developments in pain relief and anaesthesia.

Boyle’s apparatus

Henry Boyle

Visit www.aagbi.org/heritage for further information

Open Monday to Friday 10am until 4pm (last admission 3.30pm). Appointments are recommended: email [email protected] or phone 020 7631 8865. Admission is free. Group visits for up to 20 people can be arranged at a small cost per person.

Marshall’s apparatus

* A line from Keep the Home-Fires Burning by Ivor Novello

A Silver Lining Through the Dark Clouds Shining : The Development of Anaesthesia During the First World War

*

Geoffrey Marshall

Lifeboxes for Rio is a two year fundraising campaign aiming to raise funding for 600 lifesaving Lifebox pulse oximeters, the same number as team GB athletes attending the next Olympic and Paralympic Games in Rio de Janeiro in 2016. That’s £96,000 to save thousands of lives around the world where patients are at risk of death from hypoxia during surgery.

The AAGBI wants to involve its members. There are lots of ways to take part and help us raise the funds.

www.aagbi.org/lifeboxesforrioAAGBI Foundation: Registered as a charity in England & Wales no. 293575 and in Scotland no. SC040697Lifebox: Registered as a charity in England & Wales (1143018)

Bake, bike ride, run or walk – or devise your own fundraising concept.

20 Anaesthesia News February 2015 • Issue 331 Anaesthesia News February 2015 • Issue 331 21

The role of the trainee educational lead

Teaching programmeOne of the primary functions of the TEL is to organise and lead the internal CPD programme. The programme covers a range of clinical and non-clinical topics, mapped to the Royal College of Anaesthetists (RCoA) CPD matrix, and is relevant to both trainees and consultants. This addresses the previous lack of formal teaching available to post-fellowship trainees working at the Trust.

Teaching is weekly, apart from during school holidays, and trainees are routinely released from their lists to attend. The TEL audits attendance and feedback ensuring the programme fulfils the requirements for internal CPD points. Devising a teaching programme that maps the RCoA matrix increases the TEL’s knowledge of the matrix and how to use it as a consultant. Many trainees are aware of the existence of the matrix but have no real comprehension as to how it informs consultant CPD.

There is plenty of scope for the TEL and other senior trainees to deliver teaching and get feedback; this is a requirement for completion of higher training within the school. Trainees often choose subjects quite different to those chosen by their consultant colleagues. For example, several of our trainees are involved in pre-hospital care and have given interesting and informative presentations linking the pre-hospital environment to that of care in the hospital, from the Emergency Department through theatre and ultimately to intensive care. This increased shared understanding of the pre-hospital setup has no doubt enhanced the patient care within the Trust.

The TEL is also responsible for ensuring that all trainees are appropriately allocated on the weekly rota to exam or new starter teaching. The co-ordination of attendance at multiple departmental programmes, anaesthetic school teaching and deanery-wide education days can prove a bit of a headache at the beginning of the year!

While undertaken in an educational context, the TEL is essentially a managerial role. Organisation and communication are required to recruit speakers, especially those from outside anaesthesia. Building inter-departmental relationships, often months in advance, has guaranteed us a highly varied and interesting programme. To maximise attendance, trainees receive e-mails and text message reminders through a service facilitated via NHS.net.

Supportive rolesAlongside the TSL, the TEL is responsible for organising and running the bimonthly Anaesthetic Trainee Forum, where trainees can air concerns about departmental training and service provision. As well as attending and speaking at meetings there is scope for trainees to add more sensitive issues to the agenda anonymously, thus maximising the ways in which trainees can have their voices heard.

The discussions from the Trainee Forum are fed back to the management and college tutors at the bimonthly Anaesthetic Education Forum, which provides vital two-way communication between consultants and trainees and, where possible, issues are addressed. Solutions and concerns raised by consultants can be fed back to the trainees via email or, if discussion is required, at the next Anaesthetic Trainee Forum. The opportunity to participate in this type of managerial role is excellent preparation for the managerial tasks taken on at consultant level.

Other roles include assisting with the induction of trainees new to the department and appointing a replacement TEL. Participating in a formal interview process provides invaluable experience, particularly useful for senior trainees approaching consultant interviews. The interview process is organised by the TEL in conjunction with one of the college tutors.

Adapting the TEL roleEach trainee who has undertaken the role to date has led it in a slightly different direction. An interest in simulation was accommodated; some sessions have been videoed with a view to formulating a web resource for consultants and trainees unable to attend. One of the previous TELs devised a teaching package for anaesthetic new starters and introduced the formal interview and handover process. The previous TEL has drawn on the wealth of knowledge and experience that exists in a teaching hospital by recruiting consultants from other specialties to give presentations. The current TEL is seeking to consolidate the weekly teaching into an afternoon of protected teaching once a month to further increase the speakers that are able to present while maximising the attendance of senior trainees.

