1. science
2. medicine
3. surgery

ANAESTHESIA
The Newsletter
of the
Association
of Anaesthetists
of Great Britain
and Ireland
NEWS
ISSN 0959-2962
No. 328
NOVEMBER 2014
INSIDE
THIS ISSUE:
Social media
networks as
a learning
platform – the
anaesthesia
trainees’
perspective
What's new in
regional anaesthesia?
Still bleeding after
all these years
X-Porte – The World’s
First Ultrasound Kiosk
Editorial Contents
Social22
1
22/09/2014
15:43
03Editorial
04 What's new in regional anaesthesia?
04
08 Social media networks as
a learning platform – the
anaesthesia trainees’ perspective
One look and the difference is clear:
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07 Museum, Library and Archives Committee Report
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The production schedule for Anaesthesia News requires us to write
these introductions six weeks or so before publication. So I am writing
this from Annual Congress in Harrogate. And what a Congress it is
proving to be! Over 800 delegates, a fantastic ‘buzz’, lots of great
talks, workshops, poster and abstract presentations and our keynote
lectures. In addition, over 30 (hard core) cyclists have raised money
for charity by riding here from Bristol and London and receiving
pledges of over £13,000 for two charities (Lifebox and CTC). If, like
me, you are humbled by their fantastic efforts please consider giving
– it’s not too late: http://www.aagbi.org/about-us/aagbi-fundraising/
cycle-for-guy/chosen-charities
For many members, the AAGBI meetings are the jewels in the crown
of our activities. Even before Annual Congress started the scientific
programme for WSM London in January was published. A particular
delight at recent meetings has been the increase in the number of
abstract submissions; many are from trainees and some are from
medical students. As an aside can I remind members that the AAGBI
offers medical students funding for undergraduate electives that
exposes them to anaesthesia or intensive care. The next round is
now open and the closing date for applications is 5 January 2015,
so please let any students passing through your department know.
We are particularly keen to support those who wish to travel to the
developing world. Visit http://www.aagbi.org/undergraduate-awards
for further details.
This month’s Anaesthesia News contains two articles on social
media and one on the value of sending trainees to the developing
world. We publish many articles on the developing world and this
one is particularly interesting as it reports just how beneficial such
programmes can be to both parties.
Finally, Nigel Bedforth and colleagues have written about the future
for regional anaesthesia. Of course, it is not just enthusiasts who
undertake blocks. However, those developing new ideas, techniques,
equipment and drugs continue to advance this area. We thought
such an update and future gazing would help to set the scene for the
rest of us.
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.
Our Association continues to grow with an ever-increasing range of
activities and services for its members. See you in London in January?
08
10 News from the European
Society of Anaesthesiology
11 Cadaveric training courses: a realistic environment to learn anaesthetic technical skills?
13 Ultrasound technology
11
15 Still bleeding after all these years…
17 Anaesthetic training in underdeveloped countries: what is the role of junior trainees?
15
19 Social media in anaesthesia - uniting the trainees
24 Your Letters
27 Anaesthesia Digested
28 Particles
17
The Association of Anaesthetists of Great Britain and Ireland
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Anaesthesia News
Chair Editorial Board: Nancy Redfern
Editors: Phil Bewley and Sally El-Ghazali (GAT), Nancy Redfern,
Richard Griffiths, Sean Tighe, Tom Woodcock, Mike Nathanson, Rachel Collis,
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Copyright 2014 The Association of Anaesthetists of Great Britain and Ireland
Mike Nathanson
AAGBI Council Member
Anaesthesia News November 2014 • Issue 328
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3
What’s
in
regional anaesthesia?
In this article we discuss some recent developments in regional anaesthesia including
innovation in imaging technology, needle position detection and drug development.
New approaches
Strain and shear wave elastography
Ultrasound imaging has allowed regional anaesthetists to rely less
on traditional anatomical landmarks and develop new innovative
approaches to nerves. These include ‘body wall’ blocks such as the
transversus abdominis plane,1,2 sub-sartorial canal3 and thoracic
wall blocks.4 The development of some of these is ongoing and
their efficacy and place in clinical practice yet to be fully determined.
Ultrasound also allows targeting of small nerves and delivery of highly
accurate, low volume blocks, for example blocks around the ankle5
or shoulder.6 Ultrasound is now being used to develop motor sparing
sensory blockade around the knee; this may prove to be a useful
approach following knee surgery.7
The elasticity of a material describes its ability to return to its original
shape after being stretched. In the body, stiffer tissues will deform
less than softer tissues following application of a force. Ultrasound
can be used to image or measure tissue elasticity following
application of a force by, for example, pressure from the transducer
or following injection of a fluid. Local anaesthetic tissue displacement
is represented by colour changes on screen. Shear waves created
by ultrasound can be used to detect tissues with differing hardness,
and may provide extra information when differentiating nerves from
other tissues.14 Elastography in regional anaesthesia has not yet been
shown to have definite advantages over standard imaging in patients,
so we await further studies.
3D ultrasound scanning
Three-dimensional ultrasound imaging provides the user with a view
of a whole volume of interest rather than the standard narrow slice.
The image can be displayed as a whole volume rendered image
(rather like a hologram) or in a multiplanar view, where a series of
slices are displayed simultaneously (usually orthogonal - three
planes at right angles to each other). Ultrasound machines can
now provide 3D imaging in real time; also termed four-dimensional
imaging. Despite these developments, 4D imaging has not yet been
incorporated into common practice, with clinical experience limited
to a number of reports including the popliteal fossa,8 interscalene
catheter placement9 and radial nerve blockade.10 This is because
the machines are expensive, the probes unwieldy and the resulting
images are somewhat complex and difficult to interpret. The potential
advantages of 4D ultrasound imaging are improved visibility of
structures to reduce needle overshoot11 and improved visualisation of
local anaesthetic spread, catheter position and the needle tip to nerve
relationship. Time will tell if these potential advantages translate into
clinical practice.
Fusion scanning
This produces improved accuracy for ultrasound-guided biopsy
procedures and has the potential to facilitate certain regional
anaesthetic techniques. These would include deep techniques or
those where bony structures may impede ultrasound penetration
such as lumbar plexus and paravertebral blockade or interventional
pain procedures such as spinal injections and coeliac plexus blocks.
The two images have to be accurately aligned to avoid a target
registration error.
This can either be done using external markers (frames), fixed points
on the bony skeleton or using organ surfaces as markers or vascular
structures to align image volumes. The pre-procedural MRI or CT scan
and the ultrasound scan should be performed in the same position
and as close together in time as practical to minimise alignment
errors.15 Radiologists are increasingly using this technology to target
biopsies in major organs (for example breast, prostate and liver)
and for musculoskeletal injections such as the sacroiliac joint. There
is limited experience of this new technique in anaesthesia but the
potential to use the ever-increasing number of MRI and CT studies,
that many patients have, to aid in regional anaesthesia and pain
procedures is an exciting prospect.
Very high frequency scanning
Ultrasound transducers have now been developed which produce
ultrasound at frequencies up to 50 MHz. Frequencies this high
produce short wavelengths and images with a resolution capable
of discerning features as small as 40 µm (compared with standard
ultrasound which will discern features of approximately 200 µm). This
technology gives us the opportunity to obtain much higher detail in
our images, for example allowing us to visualise nerve architecture
in fine detail and produce better understanding and control of the
needle tip to nerve interaction (Figure 2). The challenge will be to
produce pictures with enough tissue penetration to be clinically
useful.
Magnetic resonance imaging and x-ray computed tomography (MRI
and CT) have excellent spatial resolution and soft tissue recognition
but are impractical for real-time needling due to the radiation,
magnetic field, equipment size and need for immobility of the subject.
Ultrasound is suitable for real time imaging, but is limited by the depth
of structures to image, the presence of bone and need for needle
angulation away from the probe. Fusion imaging uses pre-procedural
MRI or CT and fuses this into the same screen as the live ultrasound
images (Figure 1).
Encapsulating agents
One of the ultimate advances in regional anaesthesia would be the
development of a local anaesthetic agent with an ultra-long action.
This could be applied to target nerves in very low concentrations,
to achieve prolonged analgesia without motor blockade. This would
see an end to the requirement for either a large single-shot dose
of local anaesthetic or for postoperative perineural local anaesthetic
infusion. Encapsulating agents are biodegradable and can carry
local anaesthetics and slowly release them to produce a prolonged
period of action. Two such agents are liposomes and microspheres
constructed from hydrophobic substances such as polylactic and
polyglycolic acids. Liposomes seem to have the lowest toxicity
and a liposomal bound local anaesthetic preparation has gained
FDA approval, so we should now expect to see development of the
evidence base.16
Microsphere-coated mesh
Recently, mesh coated with polylactide co-glycolic acid microspheres
containing bupivacaine out-performed single-shot bupivacaine given
at the time of surgical insult in a rat model. This may prove to be
a useful way of delivering the slow release local anaesthetic to the
tissues.17
Needle technology
Recent needle developments include needle guidance systems.
One example is the Ultrasonix GPSTM guidance system (Ultrasonix
Medical Corporation, High Wycombe, UK). Sensors mounted in the
needle tip communicate positional information to sensors mounted
in the transducer. The needle position is superimposed on the
ultrasound image to provide the operator with improved information
regarding orientation of the needle to the transducer. Another such
system is the eGuide Freehand Navigation system (eZono AG, Jena,
Germany) that uses magnetism to detect the position of the needle
in relation to the transducer and plot the needle trajectory on-screen
(Figure 3). There is currently little proof of benefit of these systems in
regional anaesthesia,18 but they may have particular use in facilitating
training.
Robotics
Robotic technology is being used successfully in some surgical
specialties. A robotic system has recently been applied to regional
anaesthesia. Workers have successfully placed needles in phantoms
and, more recently, 13 patients underwent popliteal sciatic nerve
blocks.12,13 We await further investigation to show the advantages, if
any, over the standard technique. The astronomical price involved
means that the benefits of any robotic technique would have to be
substantial!
