GAT 03–05 APRIL 2013 OXFORD, UK

ABSTRACTS OF THE

ANNUAL SCIENTIFIC MEETING

www.gatasm.org

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LIST OF POSTERSCase Presentation Posters

No. Title Author(s)

1 Ultrasound guidance helps avoid wrong operation and improves patient safety. V Athanassoglou, C Morris

2 A cause of uvular necrosis never before seen. V Athanassoglou, A Waddell, M Blahut-Zugaj

3Peripartum cardiomyopathy: A likely cause of profound hypotension and myocardial ischaemia following spinal anaesthesia for an elective caesarean section. J Blackshaw, H Hall

4 Uterine dehiscence following B Lynch suture. O Boyle, D Milne

5 A case study and guidance for the management of a patient with epidermolysis bullosum. A Bradley, R Croft

6 A case report of necrotising, haemorrhagic pneumonia caused by panton-valentine leukocidin positive staphylococcus aureus. C Bullen, N Ahmed

7 Hyperlipidaemic pancreatitis of pregnancy. M Chazapis

8 A case of negative pressure pulmonary oedema: understanding pathophysiology a key to understanding management. C Conroy

9 Management of an unusual adult case of acute stridor in a small district general hospital. T Crilley, J Snelling, J Everatt

10 Severe adult respiratory distress syndrome and extracoporeal membrane oxygenation. R De Las Casas, L Forbes, A Chakladar, S Marstin

11 Visualisation of an epidural septum that prevented the bilateral spread of contrast in the lumbar epidural space. V Dhokia, S Smith, S Ramani

12 Ventricular tachycardia complicating the anaesthetic management of cauda equina syndrome. C Dickson, T Sams, I Kannan

13 One-lung ventilation in a patient with sickle cell disease: A case report. K Francis, J Collins, D Pigott

14 Retrograde extradural catheter “traction technique” for awake difficult tracheal intubation. S Ghaffar, D Ball

15 A case report of concurrent thyrotoxic crisis and diabetic ketoacidosis. V Humphrey, B Slater

16 Perioperative presentation of traumatic carotid artery dissection. B Ivory

17 Infection due to tuberculosis bovis in ulcerative colitis patient treated with infliximab. V Mandava, C Webb, B Das

18 Anaesthetic management in a parturient with uncorrected Tetralogy of Fallot. J Parker, C Grange

19 Midazolam-induced hyperactivity treated with flumazenil.S Potru, A Joseph, R Rajendram

20 Life threatening intraoperative hypoxemia in a patient with thalassemia major. K Grange, S Kannan, S Sivasubramaniam

21 GHB causes GBH when withdrawn. N Pritchard, R Hewson

22 Seizures post-partum due to an acquired long QT Syndrome. R Rajendram

23 Not all smokers who are short of breath have COPD. R Rajendram, R Parker

24 Treating Cushing’s: A renaissance for etomidate infusions in ICU. R Rajendram, S Schirru, J Griffiths

25 Spinal anaesthesia for elective caesarean section in a woman with multiple sclerosis. C Richardson, R Jones, J Greenwood

26 Overdose of ethylene glycol with an unexpected neurological recovery. W Rutherford, D Quemby, T Guest

27 Just a little tongue biopsy... C Seeley, I Driver, I Hatcher

28 Awake fibreoptic intubation in a patient with isolated laryngeal fracture. S Shotter, G Sommerville

29Phaechromocytoma presenting under anaesthesia for day surgery: The role of magnesium in the patient’s subsequent management and a complication possibly related to its use.

E Sleap, M Jenkins, A Wade, J Wells

30 Regional obstetric anaesthesia in non-surgical scoliosis patients. S Stobbs, S Cross, R Burns

31 Major haemorrhage from scalp laceration. A Sykes, P Dowson

32 Abdominal hypertension masking propofol infusion syndrome.E Traer, R Rajendram, J Mandeville, J Griffiths, J Westbrook

33 Normoglycaemic diabetic ketoacidosis in pregnancy. S Vasdev, J Salim, T Jovaisa

34 Chylous ascites: An unusual cause of a pleural effusion. J Wakeford, P Farquhar-Smith

35 Back pain. A cautionary tale. C Williams, T West, S Bell, L DeLloyd, S Harries, R Baraz

36 TOE scan or not TOE scan (on GICU). Ask and it shall be given to you; seek and you will find. C Williams, S Ahmed

37 Starting a remifentanil infusion at the end of surgery to facilitate smooth emergence from anaesthesia in a potentially difficult airway. M Wilson, C Burnand

Abstracts of the GAT Annual Scientific Meeting03–05 April 2013Oxford, UK

This abstract book has been produced using author-supplied copy. Editing has been restricted to some corrections of spelling and style where appropriate. No responsibility is assumed for any claims, instructions, methods or drug dosages included in the abstracts: it is recommended that these are verified independently. The contents contained herein are correct at the time of printing and may be subject to change.

All submitting authors have declared that appropriate ethical approval has been obtained and that written informed consent has been obtained from research subjects, and written consent for publication from patients for case reports.

These abstracts will appear online on the GAT website:

www.gatasm.org/content/oral-poster-prizes

Title Presenting Author(s)

The effect of anaesthetist led sedation training on the quality of sedation practices in Derriford hospital cardiology department Dr B Ivory

A new method of securing epidural catheters using histoacryl® skin adhesive Dr S Leach

The ‘go-between’ study: the Traffic Lights tool as a means of effective communication between anaesthetic staff Dr S MacDougall-Davis

Improving ITU discharge documentation Dr C Parikh

Returning to work in the West Midlands Deanery: a survey of recent trainee experience and introduction of a return to work programme Dr E Plunkett

Management of post operative surgical epidural analgesia Dr H Yusuff

Case Presentation Oral Prize

A broken heart in day case – do anaesthetists know enough? Dr B Spooner

A role for intravenous lipid emulsion in cardiac arrest secondary to life-threatening carbamazepine overdose Dr A Sud

Post operative cerebral salt wasting syndrome following spinal tumour resection Dr R West

Anaesthesia History Prize winner presentation

The historical role anaesthesia has played in discovering the nature of consciousness Dr M John

RSM Essay Prize winner presentation (supported by the RSM Section of Anaesthesia)

Leading change in anaesthesia in a multi-disciplinary setting Dr C Johnston

Dräger Oral Presentation Prize

LIST OF FREE PAPERS

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Poster Competition Foundation Year

No. Title Author(s)

38 ICU patient pain assessments are often limited, with different factors affecting medical and nursing reviews. S Alderson, F Frame, C Goh, S McKechnie

39 An audit of anaesthetists’ awareness of the contents of the difficult airway trolley. T Barge, P Duggleby

40 Delirium in cardiothoracic ICU patients: Is recognition improved with the use of a daily assessment tool and period of education. A Bing, J Wang, P Alston

41 Continuous venovenous haemofiltration: Improving patient safety in our unit. J Harrison, A Jacques

42 Low flow audit. D Macrosson, R Brits, Z Kovacsai

43 Effectiveness of procedure-related pain management during burns dressing changes – is there a need for distraction techniques? Y Mustafa, C Small, M Bowden

44 Risk of readmission to intensive care units. D Patel, D Young

45 Admissions and outcomes of vascular surgery patients admitted to Peter’s Intensive Care Unit before and after service expansion. M Sweeney, M Parris

No. Title Author(s)

46 Returning to work after maternity leave; Are we following the recommendations? K Arrow

47 Bispectral index monitoring in patients undergoing elective surgical resection of non-small celllung Cancer; An Observational Study.M Aslam, J Yeung, M Wilson, B Naidu, T Melody, F Gao-Smith

48 Nasendoscopy use in a district general hospital. A Biffen, A Varvinskiy

49 Organ donation survey: Assessment of the attitudes and knowledge of appointed clinical leads in organ donation. J Blackshaw, J McCann

50 Reducing starvation times and improving patient experience in elective caesarean section patients: preoperative isotonic drinks. K Bosworth, M Davies, J Marriott, S Millett

51 An audit of consent in anaesthesia. K Bosworth, M Davies, S Risebero

52 Timekeeping within the Leicester Royal Infirmary operating department. M Charlton, A Packham

53 Sepsis recognition and management at Kettering General Hospital: Audit of current practice. M Charlton, P Watt

54 A service evaluation on the use and interpretation of ROTEM® six months after its introduction in a regional trauma centre. T Clarke, B Batuwitage, S Mercer

55 The rate of blood culture contamination in an intensive care unit. J Clifford-Brown, N Cree

56 A review of high risk obstetric patients requiring anaesthetic intervention in Middlemore Hospital. M Cockroft, C Matthews, J Taylor, J Dimech

57 A survey comparing anaesthetic consent between two regions. G Davenport, Y Rajendran, G Yap, S Halder, S Bates

58 Performance of single-use laryngeal mask airways, an audit. M Davies, J Lee, A Norman

59 Emergency Laparotomy at West Wales General Hospital: Identification of factors affecting outcome. S Elgarf, S Jha, G Milne

60A preliminary study to determine predictors of blood product requirements in burns surgery, and whether tranexamic acid reduces perioperative blood product requirement.

A Fisher, M Kelly, Y M Foong, S Desilva, T Mahambrey

61 CPR status – can we improve advance planning? D Hall, I Mohamed, E Buchanan

62 Extending lifebox beyond the operating room. A Hewitt Smith, R Hallam

63 Pre-Operative Assessment Documentation. K Hill, M Moneypenny

64 Audit of timing of emergencies on the 24 hour clock. H Lindsay, V Cherian

65 An audit of anaesthetic machine logbook completion: have new guidelines made an impact? F Mazzola, A Jandziol

66 Retrospective study of an enhanced recovery programme for total knee replacement patients. L McLoughlin, S Fludger, N Airey

67 An audit of basic airway equipment. R Medlock, S Webster-Edge

68 Consent in anaesthesia: an audit of practice. R Medlock, D Stevenson

Poster Competition ACCS/CT1/CT2

No. Title Author(s)

69 Ability of anaesthetic staff to reliably identify extremely high tracheal tube cuff pressures by palpation of the pilot balloon. S Michlig

70 A multi-site audit of anaesthetic equipment timing. B Millette, K McGlennan

71 Resuscitation equipment checks - are we getting them right? I Mohamed, D Hall, E Buchanan, F Dallas

72 An audit of post-operative analgesia in patients undergoing DIEP flap breast reconstruction. A Muirhead-Smith, N Bourne, J Myatt

73 Conversion from regional to general anaesthesia for caesarean section: We are meeting the standards? A retrospective audit of practice. A Nash, P Stevens

74 An audit of analgesia for fractured neck of femur at Darent Valley Hospital. D Neely, L Oswald, M Kanagarathnam, M Satisha

75 Perioperative venous thromboembolism prophylaxis: The anaesthetist’s potential impact on patient safety. W Shippam, S Phillips, M Peck

76 A simple card makes drug prescription and administration safer. W Shippam, J Jackson, J Kirk-Bayley, A Raj

77 An audit of volatile use and fresh gas flows in a District General Hospital. B Smith, L Davis, M Tindall

78 Antibiotic duration: Can procalcitonin rationalise prescribing in a district general hospital? F Tait, D Marriott, P Watt

79 Theatre simulation training. J Vedwan, T Everett, A Vaughton, R Jee

80 Elective major joint replacement- an ongoing comfortable journey. M Yeoh

81 Quality care in quantity. M Yeoh

No. Title Author(s)

82 The prevalence of high obstetric body mass index and its impact on anaesthetic service provision. N Abu Al-Saad, C Williams

83 Intensive care glycaemic control, is it optimal? A Al-Dujaili

84 Be aware of air. A Allen

85 Randomised controlled trial data of preemptive analgesia to prevent the development of neuropathic pain after cardiac surgery.S Anwar, J Rahman, C Sharma, A Hemming, R Langford

86 Use of the Bivona Fome-Cuf tracheostomy and bed head signs. G Barker, R Rajendram

87 Enhanced recovery after surgery in obstetrics: a regional (west midlands) survey of current practice. A Bodh, M Ramamoorthy, S Dinesh

88 Complete audit cycle of fasting times for children having non-elective surgery at The Royal Manchester Children’s Hospital. A Bradley, S Rolfe, D Patel, V Oshin, B Lomas

89 Raising the alarm again. S Campbell

90 Data driven healthcare; right under our noses? S Campbell

91 A audit of emergency theatre delays in a district general hospital. L Carrick, K Szypula

92 Urinary catheterisation in elective hip and knee arthroplasties following introduction of the enhanced recovery protocol. S Chauhan, F Ismail, L Handcock

93The North West Airway Management Database (NWAD) - a reporting system to improve patient safety and airway management training (www.eanaesthesia.com/nwad). C Conlon, JP Lomas

94 Review of a new “DNACPR/Acute care limitation of treatment plan” form. S Dunlop, R Ferrie, T Birke, P Smith

95 Substantive locum anaesthetic jobs are said to be the normal route for post CCT trainees, a glimpse at jobs for the last five years. C Fiandeiro, J Petrie, N Eltom, S Yentis

96 Development of a multidisciplinary simulation programme based upon the Royal College of Anaesthetists curriculum. L Forbes, C Eitel, D Melville, J Turner

97 Learning from NAP 4 - multidisciplinary simulation training in airway emergencies. V Fox, P Patel, O Boomers, I Sockalingam

98 How the use of a non invasive cardiac output monitoring device influenced fluid management in major colorectal surgery - a retrospective audit. P Garry, S Menon

99 An audit of malignant hyperthermia crisis management. D Glasgow, D Hughes

Poster Competition ST3+ Doctors

WITHDRAWN

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No. Title Author(s)