It is a challenging role as speakers’ commitments can be unpredictable and some have been forced to drop out at short notice resulting in creative improvisation for some sessions. Endeavouring to create a programme that focuses on post-fellowship trainees, but is inclusive to the rest of the department, is also testing but popular sessions have proved exceptionally rewarding.

The TEL has half a day a week of administration time to facilitate the role.

Other opportunitiesThe TEL role has facilitated many other ways of increasing the trainee’s involvement within the department, including attendance at the Anaesthetic Staff Committee meeting which provides valuable insight into the inner workings of the department at consultant level.

Future developmentsWe are planning to record the presentations made at the weekly CPD meeting and make them available via the hospital’s intranet, so the resources are available to trainees who have been unable to attend teaching and to consultants as an aid to revalidation.

The TEL role has proved to be rewarding and challenging. Reviewing the feedback from each teaching session and conveying it back to the individual speakers is a particular highlight, especially when positive. As the role continues to develop and expand, we are confident that the rewards for the department and trainee will continue to expand.

Dr Rachel Moore and Dr Katy MillerSpecialty Registrars, Queen Elizabeth Hospital, Birmingham

Reference1. Plunkett E, Cullis K, Clift K. Trainee service lead: management

experience for trainees in the Birmingham School of Anaesthesia Anaesthesia News 2013; 309: 11–12.

Senior anaesthetic trainees often strive to enhance their CVs by complementing clinical work with managerial and educational experiences. One excellent opportunity in our department is the role of trainee educational lead (TEL). It is open by competitive application to post-fellowship trainees and is undertaken for six months. Our department has the well-established position of trainee service lead (TSL) and the TEL is complementary to this role. The TSL is a managerial position focused on assisting with running the department and provides a vital link between trainees and consultants, management and administrative teams.1 Alongside this, the TEL is predominately focused around the formalised departmental teaching programmes.

Now entering its third year, the TEL role has adapted and changed with each new incumbent. Its uniting aim has been to provide training, educational and managerial opportunities for the post holder and to facilitate the smooth running of teaching programmes.



SAFETY MATTERS Denture glue

We would like to report an incident involving a patient with a full set of dentures undergoing elective surgery. Induction of anaesthesia, surgery and extubation were uneventful. We then encountered a rather peculiar scenario in the recovery unit when we found a gum-like structure inside the patient’s face-mask. It was pink in colour, found near to the patient's lips on the inner side of the face-mask, minty in odour, of gum-like consistency, about 1–2 cm in size and was not human tissue! We thought it was chewing gum. The patient denied using chewing gum in the pre-operative period. However, after she fully recovered and was able to comprehend and communicate, it became apparent that this was the glue she used to fix her upper dentures. She removed these in the anaesthetic room, so as to stay edentulous for the minimum possible time. The glue includes calcium/ sodium PVM/MA copolymer, petrolatum, cellulose gum, paraffinum liquidum, and aroma, CI45430. The glue is a paste and is available in most supermarkets and pharmacies. We suggest patients are encouraged to remove any remaining glue after removing their dentures.

S Jose ST6 Anaesthetics

S Mitra Consultant Anaesthetist

Ysbyty Gwynedd, Betsi Cadwaladr University Health Board

The Yellow Card Scheme 50th Anniversary Strategic Forum

I represented the AAGBI at this forum in November at which the objective was to develop a ‘roadmap’ for the good old Yellow Card Scheme. Four themes were considered, each having three invited speakers followed by round table discussions. We were also addressed by George Freeman MP, the Parliamentary Undersecretary of State for Life Sciences. Before entering parliament, Mr Freeman was a biomedical venture capitalist. It was unthinkable, he said, that a doctor would fail to report his or her suspicion of an adverse drug reaction (ADR).

Theme 1: embedding reporting in the system

This was essentially a debate about the carrot/stick approaches that could be taken. Some lay delegates were enthusiastic about mandatory or required reporting, but I think the many arguments in favour of carrots won the day. The UK, we were told, has a very good response rate for ADR reporting, and we must not risk alienating the good guys and gals.

Theme 2: Yellow Card reporting and professional education

Among the tricks that emerged for improving the response rate, the ones that impressed me were:

• departments, trusts and national organisations to promote ‘good vigilance’ practice, within which the rate of ADR reporting is a measure of quality of care;

• Yellow Card champions within organisations to promote reporting;

• inclusion of ADR reporting in education programs and academic curricula;

• ‘Yellow Card of the Month’ presentations;

• a prize for a report that leads to the acceptance of a novel ADR;

• a call for more clinical pharmacologists; it seems there is only one clinical pharmacologist for every million people in the UK.

Theme 3: making the best use of Yellow Card data

This debate drew cautions about the danger of swamping the system if every professional reported every suspicion of an ADR. Nonetheless, there was a desire to reward reporters with encouraging feedback. It was acknowledged that there might have to be ‘Watch Lists’ of suspected drugs to encourage extra vigilance amongst prescribers.