4
Figure 1
A fusion image of ultrasound and MRI scan at the level of iliac crest; the ultrasound
image is impaired due to overlying bony cover and depth, but by using the MRI
image, which provides excellent resolution of psoas muscle and lumbosacral
plexus, it should be possible, with needle guidance, to place the needle in the
appropriate site for a lumbar plexus block (figure courtesy of T Bentsen MD,
Aarhus, Denmark)
Anaesthesia News November 2014 • Issue 328
Figure 2
Figure 3
A high frequency scan of the median nerve at the wrist; note the increased
resolution of the nerve architecture; also note the limited depth of the picture
(picture taken following ethical approval with MS550D transducer with 55 MHz
peak and 40 MHz centre frequency, Vevo 2100 preclinical ultrasound system,
courtesy of Fujifilm VisualSonics, Sonosite Ltd, London, UK)
A needle guidance system during an out-of-plane needle approach to a target;
the green target box turns green as the needle tip enters the plane of the
ultrasound beam and becomes visible as a hyperechoic dot (figure courtesy of
eZono AG, Jena, Germany)
Anaesthesia News November 2014 • Issue 328
5
26th Anaesthesia, Critical Care
and Pain Update
Val d’Isere, 2-5 February 2015
Centre de Congrés
Multidisciplinary meeting
Lectures | Workshops
Joint and Satellite sessions
Short paper competition
Guest speakers
The introduction of ultrasound to regional anaesthesia has seen an
unprecedented surge in enthusiasm and delivery of these techniques.
Innovation still abounds, and these authors wait with some excitement
to see how the next generation of drugs, ultrasound equipment and
needles will improve regional anaesthesia delivery to the further
benefit of our patients.
N. Bedforth and K. Mohammed Rafi
Queen’s Medical Centre, Nottingham, UK
B. Nicholls
Musgrove Park Hospital, Taunton, UK
References
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6
Tran TMN, Ivanusic JJ, Hebbard P, Barrington MJ. Determination of spread of
injectate after ultrasound-guided transversus abdominis plane block: a cadaveric
study. British Journal of Anaesthesia 2009; 102: 123–7.
Heil JW, Ilfeld BM, Loland VJ, Sandhu NS, Mariano ER. Ultrasound-guided
transversus abdominis plane catheters and ambulatory perineural infusions for
outpatient inguinal hernia repair. Regional Anesthesia and Pain Medicine 2010;
35: 556–8.
Jenstrup MT, Jaeger P, Lund J, et al. Effects of Adductor-Canal-Blockade on
pain and ambulation after total knee arthroplasty: a randomized study. Acta Anaesthesiologica Scandinavica 2012; 56: 357–64.
Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: a novel
ultrasound-guided thoracic wall nerve block. Anaesthesia 2013; 68: 1107–13.
Redborg KE, Sites BD, Chinn CD, et al. Ultrasound improves the success rate of
a sural nerve block at the ankle. Regional Anesthesia and Pain Medicine 2009;
34: 24–8.
Maybin J, Townsley P, Bedforth N, Allan A. Ultrasound guided supraclavicular
nerve blockade: first technical description and the relevance for shoulder surgery
under regional anaesthesia. Anaesthesia 2011; 66: 1053–5.
Egeler C, Jayakumar A, Ford S. Motor-sparing knee block - description of a new
technique. Anaesthesia 2013; 68: 542–3.
Feinglass NG, Clendenen SR, Torp KD, Wang RD, Castello R, Greengrass RA.
Real-time three-dimensional ultrasound for continuous popliteal blockade: a
case report and image description. Anesthesia and Analgesia 2007; 105: 272–4.
Clendenen SR, Riutort KT, Feinglass NG, Greengrass RA, Brull SJ. Real-time
three-dimensional ultrasound for continuous interscalene brachial plexus
blockade. Journal of Anesthesia 2009; 23: 466–8.
Foxall GL, Hardman JG, Bedforth NM. Three-dimensional, multiplanar,
ultrasound-guided, radial nerve block. Regional Anesthesia and Pain Medicine
2007; 32: 516–21.
French JLH, Raine-Fenning NJ, Hardman JG, Bedforth NM. Pitfalls of ultrasound
guided vascular access: the use of three/four-dimensional ultrasound.
Anaesthesia 2008; 63: 806–13.
Morse J, Terrasini N, Wehbe M, et al. Comparison of success rates, learning
curves, and inter-subject performance variability of robot-assisted and manual
ultrasound-guided nerve block needle guidance in simulation. British Journal of
Anaesthesia 2014; 112: 1092-7.
Hemmerling TM, Taddei R, Wehbe M, Cyr S, Zaouter C, Morse J. Technical
communication: First robotic ultrasound-guided nerve blocks in humans using
the Magellan system. Anesthesia and Analgesia 2013; 116: 491–4.
Munirama S, McLeod G. Novel applications in ultrasound technology for regional
anesthesia. Current Anesthesiology Reports 2013; 3: 230–5.
Rasoulian A, Abolmaesumi P, Mousavi P. Feature-based multibody rigid
registration of CT and ultrasound images of lumbar spine. Medical Physics 2012;
39: 3154–66.
Weiniger CF, Golovanevski L, Domb AJ, Ickowicz D. Extended release
formulations for local anaesthetic agents. Anaesthesia 2012; 67: 906–16.
Ohri R, Wang JC-F, Pham L, et al. Prolonged amelioration of experimental
postoperative pain by bupivacaine released from microsphere-coated hernia
mesh. Regional Anesthesia and Pain Medicine 2014; 39: 97–107.
Brinkmann S, Vaghadia H, Sawka A, Tang R. Methodological considerations of
ultrasound-guided spinal anesthesia using the Ultrasonix GPS™ needle tracking
system. Canadian Journal of Anaesthesia 2013; 60: 407–8.
www.doctorsupdates.com
education in a perfect location
doctorsupdates
TM
Conclusions
Advanced Airways
Techniques
May 2015
This course has been running for many years
and continues to develop. It is aimed at
anaesthetists who wish to develop advanced
airways management knowledge, skills and
strategy planning to deal with a variety of
clinical scenarios.
Key features that make this course of high
education value includes tutor:delegate ratio of
mostly 1:1; experienced consultants as tutors;
use of cadavers, animal and manikin models; and
a mixture of hands-on practice and discussion
on case management.
No previous experience of advanced airways techniques is required.
Course Fee: £325
Full details and online registration available at
http://www.cuschieri.dundee.ac.uk/ Cuschieri Skills Centre – University of Dundee
Ninewells Hospital and Medical School, Dundee,
Tayside, DD1 9SY Scotland
Tel: +44(0)1382 383400 Fax: +44(0)1382 646042
Anaesthesia News November 2014 • Issue 328
Museum, Library
and Archives
Committee Report
The growth in visitors to the Heritage Centre continues. Visits by individuals
are up by 18% on the previous year and visits by groups are up by 260%.
The groups comprised three school/students groups, eight adult groups,
one adult group from overseas and one adult specialist group from industry
(Intersurgical). Three new volunteers were also welcomed into our existing
volunteer group: Mrs Hilary Riches (granddaughter of Charles King, founder
of the Heritage Centre), Hannah Brayford (medical student with an interest in
a career in anaesthesia) and Richard Birks (past president).
This year we have managed to secure ‘The Joseph
Clover manuscript’ which has attracted international
attention from Australia. Clover was an early
pioneer of anaesthesia; he designed equipment
to deliver anaesthetics, improved techniques and
pioneered monitoring during anaesthesia. Earlier
this year, a couple of members of the Heritage
Committee visited and inspected the graves
of John Snow and Joseph Clover in Brompton
Cemetery and can report that, apart from minor
works, the memorials are in good order. We have
also received some very nice donations of books
and equipment from Frenchay Hospital, Great
Ormond Street Hospital and from the executors of
Edith Gilchrist. The AAGBI is very grateful for these
objects and will take great care in preserving them
for future generations.
A very big challenge that we face over the next four
years is the launch and continuation of the World
War 1 exhibition. The conflict, which devastated
Europe for over 4 years, was arguably a pivotal
event in the development of the specialty of
clinical anaesthesia. Securing funding for the
World War 1 project and making it accessible to
non-AAGBI members will mark out the next four
years. We will increase our outreach to a nonspecialist audience via an education pack, specific
events and themes to the exhibitions, such as The
Somme, Boyle against Marshall and the treatment
of shock. We want to raise awareness of the
advances made in anaesthesia as a result of World
War 1 and to show that later conflicts have had the
same effect.
Over the next year we have various challenges
and priorities. There are IT challenges, as it is
important for us that we manage to transfer as
Anaesthesia News November 2014 • Issue 328
Anaesthesia News November 2014 • Issue 328
much of the audio and video archive to a digital
format. Completing an inventory of our objects
that are kept in a remote out-store and working
to make them available to people through social
media, temporary exhibitions and our website
will form an important part of our work. We will
continue to prepare our database, AdLib, for the
release of a new software package. This will involve
data cleaning, keeping in touch with the software
developers and being aware of how it is developing.
We’ll also be increasing our use of social media.
The series of World War 1 exhibitions will be
promoted and developed and we’ll be working
with an education consultant to explore ways of
working with schools, colleges and universities.
We will work to support the development of the
Anaesthesia Heritage Centre and will consider
the provision of more tablets to make the history
of anaesthesia more accessible and to make more
information available electronically.
We hope that the work of maintaining the heritage of
anaesthesia remains relevant to the core activities
of the AAGBI. We aim to support members and
educate the public about the rich history of our
specialty, promoting the knowledge and training
of anaesthetists and we will continue to make the
most of our collections within a limited space.
www.aagbi.org/education/heritage-centre
Dr Richard Griffiths
Chair of the Museum, Library and Archives
Committee
Trish Willis
Heritage and Records Manager
77 Social media networks as a learning platform
– the anaesthesia trainees’ perspective
Social22
Facebook is just a decade old yet social media
networks (SMN) have rapidly established
themselves as household names. Medical
institutions have also become involved. The
General Medical Council (GMC), the Royal
College of Anaesthetists (RCoA) and the
AAGBI boast Facebook and Twitter accounts.
Anaesthetists have always prided themselves
on being leaders in medical education. The
AAGBI1 and the RCoA2 have introduced
e-learning platforms which are very popular.
Other enthusiasts have taken this further using
SMN to provide an accessible and interactive
learning environment.3 It has been assumed
that SMN must be the way forward for medical
education, but this is without consulting
potential users. We explored the views of
anaesthesia trainees on using social media as
a learning platform, how much they use SMN
currently and what obstacles or concerns they
have which may prevent their engagement.
22/09/2014
15:43
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A questionnaire with two distinct aims was sent to all anaesthetic
registrars in the Northern School of Anaesthesia. First, we wished to
establish how prevalent social media use was among the registrars
and how they accessed their social media. Second, we wanted to
explore their thoughts regarding the use of social media as a learning
platform, what role it could play and to establish any concerns and
reservations.
A total of 25 responses were received (response rate 37%). This
number of respondents was considered adequate for the purposes
of a focus group. The overwhelming majority (92%) stated that they
regularly used social media and nearly all (96%) used a Facebook
account. The second most common network of choice was Twitter
(16%). Forty-six percent were signed up to a single social network,
33% were signed up to two, and 17% were signed up to more than
two. Most (65%) primarily accessed their social media using their
mobile devices (mobile phone 52%, tablet 13%), the remainder
opting for conventional computer systems. Almost all (92%) currently
used online learning resources with the majority (80%) regarding
them as useful to varying degrees.