100 Daily sedation holds in the intensive care unit: an audit of local practice following introduction of a sedation protocol. C Goh, G Barker, S Alderson, S McKechnie

101 High fidelity simulation training for the primary FRCA OSCE. R Harvey, C Gillan, S Edgar

102 Lung care during general anaesthesia: A survey of anaesthetic practice in the UK. D Horner, A Lumb

103 Text message reminder to prompt administration of pain relief after children’s day surgery – a proof of concept initiative. L Hulatt, O Hussain, V Allen, D Mason

104 Anaesthesia and the environment: an audit of anaesthetic waste disposal in the operating theatre. C Ivermee, T Katawala

105 The projected cost savings with the use of recycling bins on an ICU in the UK. B Ivory

106 Setting up a regional trainee committee and teaching programme in the Oxford Deanery. C Janes, M Rowland, J Shorthouse, O Dyar

107 Implementation of Thromboelastography® Platelet Mapping™ to reduce cancellations in surgical patients on antiplatelet therapy. R Kasivisvanathan, K Mitchell, S Mallett

108 Safety cannulas - one cannula to rule them all? R Khirwadkar, A Bhalla, C Dragomir, C Chevanesse

109 ‘A pain in the neck’: establishing a safe system for changing tracheostomy tubes in hospitalised patients.M Kigozi, S Esprit, T Moorthy, C Bradley, L Clarke, R Yorke, J Dunne, C Holland, S Uddin

110 Shared mental models, team expertise and patient safety in anaesthesia. N Lau, S Malhotra, M Burtscher, N Sevdalis

111 Total knee arthroplasty: local infiltration of anaesthetic versus other methods of analgesia. S Liddle, V Annam

112 Audit of anaesthetic volatile use at a large tertiary referral centre in Northern England. S Lobaz, M Hamilton, A Sweenie

113 Have lessons been learnt? An audit of difficult airway planning and experience in anaesthetists. J Longbottom, S Varshney

114 Aseptic precautions in paediatric caudal anaesthesia. A Maddock, P Jefferson, D Ball

115 End-of-life care in four adult intensive care units in the Oxford University Hospitals Trust. N Makris, T Kauhanen, W Seligman

116 An audit of money saved with the purchase of a new ultrasound machine. J Mathers, D Patel, A Hayward

117 Audit of preoperative fasting times for elective caesarean section: Are we compliant with new guidelines? V Nalawade, R Thompson

118 Prospective caesarean section GA audit: Are we compliant with revised RCOA standards? V Nalawade, U Misra, Z Arfeen

119 Anticonvulsant use in traumatic brain injury (TBI). G Nickols, D Janssen, A Manara

120 Elective asleep fibreoptic intubation for teaching. A retrospective analysis of 136 cases. C Oscier, T Pepall, P Sidebottom

121SMART-COP score for patients admitted with community acquired pneumonia (CAP) to an ICU in a district general hospital: A smarter way of identifying patients with severe CAP? M Pachucki, F Kelly, A Padkin

122 Improving access to critical incidents management guidelines in district general hospital theatres. M Pachucki, P Hersch

123 An integrative review of physical rehabilitation on ICU.R Parker, J Halliday, R Rajendram, J Griffiths

124 Assessment of how well the safer surgery WHO theatre checklist is completed. J Parmar, N Hickman, T Bourne

125 Survey of anaesthetists’ preferred method for postoperative oxygen supplementation following simple general anaesthesia. J Parmar, W Russell, O Williams

126 Intraoperative CPR in the prone position, would you perform it? S Phillips, F Lamb, M Mackenzie

127 Prevention of cough at tracheal extubation: A meta-analysis of six techniques. R Rajendram, A Joseph, SK Ramachandran

128A randomized, crossover, observational simulation-based survey comparing use of a needle-guide with the freehand technique for in plane US guided regional anaesthesia. R Rajendram, J McGrath

129 The provision of an on call service for regional anaesthesia. R Rajendram, J McGrath, S Stamatakis, A Joseph

130 Optimising fasting of children prior to elective cardiac surgery. R Rajendram, B Clevenger, E Haxby

131 Readmissions to ICU after small bowel transplantation. R Rajendram, I Edmond, T Thomas, J Millo

132 Improving use of the WHO Surgical Safety Checklist. R Rajendram, A Joseph

133 Readmission to ICU after kidney and pancreas transplantation. R Rajendram, G Hadjipavlou

134 Agreement on ECG rhythm strip interpretation by anaesthetists. R Rajendram, S Kale, S Patel, V Nangalia

135 Prolonged clear fluid fasting times on the gastroenterology suite: the unintended consequence of the recommended fasting time. K Richardson, J Smith, A Pearson

136 Regional anaesthesia for facial plastic surgery. A Riskalla, P Modayil, A Joseph, R Rajendram, A D'Souza

137 Northern deanery primary FRCA trainee survey. T Sams, C Dickson

138 Data storage and backup: An audit of trainees’ habits. A Simpson

139 The impact of electronic prescribing in a district general hospital intensive care unit on medication error rates – a completed audit cycle. J Strachan

140 Informed consent for general anaesthesia – an audit of risks discussed with patients. L Talbot, G Paddle

141 Setting up an ‘ introduction to tracheostomy management course’ for health care professionals in the west of Scotland. K Tober, K Owen

142 Improving morbidity and mortality in the emergency laparotomy patient. A Vaughton, S Baker

143 Audit of timing of epidural top-ups prior to delivery; a completed audit cycle. J Wakeford, M Stevens

144 An audit of hydrocortisone use in the treatment of septic shock. D Whitmore

145 Anaesthesia For organ donation in brainstemdead patients: A UK national survey. M Wilson, J Cupitt

146 Re-audit of Management of fracture neck of femur. Are we improving? C Yeow, P Poh, E Pillai, J Dedhia

Medical Students Prize Poster Competition

No. Title Author(s)

147 Provision for the higher risk surgical patient, the Royal Cornwall Hospital perspective. D Bunce

148 Are their faces really smiling? - Paediatric pain assessment. H Donaldson, H Laycock, C Bantel

149 Privacy and dignity in the recovery room after surgery audit at the Bradford Royal Infirmary (BRI). T Foulcher, S Griffith

150 Epidural anaesthesia and analgesia in hepatic resection. T Jarbawi

151 Audit on the emergency induction checklist. M Jones, D Maloney, RM Knights

152 In-situ patient simulation as a tool for prehospital training. R McCarthy, S Mitra

153 A cry that can’t be heard.

I Savage, Z Sheng, B Macpherson, C Connell, G Kennedy, C Marshall, S Mckerron, I Ross

154 The relationship between stigmatization and self-esteem in chronic pain patients. M Wall, D Hegarty

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The effect of anaesthetist led sedation training on the quality of sedation practices in Derriford hospital cardiology departmentB Ivory1, A Millar-Brown1, M Bennett1

1. Derriford Hospital, Plymouth, UKbenivory@doctors.net.uk

A 2008 NPSA rapid response report made a number of recommendations about the safe use of midazolam sedation including the importance of an organisational policy for sedation and theappointment of a senior clinical (usually an anaesthetist) to overall responsibility [1]. Overdose of midazolam during sedation was added to the Department of Health list of ‘Never Events’ in 2011 [2]. This audit was performed to assess the quality of cardiologist administered sedation in Derriford Hospital and to assess the effect of an anaesthetistdesigned and led program of sedation training.

MethodsStandards were defined in three areas of sedation practice: documentation, personnel and safe conduct of sedation. For documentation, the recording of patient fasting status, drug history and allergies was audited. The standards for personnel were that there should be a member of staff dedicated to monitoring the patient and that an advanced life support provider should be present. The standard for sedation conduct was that flumazenil should not be administered to any patients. Initial data collection took place between March and April 2010. After initial data collection and dissemination a compulsory program of seminar- based training was conducted for all staff involved in sedation in the cardiology department. The audit was repeated in May 2012.

ResultsSummary of key results from both data collection points

April 2010 cases n=46

May 2012 cases n=85

Flumazenil administered (%) 7/46 (15%) 0/85 (0%)Respiratory rate monitored (%) 39/46

(85%)83/85 (98%)

Allergies recorded (%) 40/46 (87%)

81/85 (95%)

Existing medications recorded (%)

35/46 (76%)

64/85 (75%)

Fasting status recorded (%) 40/46 (87%)

83/85 (97%)

Person dedicated to monitoring present (%)

38/46 (83%)

57/85 (67%)

ECG and sats monitored (%) 46/46 (100%)

85/85 (100%)

DiscussionSignificant improvements were seen in the key quality areas of flumazenil usage (15% of cases c.f. 0% post intervention) and respiratory rate monitoring (85% c.f. 98%). The provision of a staff member dedicated to patient monitoring did not improve, but this may represent problems with funding rather than a failure of the education program.

References1. Department of Health 2008. Reducing risk of overdose with

midazolam injection in adults. Department of Health. http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59896.Accessed 10th January 2013

2. Department of Health 2011. The ‘never events’ list for 2011/12. Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124552 Accessed 10th January 2013

A new method of securing epidural catheters using histoacryl®skin adhesive

S. Leach1, J.Wilkinson2

1Great Ormond Street Hospital, London, 2Northampton General Hospital, NorthamptonCorrespondence: ispysi@doctors.org.uk

A large survey of UK practice, demonstrates that premature epidural detachment varies widely from 1% to 35% [1]. Premature fall-out results in failure of the primary mode of analgesia. A Royal College of Anaesthetists standard states, “less than 7% of patients should experience failure of analgesia in first 24h after surgery”. The Audit Commission (UK) proposed that less than 20% of patients should experience severe pain following surgery and that this should reduce to less than 5% by 2002 [2]. We audited our current practice to ascertain whether we were meeting these standards.

MethodsThirty-six epidurals were sited over a four month period in 2010. Of these, 12 (33%) fell out or failed prematurely when secured only with an adhesive dressing. This demonstrated poor control of the process. We then adopted a new technique using Histoacryl® (B-Braun) skin adhesive to secure the epidural catheters [3]. After insertion, the catheter was coiled and three points on the coil were bonded to the skin, with a further bonding point at the entry site. The whole catheter loop was then covered with a transparent, adhesive dressing. Our anaesthetists, pain control team and ODP’s were educated in this new technique. A new epidural trolley was set-up containing laminated guidance and adhesive was added to epidural packs. Over the next three months, the fixation status of all patients with epidurals in situ was analysed by the acute pain team as part of their routine rounds.

ResultsThe Histoacryl® glue technique reduced the epidural premature fall-out rate from 12 of 36 sited (33%) to 1 of 38 sited (2.6%). There were no skin reactions or mechanical problems with the catheters. The glue fixation was comfortable and highly acceptable to the patients. The ward staff reported no aftercare issues.

DiscussionGood post-operative analgesia is the gold standard for all patients undergoing surgery and we are now above the quoted standards set by the RCOA and the Audit Commission. There is evidence that good analgesia helps minimize post-operative morbidity and mortality [4]. Loss of an effective epidural exposes patients to the complications of inadequate analgesia, the side effects of alternatives and potentially increases length of stay. Histoacryl® glue fixation is a safe, effective and inexpensive method of securing epidural catheters (the NHS cost of a vial of Histoacryl ® is about £4). Furthermore, it provides protection against epidural related infections [5] and is both quick and simple to perform.

References1. Wilkinson JN, Sycamore HL. A survey of UK epidural

practice. Journal of the New York School of Regional Anaesthesia. (Online).

2. Audit Commission. Anaesthesia Under Examination. Audit Commission, London, 1997.

3. Wilkinson JN, Chikhani M. The use of Histoacryl skin adhesive to secure thoracic epidural catheters. Regional Anaesthesia and Pain Medicine. September-October 2007;32: 5.

4. Tsui SL, Law S, Fok M et al. Postoperative analgesia reduces mortality and morbidity after esophagectomy. TheAmerican Journal of Surgery. 1997 Jun;173(6):472-8

5. Wilkinson JN, Gill S, Chikhani M, Mortimer K. The antimicrobial effect of Histoacryl® adhesive. Anaesthesia.2008; 63(12): 1382-1384.

The ‘go-between’ study: the Traffic Lights tool as a means of effective communication between anaesthetic staff

S. R. MacDougall-Davis, L. Kettley, T. M. Cook

Royal United Hospital, Bath, UK. sophiemd@doctors.org.uk

Problems with communication are common in critical incidents. It is common during anaesthetic care that a trainee cannot leave the patientbut needs to communicate to a senior colleague for reasons ranging from non-urgent advice to immediate direct assistance. Information is transmitted by a ‘go-between’: often a non-anaesthetic healthcare professional. Precise communication of the urgency and content of a request for assistance is critical for patient safety in both theatres. The Department of Health recommends the SBAR (Situation, Background,Assessment, Recommendation)1,2 tool. This study evaluates whether a new ‘Traffic Lights’ tool improves communication of urgency, clarity, speed and content of a request for assistance between anaesthetists.

MethodsA Traffic Lights tool was devised: ‘RED ALERT’ (help required immediately, life threatening emergency), ‘AMBER ASSIST’ (help required promptly, within minutes) and ‘GREEN QUERY’ (query/advice required, non-urgent). Forty anaesthetic consultants and trainees validated the tool using an online survey of 12 scenarios of varying urgency. A simulation-based study was carried out using thesescenarios. There was no requirement for ethics approval but local R&D approval was obtained prior to the study. Participants were trained to use the SBAR tool and then directed to use it to communicate during clinical simulations. Each scenario was run with a trainee (message sender) and consultant anaesthetist (message recipient), an anaesthetic assistant and another theatre staff member (‘go-between’) in a simulated theatre environment. The trainee requested help via the go-between who then relayed the message to the consultant in a separate ‘theatre’. Upon receipt of the message, the consultant recorded the content of the message and rated clarity and urgency of the requested response using Likert scales. Time taken to relay the message and compliance with the intended tool was recorded. Participants, previously blinded to the traffic light tool, were then trained in its use, and repeated the above process with different scenarios. All participants completed 6 scenarios with each communication tool, block randomised to include two each of red, amber and green. Finally, participants rated the usefulness of the two communication tools. Mann-Witney U tests were used to compare ordinal and continuous data and Fishers Exact test for categorical data.