Theme 4: effective engagement with patients

This highlighted an initiative launched this year to harness the power of social media. Called WEB-RADR it is hoped that it will detect signals of drug harm from the pages of Twitter and Facebook.

My personal reflective pearls were that this could be a worthwhile initiative in anaesthesia, critical care and pain medicine. Might we have discovered the problems with starches earlier if we routinely reported acute renal dysfunction after surgery? And, is hyperchloraemic renal injury more than a suspicion? I recall a case report of renal failure after gelatin infusion back in 1989,1 which had little impact. Would we be more receptive now?

Tom Woodcock Chair, AAGBI Safety Committee

Reference

1. Hussain SF, Drew PJT. Acute renal failure after infusion of gelatins. BMJ 1989; 299: 1187–8.

Figure 1. Substance found inside face-mask in recovery

Similar ampoules

We would like to highlight another potential risk of administering the wrong drug due to visually similar ampoules. Our hospital had 0.25% levobupivacaine ampoules supplied by Abbott (Maidenhead, UK) and 0.9% normal saline ampoules supplied by Fresenius Kabi Ltd (Runcorn, UK). Both these ampoules come in 10 ml volumes with a white and green label (Figure 1). Although there is a slight difference in size, this can only be appreciated if the ampoules are side-by-side. A lack of attention, especially during an emergency situation, could lead to a fatal error or unsatisfactory patient care with levobupivacaine mistaken for normal saline and injected intravenously resulting in local anaesthetic toxicity. These vials have now been withdrawn. We suggest a standard colour coding for all drugs across all pharmaceutical manufacturers to reduce this potential patient safety issue.

V Salota ST6 Anaesthetics

N Seth Consultant Anaesthetist

Evelina Children’s Hospital, London

Giving set failure

We wish to highlight two isolated failures of an Alaris® giving set (CareFusion UK, Basingstoke, UK) attached to a 50 ml BD Plastipak Luer-lokTM syringe (Becton Dickinson and Co Ltd, Ireland) used to administer propofol infusions within our intensive care department. During the administration of propofol to two separate patients, it was noted that sedation was inadequate. On inspection of the medical equipment in use, it became apparent that the giving sets were leaking propofol resulting in failure of drug administration to these patients. After administering propofol boluses and setting up new propofol infusions, the syringes and giving sets were examined and the ports of the giving sets were discovered to have split (Figure 1) without excessive force being applied during their assembly. Thanks to attentive nursing staff, this issue was quickly recognised. All staff on the unit were subsequently informed of this risk during daily departmental safety briefs. We wish to raise awareness of this problem and the need for caution when assembling these devices. We have reported the problem to the Medicine and Healthcare products Regulatory Agency.

Electrical interference

We write to report a problem we encountered with an enFlow™ fluid warmer (GE Healthcare, Chalfont St Giles, UK) causing interference with pulse oximetry monitoring.

Soon after the introduction of enFlow devices to our operating theatres we noticed an abnormal pulse oximetry pattern in one particular theatre. There was an artefact of the oximetry waveform, which resulted in an oximetry deduced pulse rate of over three times that measured from the ECG and arterial blood pressure measurements (Figure 1). Upon switching off the enFlow device, the oximetry waveform and associated pulse rate returned to normal. We note a previous report of enFlow warmers causing electrical interference in electrocardiography and neurological evoked potential monitoring, which was resolved by the manufacturers.1 On assessing the devices at our hospital, the manufacturers were unable to reproduce the artefact with use of this specific device, nor in any of our other enFlow warmers. However, the problematic device was withdrawn and replaced and there has been no recurrence of the issue.

S Tomlinson Consultant Anaesthetist

Salford Royal NHS Foundation Trust

Reference

1. Saliba DL, Reynolds JE, Winston-Salem NC. Fluid warmers interfere with ECG. http://www.apsf.org/newsletters/html/2009/spring/06_dearsirs.htm (accessed 18/10/2014).

L Darwin ST6 Anaesthesia

North Western Deanery

M Bell ST3 Anaesthesia

University Hospital Bristol, Bristol, UK

Figure 1. Levobupivacaine and 0.9 saline ampoules

Figure 1. Split propofol giving set attached to syringeFigure 1. Artefact seen on pulse oximetry waveform

LJ Webber Foundation Year 2 Doctor


your LettersSEND YOUR LETTERS TO:

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

Dear EditorThe powers of a super-hat (a theatre hat, that is...)

I am amazed at how many brilliant days I have had at work recently. It is all because of my theatre hat. Since 2003 I have bought funky theatre hats and now own about 15. I have bought them and given them away as part of a ’welcome to the rest of your career‘ pack for novices or as ’good bye/ good luck‘ message for overseas colleagues. But, I will state that none compare with my last hat. It is a ‘girl power superhero hat’. Patients and relatives talk to me about my hat and surgeons who I’ve never worked with before comment about Wonder Woman working alongside them. My colleagues ask me where I got it. Complete strangers stop me in the hospital corridors to tell me what a great hat I have. In the coffee room, a maxillo-facial surgery consultant sang to me what was once the Wonder Woman theme...and, last Sunday, a patient asked me to marry him. Super-hat powers are definitely rubbing off on me. Epidurals glide in and work! Are you looking for the best labour experience you have ever had? I deliver! Literally. As a proud father with one newborn baby in his arms pointed out yesterday.