8
1
formal guidance regarding the use of social media by doctors and
what may constitute inappropriate usage.7 Information governance,
patient confidentiality and data protection are at the forefront of
many NHS Trusts’ corporate reasoning driving strict internet access
policies. It may well be that the perceived rewards from a social
media learning resource could be overshadowed by the grim
warnings Trusts have made regarding potential breaches. It can be
seen how some registrars would just feel that it is more trouble than
it is worth!
benefit, although most users commented on the ease of access
to educational material through social media, its portability and the
speed of publishing. A similar proportion voiced concerns regarding
privacy (50%), with 17% opting to post using pseudonyms. A third
voiced concerns regarding mixing their work and private lives, and
commented on tactics they used to separate the two (e.g. excluding
senior clinicians from their networks, avoiding discussing real
cases, adjusting privacy settings, not divulging work locations and
anonymising posts).
In keeping with modern trends, most of our respondents accessed
their social media with mobile devices rather then traditional
computers. This enables users to circumnavigate tight Trust internet
policies, and the rapidly advancing technology and increasing ease
with which social media can be accessed would suggest significant
potential for use as a learning platform. However, the enthusiasm for
such a resource was lukewarm. Pushing the boundaries of medical
education into the realms of social media has introduced more than
just the expected technological and ethical challenges. It has also
resulted in a blurring of the intersection between personal and work
lives, creating a dilemma for many.
It seems that active users engage with a variety of different networks
on a regular basis, and most are cautious with what they post. Many
use a network where no login credentials are required (YouTube),
hence avoiding divulging any private information and users have
employed a number of strategies to deal with commonly arising
concerns.
Mixing work with social activity
Of the small majority (52%) that wanted a social media resource,
equal proportions considered potential roles for group discussions,
notifications, one-to-one advice, and for exam studying. Interestingly
almost half (48%) said that they would not use social media in this
context. Most commented that they felt it was risky and did not
feel they wanted to mix work with social media. Furthermore, when
asked if they would like a social media learning resource, the same
proportion (48%) responded that they would not. The most common
concern (52%) was about privacy issues, with the rest concerned
about lack of accessibility or usefulness.
Several surveys and studies have been conducted to estimate SMN
use among medical professionals, some suggesting that up to 90%
of doctors may use social media platforms for personal use, and 65%
for professional purposes alone.4 Our results confirm this ubiquity.
Other studies have examined the content of individual profiles and
accounts, with some disquieting findings.5,6 These studies raise
numerous concerns regarding inappropriate content, unprofessional
conduct, ethical breaches, violations of patient privacy and conflicts
of interest. It is therefore not surprising that the GMC recently issued
Anaesthesia News November 2014 • Issue 328
Our results suggest that privacy seemed to be the biggest concern
for anaesthetic registrars, and the idea that both work colleagues
and personal friends could see and participate in the same virtual
space can be quite unappealing. What one might want to share with
family and friends may not be something you wish work colleagues
to know. Some things may even be inappropriate.5 While most
social media networks have filtering options allowing content to be
visible and accessible only by certain groups of people, these are
often not well known or understood by users. When faced with this
dilemma, it can be seen why most would opt for avoidance. In an
era of increasing shift work and more non-clinical work, it can also
be extremely difficult to maintain an adequate and healthy work-life
balance. In this environment, the desire to avoid mixing work with
social activity may be another factor. Available evidence also shows
that with advancing medical experience, many clinicians attempt to
keep clear boundaries between work and personal lives.6
The above results do pose a question. There are several SMN
e-Learning resources in existence. They are popular – GasClass
has over 1000 registered followers – and are presumably used by
a similar cohort to the one we surveyed. How do those who are
engaged in the process deal with the concerns raised above?
Another survey was undertaken to look at this. The administrators
of GasClass kindly allowed us to survey their members at the end
of their winter term. We found that, after Twitter, the most commonly
used network for educational purposes was YouTube (58%) and 21%
did not use any other network. Active users almost exclusively used
mobile devices or a tablet (92%) for accessing social media. Usage
was similar with most users (50%) engaged with social media for
1–2 hours a day. Peer group discussion was reported as the main
Anaesthesia News November 2014 • Issue 328
As is often the case, more work needs to be done in this area. Both
surveys raise some interesting questions, especially about privacy.
The further work we have done shows that using the right network,
with the right controls may increase participation greatly. Ultimately
any e-learning resource should take into account the needs,
opinions and concerns of the intended audience. This would enable
medical education to be delivered in a way that maximises support
and encourages active engagement.
Majid Saleem
ST6 – Anaesthesia
Naveed Kara
ST8 – Otolaryngology
James Cook University Hospital, Middlesbrough, UK
References
1.
2.
3.
4.
5.
6.
7.
Learn@AAGBI. http://www.learnataagbi.org
E-Learning Anaesthesia (e-LA). http://www.e-LA.org.uk
Doran M, Williamson S, Whitehead I. Welcome to Gasclass – An
online discussion for anaesthetists. Anaesthesia News 2013; 306: 12.
Modahl M, Tompsett L, Moorhead T. Doctors, patients & social
media. QuantiaMD, 2011. http://www.quantiamd.com/q-qcp/
doctorspatientsocialmedia.pdf
Bosslet GT, Torke AM, Hickman SE, et al. The patient-doctor
relationship and online social networks: results of a national survey.
Journal of General Internal Medicine 2011; 26: 1168-74.
Thompson LA, Dawson K, Ferdig R, et al. The intersection of online
social networking with medical professionalism. Journal of General
Internal Medicine 2008; 23: 954–7.
http://www.gmc-uk.org/publications/21833.asp
9
Cadaveric
News from the
European Society
of Anaesthesiology
The notable news from the ESA is that the annual
congress in 2016 will be held in London (28 May–31 May).
The meeting is the ‘jewel in the crown’ of ESA activities.
This year there were more than 5000 delegates and around 10%
were from the UK and Ireland. As the national society of the
host country, the AAGBI will form part of the National Organising
Committee. The majority of the scientific programme is developed
by the ESA’s Scientific Committee; however the host country
society has the opportunity to recommend local speakers for one
or two sessions. In addition the AAGBI will help with organising
social events and the opening ceremony.
Members of the AAGBI based in the UK and Ireland have a good
track record of supporting ESA activities including the annual
congress, the European exam (EDAIC), research networks and
guideline production. Many of these roles require an application
to join the relevant committee, all of which are reviewed by the
Nominations Committee (the only ESA committee directly elected
by ESA members at the Annual Meeting). The by-laws for the
ESA for election to the ESA Council allow support by the relevant
national society, and for the UK and Ireland this is the AAGBI.
However, for many other posts a similar letter of support from the
national society can be useful to demonstrate credibility, relevant
experience and links to a wide audience. While certainly not
essential, candidates for posts are advised to consider obtaining
such support. Often your colleagues from other countries will be
doing the same. The AAGBI is happy to offer support to members
in good standing and by including a brief CV with your request
the AAGBI’s letter to the ESA can be drafted to draw attention to
relevant facts.
Please consider applying for these posts when they are advertised
on the ESA website or in the e-newsletter, and if you seek AAGBI
support please contact the Honorary Secretary of the Association
(honsecretary@aagbi.org).
For general advice or any other information about the ESA please
contact me at mike.nathanson@nuh.nhs.uk
Mike Nathanson
Council Member, AAGBI and Council Member, ESA
10 GAT ASM
ABSTRACT SUBMISSION
MANCHESTER 2015
GAT Oral and Poster Prizes
Trainee anaesthetists are invited to submit an abstract for oral
or poster presentation at the GAT ASM. The authors of the six
highest-scoring abstracts in the preliminary review will be invited
to present their work orally and will be eligible for the Oral
Presentation Prize. A cash prize will be awarded to the winner.
training
courses
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a realistic envir
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it
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ay
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lications
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’
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but for the mos
Case Presentation Prize
Trainees are asked to submit an abstract of an interesting case
that they have been involved in, and which has learning points
that may aid other anaesthetists in their management of similar
cases. The three best submissions as judged in the preliminary
review will be invited to present their work orally at the ASM and
the audience asked to vote for their favourite. A cash prize will
be awarded to the winner.
Poster Competition
The remaining successful authors will be invited to present a
poster. Entries will be allocated into one of the following three
categories depending on the grade of the presenting author:
Foundation Year Trainees; ACCS/Core Trainees; ST3+ Doctors.
A cash prize and a certificate will be awarded to the winner
in each category. The judges also reserve the right to award
discretionary certificates.
Medical Students Poster Prize
Medical students are invited to submit an abstract for poster
presentation on a theme related to Anaesthesia/Pain/ITU.
A cash prize will be awarded to the winner.
Prize
The Anaesthesia History Prize
The Association of Anaesthetists and the History of
Anaesthesia Society will award a cash prize for an original
essay on a topic related to the history of
anaesthesia, intensive care or pain
management written by a trainee member
of the Association.
A £500 cash prize and an engraved
medal will be awarded for the best entry,
and the winner will be invited to present
their paper at the ASM.
CLOSING DATE FOR SUBMISSIONS: MONDAY 19 JANUARY 2015
For full details and to apply please go to the GAT ASM
website www.gatasm.org/content/oral-poster-prizes
If you have any additional queries, please contact the AAGBI
Secretariat on 020 7631 1650 (option 3) or email gat@aagbi.org
Anaesthesia News November 2014 • Issue 328
We can all remember the nerve-wracking experience of performing
a procedure such as venous cannulation or central neuraxial
blockade for the first time on a patient. Trying to appear confident
and competent when you don’t know what it will actually feel like
to perform, even though you have read about it and observed it.
Add to this is a sense of responsibility to the patients, all of whom
deserve the best possible care, and a feeling of anxiousness that as
a novice performing the procedure you may not be providing this. In
addition to the ethical dilemma of ‘practicing’ on patients, trainees
are required to learn a greater number of techniques in fewer hours,
for increasingly complex patients. Acquiring the technical skills
required to become an anaesthetist can prove challenging.
The ‘see one, do one, teach one’ philosophy is no longer acceptable.
A recent review1 of the ethical and legal difficulties associated with
medical training involving patients noted that the learner has a
responsibility to fulfil the preparatory requirements for the skill being
learned, to gain the necessary knowledge in the classroom and
the manual dexterity in skills labs and simulations, before gaining
experience with patients.