ResultsBoth tools were effective at conveying the urgency of the message. Compared to SBAR, Traffic Lights was more reliable, transferred information better and was judged to lead to greater clarity (all p<0.0001). Traffic Lights reduced message delivery time (20sec vs 45sec, median difference 25sec, 95% confidence interval 19-30sec).Both trainee (p<0.0001) and go-between (p=0.008) were more likely to use the intended message structure using Traffic Lights than SBAR. The majority of participants preferred Traffic lights (23/24, 96%).

DiscussionThe Traffic Lights tool has the potential to improve patient safety through more accurate and timely communication and improvedadherence to message structure. We recommend the adoption of this communication tool as standard practice for anaesthetic teams.

References1. Leonard M, Graham S, Bonacum D. The human factor: the

critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Healthcare. 2004; Oct 13: Suppl 1:i85-90.

2. NHS Institute for Innovation and Improvement website. http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/sbar_-_situation_-_background_-_assessment_-_recommendation.html

Improving ITU discharge documentation

C. Parikh1

St.Richard’s hospital, Chichester, UK.Chandniparikh86@hotmail.com

The majority of patients discharged from St.Richard's hospital ITU prior to November 2011 were discharged with no formal documentation. This was observed on both ITU and HDU. General pattern observed: Incomplete discharge documentation usually occurred after 5pm on weekdays and weekends. Discharge documentation help ensure patients are handed over appropriately and accurately [1].

Aims• To look at the number of discharge summaries written and

correctly completed for each patient discharged from ITU/ HDU in a one month period.

• To produce a ITU discharge proforma.• To re-audit discharge documentation for a month period,

post- introduction of discharge proforma.

MethodsAll patients on ITU and HDU discharged from 1st October 2011 for a month. The number of completed discharge summaries were counted.If discharge documentation present, analysis of 8 subsections within the discharge summary were sought for. The same methods were used when re-auditing from 1st March 2012 for a month.

ResultsIn October 2011 there was a total of 45 discharges of which there was 35 discharge-summaries present (78%). Only 2 of 35 were completely filled out with the relevant subsections (6%).After the discharge proforma was introduced data was collected in March 2011.In March 2011 there was a total of 44 discharges of which there was 42 discharge summaries present (95%). There were 38 out of 42(90%) discharge documents which were filled out with all the relevant subsections.

DiscussionIntroducing a discharge proforma has increased the number of discharge summaries being completed. Using an ITU discharge proforma has enabled receiving teams to be more informed as more subsections are being filled. Providing more information to receiving teams. Completion of proformas with pertinent information regarding patient's clinical care has helped to ensure patient's safety.

References1. Thomas, MJ. Failures in transition: Learning from incidents

related to clinical handover in acute care. Journal of healthcare quality. 11: 1945-1474.

Dräger Oral Presentation Prize

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Returning to work in the West Midlands Deanery: a survey of recent trainee experience and introduction of a return to work programme

E. V. E. Plunkett1, C. L. Baxendale2, N. Osborn2, J. Budd1, K. Cullis3

and A. Malins4

Worcestershire Royal Hospital, Worcester, UK, Heartlands Hospital, Birmingham, UK, Queen Elizabeth Hospitals, Birmingham, UK and Postgraduate School of Anaesthesia, Critical Care and Emergency Medicine, West Midlands Deanery, UKemmaplunkett@doctors.org.uk

There have been several documents published recently on the subject of Returning to Work: an update of the Royal College of Anaesthetists (RCoA) Return to Work Guidance [1] and a new guidance document from the Academy of Medical Royal Colleges (AoMRC) [2]. These give recommendations regarding what a re-introduction to the workplace should involve. The Wessex Anaesthetists have developed a Return to Work Programme [3] which has been recognised as “an example of good practice” by the RCoA. There has also been a recent increase in Return to Work (RTW) courses for anaesthetists returning to work after a break. Our aim was to establish what the experience of our local trainees has been, with a view to improving this whilst also accounting for recently published guidance.

MethodsWe designed an online survey which was sent out in May 2012 to all trainees in the West Midlands who had had a recent return to work following a period of maternity leave.

ResultsThe survey was sent to 25 trainees and there was a 72% response rate (18/25). Four surveys were incomplete. The return to work date ranged from December 2008 to February 2012. 78% (14/18) of respondents returned less than full time and the average length of time off was 10.5 months (range of 7-13 months). Most (72%) traineeswere ST5+. 39% (7/18) stated they did not receive any advice regarding their RTW. Only three trainees used Keeping in Touch (KIT) days and no trainees did specific RTW courses. No respondents did extra assessments as part of their return to work and there was an average (mean) of 2.7 weeks before starting on calls (range 0-7 weeks, median and mode = 2). Trainees returning full time found their confidence returned rapidly (1-3 weeks) but this was more variable for LTFT trainees. 10/14 (71%) reported one or more problems on returning to work.

DiscussionOn the basis of these findings, an action plan of ways that trainees’ RTW could be improved has been agreed. This includes increasing awareness of RTW guidance, KIT days and RTW courses. Most importantly an RTW programme has been introduced for anaesthetic trainees. This is similar to the Wessex programme but is extended to include “Pre-leave planning” in addition to a “Record of Re-introduction to Duties”. Our associated paperwork includes guidance for trainees and their supervisors and all the relevant items from the AoMRC checklist, formatted in a way to make it user friendly for our speciality and region. A generic deanery “Return to Training” policy is also in preparation based on the anaesthetic programme.

References1. Royal College of Anaesthetists. Returning to work after a period

of absence. May 20122. Academy of Medical Royal Colleges. Return to Practice

Guidance. April 20123. King W, Haigh F, Aarvold A, Hopkins D, Smith I. Returning to

work the Wessex Way. Anaesthesia News June 2012; 299: 18-19

Management of post-operative surgical epidural analgesia

H. Yusuff1, S. Chadwick1 and I. Clegg1

1-North Manchester General Hospital,Manchester UK

Email- haty_67@yahoo.co.uk

In 2002, a patient had an epidural abscess and a number of contributory factors in the postoperative management were highlighted in an audit. A trust wide protocol was produced and implemented across the three hospitals in the trust. We conducted an audit to evaluate the management of surgical patients receiving epidural analgesia over a 5 year period to find out if practice has changed. We also analysed the microbiology results of all the epidural catheter tips.

MethodsWe retrospectively analysed 1932 patients who received post operative epidural analgesia between 2007 and 2011. We excluded obstetric patients. Data was extracted from clinical notes by the acute pain nurses and the laboratory results data base. The data was analysed using Microsoft excel and stats direct

ResultsFive hundred and hundred and eighty two patients had a positive microbiology catheter result of which most were normal commensals. Eighty four patients (14%) grew pathogenic organisms (fig 1). Fifty percent of Catheters kept in for longer than 5 days belonged to patients in the7th and 8th decade. Twenty one percent of patients with pathogenic catheters had diabetes and a similar percentage had an active infection in a separate anatomical location, the most common site being respiratory. Hepatobiliary (27%) and Colorectal (23%) surgery were the most prevalent specialties in the pathogenic group. There was no case of epidural abscess.

Table 1: Organisms cultured from epidural catheters

DiscussionFrom the results the elderly were more likely to have the catheters left in situ for longer, a risk factor which can be modified. It is especially necessary to modify this risk factor as the elderly have a higher mortality when they develop epidural abscess2. It is likely that patients with cancer having received adjuvant chemo-radiotherapy are at increased risk as demonstrated by a high prevalence of positive catheters in patients who have had Hepatobiliary and Colorectal operations. We have changed the trust wide protocol to include sending epidural tips for culture and early removal of catheters especially in high risk patients.

References1. T. M. Cook, D. Counsell and J. A. W. Wildsmith on behalf

of The Royal College of Anaesthetists Third National Audit Project. Major complications of central neuraxial block British Journal of Anaesthesia 2009; 102 (2): 179–90

2. Sendi P, Bregenzer T, Zimmerli W. Spinal epidural abscess in clinical practice. Quarterly Journal of Medicine.Jan 2008;101(1):1-12.

Organism NumberStaph. Aureus

including MRSA22

Enterococcus 12Pseudomonas. A 3Escherichia. Coli 8

Coagulase negative staph

157

Dräger Oral Presentation Prize Case Presentation Oral Prize

A broken heart in day case – do anaesthetists know enough?

BB Spooner1, AJ Gait1, R Huggett1

Russells Hall Hospital1, Dudley, West Midlands, UKbspooner@doctors.org.uk

We report the unusual case of a 37 year old female patient with Downs syndrome who suffered cardiac arrest immediately following induction of general anaesthesia. She was later found to have a stress induced cardiomyopathy (also known as broken heart syndrome or takotsubo cardiomyopathy). Stress induced cardiomyopathy has been reported in the perioperative period [1], but not in a patient with a learning difficulty.

Case reportThe patient was scheduled to have dental extractions under general anaesthesia as a day case procedure. She did not have any cardiovascular complications of Downs syndrome. She received no premedication. Before induction of anaesthesia her heart rate was 120 beats min-1 and her blood pressure 160/110 mmHg. She was uncooperative and had an inhalational induction. Following induction of anaesthesia she became profoundly bradycardic and then suffered an asystolic cardiac arrest. Cardiopulmonary resuscitation was commenced with 1mg of adrenaline which led to a return of spontaneous circulation within two minutes. Electrocardiogram showed ST elevation in leads I and aVL without reciprocal changes.Echocardiogram showed apical akinesia of her left ventricle. Her peak troponin was elevated at 5.0 µg/l (<0.01). A diagnosis of stressinduced cardiomyopathy was made. Coronary angiogram was not performed as the patient would have required further general anaesthesia. Her echocardiogram and ECG returned to normal eleven days after the event and she recovered fully.

DiscussionStress induced cardiomyopathy (also known as takotsubo cardiomyopathy or broken heart syndrome) was first described in 1990 in Japan [2], and not described in the perioperative period until2006 [1]. It is a transient non-ischaemic reversible myocardial dysfunction which usually occurs following psychological, emotionalor physiological stress [3, 4]. The most commonly accepted cause is excessive adrenergic stimulation following stress leading to coronary artery spasm [4]. It mimics myocardial infarction, but coronary angiography is normal. Echocardiography typically demonstrates left ventricular apical ballooning, which resembles a fishing pot used in Japan for catching an octopus (“tako tsubo”). It has been described in the perioperative period in patients with anxiety [4]. The subsequent anaesthetic management of this condition is yet to be established. Awareness of this condition amongst anaesthetists is important astheir patients are often anxious and stress induced cardiomyopathy is an important differential diagnosis for all perioperative cases of myocardial dysfunction. It may have been under-diagnosed previously. The use of premedication to reduce anxiety has not been researched but could be considered to potentially reduce the risk of stress induced cardiomyopathy in patients with anxiety or learning difficulties.

References1. Gavish D, Rozenman Y, Hafner R et al. Takotsubo

cardiomyopathy after general anesthesia for eye surgery.Anesthesiology 2006;105:621-3.

2. Dote K, Sato H, Tateishi H et al. Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases.Journal of Cardiology 1991;21:203–14.

3. Scott WS, Lesser JR, Andrey GZ et al. Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation 2005; 111: 472-479.

4. Wong AK, Vernick WJ, Wiegers SE, et al.Preoperative takotsubo cardiomyopathy identified in the operating room before induction of anesthesia. Anesthesia and analgesia 2010 ;110: 712-5.

A role for intravenous lipid emulsion in cardiac arrest secondary to life-threatening carbamazepine overdose.

A. Sud1 and K. Chidley 2

Gloucestershire Royal Hospital, Gloucester, UK 1,2.anikasud@googlemail.com

We report a case of cardiac arrest in a 20 year old male, following oral ingestion of a potentially fatal overdose of carbamazepine, which responded to intravenous lipid emulsion (ILE, Intralipid®) therapy. The patient made a full neurological recovery.

Case ReportA 20 year old man, with a history of temporal lobe epilepsy, presented with dysarthria, confusion and agitation following an intentional overdose of unknown quantities of his carbamazepine and levetiracetam medication. Initially he had a Glasgow Coma Score of 14 which decreased to five, requiring intubation, ventilation and transfer to ICU. He was on pressure support ventilation 13/5, FiO240%, with pH 7.38, PO2 24 kPa, PCO2 4.8 kPa, HCO3

- 22 mM, BE -3.3 mM and lactate of 3 mM; was hypotensive; and had right bundle branch block on ECG. Conservative management was instituted with intravenous (IV) crystalloid resuscitation; metaraminol infusion; IVNaHCO3 1.26%; propofol sedation; and multi-dose activated charcoal to reduce enterohepatic cycling of carbamazepine. Initial carbamazepine level was 56.2 mg/L, which increased maximally to 69.8 mg/L. Within 24 hours he had a generalised tonic clonic seizure,followed by cardiac arrest - initially pulseless ventricular tachycardia and then asystole. Following 14 minutes of cardiopulmonary resuscitation, administration of 1 mg adrenaline as per protocol, 50 mM of sodium bicarbonate, 1 mg atropine and 150 mL of 20% ILEinfusion (on advice from National Poisons centre), there was a return of spontaneous circulation. A further 350 mL of 20% ILE was theninfused over 30 minutes. Post-arrest, he was cooled to 34 degrees; loaded with phenobarbitone 900 mg IV over 10 minutes, followed bya maintenance dose and midazolam infusion to prevent further seizures; and haemofiltered. He was extubated three days later and made a full neurological recovery.