You might ask if there is anything bigger than my theatre hat? Think about the combined powers of a super-hat and an iPad, Minion Rush App included, for paediatric induction...who needs play therapists? I am a one woman show; complete with GCP training and Despicable Me tokens.

Thank you eBay for my girl power superhero hat. Thank you enlightened hospital managers for allowing me to wear it. I am breaking down communication barriers like never before. Emergency lists run smoothly when Wonder Woman is around. ODPs amazingly find any piece of equipment I need. Theatre coordinators sing my praises. They even gave me a cape made from a biohazard refuse sack to match my outfit. All superheroes have a cape. There is nothing like the confidence my hat instills in my patients. They actually believe Wonder Woman is present.

With all that in mind I am off to bake a cake for the Macmillan World’s Biggest Coffee Morning - Wonder Woman style. Yep, you’ve probably guessed by now: I am an anaesthetist and love every minute of it!

Monica Morosan Post-CCT trainee Anaesthesia, Norwich

Dear EditorAn unusual airway dilemma

I would like to report a case of an interesting airway dilemma, should anyone else find himself or herself with a similar case. A 9-year-old patient presented for general anaesthesia with the lid of a sport drink bottle stuck firmly to the tip of her tongue. It had been there for 8 hours. Multiple attempts at conservative management and removal had failed. The bottle lid prevented pre-oxygenation and bag-valve-mask ventilation. We pre-oxygenated the child via a nasal mask followed by an intravenous induction with propofol. It was possible to site a size 2.5 flexible LMA by pulling the lid and tongue out of the way (Figure 1). Anaesthesia was maintained with oxygen, nitrous oxide and sevoflurane along with fentanyl boluses. The surgical team used a dental drill to cut through the plastic and remove the bottle top.

Our plans B, C & D involved blind nasal intubation, oral fibreoptic intubation and emergency surgical cricothyroidotomy. We are immensely grateful that plan A worked!

S Dunlop ST7 Anaesthesia, Northampton General Hospital

Figure 1. Sport drink bottle lid attached to a child’s tongue

Dear EditorI sympathise with my colleague who described their drug error1 because I've been there too. And, as they found out afterwards, most anesthetists become members of the 'drug error gang' sooner or later. I'd like to add two things to their account. Firstly, make the incident an item in the Morbidity and Mortality section of an audit meeting as a formal opportunity to analyse and describe the incident, to receive the sympathetic criticism of your peers who will then be informed of what went wrong, and to ensure that department policies are changed, if possible, to prevent a recurrence. Before then, as my colleague said, it is essential to tell the patient what happened. Not only is it the 'right' thing to do, mandated by the GMC, but also it is properly humbling. When I made my drug error, different but just as potentially lethal, and with just as a happy a result, I admitted it to the patient and they thanked me, saying I had saved their life! The opposite was so nearly true and I could only thank them for their forgiveness and leave, feeling about two feet high.

Dr John Davies

Retired consultant anaesthetist, Lancaster

Reference1. Reflections on a drug error. Anaesthesia News 2014; 329: 25.

Figure 1. Me and my hat!

DATES FOR YOUR DIARY

Delegates can register for one

or both days

Check availability and book online todaywww.aagbi.org/education

All meetings & seminars are held at 21 Portland Place, London unless otherwise stated.

All AAGBI seminars are priced as listed below unless otherwise stated

£133 - AAGBI members£88 - AAGBI trainee members

£66.50 - Retired members£260 - Non-members

Trainees

FEBRUARY 2015Ultrasound in anaesthesiaTuesday 03 February 2015Organiser: Dr Andrew McEwen, Torquay

Joint AAGBI & RCoA meeting: Becoming a consultantWednesday 04 February 2015Organisers: Dr Matthew Checketts, Dundee & Dr Sumit Gulati, Liverpool

End of life & intensive careThursday 12 February 2015Organisers: Drs Piotr Szawarski & Tiina Tamm, Slough

Hip fracture careThursday 26 February 2015Organiser: Dr Richard Griffiths, Peterborough

Scottish Standing Committee open meetingFriday 27 February 2015 Location: Discovery Point, Discovery Quay, Dundee, DD1 4XAOrganiser: Dr Jamie MacDonald, Aberdeen

MARCH 2015Annual update in thoracic anaesthesiaTuesday 03 March 2015Organiser: Prof Fang Gao & Dr Joyce Yeung, Birmingham

2 day airway updateWednesday 04 & Thursday 05 March 2015Organisers: Drs Vassilis Athanassoglou & Mridula Rai, Oxford & Dr Rehana Iqbal, London