Anaesthesia News November 2014 • Issue 328
The medical education community has responded to this by
developing increasingly sophisticated part task simulators to take
the place of the patient. This allows healthcare professionals to begin
to learn technical skills such as cannulation and central neuraxial
blockade. On trauma and resuscitation courses, animal models
are also used as surrogates on which to practice procedures such
as chest drains and surgical cricothyroidotomy. These simulated
patients allow the novice to experience a technique for the first time
without practising on a patient.
Even more ‘real’ is the use of cadavers to teach practical procedures.
Changes to the Human Tissue Act in 2004 (England/Wales/
Northern Ireland) and the Anatomy Act (Scotland) in 2006 made it
possible to perform surgical procedures on cadavers. The surgical
specialties were the first to explore the opportunities this change
in the law afforded for medical training; however anaesthesia has
now also started to utilise cadavers as a teaching resource. Over
recent months I have attended two training courses which have
used a combination of part task simulation and cadavers to teach
anaesthetic practical procedures.
11 Advertorial
The first, a thoracic epidural course at the Newcastle Surgical Training
Centre (http://nstcsurg.org/), catered for a mixture of participants,
with all grades of trainee and consultants present. Part task
simulators and fresh frozen cadavers were used to give novices the
opportunity to undertake the whole procedure several times in a low
pressure, low risk environment. More senior trainees and consultants
had the chance to practice less commonly used techniques on a
cadaver rather than a patient, such as the paramedian approach
and tunnelling of catheters, increasing confidence to use these skills
in clinical practice.
The second was an advanced airway course, for senior trainees
and consultants, at the Cuschieri Skills Centre, Dundee (http://www.
cuschieri.dundee.ac.uk/). NAP4 made strong recommendations
regarding improvements in airway training including the teaching of
advanced and emergency airway techniques.2 This course teaches
these airway skills using a mixture of part task simulators, animal
models and cadavers to simulate patients. The cadavers used
during this course were Thiel embalmed, a type of soft-fix tissue
preservation, which retains more lifelike tissue colour and flexibility
compared to other methods of preservation. Certainly during
fibreoptic intubation, while concentrating on the screen, the lifelike
colour and feel of the tissues meant the experience of performing
the procedure seemed ‘real’. We also practiced front of neck access
on the cadavers using needle cricothyroidotomy followed by jet
ventilation using the rise and fall of the chest to confirm success. As
the Thiel cadavers are an expensive resource and the more invasive
surgical cricothryroidotomy would have required each participant
to have sole access to a cadaver, animal models (porcine larynx)
were used to practice this technique instead. This course provided
a valuable opportunity to practice emergency airway procedures,
which it is vital all anaesthetists are competent to perform, but which
we rarely use on patients. The high ratio of equipment and trainers to
candidates meant there was lots of time to practice and consolidate
all the technical skills taught.
Thiel embalming
Thiel embalming was first described in the 1990s by Professor Thiel
of the University of Graz, Austria, and was introduced to the UK in
2009 by the Centre for Anatomy and Human Identification, University
of Dundee (http://cahid.dundee.ac.uk). This preservation method
involves an initial perfusion of the cadaver followed by three months
submersion in an embalming fluid based on water, glycol and various
salts. This method costs more than formalin based preservation
techniques but this is balanced by the large number of procedures
that can be performed on each cadaver, as they can be stored at
room temperature and re-used over a period of years.3
The lifelike retention of tissue flexibility and quality is thought to be
due to disruption of the muscle fibres by the boric acid component of
Thiel embalming, while the muscles themselves remain intact within
their fibrous sheaths. The superiority of Thiel embalming over other
methods has been confirmed for several surgical procedures.4
most training courses in USGRA use live models for scanning with
needling practiced on phantoms, the steepest learning curve for most
involves the skill in putting these two aspects together. Cadavers can
offer a realistic model on which to combine scanning and needling.
Research would suggest that Thiel embalming offers some benefits
over fresh cadavers in the positioning of limbs, ease of visualisation
of both anatomy and needle and in the lifelike ‘pop’ sensation when
fascial layers are punctured.6,7
Clearly the competence to perform a practical technique also
requires an understanding of when the technique is required and
how to manage the team involved as well as any complications which
may occur. Both the courses I attended had adequate time allotted
for scenario discussions around the equally important human factor
aspects of both central neuraxial procedures and difficult airway
training.
Sarah Gibb
ST7
Northern School of Anaesthesia
Declaration of interest
The GAT Committee were given a complimentary registration to the
Dundee Advanced Airways Course.
Permission to print the photographs illustrating this article was given
by Roos Eisma, Operational Manager and Scientific Officer, CAHID.
References
1. Iqbal R, Rhys Hooper C. Ethico-legal considerations of
teaching. Continuing Education in Anaesthesia, Critical Care
and Pain 2013; 13: 203–7.
2. Major complications of airway management in the United
Kingdom. The 4th National Audit Project of the Royal College
of Anaesthetists and Difficult Airway Society. Report and
findings, March 2011. http://www.rcoa.ac.uk/nap4 (accessed
04/09/2014)
3. Eisma R., Mahendran S, Majumdar S, Smith D, Soames RW.
A comparison of Thiel and formalin embalmed cadavers for
thyroid surgery training. The Surgeon, 2011; 9: 142–6.
4. Benkhadra M, Bouchot A, Gérard J, et al. Flexibility of Thiel’s
embalmed cadavers: The explanation is probably in the
muscles. Surgical and Radiological Anatomy 2011; 33: 365–8.
5. Raju PKBC. et al. Thiel cadavers: A further step in teaching
airway skills. Poster Presentation. Difficult Airway Society 2013.
6. Benkhadra M, Faust A, Ladoire S, et al. Comparison of fresh
and Thiel’s embalmed cadavers according to suitability for
ultrasound-guided regional anaesthesia of the cervical region.
Surgical and Radiological Anatomy 2009; 31: 531–5.
7. Macleod G, Eisma R, Schwab A, Corner G, Soames R,
Cochran S. An evaluation of Thiel-embalmed cadavers for
ultrasound-based regional anaesthesia training and research.
Ultrasound 2010; 18: 125–9.
The Dundee group’s pilot study to evaluate the use of Thiel
embalmed cadavers during airway training demonstrated that the
cadavers were rated superior to manikins for direct laryngoscopy,
insertion of supraglottic airway device, videolaryngoscopy, fibreoptic
intubation and cricothyroid puncture. Thiel embalmed cadavers also
do not have the strong smell associated with formalin preservation
making it more acceptable to participants.5
12 ULTRASOUND TECHNOLOGY;
A REVELATION FOR REGIONAL
ANAESTHESIA AND CHRONIC
PAIN MANAGEMENT
Point-of-care ultrasound technology has come a long way in the last decade,
from the early systems with tiny screens producing a grainy image, through
to modern state-of-the-art instruments with outstanding resolution; the
development of ultrasound technology has been nothing short of phenomenal.
As a result, the popularity of using point-of-care ultrasound to
guide regional anaesthesia continues to grow and, like many
in the UK, the anaesthesia department at Morriston Hospital,
Swansea, has turned to this technique for routine hand
surgical lists. Interest in point-of-care ultrasound began with
the acquisition of some very basic instruments to meet NICE
guidelines for central venous access, however, it was soon
clear that these systems would also be ideal for performing
nerve blocks, and could potentially revolutionise both regional
anaesthesia and chronic pain management.
Using ultrasound for the hand lists alone has introduced
massive financial savings, recovering the cost of the
ultrasound instrument several times over. Where general
anaesthesia requires a dedicated consultant anaesthetist
for each theatre list, ultrasound-guided regional blocks can
be handled safely and effectively by just one anaesthetist
covering two theatres, allowing as many as eight patients to
be treated in an afternoon. The system has been in use for
seven years now, with a success rate close to 100%, allowing
more than 90% of hand surgical procedures to be carried out
as day-case patients, maximising throughput efficiency and
helping to reduce waiting times. Patients appreciate regional
anaesthesia too; those unsuitable for general anaesthetic can
still be treated, and time to discharge is much faster. Surgery
while the patient is awake also makes it easier for the surgeon
to explain the treatment, showing them what is happening.
Most patients engage with the process and find it fascinating.
Today, the hospital has access to a wide range of ultrasound
systems – SonoSite’s iLook®, MicroMaxx®, M-Turbo®,
S-Nerve™ and the recently launched X-Porte® – and is
benefitting from increasingly advanced technology in
even more applications where precise needle placement
is essential. Another example at Morriston is in replacing
fluoroscopy imaging with ultrasound guidance in the
management of spinal chronic pain interventions. While
fluoroscopy outlines the bony structures, allowing the
anaesthetist to establish whether the needle is in an optimal
Cadavers are also being used to teach the practical skills required to
perform ultrasound guided regional anaesthesia (USGRA). Although
Anaesthesia News November 2014 • Issue 328
ANAESTHESIOLOGY
Anaesthesia News November 2014 • Issue 328
or suboptimal position, ultrasound has the advantage of also
visualising soft tissue structures, adding an extra dimension
to the accuracy of the procedure. Fluoroscopy may require
several attempts to position the needle accurately, whereas
with ultrasound it is possible to identify the target and
correctly place the needle first time, which is far easier for a
patient to tolerate. From a practical perspective, medical staff
are no longer repeatedly exposed to radiation which, although
very low level, requires a heavy protective gown to be worn.
Ultrasound also offers cost savings – there is no need for an
expensive X-ray suite or the services of a radiographer, and
fewer staff are required – and increased flexibility. Often,
patients are unable to adopt the position necessary to perform
an X-ray-guided injection, or lie still on the table. With
ultrasound, there is the flexibility to adapt procedures to the
needs of the individual patient, while still maintaining accuracy
of injection.
Dr Christian Egeler
Consultant Anaesthetist,
Morriston Hospital,
Swansea
Affordable ultrasound:
No running costs with
the SonoSite standard
5 year warranty
Such precision is applicable to all other chronic pain
interventions, offering the possibility of new treatment
approaches. As a further advantage, ultrasound enables
the anaesthetist to see the spread of the injectate. In many
cases, this additional accuracy enables the drug dosages to
be reduced, reducing the risk of side effects and increasing
the cost-effectiveness of the procedure. While further studies
are necessary, from experience, ultrasound certainly seems to
enhance the safety of injection, opening up new possibilities
and improving patient experience. Overall, it has transformed
regional anaesthesia and chronic pain interventions, proving a
cost-saving modality in modern anaesthesia.