DiscussionCarbamazepine is a lipophilic, voltage-gated sodium channel blocker, with a toxicity directly related to its blood level [1]. Levels > 40 mg/L, as in our case, are associated with coma, respiratory depression, arrhythmias and seizures. ILE is an effective treatment, acting as a ‘lipid sink’, for cardiovascular collapse associated with local anaesthetic toxicity, and has also been reported as beneficial in cardiovascular collapse caused by several lipophilic drugs e.g. verapamil, quetiapine and propranolol [2, 3]. However, in the literature to date, there are no documented cases of ILE resulting inreturn of spontaneous circulation in cardiac arrest, secondary to carbamazepine overdose. This case also highlights the need to initiateintravenous sodium bicarbonate and multi-dose activated charcoalwhilst carbamazepine levels are established, regardless of the patient’s history.

References1. Hojer J, Malmlund H and Berg A. Clinical Features in 28

Consecutive Cases of Laboratory Confirmed Massive Poisoning with Carbamazepine Alone. Clincial Toxicology 1993; 31: 449-458.

2. Weinberg G. Lipid Emulsion Infusion: resuscitation for local anesthetic and other drug overdose Anesthesiology 2012; 117:180-7.

3. Cave G, Harvey M and Graudins A. Review article: Intravenous lipid emulsion as antidote: A summary of published human experience. Emergency Medicine Australasia 2011; 23: 123-141.

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Post operative cerebral salt wasting syndrome following spinal tumour resection

R West1, R Pilling2 and P. Gunning2

1. Royal Free London Hospital, London, UK, 2. Royal National Orthopaedic Hospital, Stanmore UKraharahmanwest@googlemail.com

Cerebral salt wasting syndrome (CSWS) is a disorder of natriuresis resulting in hyponatraemia and hypovolaemia. It frequently occurs following intracranial pathologies, such as subarachnoid haemorrhage or cerebral space occupying lesions. We report an extremely rare clinical presentation of CSWS in the postoperative period following spinal tumour resection. Informed consent was completed.

Case report: A 56 year old gentleman presented with back pain found to be caused by cord compression from a metastatic deposit to his 5th

thoracic (T5) vertebra. He underwent an elective partial posterolateral vertebrectomy of T5 and fusion of T2 to T8. The tumour was completely resected, and right T5 nerve root was sacrificed. His past medical history included a left pneumonectomy the previous year for primary adenocarcinoma of the lung. Medication history comprised ofanalgesia and dexamethasone (4mg) reducing dose for 3 weeks prior to the surgery. On day 1 post-op he presented with polyuria of 500ml/hr, hypotension and tachycardia. Blood results showeddecreased sodium (131 mmol/L) and osmolality (276mOsmol/kg). Urinalysis showed increased urinary sodium (208 mmol/L) and osmolality (555 mOsmol/kg). Twenty four hour urine output was 5600 ml. A diagnosis of CSWS was made due to the high volume of concentrated urine and high urinary Na together with normal serum osmolality. Normal thyroid function, liver function, preoperative renal function and marginally suppressed cortisol level aided us in excluding other causes of hyponatraemia. The high urinary sodium content also excluded diabetic insipidus (DI) and Syndrome of inappropriate release of antidiuretic hormone (SIADH). We treated the hypovolaemia with 0.9% saline to replace hourly volume of urine output. We also commenced fludrocortisone 100mcg TDS 12 hours post presentation. On day 3 we started slow release sodium tablets of 40 mmol 4 times a day. Over the next 5 days serum sodium returned to normal and high renal sodium loss ceased.

Discussion: To our knowledge, this is the first case report associating CSWS with surgical resection of spinal tumour. The differentialdiagnosis between CSWS and SIADH can be confusing as both may present with similar laboratory and clinical findings. The fundamental difference is the extra cellular fluid volume status. The key feature of CSWS is extra cellular volume depletion and natriuresis. SIADH is characterized by dilutional hyponatremia secondary to increased total body water and high levels of antidiuretic hormone. Thepathophysiology of renal sodium loss in CSWS is unclear. Postulated mechanisms includes natriuretic peptide induced natriuresis and disruption of sympathetic neural input to the kidney. [1] Fludrocortisone is thought to work via direct action on the renal tubule to reduce sodium excretion. Our case demonstrates that CSWS could occur without intracranial pathology following spinal tumour resection. Postoperative hyponatraemia may be a common finding in the postoperative period. However it may rarely be due to a CSWS – acondition that can be clinically challenging. Making a distinction between CSWS and SIADH is of crucial importance given the divergent nature of therapy.

References1. Yee AH, Burns JD, Wijdicks E F.M. Cerebral Salt Wasting: Pathophysiology, Diagnosis, and Treatment. Neurosurgery clinics of North America 21 2010; 339-352

Case Presentation Oral PrizeAnaesthesia History Prize winner presentation

RSM Essay Prize winner presentation (supported by the RSM Section of Anaesthesia)

The historical role anaesthesia has played in discovering the nature of consciousnessDr M John

This essay is available on the GAT website: www.gatasm.org/content/oral-poster-prizes

Leading change in anaesthesia in a multi-disciplinary setting Dr C Johnston

This essay is available on the GAT website: www.gatasm.org/content/oral-poster-prizes

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Ultrasound guidance helps avoid wrong operation and improves patient safety

V. Athanassoglou1, C. Morris1

Wycombe General Hospital, High Wycombe, UKathanass@mac.com

We present a case where ultrasonography changed the operation the patient had consented for and was critical in the patient’s management.

Case reportA 61-year-old woman had been placed on the emergency list for a left below knee amputation. She appeared ill. She declined a spinal anaesthetic. We planned to perform a general anaesthetic, popliteal andsaphenous nerve blocks for postoperative analgesia. On positioning for the nerve block, a preliminary ultrasound scan revealed gas in the soft tissues over the popliteal fossa. On further scanning it became obvious the disease process had spread proximally. The extent of the disease was not obvious from external limb examination. Only the ultrasounddisplayed the real extent. A below knee amputation was the wrong operation to perform as the disease had already spread distally. However, on review of the consent form the patient had not been consented for an above knee amputation. Therefore, on full consultation the surgeon, anaesthetist, and theatre team we decided to not proceed with the operation and wake up the patient. Once the patient recovered from the anaesthetic they were consented for an above knee amputation and the procedure was performed later that evening. The anaesthetic and operation were uneventful and the patient was safely discharged home 14 days later.

DiscussionThe use of ultrasound guided popliteal and saphenous nerve blocks provide good anaesthesia and analgesia for below knee, ankle and foot surgery.1 Ultrasound is not a common mode of investigation for the extent of gas gangrene, despite it being a specific and sensitive modality to detect subcutaneous and intramuscular air.2 It has aided the early diagnosis of patients with scrotal swelling of unknown origin,3 lower limb subcutaneous emphysema of abdominal origin,4 and necrotizing fasciitis.5 This is the first reported case of ultrasound aiding the diagnosis of lower limb gas gangrene. While evidence accumulates for increased efficacy and speed of regional anaesthesia under ultrasound guidance, an increased safety profile has yet to be confirmed. The classical technique for popliteal and saphenous nerve blocks is relatively straightforward, and ultrasound may appear to add little to an already effective and low risk procedure. However, the use of ultrasound in our case allowed us to alter management and avoid the wrong operation. In this instance the use of ultrasound undoubtedly improved patient care but the ethical implications of incidental ultrasound findings is still aconcern and hindrance for scanning all patients.

References1. Salinas FV. Ultrasound and review of evidence for lower

extremity peripheral nerve blocks. Regional Anesthesia Pain Medicine 2010;35: S16-25.

2. Butcher CH, Dooley RW, Levitov AB. Detection of subcutaneous and intramuscular air with sonography: a sensitive and specific modality. Journal Ultrasound Medicine 2011;30: 791-795.

3. Morrison D, Blaivas M, Lyon M. Emergency diagnosis of Fournier’s gangrene with bedside ultrasound. American JournalEmergency Medicine 2005;23: 544-547.

4. Jager GJ, Rijssen HV, Lamers JJH. Sucutaneous emphysema of the lowere extremeity of abdominal origin. GastrointestinalRadiology 1990;15: 253-258.

5. Anreasen TJ, Green SD, Childers BJ. Massive infectious soft tissue injury: diagnosis and management of necrotizing fasciitis and purpura fulminans. Plastic & Reconstructive Surgery2001;107: 1025-1034.

A cause of uvular necrosis never seen before

V. Athanassoglou1, A. Waddell2, M. Blahut-Zugaj2

Wycombe General Hospital, High Wycombe, UK, Great Western Hospital, Swindon, UKathanass@mac.com

Sore throat is common after operations. Several factors contribute to postoperative sore throat. The incidence varies with the method of airway management [1]. However, persistent or worsening pain associated with the feeling of something in the throat is likely to indicate localised trauma to either the uvula or other oropharyngeal structures. The i-gel supraglottic airway, an alternative supraglottic device with a small, noninflatable, anatomically shaped cuff, has been found to result in a lower incidence of sore throat [2]. Uvular necrosis is thought to result from ischaemic necrosis due to mechanical interruption of the blood supply.

Case reportWe report a case where the use of an i-gel caused uvular trauma. A 43 year old presented for a hip arthroscopy. On review of her previous anaesthetic charts she had had i-gel supraglottic devices before. We used a size 4 i-gel device, which was appropriate according to the patients weight and size. Throughout the procedure the patient was breathing spontaneously on the i-gel and airway pressures did not exceed 2cmH2O. The lubricated airway was inserted easily on the first attempt without difficulties. The procedure lasted 90 minutes. She was discharged home later that day. Seven days after her operation her husband contacted our anaesthetic department and showed us a picture of his wife’s throat showing marked redness and soft palate swelling. The symptoms started on the second postoperative day but they were tolerable. We referred her to an Ear, Nose and Throat (ENT) clinic, where a diagnosis of uvular necrosis was made. She was kept under review in the ENT clinic but never needed any specific treatment.

DiscussionUvular necrosis has been reported after tracheal intubation as far back as 1978 [3]. It has occurred after LMA use [1], long-term intubation[4], and blind suctioning [5]. Review of the literature did not produce a case where uvular necrosis has been produced due to an i-gel. There are 14 reported cases from 1984 where routine perioral interventions have led to uvular necrosis [6]. LMA cuffs are permeable to nitrous oxide and carbon dioxide, which could potentially lead to increased cuff volume and pressure during long procedures, resulting in postoperative sore throat due to uvular and pharyngeal oedema. However, the i-gel due to its small noninflatable cuff should obviate that risk and therefore localized airway complications should be less with a well-placed i-gel. Whatever the mechanism of trauma leading to uvular necrosis, potentially severe airway compromise may occur. Therefore, it is vitally important whatever airway device we use to place it carefully minimizing oropharyngeal trauma.

References1. McHardy FE, Chung F. Postoperative sore throat: cause,

prevention and treatment. Anaesthesia 1999;54: 444–53.2. Keijzer C, Buitelaar DR, Efthymiou KM, et al. A

comparison of postoperative sore throat and neck complaints after the use of the i-gel® and the La Premiere® disposable laryngeal mask: A double-blinded, randomized, controlled trial. Anesthesia Analgesia2009;109: 1092-1095.

3. Ravindran R, Priddy S. Uvular edema, a rare complication of endotracheal intubation. Anesthesiology 1978;48: 374.

4. Harris MA, Kumar M. A rare complication of endotracheal intubation. Lancet 1997;350:1820-1821.

5. Bogetz MS, Tupper BJ, Vigil AC. Too much of a good thing: uvular trauma caused by overzealous suctioning. Anesthesia Analgesia 1991;72: 125-6.

6. S. R. Emmett, S. D. Lloyd, M. N. Johnston, Uvular trauma from a laryngeal mask, British Journal of Anaesthesia,2012;109: 468.

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Peripartum cardiomyopathy: a likely cause of profoundhypotension and myocardial ischaemia following spinal anaesthesia for an elective caesarean section.

W. J. Blackshaw, H. Hall

Warrington and Halton NHS Foundation Trust, Warrington, UKjonblackshaw@doctors.org.uk

Peripartum cardiomyopathy (PPCM) is an idiopathic cardiomyopathy that presents with heart failure secondary to left ventricular systolic dysfunction toward the end of pregnancy or in the months after delivery, in the absence of any other cause of heart failure [1].Symptoms suggestive of cardiac disease are often experienced during normal pregnancy; this, combined with the late and often subtle onset of symptoms, makes diagnosis of PPCM difficult in the antenatal period. An abnormal cardiovascular response to neuraxial anaesthesia may be the first indication that cardiac function is impaired.

Case ReportA 34 year-old woman, G2P1, attended hospital for an elective caesarean section on week 39 of a normal pregnancy. She had a past medical history of ankylosing spondylitis. Induction of spinal anaesthesia was achieved with 2.2 mls of 0.5% hyperbaric bupivacaine and 300 mcg of diamorphine at L3/L4 level. A period of profound hypotension ensued which was refractory to fluid, ephedrine and metaraminol boluses. During this period, the patient suffered chest pain with ECG evidence of global myocardial ischaemia. Early arterial and central venous catheter insertion with inotropic support were achieved before delivery of a healthy baby by caesarean section.The mother required three days of inotropic support but was discharged from hospital after one week. Serial echocardiograms showed initial moderate left ventricular dysfunction with recovery of normal function after two months.