Perioperative complications in anaesthesia – Prevention & cureMonday 09 March 2015 Organisers: Dr Jane Sturgess, Cambridge & Dr Kamen Valchanov, Papworth

Fibreoptic & ultrasound workshopsTuesday 10 March 2015Organisers: Dr Kim Chishti, Taunton & Dr Sudheer Medakkar, Torquay

Orthopaedic anaesthesiaWednesday 11 March 2015Organiser: Dr Jan Cernovsky, Stanmore

Special fees apply

Trainees

Trainees

AAGBI with coaching & mentoring consultants - 4 day mentoring courseDates: 16-17 March, 16 April & 13 May 2015 Organiser: Dr Nancy Redfern, Newcastle upon Tyne

Obstetric anaesthesia – For the advanced traineeThursday 19 March 2015Organiser: Dr Lynn Fenner, Bath

GAT: Consultant interview Wednesday 25 March 2015 Organiser: Dr Lyndsey Forbes, Dundee

2 day ENT in anaesthesiaMonday 30 & Tuesday 31 March 2015 Organisers: Dr Ramana Alladi, Ashton-under-Lyne & Drs Catriona Ferguson & Anil Patel, London

APRIL 2015Ultrasound in obstetric anaesthesia - An introductory workshop on spinal ultrasound and focused transthoracic echocardiographyTuesday 14 April 2015Organisers: Drs Nhathien Nguyen-Lu & Mubeen Khan, London

JUNE 2015Ultrasound guided spinal & paraspinal blocks for anaesthetistsTuesday 02 June 2015Organiser: Dr David Pappin, Torbay

Anaesthetists and the LawWednesday 03 June 2015Organiser: Dr Steve Yentis, London

Delegates can register for one

or both days

AAGBI_Feb_ANews_Ad.indd 1 18/12/2014 09:33


February 2015

Digested

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

I can’t remember the last time I used a pulmonary artery catheter (PAC): associated complications mean their routine use has rather fallen out of favour – which is a pity, because I used to find them accurate and reliable in determining patients’ responses to haemodynamic interventions in the intensive care unit. Indeed PACs remain the ‘gold standard’ for measuring changes in stroke volume and cardiac output. This study sought to compare stroke volume measurement using PAC thermodilution with an algorithm-derived 4D estimation of left ventricular stroke volume using 3D transoesophageal echocardiography (TOE) in 40 elective cardiac surgery patients without valvular heart disease or heart rhythm abnormalities.

Single experienced investigators measured either PAC or 3D stroke volumes in the same patient, blinded to the results of the other. When the patients were cardiovascularly stable before cardiopulmonary bypass, a range of parameters (MAP, HR, PAP, CVP, SV, SVR) were measured before and 2 minutes after administration of either 100μg phenylephrine or 5mg ephedrine; investigators were blinded about which drug had been given. Researchers collected 213 paired data points, 161 after

phenylephrine and 52 after ephedrine administration. The researchers found that echocardiography reliably measured the same stroke volume as that measured using PAC, undermeasuring by a mean of only ~1.2mls, and with a percentage error between readings of considerably less than 30%. However, they found that values for the change in the stroke volume after either phenylephrine or ephedrine administration did not agree to a clinically acceptable degree; concordance rate (PAC and 3D-measured changes either both positive or both negative) was 75% and 84% respectively, short of the > 92% acceptable rate.

These results indicate that 3D TOE may have potential as an alternative to PAC, at least in anaesthetised patients. It reliably measures stroke volume accurately, and may yet have a role in monitoring dynamic, trending responses to other interventions (fluid challenges and vasopressor infusions, for example), although perhaps only after further refinement of both the software algorithm, with re-analysis, and the TOE’s ease of operator use, the researchers having commented that TOE stroke volume measurement was ‘more complicated and time consuming than…using the pulmonary artery catheter’.

This must have been an interesting study both for the researchers to conduct and for the eight volunteer anaesthetists to participate in: physiology in action! By simultaneously attaching or inserting four minimally invasive cardiac output monitors (FloTrac, LiDCOrapid, USCOM and CardioQ oesophageal Doppler), each zeroed and monitored by an experienced anaesthetist blinded to the other monitors and degree of blood loss, researchers were able to assess how accurate each monitor was at detecting incremental 2.5% blood volume venesection losses in the awake, euvolaemic volunteers. Two readings were taken every five minutes, one before and one after a passive leg raise manoeuvre, and venesection occurred at random time points. Up to 20% estimated blood volume (a mean of ~ 1L) was venesected from each volunteer, then re-infused slowly while the volunteers were still being monitored.