For more information about FUJIFILM SonoSite products,
please contact:
FUJIFILM SonoSite Ltd
Tel: +44 (0)1462 341151
Email: ukresponse@sonosite.com
www.sonosite.co.uk
13 Still bleeding after all these years…
14th Obstetric
Anaesthesia Symposium
9th December 2014
Lumley Castle, Co.Durham
Maternal Critical Care: a view point
Dr A Vercueil – London
Training for Obstetric Emergencies
Dr N Hayes – Dublin
Anaesthesia for the Developing Brain
Dr T Girard- Switzerland
Top Tips for Optimising Labour
Analgesia: the best in evidence based
practice
Dr G Stocks - London
Haemodynamic Monitoring of the
Pregnant Mother
Dr S Armstrong – Surrey
NAP5 – Awareness in Obstetric
Anaesthesia
Dr N Lucas - London
Uterotonics in Prevention and Treatment
of PPH
Dr T Girard - Switzerland
The Invasive Placenta: Regional Policy for
Screening and Management
Professor S Robson - Newcastle
How (not) to Publish a Paper
Dr R Russell – Editor in Chief IJOA
Decision Making for Obstetric
Emergencies: can the Obstetrician make
it better for the anaesthetist
Mr K Hinshaw - Sunderland
Fees:
Consultants
£150
Staff Grades
£100
Trainees
£50
Midwives
£40
ANAESTHESIA NEWS
5 CPD Points Applied for
Course Organisers
Dr U Misra Consultant Anaesthetist &
J Williams Anaesthetic Secretary
Sunderland Royal Hospital
Tel No: 0191 5656256 Ext 42447
Email: janice.williams@chsft.nhs.uk
The AAGBI Bleeding,
Clotting and Haemorrhage
seminar celebrates its 10th
anniversary this December
with a special two-day
meeting in London. It has
evolved into one of the most
established and popular
seminars run by the AAGBI,
having been attended by
over 1000 delegates since
its inception.
Anaesthesia News now reaches
over 10,500 anaesthetists every
month and is a great way of
advertising your course, meeting,
seminar or product.
Anaesthesia News
is the official magazine
of the Association of
Anaesthetists of Great
Britain & Ireland.
The inaugural seminar was fully booked two months before the event
and ongoing popularity has dictated a move to a larger venue to
accommodate demand. From the outset, Ravi has always been able
to attract a host of national and international experts to speak on key
aspects of haemorrhage management.
Anaesthetists take a lead role in almost all major haemorrhage
management across a wide variety of hospital settings. All
anaesthetists are expected to manage bleeding patients appropriately
- be it in elective or emergency surgery, trauma, obstetrics or in
critical care. Current knowledge of development and best practice
is essential to ensure that our patients receive optimal care.
In the words of Richard Dutton (Executive Director of the American
Society of Anesthesiologists Quality Institute, anaesthesiologist
at Baltimore Shock Trauma Centre and a regular speaker) the
Bleeding, Clotting and Haemorrhage seminar ‘has significantly
advanced the practice of resuscitation; as well as the awareness
of trauma as a disease that is amenable to a systematic, scientific,
multi-disciplinary approach. The concepts of early recognition of
life-threatening hemorrhagic shock, a 'damage control’ approach
to surgery, deliberate hypotension, early (and diverse) coagulation
testing, and timely support with plasma and platelets were all early
scientific topics at this meeting’.
For further information on advertising
Tel: 020 7631 8803
or email Chris Steer:
chris@aagbi.org
Dr Les Gemmell
21 Portland Place, London W1B 1PY
Evolution
Significant advancements have been made in understanding the
pathophysiology of major haemorrhage, development of tissue
damage associated coagulopathy in trauma and the role of platelets
and fibrinogen in haemostasis. A host of novel pharmacological
options and new blood component therapies have been introduced
into clinical care - some with more success than others. Near patient
testing has become more widely established and accepted beyond
the cardiac theatre to guide blood component therapy optimally.
CALL
NOW FOR
A MEDIA
PACK
Immediate Past Honorary Secretary
The long running organiser is Dr Ravishankar Rao Baikady, a
consultant anaesthetist at the Royal Marsden Hospital in London,
with an interest in anaesthesia for major cancer surgery and preoperative assessment. While working as a senior registrar at St
George’s Hospital in 2003, he was part of a group who published
research on the role of recombinant Factor 7 (Novoseven) in fixation
of pelvic fractures.1 During this time he identified that there was a
great degree of confusion among clinicians regarding management
of major haemorrhage. In his own words, ‘the most striking element
was a lack of ownership and poor communication between clinicians
- anaesthetists, transfusion practitioners, haematologists and
surgeons’. The seminar was designed to collate expert opinion from
a variety of backgrounds and efficiently update anaesthetists with
recent developments on the management of major haemorrhage.
Transfusion practice and the management of major haemorrhage
have evolved substantially over the last ten years. Clinical practice
now involves widespread use of major haemorrhage protocols, 1:1
red cell to plasma ratios and near patient coagulation testing with
TEG or ROTEM to guide component therapy. Establishment of local,
national and international guidelines and multidisciplinary hospital
transfusion committees have fostered a much better understanding
between anaesthetists, surgeons, haematologists and the blood
bank, helping to facilitate a more coordinated and efficient process.
www.aagbi.org/publications
14 Origins
Anaesthesia News November 2014 • Issue 328
Anaesthesia News November 2014 • Issue 328
This year’s event promises to excel, with a host of international
experts speaking on a variety of themes relevant to all anaesthetists.
The first day includes updates on current research in haemostasis,
coagulopathy monitoring and point of care testing and the role of
red blood cells; finishing with a session on current controversies in
haemorrhage management. The second day explores best practice
in trauma, subspecialty haemorrhage management and drugs in
haemostasis. It promises to be a truly comprehensive account of
current knowledge, delivered by excellent speakers from across the
globe.
Secrets of a successful seminar
The AAGBI is always interested in hearing from clinicians who are
keen to establish new seminars. Ravi’s advice is to ‘identify a topic
which is not well understood or where research is informing rapid
developments in practice. Choice of topics and speakers is key.
I always believed in a mix of international and national speakers,
there is lot to learn from practice in other countries’. The evidence
suggests that his approach can be very successful and he deserves
great credit. Again, the words of Richard Dutton: ‘it has been my
great pleasure to be a participant in the meeting over the years. I
cannot say enough about Ravi's skills as a creator, organiser and
convener’.
The future
It is likely that developments will continue to evolve in this field and
there is an undoubted requirement for a forum at which anaesthetists
can acquire current knowledge. Improvements in understanding the
pathophysiology associated with major haemorrhage are likely to
lead novel pharmacological targets. ‘Patient Blood Management’
is a multi-faceted WHO concept from 2011 which is yet to be fully
integrated into British hospitals but one which dovetails with many of
the Enhanced Recovery themes.2
Conclusions
The AAGBI Bleeding, Clotting and Haemorrhage seminar continues
to thrive. It is an excellent opportunity to hear experts speak on
a topic which pervades all aspects of anaesthesia. Places for
December will go fast, better sign up now!
Dr Jonny Price
ST6 Anaesthesia and Intensive Care Medicine, London
GAT Elected Committee Member
Acknowledgements
With thanks to Ravishankar Rao Baikady and Richard Dutton
for their contributions.
References
1.
Raobaikady R, Redman J, Ball JA, Maloney G, Grounds RM. Use of activated
recombinant coagulation factor VII in patients undergoing reconstruction
surgery for traumatic fracture of pelvis or pelvis and acetabulum: A double-blind,
randomized, placebo-controlled trial. British Journal of Anaesthesia 2005; 94:
586–91.
2.
Spahn DR, Theusinger OM, Hofmann A. Patient blood management is a win-win:
A wake-up call. British Journal of Anaesthesia 2012; 108: 889–92.
15 Anaesthetic training in underdeveloped
countries: what is the role of junior trainees?
The view of the UK trainee
On completion of my basic anaesthetic training in the London Deanery
I had an opportunity to experience anaesthesia in Zambia as part
of the MMed Anaesthesia Programme at the University Teaching
Hospital, Lusaka. This teaches Zambian doctors to become specialist
anaesthetists. I had no idea what to expect or how I would fit in to the
programme, so I attended a faculty meeting in London and spoke to
Professor Kinnear, the head of the MMED Anaesthesia Programme.
My brief was to help the UK consultant faculty deliver basic science
teaching to the Zambian trainees and provide UK style MCQ/viva
practice. My secondary objective was to ascertain if other UK trainees
would benefit from this role as part of a larger, more formalised training
programme. I also expected to learn from the first cohort of anaesthetic
trainees and experience anaesthesia in unfamiliar surroundings.
My primary FRCA gave me the perfect grounding in basic science
knowledge and exam skills to help the UK consultant faculty cover
important elements of the syllabus and provide a more junior
perspective to the teaching programme. Teaching helped me to
embed my basic sciences knowledge. Due to the intermittent visits
of the UK consultants, local students were not able to have regular
exam viva practice. I spent time practising mock viva and MCQs with
them. This was well received and allowed the MMED students to gauge
the standard of clinical knowledge of a UK trainee at a similar level of
experience. It was evident that Zambian and UK trainees have similar
anxieties regarding training and exams.
I also learned about anaesthesia using limited resources in unfamiliar
surroundings. There were some stark differences in practice, such as
the almost universal non-availability of capnography, but I put this to
good use by explaining how capnography works and the huge benefits
that UK practice has gained from its consistent use. Lack of monitoring
allowed me to recognise that safe anaesthesia can still be delivered
without the plethora of anaesthetic devices we employ in the UK.
I put into practice theory about anaesthetic devices/drugs that I had
only seen images of and read about in books. For example, using
halothane and draw over vaporisers, and coping with antiquated
anaesthetic machines. Holding and using equipment and applying
somewhat turgid learning about physical properties is priceless in my
view. With the pace of technological change in UK based anaesthetics,
equipment that was in use only 10 years ago is now historic for junior
UK trainees.
16 A surprising aspect of my experience was my increased appreciation
of the role of managers in the NHS, having seen the clinicians at UTH
hospital deal with complex organisational issues as well as their clinical
work on a daily basis. A hospital like UTH run on a limited budget also
illustrated to me how to save money and stop the unnecessary waste
that is commonplace in UK hospitals, a lesson I now try to apply in my
own practice. As a junior in UK training there is no opportunity to gain
insight into the running costs of a department and to realise that all
members of the team are responsible for driving down costs.
This attachment is a worthwhile partnership between an overseas
training programme and UK trainees. It provides a platform for colearning, discovery of differing practice, and allows UK trainees to
gain new skills that would be impossible to obtain in a UK training
programme. This experience has been invaluable for my continuing
anaesthetic career. I look forward to becoming more involved in the
programme in the future and hope my experience will serve as a model
for improved training for both Zambian and UK junior anaesthetists.