DiscussionThis report discusses the anaesthetic management of the unexpected cardiovascular instability resulting from spinal anaesthesia on a likely background of reduced cardiac contractility. It highlights the need for prompt multidisciplinary decision making to achieve the most favourable outcome and examines whether steps could be taken to better identify women with this problem.

References1. Sliwa K, Hilfiker-Kleiner D, Petrie MC et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail Aug 2010;12(8): 767-78.

Uterine dehiscence following B Lynch suture

O Boyle, D Milne

Pinderfields Hospital, Wakefield, UK Owenboyle@doctors.org.uk

Introduction: A B-Lynch suture is a commonly used method [1] for treating an atonic uterus preventing the need for hysterectomy following caesarean section. We describe a case where complications ensued 10 years post procedure in a subsequent pregnancy with devastating effect.

MethodsCase report: In 2002 a 22 year old women who was at 29 weeks gestation attended the emergency department as an unrestrained passenger involved in a road traffic collision. Significant abdominal injuries were sustained that led to haemodynamic compromise and foetal death. Following a massive transfusion an emergency caesarean section was performed. Due to uterine atony a B-Lynch suture was placed which successfully provided haemostasis and preserved the uterus. Subsequently a splenectomy and liver laceration repair were undertaken. In 2012 the same patient presented to hospital complaining of right sided abdominal pain at a gestation of 31 weeks. She had injected heroin earlier that morning which masked the severity of her pain leading to a presumptive diagnosis of appendicitis secondary to an elevated white cell count. Foetal heart rate was detected and the patients observations were normal. After approximately five hours the patient rapidly deteriorated demonstrating signs of hypovolaemic shock. Due to the patients history of intravenous drug use venous access was very difficult. The patient was transferred to recovery on labour ward so central venous access and resuscitation could take place. Prior to transfer the patient became profoundly hypotensive and bradycardic. The major haemorrhage protocol was initiated. A consultant radiologist noted extensive free fluid in the abdomen. The patient was immediately transferred to theatre for an emergency laparotomy. On exploration she was found to have complete dehiscence of the upper and posterior aspects of the uterus with the foetus demised and free in the abdomen. The uterus was repaired and haemostasis was achieved and the patient was discharged from hospital a few days later.

DiscussionThroughout the pregnancy there was no evidence of uterine pathology and until this point the pregnancy had been uneventful. This case highlights the potential risk of B-Lynch sutures obtunding the blood supply to areas of the uterus potentially weakening the uterine wall endangering the life of mothers in subsequent pregnancies. The use of heroin prior to attending hospital may have masked her pain earlier in the progression of her pathology. Earlier detection may have resulted in a better outcome given foetal heart sounds were detected on admission. This case also highlights the difficulties associated with resuscitating intravenous drug users and difficulty obtaining venous access.

References 1. Grotecut CA, Larsen FW, Jones MR, Livingston E. Erosion of a

B-Lynch suture through the uterine wall: a case report. Journal of Reproductive Medicine 2004;49: 849 -52.

A Case Study And Guidance For The Management Of A Patient With Epidermolysis Bullosum

A. Bradley1, R Croft1

1Royal Manchester Children’s Hospital, Manchester, UKEmail of corresponding author: anthony.bradley@nhs.net

Epidermolysis Bullosa encompasses a group of inherited disorders that are characterised by the generation of blisters at the site of mechanical trauma. Genetic changes cause defective connective tissue formation and present shortly after birth. This dermatological condition provides challenges during the perioperative period.Unfortunately, as of yet, there is no medical cure.

Case ReportA 3 year-old child presented with extensive scald injuries from bath water. She was known to have a background history of Epidermolysis Bullosa and was receiving specialist care in another tertiary centre.During her admission, she required multiple surgical interventions,which presented many difficulties for the anaesthetists concerned.Guidance for her care was sought from her specialist centre.

DiscussionEpidermolysis Bullosa affects all squamous cell epithelium including the oral mucosa, potentially posing the biggest issue to the anaesthetist. Repeated trauma, either iatrogenic (e.g. airway instrumentation) or spontaneous (e.g. brushing teeth or mastication), causes blister formation and then subsequent scarring. This can resultin a difficult airway, seen in up to a third of all these patients undergoing procedures or surgery. Other issues include fixing of dressings, as well as monitoring and handling of the patient. Securingintravenous (I.V.) devices may be difficult due to shearing forces found between adhesive dressings and the epidermis below, risking further bullae formation. Cardiac monitoring is of concern, as the transducers are traditionally adhesive to ensure adequate contact. This results in the same issues as for I.V. or surgical dressings. It has, for this reason been noted that minimal standards of the Association of Anaesthetists of Great Britain and Ireland have at times been disregarded. Dealing with an anaesthetised patient requires manual handling. This must be undertaken with the greatest degree of care to avoid shearing forces on the skin. Handling and consoling by well-meaning recovery staff has been associated with the development of new blisters therefore effective handover is essential. With our experience of regularly anaesthetising this child for her frequent surgical procedures, combined with other centres’ recommendations, we have managed to find ways of overcoming all the above issues. We have therefore been able to provide safe and effective anaesthesia for patients with this condition.

SummaryAt first glance Epidermolysis Bullosa looks very challenging to the Anaesthetist. But other than a potentially difficult airway, all other issues can be readily overcome with careful attention to detail, planning and communication with all team members. This means that a safe and AAGBI-compliant anaesthetic should be available to all patients with Epidermolysis Bullosa.

ReferencesWA Ames, BJ Mayou and K Williams; Guidance for anaesthetic management of patients with Epidermolysis Bullosa – British Journal of Anaesthesia 1999 82 (5): 746-51Lohom G, Lyons B; Anaesthesia for children with Epidermolysis Bullosa: a review of 20 years’ experience – European Journal of Anaesthesiology. Nov 2001; 18(11): 754-54 Elliot Krane MD; Lucile Packard children’s hospital Stanford university, paediatric anaesthesia and pain management – Guidelines for anesthetic management of EB

A case report of necrotising, haemorrhagic pneumonia caused by panton-valentine leukocidin positive staphylococcus aureus

C Bullen¹, N Ahmed²

Croydon University Hospital, London, UK Carolineb@doctors.org.uk

Panton-Valentine Leukocidin (PVL) is a cytotoxin associated with increased virulence of certain strains of staphylococcus aureus. It often leads to skin and soft tissue infections, but can also cause asevere, necrotising pneumonia the mortality rate of which is up to 75% [1]. Here we present a case of rapidly progressive respiratory failure, haemoptysis and sepsis in a patient with influenza B and a community acquired PVL-positive MRSA pneumonia.

Case Report: A previously healthy 46 year old lady presented with a 3 day history of flu-like symptoms, and new onset haemoptysis the day of admission. On examination she demonstrated signs of septic shock and respiratory failure with oxygen saturations of 63% on air.Investigations revealed neutropenia and leucopoenia with elevated CRP, and a progressively falling platelet count. Chest radiograph showed bilateral dense infiltrates, with diffuse alveolar haemorrhagereported on CT. She deteriorated rapidly in accident and emergency where she was intubated, with heavily blood stained secretions pouring from the endotracheal tube. She was transferred to intensive care where she was treated aggressively with antibiotics, steroids, intravenous immunoglobulin and recombinant factor VIIa (Novoseven). She continued to deteriorate with increasing inotropic and vasopressor requirements, and worsening respiratory failure –Po2 of <7 with Fi02 100%, and peak pressures reaching 44cm h20 if ventilated with normal tidal volumes of 6-7 mls/kg. Bronchoscopy (post novoseven) revealed florid pulmonary oedema but no obstructing clots or bleeding. She was referred for extra-corporeal membrane oxygenation (ECMO) as a last resort – but unfortunately the patient passed away before the retrieval team could arrive, only 10 hours after initial presentation to accident and emergency.

Discussion: Necrotising pneumonia due to PVL-positive staphylococcus aureus is a highly lethal infection which has a propensity for infecting young adults with few or no co-morbidities [2]. This diagnosis should be considered in any patients with a history of a flu-like illness withleukopenia associated with respiratory failure and haemoptysis. Current recommendations for treatment from the health protection agency (HPA) include linezolid, clindamycin, IVIG and rifampicin[3]. The HPA also recommends MRSA screening and decolonisation for close contacts of those with necrotising pneumonia (including health care professionals). Even with early, directed treatment the mortality from this rare infection remains high.

References:

1. McGrath B, Rutledge F, Broadfield E. Necrotising pneumonia, Staphylococcus aureus and Panton-Valentine leukocidin. Journal of the Intensive Care Society 2008; volume 9, number 2: 170-172

2. Kreienbuehl L, Charbonney E, Eggimann P. Community acquired necrotising pneumonia due to methicillin-sensitive staphylococcus aureus secreting Panton-Valentine leukocidin: a review of case reports. Annals of Intensive Care 2011; 1:52 (1-7)

3. Guidance on the diagnosis and management of PVL-associated Staphylococcus aureus infections (PVL-SA) in England. Report prepared by the PVL sub-group of the Steering Group on Healthcare Associated Infection.Health Protection Agency. Second Edition. 2008; 1-51

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Hyperlipidaemic Pancreatitis of Pregnancy

M. Chazapis

University College Hospital, London, UKm.chazapis@yahoo.com

A case report of a rare complication of pregnancy, requiring very close multidisciplinary care between obstetricians, general surgeons, anaesthetists and intensivists.

MethodsA 36 year old primigravida, with an uncomplicated pregnancy presented at 34+4 weeks gestation with acute epigastric pain. She was admitted, and quickly deteriorated, with increasing pain resistant to morphine, maternal tachycardia and falling oxygen saturations. Lipid profiling revealed a grossly lipaemic sample, with a cholesterol of 37.8 mmol/L, and triglycerides >57 mmol/L. An abdominal ultrasound was unremarkable.

ResultsAfter discussion with the medical team, general surgeons and obstetricians, following a deteriorating clinical picture of the patient, a decision was made to proceed to emergency Caesarean section, using a midline incision, for direct inspection of possible pathology. The pancreas looked inflamed, and there was gross ascites. The baby was delivered safely, and the mother taken intubated to the intensive care unit. A baseline insulin infusion was started, and haemofiltration to reduce the triglyceride levels was considered, but the lipid profile normalised over 24 hours following delivery. The patient left hospital ten days later.

DiscussionPancreatitis in pregnancy is an unusual but serious disease, associated with a maternal mortality of over 30%1

. Most cases are secondary to gallstones. In pancreatitis associated with hyperlipidaemia, the effect of delivery on the decline of plasma triglyceride levels can be immediate and dramatic.

References1. Wilkinson EJ. Acute pancreatitis in pregnancy: A review of 98

cases and a report of 8 new cases. Obstetrical and Gynecological Survey 1973; 28: 281-303.

A case of negative pressure pulmonary oedema: understanding pathophysiology a key to understanding management.

Dr Clare Conroy

Ealing Hospital, Southall, UKcjconroy@doctors.org.uk

Negative pressure pulmonary oedema (NPPO) is a well recognised complication of laryngospasm and other forms of upper airway obstruction [1,2,3]. An understanding of the pathophysiology involved has implications for its management.

Case ReportA 35 year old ASA 1 male presented to the surgeons with a one day history of severe abdominal pain. A CT demonstrated a grossly distended stomach measuring 26 cms. He underwent an emergency laparotomy for acute bowel obstruction. A standard rapid sequence was performed, he was intubated with a size 8mm endotracheal tubeand a nasogastric tube was inserted. The intraoperative course was uneventful and he was easily ventilated and oxygenated. On extubation, the patient became very restless and bit down hard on his endotracheal tube before self extubating. He continued to be very restless and agitated, his oxygen saturations began to drop and he developed signs of laryngospasm. Initial management involved positive pressure mask ventilation with 100% oxygen and two boluses of 50mg propofol. The oxygen saturations initially improved, howeverhe kept developing intermittent laryngospasm with periods of hypoxia. About 20 minutes after initial extubation the patient was atraumatically re-intubated and sedated. On auscultation bilateral crackles were present and suctioning from the endotracheal tuberevealed pink frothy sputum. A diagnosis of possible NPPO was made and the patient was transferred to ICU. Supportive management which included CPAP was given and he was successfully extubated within 12 hours and non invasively administered continuous positive pressure (CPAP) ventilation was continued. A toxicology screen was positive for cocaine, cannabinoids and benzodiazepines. His oxygenation improved over the next 16 hours and he was discharged from the ICU after 72 hours.

DiscussionThis case report shows a probable diagnosis of NPPO following acute laryngospasm post extubation. NPPO has been widely reported in young, athletic and healthy men who suffer upper airway obstruction and reports have shown an increase in alveolar permeability in crack cocaine users [1]. NPPE is characterised by an acute onset with a rapid recovery with 12-24 hours [1]. Management is normally supportive utilising ventilatory support whether it is intubation or CPAP and controversially the use of loop diuretics [2]. The main mechanisms thought to be involved in the pathophysiology of NPPEare mechanical. The generation of a large negative intrathoracic pressure, of the order of 100 – 150 cm H2O [2], with a concomitant massive increase in transmural pressure leads to stress failure at the alveolar capillary membrane [1, 3] as well as an increase in cardiac afterload and not only large fluid shifts. Because of this the use of diuretics in euvolaemic patients is probably unwarranted.

References1. Schwartz D, Maroo A, Malhotra A, Kesselman H. Negative

Pressure Pulmonary Haemorrhage. Chest 1999; 115: 1194-1197.2. Krodel D, Bittner A, Abdulnour R, Brown R, Eikermann M.

Case Scenario: Acute Postoperative Negative Pressure Pulmonary Edema. Anaesthesiology 2010; 113: 200-7.