As expected, increasing blood loss was compensated for homeostatically: heart rate increased (mean 71 bpm to 77 bpm after 17.5% loss), systolic blood pressure decreased (mean 144 to 154 mmHg after 2.5%, remaining similar subsequently) and passive leg raising to 300 increased stroke volume (only after 20% loss), but did not result in absolute values that

would normally have alerted an anaesthetist to ongoing blood loss. In contrast, the first significant change from baseline stroke volume was detected after 2.5% blood volume loss using the LiDCO, 7.5% using the USCOM and 12.5% with the CardioQ and FloTrac. Interestingly, significant stroke volume recovery was detected in the reverse order, after 10% reinfusion using the CardioQ and FloTrac, and after 15% and 20% using the LiDCO and USCOM respectively.

Although this was only a small proof of concept study, the authors were able to conclude that all four monitors were better at detecting moderate blood loss (>10%) than was possible using standard intra-arterial blood pressure monitoring, at least in young, healthy awake volunteers, and that the detection of fluid loss might be a more ideal role than their use in stroke volume optimisation. However, the authors note that ‘the utility of the devices may vary according to the clinical setting’, as the nasal CardioQ was poorly tolerated, and only successfully placed in six of the awake volunteers. The authors suggest that larger studies using this methodology will allow for more accurate calculation of a single ‘chance of blood loss’ score.

S. M. White Editor, Anaesthesia

The utility of intra-operative three-dimensional transoesophageal echocardiography for dynamic measurement of stroke volumeSuehiro K, Tanaka K, Yamada T, et al.

Evaluation of the utility of the Vigileo FloTracTM, LiDCOTM, USCOM and CardioQ to detect hypovolaemia in conscious volunteers: a proof of concept studyO’Loughlin E, Ward M, Crossley A, Hughes R, Bremner AP, Corcoran T.

Aberdeen Exhibition & Conference Centre

ANNUAL SCIENTIFIC MEETING

14th-15th May 2015

Association of Paediatric Anaesthetists of Great Britain & Ireland and the Society for Pediatric Anesthesia

Half day meeting on CongenitalCardiac Anaesthesia

13th May 2015

Plus

Jointly presented by the Congenital Cardiac Anaesthesia Network and Congenital Cardiac Anesthesia Society

Joint meeting with Society for Pediatric Anesthesia, providing an opportunity to compare and contrast practice on both sides of the Atlantic

www.apagbi2015.co.uk

Programme Highlights:

Parallel specialist and general streams

Workshops on human factors and surgical skills plus a special one on Highland hospitality!

Annual Dinner at the Beach Ballroom

APA_Advert_ANews.indd 1 10/12/2014 11:34

Early bird rate available

Par

ticl

es

Anaesthesia News February 2015 • Issue 331 29 28 Anaesthesia News February 2015 • Issue 331

GS Murphy, JW Szokol, MJ Avram, SB Greenberg et al.

Effect of ventilation on cerebral oxygenation in patients undergoing surgery in the beach chair position: a randomized controlled trial. British Journal of Anaesthesia 2014; 113: 618–27

BackgroundIt is common for anaesthesia in the ‘beach chair’ position (BCP) to result in systemic hypotension,1 reduced cerebral blood flow and oxygenation. Hypocarbia is also known to decrease cerebral blood flow.2 This study was conducted to test the hypothesis that ventilating to end tidal carbon dioxide (E’CO2) values of 40–42 mmHg would result in increased cerebral tissue oxygen saturation (SctO2) compared to ventilating to values of 30–32 mmHg (standard practice in the investigating institution).

MethodsThis was a randomised controlled trial involving 70 ASA I-III patients undergoing elective shoulder arthroscopy. Patients with pre-existing cardiorespiratory conditions were excluded. All patients were operated on by the same surgeon with no regional anaesthesia used. Anaesthetic technique was standardised and patients in both groups were ventilated initially with a tidal volume of 8cc kg-1. Respiratory rate was varied to produce the required changed in E’CO2. Cerebral oxygenation was monitored continuously intra-operatively using a non-invasive continuous wave, spatially resolved cerebral oximeter. Baseline data for each patient was collected pre- and post-induction before BCP. Number and duration of Cerebral Desaturation Events (CDEs – a drop in SctO2 of ≥20%) were recorded.

ResultsData were collected on all 70 subjects. A standardised anaesthetic technique was used and most patients stayed within the E’CO2 goals established throughout the operative period. Baseline Sct02 did not differ between the control and study groups. SctO2 values in the study (40–42 mmHg) group did not decrease over time, however measurements in the control (30–32 mmHg) group were lower than baseline values from 10–60 minutes post-induction. SctO2 was significantly lower in the control group than the study group from 16 minutes to 60 minutes post-induction (p <0.01). The incidence of CDEs was higher in the control group (55.5%) than the study group (8.8% p <0.0001). The median number of CDEs was also greater in the control group. Across both groups, 134 of the 198 CDEs (67.7%) were recorded during hypotensive episodes. The median number of CDEs occurring during hypotension were significantly higher in the control group (p <0.0003). Despite this, there were no long term measured neurophysiological consequences of CDEs in either group.