Natasha Clunies-Ross
ST3 Anaesthetic Trainee, KKS Deanery, St Richards Hospital,
Chichester
The view of the Zambian trainee
For the first time since the Zambia Anaesthesia MMed programme
began, we had a junior trainee from the UK who was here for one month,
rather than the more normal two weeks. This made a huge difference. I
was the first trainee to meet Natasha on her arrival, and I was asked by
my Head of Department, to show her around the hospital.
She did not take long to adjust to her new surroundings and engage with
delivery of the programme. She told me that she had just completed
her primary FRCA exam, and had a strong desire to teach. I remember
she asked some probing questions the very first day I was with her.
My fellow trainees and I usually have discussions in the evening and
Natasha quickly offered to stay late to help our discussion group. We
found this so humbling that someone would give up part of their leisure
time and make a sacrifice for us.
Natasha helped us with difficult topics and concepts that we found
hard to understand, especially the basic sciences where most of our
weaknesses lie. The value of these extracurricular teaching sessions
Anaesthesia News November 2014 • Issue 328
was immense and we would like to acknowledge her efforts. All the
Zambian trainees thought she equipped us well for our exam. It was
unfortunate that she had to leave before we took our exams in June.
However, she laid the foundations of our knowledge and helped
boost our confidence in facing the viva exam.
Besides helping us to prepare for the exams, Natasha helped us
with clinical cases and we learned some clinical skills from her. We
got to share many experiences, and it was encouraging to note that
many of our needs and concerns were familiar. Personally I see no
disadvantages to having a junior UK trainee who has completed
their primary FRCA exams coming over for a month in addition to the
visiting consultant lecturers, because they will impart knowledge to
the MMed trainees in their own way. We are looking forward to having
another junior trainee with a teaching spirit like Natasha CluniesRoss.
Jane Kabwe
MMed Year 3 student, University Teaching Hospital, Lusaka
The view of the
Head of Programme
The Zambia MMed Anaesthesia Programme was identified as a
priority project by the Zambian Permanent Secretary for Health
in 2009, when it was realised that the country required trained
physician anaesthetists to address its high anaesthetic mortality
rate. Postgraduate training was already available in several hospital
specialties such as surgery, orthopaedics, O&G and Paediatrics,
offered by the University of Zambia School of Medicine as a 4 year
Master of Medicine (MMed) programme. It was decided that this
should also be the format for postgraduate anaesthetic training, but
the greatest barrier was a complete absence of a curriculum, faculty
or any infrastructure support for a postgraduate programme. For this
reason the UK was approached to initiate and embed a programme,
with the aim of developing local capacity so that it could become selfsustaining over time.
The Zambia MMed Programme is now in its third year, and has
evolved a ‘hybrid’ overseas faculty model consisting of a long term
UK consultant, a 6-month senior UK trainee fellow, several shortterm UK consultants, and ad hoc junior UK trainees. The challenging
nature of the clinical environment has dictated that faculty should be
experienced, competent and independent before embarking on the
Anaesthesia News November 2014 • Issue 328
role, which meant that the exact role of the junior trainee was unclear
at first. However, a few pioneering core trainees have begun to define
the very important part that they have to play, and Natasha and Jane’s
accounts describe the symbiosis of international peer co-learning.
Jane has given a humble view of how the Zambian trainees benefited
hugely from learning the academic aspects of anaesthesia from their
UK counterpart, a paradigm completely foreign to them. Besides
the teaching, what Natasha also brought was the example of a fully
matured professional, confident of her own role in the care and safety
of patients, and the responsibility to advocate for patients. Zambia
lacks this tradition and the local trainees will certainly benefit from the
modelling of inter-professional behaviours by their UK peers to help
them to build their own professional identities.
However, what Jane has failed to describe is the huge clinical
experience she and her co-trainees have accumulated from having
to cope with complex cases almost from day one of their training.
On a normal day they have to share a porter who acts as an itinerant
assistant, they have to reuse odd bits of disposable equipment, learn
to make do with the drugs available to them on that day, and work
with equipment that is in various stages of falling apart. This takes
enormous resilience, innovation, patience, and often a good sense of
humour. They also frequently deal with surgeons unused to challenge
from anaesthetists, and have had to develop effective negotiating
skills in the face of conflict. Surely NHS trainees will benefit from
learning these rare traits?
Having started from a position of uncertainty about the role of junior
UK trainees in the challenging environment of UTH, I now have no
doubt of their value. They undoubtedly have as much to learn as they
have to teach, provided they start out with the right preparation. To
achieve maximum benefit it is important for the trainee to define the
boundaries of their clinical practice (which may be different to the UK)
since they may be faced with situations beyond their competence.
For optimal learning they should also have access to adequate
supervision for clinical, educational and pastoral support. And they
should have clear objectives for their visit. If these basic elements
can be provided, the trainee will come away having experienced and
supported something of immense educational value.
John Kinnear
Head of Programme, Zambia MMed Anaesthesia; Consultant in
Anaesthetics and Critical Care Medicine, Southend Hospital
17 The Anaesthesia Heritage Centre invites you to a series of new exhibitions:
ANAESTHESIA
HERITAGE
CENTRE
A Silver Lining Through the Dark Clouds
Shining*: The Development of Anaesthesia
During the First World War
* A line from Keep the Home-Fires
Burning by Ivor Novello
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.
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The first exhibition in 2014-2015 will look at Geoffrey Marshall
versus Henry Boyle: who really developed the Boyle machine?
s bringing back the wounded
British soldier
©IWM (Q 721) courtesy of the Imperial
War Museum
• 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
Visitor information:
The Anaesthesia Heritage Centre, AAGBI Foundation,
21 Portland Place, London W1B 1PY.
Open Monday to Friday 10am
until 4pm (last admission
3.30pm). Appointments
are recommended: email
heritage@aagbi.org or phone
020 7631 8865. Admission is
free. Group visits for up to 20
people can be arranged at a
small cost per person.
Registered as a charity in England & Wales no. 293575
and in Scotland no. SC040697
Did you know that during
the First World War
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.
Geoffrey Marshall
Marshall’s
apparatus
Boyle’s
apparatus
Henry Boyle
Visit www.aagbi.org/heritage for further information
TRAVEL GRANTS/
IRC FUNDING
Social media, once the province of youth, has now been used increasingly to communicate
and distribute information in the workplace. For example, the AAGBI and the RCoA both have
Facebook and Twitter accounts and my own department utilises WhatsApp as a means of
instant departmental communication. The immediacy and connectivity make them excellent
tools, but can they be utilised more effectively amongst the trainee body to effect change?
SAS Simulation Training
Thursday 26 February 2015
or Thursday 12 March 2015
In my Deanery there are 17 different hospitals spread across
a reasonably large geographical area. Therefore trainees are
dispersed and often not in touch with each other or aware of training
issues or opportunities others have discovered. This problem came
to my attention when I was on maternity leave and I found the
process of negotiating my return to work as a less than full time
(LTFT) trainee difficult and somewhat stressful. In a climate where
LTFT training is increasingly desired, its implementation at a grass
roots level can be variable and understandably difficult while service
provision assumes everyone works full time.
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.
For further information and an application form
please visit our website:
http://www.aagbi.org/international/irc-fundingtravel-grants
or email secretariat@aagbi.org
or telephone 020 7631 1650 (option 3)
Closing date: 02 January 2015
Venue: Centre For Clinical Practice
Chelsea and Westminster Hospital
369 Fulham Road | London | SW10 9NH
2 x one day
training
courses
Delegate registration fees: £240 per candidate
Spaces are limited. To book please contact:
simulation@chelwest.nhs.uk
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.
(CPD points applied for)
I decided to set up a closed Facebook group for LTFT trainees in my
Deanery to share experiences and information. The group has the
privacy designation of 'secret' which means that its existence and
content is known only to those who are invited to join. The Deanery
was able to confirm the number of LTFT trainees but not their details;
however, given the relatively small numbers, the identities of these
trainees was easy to obtain via word of mouth. Very quickly all the
LTFT trainees in the Deanery were members. The forum has become
a safe place to discuss our experiences of working LTFT and to
share information about working conditions on different clinical sites.
It is used on an almost daily basis.
It became clear that there were aspects of working LTFT that were
causing unhappiness and concerns over training. These were issues
Anaesthesia News November 2014 • Issue 328
about which the training committee were largely unaware. Working
as a cohesive group, Dr Jacqueline McCarthy, a fellow trainee and
active member of the Facebook group, carried out a survey of all the
LTFT trainees in our Deanery, and presented the training committee
with data representative of the experiences of all LTFT trainees in
anaesthetic training posts.
Using social media as a platform to facilitate change has had a large
impact on those trainees working LTFT in our Deanery. The forum
has facilitated information sharing, valuable data collection and
peer support for a group of trainees that can often feel isolated and
separate from the rest of the trainee body. In a climate of budget cuts,
recruitment difficulties and the European Working Time Directive,
sustainability of LTFT training appears under threat. We feel that by
uniting as a group and engaging with the training committee we can
work together to maintain and improve our training.
Miriam Stephens
ST5 Anaesthesia
Royal Alexandra Hospital, Paisley
Jacqueline McCarthy
ST5 Anaesthesia
Western Infirmary, Glasgow
19 NIAA
National Institute of Academic
Anaesthesia
JOINT NIAA AND RCS MEETING:
In September 2014, the AAGBI launched Lifeboxes for Rio. A two year fundraising campaign aiming to
raise funding for 600 Lifebox pulse oximeters, one for each British athlete attending the next Olympic
and Paralympic Games in Rio de Janeiro (5 - 21 August 2016). That’s £96,000 to save thousands of lives
around the world in countries where patients are at risk of death from oxygen starvation during surgery.
Join the campaign and become a Lifeboxes for Rio fundraiser
The AAGBI wants to involve its members all over the UK and Ireland in the
Lifeboxes for Rio fundraising campaign. There are lots of ways to take part:
Bake, bike ride, run or walk – or devise your own fundraising concept.
www.aagbi.org/about-us/aagbi-fundraising
AAGBI Foundation: Registered as a charity in England & Wales no. 293575 and in Scotland no. SC040697
Lifebox: Registered as a charity in England & Wales (1143018)
Perioperative Clinical Research:
Opportunities for surgical and
anaesthetic collaboration
Wednesday, 4 March 2015
at The Royal College of Surgeons of England,
35–43 Lincoln’s Inn Fields, London WC2A 3PE
SESSIONS INCLUDE
■
■
■
Funders’ market place, HTA, EME and i4i
Exemplar initiatives from surgery and anaesthesia
Dragons’ Den: four presentations. Submit yours to
dabrahams@rcseng.ac.uk
SPEAKERS INCLUDE
■
■
Professor Dion Morton
Professor Mike Grocott
CPD POINTS
WILL BE
AWARDED
‘Explore new collaborative research
opportunities for surgeons and anaesthetists
focusing on developments in perioperative care
and enhanced recovery.’