3. Broccard A, Liaudet L, Aubert JD, Schnyder P, Schaller MD. Anesthesia and Analgesia 2001; 92(1): 273-5

4. West JB. Cellular Responses to Mechanical Stress. Invited Review: Pulmonary capillary stress failure. Journal of Applied Physiology 2000; 89: 2483 - 248

Management of an unusual adult case of acute stridor in a small district general hospital

T. Crilley1, J. Snelling2 and J. Everatt1

Horton General Hospital, Banbury, UK1 and John Radcliffe Hospital,Oxford, UK2

trina.crilley@gmail.com

Stridor is a sign of turbulent airflow through a partially obstructed upper airway. Frequently seen in children, acute stridor is rarer in adults.

Case ReportA 49 year old male with chronic alcoholism presented to our district general hospital with a two day history of persistent vomiting. Whilst awaiting review he developed acute inspiratory stridor following an episode of vomiting and complained of something lodged in his throat. There was no preceding history of fever, cough or sore throat. The anaesthetic team were fast bleeped and on initial examination the patient was pale and sweating. He was sat upright, breathing through an open mouth, and using accessory muscles. He was tachycardic (142bpm), tachypnoeac (32 bpm), hypertensive (BP 190/90) and apyrexial.Oxygen saturations were 100% on high flow O2, dropping below 89% on air and there was an audible inspiratory stridor. Investigations revealed a raised white cell count and CRP plus renal impairment. An arterial blood gas revealed hypercapnia with a hypochloraemicalkalosis secondary to vomiting (on 10 L.min-1 O2; pH 7.48, PO2 66,PCO2 7.0, BE 14.5, HCO3

-, 14.5). Chest x-ray was unremarkable with no evidence of a foreign body. Initial management includedhumidified high flow O2, nebulised adrenaline and i.v. hydrocortisone. ENT at the tertiary centre 27 miles away were contacted andimmediately proceeded to the Horton. Nasendoscopy performed by ENT revealed a swollen epiglottis. The patient was transferred to theatre for intubation, where the surgical team were scrubbed in preparation for surgical tracheostomy in case of failed intubation.Induction of anaesthesia with sevoflurane was performed by the Consultant Anaesthetist. At laryngoscopy a Cormack and Lehane grade 3 view was obtained and an enlarged epiglottis noted. Intubation, with a size 7 cuffed endotracheal tube (ETT; bougie guided), was successful on first attempt. On day 3 post intubation a leak developed around the ETT cuff and endoscopy revealed a normal epiglottis. The patient was then successfully extubated. All microbiology cultures were negative.

DiscussionAcute stridor as a sign of upper airways obstruction in adults is bothrare and a medical emergency. Causes include recent head and neck surgery, infection, anaphylaxis, tumours, airway trauma, prolonged intubation and inhaled foreign bodies/blood/vomitus.1 In this case the cause is unclear but is likely due to physical and/or chemical trauma to the epiglottis from violent vomiting. Management of patients with acute stridor is based mainly on experience in paediatrics2 and early senior involvement is imperative. It includes humidified high flow oxygen, nebulised adrenaline (5 mg) and i.v. dexamethasone (8 mg).Heliox® may play a role as may endoscopy to determine aeitology.Definitive management involves securing the airway. Gaseous induction with sevoflurane is preferred, as it avoids muscle relaxant use, preserving spontaneous ventilation as mask ventilation may not be possible. Provision for surgical tracheostomy is essential. Since patient transfer is not usually appropriate this case highlights the importance of a multi-disciplinary team approach and timely communication with ENT in district hospitals lacking these services.

References1. Robinson N, Hall G, Fawcett V. How to Survive in Anaesthesia,Fourth Edition. Wiley and Sons, UK, 2011.2. Maloney E, Meakin G. Acute stridor in children. Continuing Education in Anaesthesia, Critical Care & Pain, 2007; 7:183-86.

Severe Acute Respiratory Distress Syndrome and Extracorporeal Membrane OxygenationDe Las Casas R, Chakladar A, Forbes L, Marstin SSt Richard’s Hospital, Chichester, UKruthdlc@doctors.org.uk

Community acquired pneumonia (CAP) accounts for approximately6% of admissions to adult Intensive Care Units (ICU) in the UK [1]. There is considerable experience in the management of these patients within such ICUs. In cases of refractory hypoxic respiratory failure retrieval for Extracorporeal Membrane Oxygenation (ECMO) is an increasingly available option. We report a case of severe Acute Respiratory Distress Syndrome (ARDS) secondary to CAP, who was retrieved for ECMO on day eight of his admission.

Case ReportA 74 year old previously fit gentleman presented to A&E with a one week history of increasing shortness of breath. Within 12 hours of arrival, his clinical condition necessitated admission to the ICU for respiratory support. He was treated for a severe CAP but deteriorated despite treatment with antibiotics and continuous positive airway pressure. On day two he was intubated and ventilated due to worsening gas exchange and exhaustion. Following a period of relative stability, he deteriorated on day six of admission, and lung protective ventilation became difficult. On day eight peak inspiratory pressure was over 40cmH20 but achieving only tidal volumes of 300mls, and despite positive end expiratory pressure of 15cmH20 and increasing of Fi02 to 0.9, hypoxia continued to worsen. Deep sedation, paralysis, permissive hypercarbia, prostacylin infusion, and adjustment of ventilation parameters proved ineffective, and our patient began to desaturate significantly during basic nursing care. His Murray score was 3.5 and he was referred to, and accepted by the regional ECMO team. Initiation of the ECMO, and transfer to the regional centre occurred within eight hours. Unfortunately, four weeks after retrieval, he developed multi-organ failure and treatment was withdrawn.

DiscussionThe conventional management of ARDS with mechanical ventilation is increasingly recognised to potentially exacerbate underlying lung injury via high airway pressures and oxygen concentrations. Whilst NICE guidance in 2011 was unable to draw firm conclusions regarding the efficacy of ECMO [2], the Intensive Care Society review in 2012 found, in light of the CESAR trial, that ECMO outcomes and safety are improving, and predicts it will become astandard critical care therapy in non-specialist units [3]. Criteria for referral for ECMO, and explanation of the Murray Score, are clearly laid out on the websites of ECMO centres. We found the ECMO team welcomed discussion, encouraged early referral, and were keen to demonstrate and explain the initiation of ECMO to our ICU team. In our experience ECMO was an accessible escalation when we reached the ceiling of critical care therapy that we could offer.

References1. Woodhead M, Welch CA, Harrison DA, Bellingan G, Ayres JG.

Community-acquired pneumonia on the intensive care unit: secondary analysis of 17,869 cases in the ICNARC Case Mix Programme Database. Critical Care 2006; 10(Suppl 2):S1

2. NICE (2011). Extracorporeal membrane oxygenation for severe acute respiratory failure in adults [IPG391]. London: NICE

3. Hung M, Vuylsteke A, Valchanov K. Extracorporeal membrane oxygenation: coming to an ICU near you. Journal of the Intensive Care Society 2012; 13: 2-9.

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Visualisation of an epidural septum that prevented the bilateral spread of contrast in the lumbar epidural space

V. Dhokia1, S. Smith1 and S. Ramani1

Northampton General Hospital, Northampton, UKvishal.dhokia@doctors.org.uk

An epidural septum, or the plica mediana dorsalis (PMD), is a midline band of connective tissue within the dorsal epidural space. Despite the appearance of the structure in different studies [1, 2], its prevalence, exact nature and clinical significance remains controversial. It is quoted as one cause of a ‘unilateral epidural’;however, anaesthetic has been shown to cross the midline even in its presence [3] and cases of unilateral epidurals have most frequently been attributed to other causes such as anterior or transforaminal placement of an epidural catheter [4].

Case ReportA 35 year old female presented to the chronic pain clinic with chronic back pain with bilateral nerve root symptoms. She had previously been treated with a lumbar epidural steroid injection with good effect which was to be repeated. The patient was positioned prone and with fluoroscopic guidance the L4-L5 epidural space was identified by a loss of resistance to saline technique using a right para-median approach. An epidurogram was performed using contrast to confirm satisfactory needle position. Contrast spread was confined to the right side and a midline septum was delineated (Figure 1). A left para-median approach was then used to access the left side; similarly the contrast was unable to spread to the contralateral side.

Figure 1.

DiscussionThis case provided a rare demonstration of an anatomical barrier, consistent with an epidural septum, or PMD, that prevented the bilateral spread of contrast in the lumbar epidural space. For epidural steroid injections we would advocate the routine use of contrast to identify such anatomy.

References1. Blomberg RG, Olsson SS. The lumbar epidural space in patients

examined with epiduroscopy. Anesthesia and Analgesia 1989; 68: 157-160.ame A, Name B.

2. Savolaine ER, Pandya JB, Greenblatt SH, Conover SR. Anatomy of the human lumbar epidural space: new insights using CT-epidurography. Anesthesiology 1988; 68: 217-220.

3. Stevens DS, Balkany AD. Appearance of plica mediana dorsalis during epidurography. Pain Physician 2006; 9(2): 268-270.

4. Asato F, Goto F. Radiographic findings of unilateral epidural block. Anesthesia and Analgesia 1996; 83: 519-22.

Ventricular tachycardia complicating the anaesthetic management of cauda equina syndrome.

C.F Dickson1, T.E Sams2 and I. Kannan3

Royal Victoria Infirmary, Newcastle upon Tyne, UK1, Freeman Hospital, Newcastle upon Tyne, UK2, and Royal Victoria Infirmary,Newcastle upon Tyne, UK3.drcfdickson@hotmail.com

We describe the anaesthetic management of right ventricular outflow tract ventricular tachycardia (RVOT-VT) complicating the emergency out of hours neurosurgical management of cauda equina syndrome.

Case ReportA 22-year-old woman presented with a two day history of worsening lumbar back pain, bilateral sciatic leg pain, difficulty initiating micturition, altered bowel habit, and altered saddle sensation. She described a history of RVOT-VT and had undergone two previous ablation procedures. On examination she was tachycardic at 135 beatsper minute (BPM), blood pressure was 135/86 mmHg, there was lumbar spine tenderness, lower limb weakness, absent lower limb reflexes, bilateral sciatic leg pain, and reduced perianal sensation and anal tone. Magnetic resonance imaging demonstrated central L4/5 discherniation causing cauda equina compression. A decision for emergency surgical decompression of incomplete cauda equina syndrome was made. Following anaesthetic review a 12 lead ECG was performed which demonstrated ventricular tachycardia (VT) (116 BPM) and left bundle branch block (LBBB). Cardiologist advice was sought and a plan to control the VT, restore sinus rhythm, and proceeded with surgery was established. Invasive arterial monitoring and central venous access were obtained. Loading and maintenance doses of amiodarone and magnesium sulphate were administeredwhich slowed the VT. Defibrillation pads were applied and induction achieved with fentanyl, propofol and rocuronium, maintained with isoflurane then desflurane. In the prone position a lumbar L4/5 discectomy was performed. Reversion to sinus rhythm occurredduring the procedure and she remained normotensive throughout. Postoperatively she was extubated and transferred to HDU and then coronary care. She made a full neurological recovery, was commenced on bisoprolol, and underwent further radio frequency ablation therapy.

DiscussionRVOT-VT is a variant of idiopathic VT which is a rare form of monomorphic VT found in structurally normal hearts. It is more common in females and is usually seen in the third to fifth decade of life. In the majority of cases it follows a benign course with a very low risk of sudden cardiac death [1]. Symptoms include palpitations,syncope, dizziness and chest pain. It is associated with a characteristic ECG morphology of VT with LBBB and inferior axis. Acute termination of RVOT-VT may be achieved with adenosine, carotid sinus massage, verapamil, and lignocaine. Betablockers, calcium channel blockers, and amiodarone are effective first line therapies. Radiofrequency ablation carries a high curative success rate. Cauda equine syndrome is rare, but potentially devastating if symptoms persist. Evidence supports urgent surgical decompression particularly in incomplete cases [2]. This case describes the management of two rare conditions out of hours. The priority was safe and timely lumbar decompression. A multispecialty approach was essential. We could find no other case report of RVOT-VT complicating anaesthesia for cauda equina syndrome.

References1. Babhwar N, Scheinman MM. Idiopathic ventricular tachycardia:

Diagnosis and management. Current Problems in Cardiology2007; 32(1): 7-43.

2. Lavy C, James A, Wilson-MacDonald J, Fairbank J. Cauda equina syndrome. British Medical Journal 2009; 338: 881-4.

One-lung ventilation in a patient with sickle cell disease

K. Francis1, J. Collins2 and D. Pigott3

1Buckinghamshire Healthcare NHS Trust, High Wycombe, UK2Royal Berkshire NHS Foundation Trust, Reading, UK3Oxford University Hospitals NHS Trust, Oxford, UKKat_francis@hotmail.com

We describe the safe management of a 19 year-old female Afro-Caribbean patient with sickle cell disease requiring one-lung ventilation for video-assisted thorascopic thymectomy. Although this technique is associated with a risk of hypoxaemia and therefore sickle crisis, our technique resulted in minimal disruption to haemoglobin oxygen saturations, and no immediate rise in the sickle haemoglobin fraction. We have found no previous reports of the management of sickle cell disease patients presenting for surgery requiring one-lung ventilation.