DiscussionThis study supports the hypothesis that cerebral oxygenation is better maintained during BCP shoulder surgery when patients are ventilated to an E’CO2 of 40–42 mmHg compared to the lower E’CO2 in the control group. Given that the majority of the CDEs occurred when MAP was ≥20% lower than baseline, hypotension should be avoided particularly in the setting of hyperventilation. Use of the lateral decubitus position or regional techniques may be useful alternatives to BCP.

Jenny BainST5 Anaesthesia, Royal Infirmary, Edinburgh, South East Scotland Deanery

References1. Pohl A, Cullen DJ. Cerebral ischaemia during shoulder surgery in the

upright position: a case series. Journal of Clinical Anaesthesia 2005; 17: 463-9.

2. Meng L, Mantulin WW, Alexander BS, et al. Head up tilt and hyperventilation produce similar changes in cerebral oxygenation and blood volume: an observational comparison study using frequency-domain near-infrared spectroscopy. Canadian Journal of Anaesthesia 2012; 59: 357–65.

Murphy G S, Szokol J W, Avram M J, et al

The effect of single low-dose dexamethasone on blood glucose concentrations in the perioperative period: a randomized, placebo-controlled investigation in gynecologic surgical patientsAnesthesia and Analgesia 2014; 118: 1204–12

BackgroundThe use of low-dose dexamethasone in the peri-operative period as a prophylactic anti-emetic is well established. The administration of a single low dose corticosteroid at induction may however precipitate intra-operative and postoperative hyperglycaemia. Previous small studies have shown an increase in blood glucose concentrations following administration of dexamethasone in the peri-operative period, but these studies were limited by small cohort size and absence of control group. This single centre randomised controlled trial aimed to investigate whether two standard doses of dexamethasone (4mg or 8mg) produced a higher risk of early or late peri-operative hyperglycaemia compared to placebo.

MethodsTwo hundred female inpatients undergoing elective hysterectomies under general anaesthesia were randomly allocated to one of six groups (3 early and 3 late). Exclusion criteria included pre-operative use of steroids or anti-emetics, pre-op diagnosis of type I or II diabetes or severe renal or liver disease. In the early group, 100 patients were allocated to receive saline, 4mg dexamethasone or 8mg dexamethasone at induction, and had capillary blood glucose measurements taken at induction (baseline), 1, 2, 3 and 4 hours post-induction. The 100 patients in the late group were allocated to receive saline, 4mg dexamethasone or 8mg dexamethasone at induction, and subsequently had capillary blood glucose measurements taken at induction, 8 and 24 hours following baseline. Peri-operative glucose concentrations were the primary outcome variables in this investigation, with the incidence of hyperglycaemic episodes (blood glucose concentration >180mg/dl) during the study period a secondary outcome.

ResultsData was collected from 195 of the 200 enrolled patients. There were no significant differences between the baseline demographic characteristics, and the anaesthesia time and intra-operative drugs used did not differ between groups. Although fewer patients in dexamethasone groups had nausea or vomiting, these differences did not reach statistical significance. A total of 777 blood glucose measurements were obtained in the early and late groups. Baseline blood glucose measurements did not differ between groups. Blood glucose concentrations increased significantly over time in all groups (from median baselines of 94 to 103mg/dl to maximum medians ranging from 141 to 161.5 mg/dl, all p <0.001). No differences in glucose concentrations were noted between the control and dexamethasone groups or between the dexamethasone groups at any measurement time.

DiscussionThe effect of single-dose dexamethasone treatment on glucose regulation in the surgical patient has been inadequately studied. Investigation has been complicated by the physiological stress response to surgery which results in the release of glucagon, epinephrine and cortisol, leading to increases in hepatic gluconeogenesis and glycogenolysis.1,2 This randomised placebo-controlled trial demonstrated that peri-operative blood glucose concentrations during the first 24 hours after administration of single low-dose dexamethasone did not differ from those observed after saline administration.

Dr Jennifer IrvineST7 Anaesthesia, South East Scotland Deanery

References1. Lipshutz AK, Gropper MA. Perioperative glycemic control: an evidence-

based review. Anesthesiology 2009; 110: 408-212. Akhtar S, Barash PG, Inzucchi SE. Scientific principles and clinical

implications of perioperative glucose regulation and control. Anesthesia and Analgesia 2010; 110: 478-97

de Montblanc J, Ruscio L, Mazoit JX et al.

A systematic review and meta-analysis of the i-gel® vs laryngeal mask airway in adultsAnaesthesia 2014; 69: 1151-62

IntroductionThe laryngeal mask airway (LMA) was first developed in 1982 to aid airway management in the spontaneously breathing patient and prevents the need for intubation. The i-gel® is composed of a solid thermoplastic elastomer rather than a cuff and moulds to fit the supra-glottic area and thus requires no inflation. It also has a lumen for gastric decompression.

This systematic review aimed to assess the clinical effectiveness of the i-gel versus the LMA.