Book your free place now: http://bit.ly/1qH7cho
REGIONAL ANAESTHESIA UK
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This is your opportunity to tell us:
- what you like
- what you would like us
to do differently
- what you don’t like
C
M
Y
CM
MY
CY
CMY
K
- help shape our future strategy
We last ran a survey in 2011: the results have
been acted on to ensure the AAGBI delivers
the services that meet your needs:
- Last time, 86% of you said that you wanted
the AAGBI to provide online facilities to
help support your revalidation CPD - we
have created Learn@AAGBI, the new
online learning and CPD zone.
- You told us you valued the AAGBI’s patient
safety guidelines – we continue to update
our guidelines and in September 2014
will be launching the new AAGBI
Guidelines App.
- 84% of you had attended an AAGBI
meeting; we have provided bigger and
better conferences offering top quality
education with record attendance figures
at Annual Congress 2013 and WSM
London 2014
- 40% of you said you used Facebook – so
we have developed the AAGBI Facebook
page and we continue to grow our
followers.
- 91% said that they thought the AAGBI
membership offers value for money – we
want to make sure that we are still
continuing to do so...
FOR MORE DETAILS, REGISTRATION OR ABSTRACT FORM, GO TO
www.ra-uk.org
Tell us how we can do even better!
UNDERGRADUATE
ELECTIVE FUNDING
UP TO £750
Medical students in Great Britain and
Ireland are eligible to apply to the AAGBI
Foundation for funding towards a medical
student elective period taking place
between April and September 2015.
A further round of funding will be
advertised in the Spring for electives
taking place from October 2015 onwards.
Preference will be given to those
applicants who can show the relevance
of their intended elective to anaesthesia,
intensive care or pain relief. Applicants
may wish to note that a key focus of
the AAGBI is support for projects in the
developing world.
For further information and to apply
please visit our website:
www.aagbi.org/undergraduate-awards
email secretariat@aagbi.org
or telephone 020 7631 1650 (option 3)
Closing date: 05 January 2015 for
consideration at the February 2015
Research & Grants Committee meeting
Should anaesthetists spend all their time giving
anaesthetics?
I read William Harrop-Griffiths’ President’s Report with my usual interest.1
A few years ago, at the time that anaesthetic practitioners were being
introduced, a senior manager remarked to me that this appeared an
excellent idea and that anaesthetists would surely welcome the opportunity
to concentrate their expertise on more interesting and demanding cases.
I replied that I did not entirely agree. For my part I needed the ‘simple’
cases as a counterbalance to ‘interesting and demanding’ ones and that
if I spent all my time on the latter I would end up feeling frazzled and burnt
out. I pointed out that ‘simple’ cases only appeared so because of our
high standard of training, and that anaesthetists themselves were prone
to forget this. I also said that there was satisfaction in managing such lists
with expedition which contributed to keeping waiting lists low.
I do not disagree with the substance of Dr Harrop-Griffiths’ argument,
and appreciate he does not propose we entirely give up anaesthetising fit
patients for minor procedures, however I hope managers do not construe
this as an opportunity to reduce consultant numbers!
Dr John R. May
‘Pinewood’, Daviot Muir, Inverness
Reference
1. Harrop-Griffiths W. President’s report. Anaesthesia News 2014;
325: 5-6.
Dear Editor,
The Wylie Medal will be awarded to the most
meritorious essay on this year’s topic related to
anaesthesia Safety in numbers written by an
undergraduate medical student at a university in
Great Britain or Ireland.
THE WYLIE MEDAL
UNDERGRADUATE
ESSAY PRIZE 2015
Prizes of £500, £250 and £150 will be awarded to
the best three submissions.
I read with interest Dr Inas Ahmed’s article on her jury summons.1 She
implies that no doctor would be employed if they had been detained at
Her Majesty’s Pleasure.
From personal experience I can recount that this is not so. In the 1980s
I was very active as an anti-nuclear Christian peace activist and spent
several short sentences in prison for non-violent protests. I continued
very contentedly in my work as a consultant anaesthetist without any
harassment. My colleagues were either bemused, amused or perhaps
quietly respectful of my stand. I was always able to change my on-call
duty without detriment to patient care. A.J. Cronin’s classic novel The
Citadel portrayed the ruthless punishment of those doctors who dared
to step out of line. It is a great novel but in my experience my colleagues
were better. I was also very privileged to be able to write a description
in the BMJ2 of the appalling unhealthy prison conditions (at the time) in
Pentonville Prison and add my small voice to the need for prison reform.
SEND YOUR LETTERS TO:
The Editor, Anaesthesia News at anaenews.editor@aagbi.org
Please see instructions for authors on the AAGBI website
Dear Editor,
Dear Editor,
Allaying a patient’s fears pre-operatively
is one of the key roles of the pre-operative
visit, and Dr Scott-Brown's approach and
use of technology is to be commended.1 The
photograph of induction shows that routine
pre-oxygenation is also practiced. Having
experienced an anaesthetic a few years ago,
I now take a slightly different approach to that
pictured.
Dr Kaye is correct that any doctor
escorting a patient on a helicopter
transfer should have the necessary
training.1 But they may need advice if
they are receiving an air transfer, or the
aircraft is collecting a patient that doesn't
need a doctor to escort them.
Lying relatively flat on a trolley, with a person
standing above your head is a little unusual.
To find a mask placed over your face, held in
a gloved hand, which partly obscures your
view, and then for that person to lean over
your head whilst stretching for the cannula,
can be a little disconcerting. To the anxious
patient it could induce a feeling of panic.
Standing in front of the patient who is in a
semi-sitting position, allows the anaesthetist
to maintain eye contact with the patient. The
patient is then offered the mask and circuit
and, if tolerated, asked to hold the mask on
their face themselves. When pre-oxygenated,
the anaesthetist can watch and talk to the
patient during induction, even feeling the
pulse (though I betray my age here), before
stepping into the usual position for intubation.
Dr Sarah McLean
ST3 Anaesthesia
Dr Kenneth Barker
Consultant Anaesthetist
Raigmore Hospital, Inverness
However, I doubt I will be getting a jury summons any time in the future.
Dr Ray Towey
Volunteer Consultant Anaesthetist,
St Mary’s Hospital Lacor, Gulu, Uganda
The overall winner will receive the Wylie Medal in
memory of the late Dr W Derek Wylie, President of
the Association 1980-82.
For further information and to apply please visit our
website: www.aagbi.org/undergraduate-awards
or email secretariat@aagbi.org
or telephone 020 7631 1650 (option 3)
your Letters
Dear Editor
References
Reference
1. Scott-Brown S. Your anaesthetic.
Everything you ever wanted to know
about your anaesthetic but were too
afraid to ask. Anaesthesia News 2014;
322: 23-5.
I am involved in motorsport medicine and
as a Chief Medical Officer have liaised
with several air ambulances on what rally
medics should do. The product of that
liaison is a page of ‘Advice for Marshals’
that is included in a major rally's
Operations Manual. The most important
point is that no-one should approach
the aircraft until signalled to do so by the
aircrew, and only from the sides, never
from the rear, due to the danger from the
main rotor, lowest at the front, and the tail
rotor.
Dr John Davies
Consultant Anaesthetist
Royal Lancaster Infirmary
Reference
1. Kaye C. Patient transportation by
helicopter. Anaesthesia News 2014;
322: 32.
For the latest
news and event
information
follow @AAGBI
on Twitter
1. Ahmed I. Jury summons: an anaesthetist’s reflection on the legal
system. Anaesthesia News 2014; 324: 6-7.
2. Towey RM. The state of the prisons. BMJ 1984; 288: 482.
Closing date: 05 January 2015
24 Anaesthesia News November 2014 • Issue 328
Anaesthesia News November 2014 • Issue 328
25 Digested
WORLD AIRWAY MANAGEMENT MEETING
November 2014
Hypersensitivity associated with sugammadex administration:
a systematic review
Tsur A, Kalansky A.
BOOKING NOW OPEN
FOR THE WORLD’S LARGEST
AIRWAY MEETING
12-14 NOVEMBER
2015
Booking is now open for next year’s biggest world airway
management meeting in Dublin. This is a joint meeting of the
Difficult Airway Society & The Society for Airway Management.
• Scientific programme • Workshops • Industry exhibition
• Poster competition • Keynote speakers • Social events
Plus, much much more!
JOINT MEETING OF THE DIFFICULT AIRWAY SOCIETY
& THE SOCIETY FOR AIRWAY MANAGEMENT
www.wamm2015.com
DUBLIN
TO MARK THE 20TH ANNIVERSARY
OF THE DIFFICULT AIRWAY SOCIETY
& THE SOCIETY FOR AIRWAY MANAGEMENT
Sugammadex is a drug that somehow I have never got around to using.
Our anaesthetic colleagues in the USA also do not use it because it
has not yet been approved by the FDA due to concerns about
hypersensitivity reactions. This review by Tsur and Kalansky should at
least help them inform their deliberations.
The authors gathered evidence of early hypersensitity reactions with
sugammadex from a wide variety of sources, including regulatory
bodies and the manufacturer. There is good evidence that the reported
reactions are actually due to sugammadex rather than other anaesthetic
drugs or combinations of drugs. All patients included in the review
survived, but there some limitations with the reported data. It only
included articles written in English so some reports of hypersensitivity,
particularly recent cases in the Japanese literature, were excluded. Also,
as a relatively new drug, it is difficult to estimate a reliable frequency of
allergic reactions without more data on patient usage. Perhaps much
of the drug that has been sold is kept for emergency use, so that sales
figures may not directly reflect patient administration to date.
Sugammadex is an innovative drug with novel advantages, but I would
personally struggle to make a case for anything other than exceptional
use. This review helps to quantify one of its major perceived
disadvantages and informs risk-benefit assessment.
The effects of intra-operative dexmedetomidine on postoperative pain,
side-effects and recovery in colorectal surgery
Cheung, CW Qiu Q, Ying ACL, Choi SW, Law WL, Irwin MG.
Dexmedetomidine seems to be another drug that I would struggle
to make a good case for using routinely. Although there is a good
theoretical basis for use in a wide variety of applications in anaesthesia
and critical care, supporting evidence for clinical benefit has generally
been unconvincing.
In this article the authors performed a randomised controlled study
on the addition of dexmedetomidine to a COX-2 inhibitor and PCA
postoperative analgesic regime for colorectal surgery, theorising that
a reduction in use of opioids with dexmedetomidine should reduce
the incidence of opioid-related side-effects and expedite recovery.