Case ReportRecently diagnosed with myasthenia gravis, the patient’s medical history included a preoperative intensive care admission forpneumonia warranting non-invasive ventilation. During that episodeher haemoglobin concentration ([Hb]) was 7.0g/dL and the sickle haemoglobin fraction (HbS) was 91.3%. This was managed with exchange transfusions such that preoperative [Hb] was 11.1g/dL and HbS 18.1%. On the day of surgery, a thoracic epidural was sited, and following pre-oxygenation, anaesthesia was induced with fentanyl,propofol and low-dose vecuronium. A 37Ch double lumen tube (DLT) was sited and satisfactory isolation of the lungs achieved. Anaesthesia was maintained with isoflurane in oxygen and air (FiO2 0.5) and remifentanil. Intra-operatively, peripheral haemoglobin oxygen saturation remained 100% during two-lung ventilation, dropping to 96-99% during one lung ventilation (the right lung having beencollapsed). Following uneventful surgery the DLT was exchanged for a single lumen tracheal tube prior to transfer to the cardiothoracic critical care unit. Full neuromuscular recovery had been demonstratedprior to extubation. The epidural provided good analgesia and she was discharged to the ward the following morning. Immediate post-operative blood results showed [Hb] of 10.3g/dL and HbS 18.9%. The patient was discharged home on the second postoperative day. Blood tests approximately two weeks postoperatively demonstrated [Hb] 11.2g/dL, and a rising HbS at 31.9%.

DiscussionSickle cell disease (SCD) is an autosomal recessive hereditary haemoglobinopathy. Sickle haemoglobin polymerises under specific physiological conditions, including hypoxia, hypothermia, dehydration, infection and acidosis. The mainstay of anaesthetising patients with SCD focuses on the maintenance of normal oxygenation, temperature, and circulating volume. The potential for surgery toexacerbate SCD has been recognised since the first major review of itsanaesthetic implications in 19551 though such operations as major vascular surgery2 and cardiopulmonary bypass3 are described in patients with SCD without complication. There exists some controversy as to whether preoperative transfusion of SCD patients reduces the perioperative complication rate. The risk of transfusion-related complications must be balanced against the potential reduction in SCD-related events. Further research is required into best anaesthetic management of SCD patients undergoing one-lung ventilation.

References1. Shapiro ND, Poe MF. Sickle cell disease: an anesthesiological problem. Anesthesiology 1955; 16: 771-802. Vipond AJ, Caldicott LD. Major vascular surgery in a patient with sickle cell disease. Anaesthesia 1998; 53: 1204-6.3. Marchant WA, Wright S. Aortic cross-clamping in sickle cell disease. Anaesthesia 2001; 56: 286-7.

Retrograde extradural catheter “traction technique” for awake difficult tracheal intubationS Ghaffar1, DR Ball2

Dumfries and Galloway Royal Infirmary, Dumfries, UK.sadiaghaffar@nhs.net

Retrograde tracheal intubation is an alternative form of airway management [1]. We report a modified retrograde technique [2] for awake tracheal intubation for an adult with a difficult airway, where visual techniques were predicted to be problematic.

Case ReportA previously well male patient fell from a roof, sustaining multiple injuries, including unstable thoracic and lumbar vertebral fractures, fractures of midface, pelvis, fibula, ribs and elbow. After stabilisation, he presented for fixation of his compound elbow fracture. There was bleeding into the oral cavity and neck movement was limited, but no cervical fracture was reported. We performed an awake retrograde approach using remifentanil and clonidine sedation with topical local anaesthesia. Head and neck position was maintained in a neutral position. Standard monitoring was used. There were five basic steps. First, needle cricothyroidomy was done by one of us (SG) using a 16G Touhy needle angulated in a cephalad direction. Second, an extradural catheter was passed through the needle and the catheter was extractedfrom the mouth by the operator (SG). Third, the catheter was tied to the side hole of a tracheal tube (6.5 mm Fastrach™, Laryngeal Mask Co, Mahe, Seychelles). Fourth, the tube was passed into the mouth, guided by pulling the catheter at the neck. When tube advancement stopped, it was pushed to complete passage through the larynx. This was confirmed by capnography. Fifth, once the catheter had been directed from the neck, it was secured to the chest with a transparent dressing to prevent accidental removal and to keep it clean. The successful intubation sequence was well tolerated. Surgery and emergence were uneventful. Awake tracheal extubation was chosen and tube, with catheter, pulled out of the patient’s mouth. He was transferred to another hospital for pelvic fracture management eightdays later, and subsequently discharged to home several weeks later.

DiscussionWe selected this technique for two reasons. First, airway soiling with blood and secretions limited a visual technique and second, neck movement was limited. Retrograde techniques may have clinical advantages over other approaches for difficult airways, including fibreoptics. They can be used when any airway view is obscured by blood or secretions, do not require extension of the neck and are usually easy to perform. The two main limitations are unfavourable neck anatomy or high-grade trismus. The “traction technique” we used involved pulling the tube rather than sliding it over a guide. Orthodox retrograde methods use some form of guide (wire or catheter) upon which the tracheal tube is threaded to direct the tube through the airway. Tension on the guide, however, may cause hold up of the tube at periglottic structures: a “cheese wire” complication [1]. The “traction technique” reduces this risk [2]. Also, the catheter may be left in place after tracheal extubation and is available for a repeat intubation if needed. This option is not possible when a guide is used. In general, retrograde approaches are uncommonly used, and the method we report has not received much clinical attention. We believe that retrograde approaches in general, and this method in particular, offer distinct clinical advantages and deserve wider application.

References1.Dhara SS. Retrograde tracheal intubation. Anaesthesia 2001; 56: 1094-1104.2. Abu-Madi MN, Trop D. Pulling versus guiding: a modification of retrograde guided intubation. Canadian Journal of Anaesthesia 1989; 36: 336-9.

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A case report of concurrent thyrotoxic crisis and diabetic ketoacidosis V. Humphrey1, B.Slater1

1 Victoria Hospital, Kirkcaldy, UKEmail correspondence to: vanessa.humphrey@nhs.net

We present a case of thyrotoxic crisis and concurrent diabetic ketoacidosis (DKA) in a 15 year old girl who was admitted to our intensive care unit via the hospital accident and emergency department. Although cases of simultaneous presentations have previously been reported [1], it is clinically unusual and this case resulted in both diagnostic and management challenges. Previous case reports demonstrate that delays in identification and prompt treatment of the two conditions can lead to serious complications and mortality [2]. We therefore believe that presentation in this forum will raise awareness with important lessons for clinical practice.

A 15 year old girl with a history of Type I diabetes mellitus and on carbimazole treatment for Grave’s disease presented to accident and emergency with deteriorating Glasgow Coma Scale (GCS), pyrexia of >38◦C, agitation, extreme sinus tachycardia of 200-220 beats per minute and hypertension of 160/100 mmHg. There was no overt sign of cardiac failure on presentation. She had significantly raised blood glucose of 34mmol/l, ketonuria and a metabolic acidosis (arterial pH of 7.04). Despite appropriate initial insulin and fluid therapy for DKA,the patient remained agitated and confused with GCS 10-11 (E1-2, V4,M5). There were no focal neurological signs and no history of drug use. Urine toxicology screens returned negative. Due to agitation she was intubated and transferred for computerised tomography (CT) scan of her head, which was reported as normal. Suspicion was raised of a thyrotoxic crisis and laboratory tests confirmed a thyroid stimulating hormone (TSH) level of <0.01 mU/L and free thyroxine (T4) level of 96 pmol/L. Metoprolol was carefully titrated to heart rate and blood pressure. Following consultation with the on call endocrinologist, the diagnosis of thyrotoxic crisis was deemed likely based on established criteria [3]. Treatment was therefore started with regular Lugol’s iodine, propranolol, hydrocortisone and propylthiouracil. She was successfully extubated the next day with rapid resolution of neurological signs and continued standard treatment for DKA. She was later discharged home following a full recovery.

This case caused several diagnostic and management challenges both from an organisational and a clinical perspective. The initial diagnosis was difficult given the concurrent nature of the two separate metabolic derangements and the unfamiliarity of staff with management of a thyrotoxic crisis. Prior to specialist advice and laboratory confirmation, we were very cautious with beta-blockade in case of unmasking cardiovascular instability due to DKA. There was also uncertainty regarding the correct use of steroid treatment for thyrotoxic crisis given her high blood glucose levels and a possible infective precipitant of DKA.

It is well recognised that Type I diabetes mellitus is commonly associated with hyperthyroidism, and poor control of one can precipitate an emergent presentation of the other. What is more, these two endocrine emergencies can occur fulminantly, atypically and potentially fatally. For this reason, we wish to highlight this unusual case of combined metabolic derangement.

References1. Gupta S, Kandpal SB. Case Report: Storm and Acid, Together...

American Journal of Medical Sciences 2011; 342 (6): 533-4. 2. Yeo KF, Yang YS, Chen KS. Simultaneous presentation of

thyrotoxicosis and diabetic ketoacidosis resulted in sudden cardiac arrest. Endocrine Journal 2007; 54 (6): 991-3.

3. Burch HB, Wartofsky L. Life threatening thyrotoxicosis. Thyroid Storm. Endocrinology and Metabolism Clinics of North America 1993; 22: 263-77.

Perioperative presentation of traumatic carotid artery dissectionB. Ivory1

1 Derriford Hospital, Plymouth, UKbenivory@doctors.net.uk

Traumatic carotid artery dissection is well recognised. We describe a case of delayed presentation in the perioperative period, the subsequent management and a discussion of the rationale for aggressive screening for blunt cerebrovascular injury (BCVI).

Case ReportA fit and well 54 year old lady presented to the emergency department via the ambulance service having been kicked in the face by a horse. On arrival in the emergency department, she had a GCS of 15/15 and no focal neurological deficit. Examination of the face was clinically suggestive of a displaced mandibular fracture. A plain X-ray of the cervical spine was performed and reported as being normal and the patient was admitted for surgical fixation of her broken mandible the following day. During the pre-operative anaesthetic visit 19 hours following the injury, the patient volunteered that over the previous hour she had developed weakness and paraesthesia of the right arm and leg. Clinical examination revealed 3/5 power in the right arm and leg, with altered sensation to light touch over the same distribution. There was also diffuse swelling over the left side of the neck. An urgent CT scan of the head and neck and CT angiogram was performed and revealed a normal cervical spine, and a dissection of the distal left internal carotid artery. No area of cerebral infarction was identified. Surgery was cancelled for that day and the patient was treated with an intravenous heparin infusion. Operative fixation of the mandibular fracture was performed four days following the initial trauma. Invasive arterial monitoring was established pre-operatively and haemodynamic variability was minimised during surgery. Postoperatively, neurological examination was unchanged and the patient was monitored on the high dependency unit for 24 hours whilst the heparin infusion was re-started. The patient was discharged on oral aspirin and at 6 months had only a mild residual weakness and had returned to riding.

DiscussionBCVI occurs in up to 1% of all blunt traumatic injuries and the diagnosis is increasingly recognised as major cause of morbidity and mortality[1]. Specific clincial factors associated with increased incidence include LeFort II and III fractures, GCS score ≤ 6, skull base fractures involving the foramen lacerum, significant neck soft tissue injury and Horners syndrome[1]. Studies evaluating targeted screening using CT angiogram (CTA) have showed yields of 29-44%with reduction in morbidity and mortality[1-3]. Presentation is often delayed, with a majority of patients only showing symptoms more than 24 hours following the injury[4]. Treatment is usually with anti-platelet or anticoagulant therapy, with no clear benefit for either modality[5]. This case serves as a reminder for anaesthetists to be aware of the possibility of asymptomatic BCVI in patients presenting for surgery following head and neck trauma, and adds anecdotal weight to the argument for CTAs to be performed as part of the routine trauma radiology work up in the emergency department. This is now part of the trauma protocol in Derriford hospital.

References1. Miller PR et al. Prospective Screening for Blunt Cerebrovascular Injuries: Analysis of Diagnostic Modalities and Outcomes. Annals ofSurgery 2002; 236: 386-3952. Miller PR et al. Blunt cerebrovascular injuries: diagnosis and treatment. Journal of Trauma 2001; 51: 279-863. Kerwin AJ et al. Liberalised screening for blunt carotid and vertebral injuries is justified. Journal of Trauma 2001; 51: 308-3144. Ahmad HA, Gerraty RP, Davis SM, Cameron PA. Cervicocerebralartery dissections. Journal of Accident & Emergency Medicine1999;16:422-4245. Engelter ST et al. Antiplatelets versus anticoagulation in cervicalartery dissection - a review. Stroke 2007; 38: 2605-2611

Infection due to tuberculosis bovis in ulcerative colitis patient treated with infliximab

V.Mandava, C.Webb, B.Das.

Burton Hospital NHS Trust.

Venkata.mandava@butonfts.nhs.uk

A man with long standing ulcerative colitis had an acute exacerbation whilst on azothiprine and mesalazine, resulting in loss of weight. Hewas commenced on infliximab. With no history of human TBexposure and a normal chest x-ray he did not have pre-treatment serology tests for latent TB (T –spot). Sadly he died one year later from respiratory failure: T-spot was positive and mycobacterium bovis was cultured from the sputum and lung tissue.

Case report:A 52 year old cattle farmer and abattoir worker was on multiple immune modulating drugs for his ulcerative colitis since diagnosis in1987. Following an acute exacerbation in 2010 and failure of other therapies Infliximab 5mg/kg was started six weekly. During the treatment period he initially gained weight and felt well in himself, but started to loose weight at 10 months. Two weeks after the ninth dose he developed of breathlessness and hypoxemia , was neutropenic with a wcc of 0.8×109/l /(neutrophils 0.3×109/L) with a chest x-ray showing widespread non specific infective changes. He was commenced on broad spectrum antibiotics. He deteriorated and on day five was started on high dose Cotrimoxazole and antifungals in view of the possibility of an opportunistic lung infection with the history of immunosupression. T-spot was positive and Endobronchial washings confirmed the presence of AAFBs. Triple Anti-TB drugs; Isoniazide, Pyrazinamide, Ethambutol were commenced. He developed multi organ failure and he sadly died after two weeks.