MethodsSeveral sources were used including MEDLINE, Embase and internet search engines for all randomised control trials (RCT) in humans to May 2013. Trials were studied for eligibility and bias by the authors. Outcomes studied were: leak pressures, time for insertion, rate of successful insertion first time, incidence of sore throat and laryngeal view with fibreoptic scope.

ResultsThirty-one RCTs were selected, all of which were assessing elective cases. There was no variation in leak pressures between the i-gel and the LMA however a subgroup analysis did find lower leak pressures in first generation LMAs versus the i-gel. The i-gel was found to reduce average time for insertion by 1.46 seconds (95% CI 0.33–2.60) compared with the LMA. When analysing the rate of successful insertion at first attempt of the i-gel versus the LMA, no difference was found. The frequency of sore throat in recovery was reduced when an i-gel was used rather than a LMA (relative risk 0.59 [0.38–0.90]). The incidence of obtaining a poor laryngeal view using a fibreoptic scope (defined according to three classifications) using the i-gel was found to be less than with a LMA (RR 0.29 [0.16–0.54]).

DiscussionThis paper has found that the i-gel reduces insertion time, frequency of post-op throat pain and difficulty in obtaining a laryngeal view using a fibrescope when compared with the LMA. Leak pressure and rate of successful insertion at first attempt was not found to be affected. The rate of sore throat being less with an i-gel may indicate the LMA cuff pressure being a factor. Limitations of the analysis included the finding of significant heterogeneity of the studies which was not reduced by subgroup analysis. Also, most studies were single-centre with a limited number of cases, however 31 studies were found with >1000 cases in each arm for the majority of results.

ConclusionThis meta-analysis is the most recent evidence of use of an i-gel versus a LMA; it finds the i-gel to be superior to the LMA in various outcomes.

Sarah StobbsST5, South East Scotland Deanery

Learn@AAGBI Reflect on educational videos from AAGBI events with Learn@AAGBI

Step-by-step guide on how to reflect using the site:Step 1. Go to www.aagbi.org/education

Step 2. Click on the ‘Learn@AAGBI’ box

Step 3. Log in note: you will need your AAGBI membership number and password

Step 4. From the search page select your required option

Step 5. From the list select the video that you wish to reflect on

Step 6. After watching the whole video, open the reflective learning form and complete it

Step 7. If you are happy with what you have written, click on ‘Submit form’, or if you would like to add more later on, click ‘save draft’. This will upload into the ‘My CPD Area’ as either ‘draft’ or a completed ‘Submitted Reflective Note’.

Go to www.aagbi.org/education and use Learn@AAGBI for your reflections at our meetings, and for your ongoing CPD and exam preparation.

The template is easy to use allowing you to reflect on the conference as a whole or on individual lectures.

AC Learn Back 2015.indd 1 15/12/2014 11:06AC Learn Back.indd 1 15/12/2014 11:09

AAGBIGUIDELINES APP

DOWNLOAD THE APP TODAY FOR APPLE AND ANDROID DEVICES

TOPICS INCLUDE:Anaesthetists in training

Clinical anaesthesia

Clinical measurement/equipment

Contractual/job planning

Elderly anaesthesia

Ethics and law

Haematology

Human factors

Independent practice

Irish anaesthetists

Obstetric anaesthesia

Resuscitation and trauma

SAS anaesthesia

Wellbeing

FREE

FOR AAGBI

MEMBERS

www.aagbi.org/guidelines-app

First update in early March

2015: 6 new guidelines

Updates to existing content

Checklist for anaesthetic equipment

Reflective learning tool

New award for excellence in sustainability

Developing a green anaesthesia agendaThe AAGBI recognises that our actions have an impact on the environment and regards global warming and climate change as pressing issues. In 2013 the Environmental Task Group of the AAGBI was formed to develop the idea of sustainable practice and to promote greener anaesthesia. The Task Group and the Association have linked with Barema, the Association for Anaesthetic and Respiratory Device Suppliers, representing companies that manufacture or supply anaesthetic and respiratory equipment in or to the UK, to establish the Barema & AAGBI Environment Award. This will recognise excellence in sustainability within the speciality and engage with industry partners to further develop a greener anaesthesia agenda.

Applicants will have to demonstrate how their activity, project, campaign or other work (including original research), related to anaesthesia, intensive care or pain management, has had (and will continue to have) a measurable beneficial effect on the environment.

The award will be for the single best initiative or project and will consist of £200 to the individual(s) or body(ies) concerned, in addition to a grant of £800 for support and development of the initiative or project.

The deadline for applications is 30 April 2015 with the winners being announced at Annual Congress in Edinburgh in September.

Apply for the NEW Barema & AAGBI Environment Award!

To find out more about the award and the application process visit

www.aagbi.org/about-us/environment or email [email protected]

ANews_Enviro_Ad.indd 1 21/11/2014 09:20

Supporting trainees returning to practice following a prolonged ...

Documents