Unfortunately, although a reduction in pain scores was seen in the
dexmedetomidine group, there was no demonstrable reduction in
opioid consumption, opioid-related complications or hospital stay. It
thus fails to confirm the opioid-sparing effect reported in other studies,
and it was insufficiently powered to detect side-effect differences
between groups for either opioids or dexmetetomidine. The authors
discuss possible confounding factors in this and other studies that may
help to explain some of the results.
Which supraglottic airway will serve my patient best?
Kristensen, MS, Teoh WH, Asai, T.
If, like me, you are puzzled about the sheer variety and claims for
perceived advantages of different supraglottic airway devices (SADs),
then this editorial, which considers evidence from no less than three
previous meta-analyses will help you understand why. They tackle the
minefield of device testing and the type of evidence needed before
considering use in patients, SADs for airway rescue and the limitations
of studies that have used simulated airways to evaluate SADs. They
also discuss the responsibilities and moral obligations of manufacturers
to produce devices fit for purpose. Despite the large number of papers
already published, there still seems to be major deficiencies in the
available data, making the question posed by the title difficult to answer.
Like all good editorials, it highlights the limitations of existing data and
gives useful suggestions about directions for future research.
BJ Jenkins
Editor, Anaesthesia
N.B. the articles referred to can be found either in a print issue or on Early View (ePub ahead of print)
Anaesthesia News November 2014 • Issue 328
27 Particles
Brown CH, Azman AS, Gottschalk A, Mears SC, Sieber FE
Neuman MD, Rosenbaum PR, Ludwig JM, Zubizarreta JR, Silber JH
Watson MJ, Walker E, Rowell S, et al.
Sedation depth during spinal anaesthesia and
survival in elderly patients undergoing hip
fracture repair
Anaesthesia technique, mortality and length of
stay after hip fracture surgery
Femoral nerve block for pain relief in hip
fracture: a dose finding study
JAMA 2014; 311: 2508–17
Anaesthesia 2014; 69: 683–6
Introduction
There are over 300,000 hip fractures in the USA per year. Regional anaesthesia
for hip fracture surgery may reduce postoperative complications. This study
aimed to compare regional and general anaesthesia techniques with regard to
30-day mortality and length of hospital stay.
Background
Hip fracture is a common orthopaedic emergency, with approximately 77,000
people admitted to hospital in the UK with fractured hips each year.1 Effective
analgesia options for patients with hip fracture include femoral nerve block.2 This
study attempted to establish the minimal effective dose of levobupivacaine that
would provide analgesia to 50% and 95% of patients with a hip fracture, when
injected around the femoral nerve using ultrasound guidance.
Anesthesia & Analgesia 2014; 118: 977–80
Background
Several studies have previously reported an association between low intraoperative bispectral index (BIS) values and increased mortality.1-4 However,
this finding was not confirmed as only a few randomised trials of BIS-targeted
anaesthesia were previously reported. It is uncertain as to whether low BIS values
can be considered as a marker of poor prognosis or whether mortality can be
reduced with targeted anaesthetic management based on BIS monitoring.
The original randomised trial was performed between 2005 and 2008 and
showed a 50% reduction in postoperative delirium5 among patients undergoing
surgical repair of hip fracture under spinal anaesthesia who had light versus
deep sedation. A later follow-up survival analysis was conducted among the
same patients with the suggestion that light sedation may reduce 1-year as well
as long-term mortality compared with deep sedation.
Methods
114 patients aged >65 were admitted following hip fracture to the Johns
Hopkins Bayview Hospital and underwent surgical repair under spinal
anaesthesia. Patients were randomised to light intra-operative sedation
(BIS>80) or deep intra-operative sedation (BIS approximately 50) by using a
propofol or midazolam infusion. Outcomes measured were 1-year mortality as
a primary outcome and overall mortality as a secondary outcome in all patients
and those with serious comorbidities.
Results
There was no significant difference in the 1-year mortality between the groups.
However 1-year mortality was reduced in patients with a Charlson comorbidity
score >4 who had light sedation (22.2%) compared with the deep sedation
group (43.6%; HR, 0.43; 95%CI, 0.19-0.97; p=0.04) during spinal anaesthesia.
Time to death was also noted to be 4.47 times longer in the light sedation group
than in the deep sedation group.
1-year mortality was also reduced in patients with a Nottingham score >4 who
had light sedation compared with the deep sedation group (HR, 0.44; 95 CI,
0.21-0.96; p=0.04), and time to death was again longer after light sedation
compared to deep sedation (RT, 4.37; 95% CI, 1.16-16.41; p=0.03).
Discussion
The trial demonstrated that 1-year mortality was reduced in patients with high
comorbidity scores who were randomised to light sedation compared with
those randomised to deep sedation. The results support the suggestion that
light sedation may have a role in reducing mortality, particularly among patients
with comorbidities undergoing surgical hip repair under spinal anaesthesia. The
results are limited because of the small sample size, unclear cause of death and
limitation to a specific surgery. Further research on reduced mortality following
light sedation during spinal anaesthesia is needed.
Methods
A matched, retrospective cohort study was undertaken using data collected
from general acute care hospitals in New York State between July 1st 2004 and
December 31st 2011.
Inclusion criteria were >50 years old, having sustained a hip fracture and the
principal procedure of ORIF, hemiarthroplasty or total hip replacement. For
patients with multiple hip fracture admissions, the first admission was the index.
Patients were matched in relation to the distance they lived from hospitals that
specialised in regional or general anesthesia. There was also a secondary
analysis included within hospital matches and across hospital matching.
The primary outcome was 30-day mortality. In-patient length of stay was a
secondary outcome. The hypothesis was that regional anaesthesia would be
associated with improved outcomes versus general anaesthesia.
Results
98,064 patients were identified for inclusion, 41,335 had missing data (those
with missing data were more likely to be from an area of greater poverty and
lower educational achievement). Of the remaining 56,729, 15,904 (28%) had
regional anaesthesia and 40,825 (72%) had general anesthesia. Those receiving
regional anaesthesia were older and had more chronic lung disease.
Overall 3032 (5.3%) people died. Mortality was 5.3% for regional anaesthesia
and 5.4% for general anaesthesia. The mean length of in-patient stay was 6
days in the regional anesthesia group and 6.3 days in the general anaesthesia
group (p <0.001)
Discussion
There was no reduction in 30-day mortality from the use of regional anaesthesia
compared with general anaesthesia. Regional anaesthesia was associated with
a slightly shorter length of hospital stay which was possibly related to a lower
rate of complications.
The authors injected 30 ml levobupivacaine 0.10% w/v in the first participant.
A reduction in pain score of ≥20 points with impaired cold sensation was
defined as effective. Subsequently, depending on whether the injection was
effective or ineffective, the levobupivacaine concentration injected into the next
patient was reduced or increased by 0.025% w/v, respectively. If cold and pain
measurements conflicted, the response was deemed ‘equivocal’ and the next
dose given at the same concentration. After recruitment of 17 patients, the ‘stepdown’ was reduced to 0.005% w/v, to make calculation of the ED50 and ED95
more efficient.
The authors used regression analysis to estimate the levobupivacaine
concentrations that would be effective in 50% and 95% of patients.3,4
Results
Data from 36/40 patients was analysed and estimated the ED50 and ED95 to be
0.026 (CI, 0.023–0.028) and 0.036 (0.027–0.047) % w/v, respectively.
Discussion
This study found that 30 ml of levobupivacaine at a concentration of 0.05% w/v
reduced rest pain by ≥20/100 points in patients with neck of femur fractures,
a concentration one-tenth to one-fifth of that typically used in clinical practice.
Christina McCarroll and Camilla Waugh
ST4 Northern Deanery
Lucy Powell
CT1 Anaesthesia, Sunderland Royal Hospital
References
1.
National Institute for Health and Clinical Care Excellence. Hip Fracture:
the Management of Hip Fracture in Adults. CG124 London: NICE, 2011.
2.
Parker MJ, Griffiths R, Appadu BN. Nerve blocks (subcostal, lateral
cutaneous, femoral, triple, psoas) for hip fractures. Cochrane Database
of Systematic Reviews 2002; 1: CD001159.
3.
Dixon WJ. The up-and-down method for small samples. Journal of the
American Statistical Association 1965; 60: 967–78.
4.
Brownlee KA, Hodges JH, Rosenblatt M. The up-and-down method with
small samples. Journal of the American Statistical Association 1953; 48:
262–77.
References
Monk TG, Saini V, Weldon BC, Sigl JC. Anesthetic management and one1.
year mortality after noncardiac surgery. Anesthesia & Analgesia 2005;
100: 4–10.
2.
Lindholm ML, Träff S, Granath F, et al. Mortality within 2 years after
surgery in relation to low intraoperative bispectral index values and
preexisting malignant disease. Anesthesia & Analgesia 2009; 108:
508–12.
3.
Leslie K, Myles PS, Forbes A, Chan MT. The effect of bispectral index
monitoring on long-term survival in the B-aware trial. Anesthesia &
Analgesia 2010; 110: 816–22.
4.
Kertai MD, Pal N, Palanca BJ, et al. Association of perioperative
risk factors and cumulative duration of low bispectral index with
intermediate-term mortality after cardiac surgery in the B-Unaware Trial.
Anesthesiology 2010; 112: 1116–27.
5.
Seiber FE, Zakriya KJ, Gottschalk A, et al. Sedation depth during spinal
anesthesia and the development of postoperative delirium in elderly
patients undergoing hip fracture repair. Mayo Clinic Proceedings 2010;
85: 18–26.
Anaesthesia News November 2014 • Issue 328
Participants were taken to theatre recovery, where a further pain score was
recorded and sensation to cold on the middle third of the anterior thigh tested
and compared with the contralateral thigh. Femoral nerve block was then
performed by one of the authors, a consultant anaesthetist, using ultrasound
and a Tuohy needle. A catheter was threaded through the needle after injection
of 30 ml levobupivacaine around the femoral nerve had raised the fascia iliaca.
Pain and cold measurements were repeated 30 min after levobupivacaine
injection, when 20 ml levobupivacaine 0.25% w/v was injected through the
catheter if the pain score exceeded 30/100.
Although this is a large observational study, the data are from just one US state
and the conclusions may not be applicable in other situations.
Mohamed Eid
ST5 Anaesthesia, Royal Victoria Infirmary
28 Method
Forty consecutive competent patients with a hip fracture and a resting pain score
of ≥50/100 before surgical fixation were included. Patients with local anaesthetic
toxicity, neurological conditions or lower limb amputation were excluded.
Anaesthesia News November 2014 • Issue 328
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