Results:Pre treatment Chest x-ray normal (2010 policy - no t-spot), Day 5 sputum – AAFB seen T-spot positive for TB complex All other cultures negative AAFB subsequently cultured as mycobacterium bovis confirmed by post mortem cultures

Discussion:It is unclear whether the M.bovis infection was acute due tooccupational exposure from the slaughter of infected cattle (aerosol inhalation) or re-activation of old infection due to prior consumption of unpasteurised milk/ meat. Without a history of human TB exposurea positive T-spot during the illness would usually suggest active TB with infection exacerbated by infliximab. Guidelines (2013) recommend a T-spot test prior to any treatment with anti TNF drugs which should uncover any latent TB. Had this man had a T-spot priorto treatment with Infliximab would it have be negative? Was he appropriate for Anti TNF therapy in this occupation? We shall unfortunately never know?

Reference:http://publications.nice.org.uk/infliximab-for-acute-exacerbations-of-ulcerative-colitis-ta163

http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Anti%20TNF%20Treatment/Guidelines/antitnf_treatment.pdf 803-4

Anaesthetic management in a parturient with uncorrected Tetralogy of Fallot

J. Parker1, C. Grange2

John Radcliffe Hospital 1, Oxford, UK, John Radcliffe Hospital 2, Oxford, UKjacquismail@gmail.com

Cardiac disease is the leading cause of indirect maternal mortality in the UK. Although Tetralogy of Fallot (TOF) is the commonest cyanotic congenital heart defect, presentation in pregnancy without surgical correction is rare. We report a case of a parturient, with uncorrected TOF, who required anaesthesia for caesarean section.

Case ReportA black 29 year old parturient (G1 P0), from Cameroon, presented to our institution at 30 weeks gestation. Past medical history included a childhood heart murmur and life long history of poor exercise tolerance and dizzy spells. A pansystolic murmur and clubbing were noted on examination. Blood pressure and jugular venous pressure were 90/50mmHg and +5cm respectively and oxygen saturations were 89% on air. Cyanosis was not evident due to skin colour. Echocardiography revealed TOF with 50% aorta override, a large ventricular septal defect (bidirectional shunting) and pulmonary stenosis. She was subsequently referred for specialist multidisciplinary management. The patient remained stable until 34 weeks gestation when she developed chest pain on exertion and a marked reduction in exercise tolerance. In view of her cardiac decompensation, she was admitted for optimisation and early caesarean delivery. During her admission she became increasingly short of breath, even at rest.Treatment included oxygen (PaO2 on air 8.7kP), diuresis, thromboprophylaxis and steroids (for fetal lung maturation). Following multidisciplinary discussion, a decision for caesarean delivery was made at 36 weeks gestation. Fetal ultrasound and growth were normal. Invasive monitoring (via arterial and central venous cannulae) was established prior to theatre and oxygen administered via face mask. Adequate anaesthesia was established with a combined spinal epidural, using a low dose spinal (0.7mls 0.5% heavybupivicaine plus 15mcg fentanyl) with slow sequential epidural top up. A phenylephrine infusion (100mcg/ml at 20-40 mls/hr) was used to maintain afterload and normotension. The patient remained cardiovascularly stable throughout surgery with the use of minimal additional metaraminol boluses. A slow infusion of syntocinon and rectal misoprostol were used to promote uterine tone. Estimated blood loss was 600mls and the baby was delivered in good condition. Analgesia was achieved with epidural opioids, paracetamol and diclofenac. The patient was discharged home on Day 4 and is currently waiting for corrective surgery.

DiscussionUncorrected TOF in pregnancy is rare with a high risk of maternal mortality. Evidence for best practice is sparse due to limited publications. Key issues surrounding the management of such cases include a thorough understanding of anatomical defects/ physiological adaption and events/ drugs that can worsen right-to-left shunt, in addition to careful multidisciplinary planning. Our aim was to deliver adequate surgical anaesthesia whilst avoiding a reduction in afterload, or increase in heart rate or contractility. The use of therapeutic vasoconstriction was paramount to prevent worsening cyanosis.

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Midazolam-induced hyperactivity treated with flumazenil

S. Potru1, A. Joseph2 and R. Rajendram3

Jackson Memorial Hospital1, University of Miami, Florida, USA,Princess Alexandra Hospital 2, Harlow, UK, and John Radcliffe Hospital3, Oxford, UKCorrespondence: rajkumarrajendram@doctors.org.uk

Benzodiazepines are characteristically anxiolytic, amnestic, and sedative. However paradoxical reactions may cause restlessness, agitation, or aggression. This case report describes successful management a postoperative paradoxical reaction to midazolam with the benzodiazepine-receptor antagonist flumazenil.

Case Report68-year-old Caucasian male presented for elective robot-assisted laparoscopic prostatectomy. He had osteoarthritis, hypertension, hypercholesterolemia, obesity, coronary artery disease but had had acoronary artery bypass graft and obstructive sleep apnoea but did not require CPAP. His regular medications included aspirin, atorvastatin, finasteride, losartan, metoprolol, mometasone furoate, nitroglycerin, terazosin, and meloxicam. He denied previous adverse drug reactionsand previous complications with general anaesthesia.He was premedicated with midazolam (2 mg i.v.) and notably was relaxed and drowsy thereafter. The patient was induced without incident using fentanyl 200 mcg, propofol 250 mg and vecuronium 10 mg. Anaesthesia was maintained with isoflurane, remifentanil infusion and intermittent boluses of morphine (total 10 mg). Dexamethasone and diphenhydramine were administered for prophylaxis against postoperative nausea and vomiting. The procedure was difficult and was aborted after two hours. Residual neuromuscular blockade was reversed, isoflurane was stopped and the patient was extubated uneventfully. However, prior to transfer to the post-anaesthesia care unit (PACU), the patient became agitated and aggressive, and insisted on urinating in the restroom despite having a urinary catheter. He pulled at the oxygen facemask and required manual restraint to prevent self harm from falling out of bed. After administration of 1 mg of midazolam the agitation increased. He struggled against the restraints and continued to try to get out of bed, despite reassurance that he had a catheter in his bladder. His vital signs remained stable throughout this period. Ten minutes later another 1 mg of midazolam was given and he appeared to settle, so transfer to recovery was initiated. En route he became more restless and struggled against his physical restraints; so, another 1 mg of midazolam was given. On arrival in the PACU, the patient’s vital signs were all stable (BP 147/83, HR 75, SaO2 96%, RR 14, T 36.4) and there was no focal neurological deficit but physical restraint was still required. Despite afurther 1 mg of midazolam the patient continued to struggle.Ultimately, flumazenil 0.5 mg was given in divided doses to reverse the effects of midazolam. Within three minutes the patient calmed,stopped struggling, answered all questions appropriately and asked for removal of the restraints. He subsequently denied having any recollection of the preceding events.

DiscussionThe aetiology and mechanism of benzodiazepine-induced paradoxical hyperactivity have yet to be elucidated, although a central cholinergic mechanism has been suggested. This report and others [1] demonstrateeven small amounts of flumazenil can be effective in treating this.Despite the risks associated with the use of flumazemil we recommend its use for both diagnostic and therapeutic purposes.

References

1. Thurston TA, Williams CGA. Reversal of a paradoxical reaction to midazolam with flumazenil. Anesthesia and Analgesia 1996;83:192.

Life threatening intraoperative hypoxemia in a patient with thalassemia major.

K. Grange1, S. Kannan1 and S. Sivasubramaniam1

1City Hospital, Birmingham, U.K.s.kannan@nhs.net.

Patients with thalassemia major presenting for surgery usually do nothave serious systemic dysfunction which significantly impact on general anaesthesia. However, they may be susceptible to complications in certain situations. We report a patient who suffered life threatening intraoperative hypoxemia. There have been no similarreports in the literature.

ReportA 34 year old Asian woman, weighing 55 kg, presented for drainage of an abscess in her left great toe. Medical history included transfusion dependent thalassemia major, hepatic haemosiderosis, hypothyroidism, hypogonadism and osteoporosis. There was no evidence of pulmonary or cardiac haemosiderosis. She rated her exercise tolerance as good. Hb concentration was 10 g % and liver function tests were normal. After preoxygenation, anaesthesia was induced with 150 mg propofol and 50 microgram of fentanyl. A size 3 laryngeal mask airway was inserted and anaesthesia was maintained using oxygen, air and sevoflurane, under controlled ventilation. Following skin incision, the airway pressures increased and the ETCO2 trace on the monitor disappeared. Attempts at manual ventilation were difficult due to high airway resistance. Additional dose of 50mg propofol, 50 microgram fentanyl and higher concentration of sevoflurane were administered without success. Due to falling SpO2, trachea was intubated using suxamethonium. Manual ventilation with 100% oxygen continued to be difficult requiring peak airway pressures of 35 mmHg and SpO2 fell to 50%. Systolic blood pressure read 50 mmHg at this point. 500 ml intravenous Hartmann’s solution fluid bolus was commenced and 500mcg IV metaraminol was given first. Suspecting anaphylaxis, 50 micrograms of IV adrenaline was given along with intratracheal salbutamol. SpO2 improved to 76%on FiO2 of 1.0. Arterial blood gas showed a PaO2 6.5 kPa and PaCO28 kPa. Auscultation now revealed bilateral air entry with scattered wheeze with no clinical evidence of pneumothorax. Blood pressurenormalised and did not require any further dose of vasopressors.Airway pressures continued to remain high at 35 mmHg with a tidal volume of 350ml. Chest X ray did not show any pneumothorax and CT Pulmonary Angiogram was negative. Thirty minutes later, SpO2improved to 95%. The patient was kept sedated and ventilated in recovery due to lack of availability of critical care bed. Patient continued to improve gradually and four hours later, blood gas and airway pressure normalised. The patient was then extubated.

DiscussionIt is likely that the first episode of high airway pressures was related to inadequate analgesia. However, in the absence of pulmonary embolism, the prolonged duration of hypoxemia with failure to recover was unexpected. Patients with thalassemia can have subclinical pulmonary hypertension [1]. The initial response to pain would have led to spasm of the airway. However, pulmonary vascular response to hypoxia and sustained efforts to increase the mean airway pressure would have led to the prolonged episode of hypoxemia. In patients with thalassemia, it is important to remember potential for subclinical pulmonary hypertension and efforts must be taken to minimise further increases in pulmonary vascular pressures.

Reference1. Aessopos A, Farmakis D. Pulmonary hypertension in β thalassemia. Annals of the New York Academy of Sciences. 2005; 1054: 342- 9.

GHB causes GBH when withdrawn

N. Pritchard1, R. Hewson1

Royal London Hospital, London, UK pritchardnaomi@hotmail.com

We report a case of gamma hydroxybutyrate (GHB) withdrawal; a diagnosis carrying high morbidity and mortality, and easy to miss given the nature of its presentation.

Case ReportA 42 year old brittle asthmatic presented agitated, tachycardic, wheezing and tachypnoeic; having recently taken GHB. Initially treated for exacerbation of asthma, he retained CO2 requiringintubation and ventilation. He was sedation tolerant and two attempts at extubation failed due to aggression and sympathetic overstimulation. Research revealed his symptoms were consistent with GHB withdrawal, a new diagnosis to the treating team. He was resedated, treated with benzodiazepines and methadone. He had a tracheostomy and was discharged 20 days later.

DiscussionGHB, (endogenous gamma aminobutyric acid (GABA) precursor and direct GABAB receptor agonist) is used clinically but more commonly abused recreationally [1]. Withdrawal may be caused by down-regulation of GABA receptors [2], occurs after 7 days use, peaks at 24 hours post cessation, lasting up to 14 days [3]. Severe agitation, seizures, rhabdomyolysis and hallucinations accompany autonomic instability, tachycardia, hypertension, tremor and temperature dysregulation [3]. Benzodiazepines are recommended for psychotic agitation with barbiturate and propofol sedation to decrease muscular activity [3]. GABAB agonist Baclofen may be useful. β-blockade and antipsychotic medications may be harmful. Diagnosis is distracted by co-morbid life-style factors, credible alternative diagnoses and variable symptomatology. Quicker recognition may have prompted earlier tracheostomy, avoided failed extubations and nursing an aggressive, under-sedated patient. With increasing availability of GHB products, tolerance and dependence may increase.

References1. Wax AU. Just a click away: recreational drug Websites on

the Internet. Pediatrics. 2002: 109(6)2. Benzer TI, Cameron S, Russi CS. Gamma-

Hydroxybutyrate Toxicity. http://emedicine.medscape.com/article/820531-overview#a0104 (accessed 26.8.2012)

3. Dyer JE, Roth B, Hyma BA. Gamma-hydroxybutyrate withdrawal syndrome. Annals of Emergency Medicine.2001: 37(2):147-53.

Seizures post-partum due to an acquired long QT Syndrome

R. Rajendram

John Radcliffe Hospital, Oxford, UKCorrespondence: rajkumarrajendram@doctors.org.uk

Seizures caused by global cerebral ischaemia due to reduced cardiac output may be clinically indistinguishable from those caused by epilepsy. In this case arrhythmias induced by an acquired long QT syndrome presented as seizures.

Case ReportA 43 year old woman underwent elective Caesarean section for placenta praevia 36 weeks into her second pregnancy and was discharged home five days later. She was readmitted with sepsis due to pyelonephritis ten days post-partum. The patient was managed in a room on the labour ward so she could be with her baby. She was treated with intravenous cefuroxime. She continued to deteriorate developing diarrhoea, vomiting and became confused and agitated. This was treated with cyclizine and haloperidol. Two days later admission urine and blood cultures grew Pseudomonas. Cefuroxime was replaced with intravenous ciprofloxacin and the patient improved. Three days later the patient had a tonic-clonic seizure whilst in bed. This was witnessed by a midwife who reported that the seizure terminated spontaneously within one minute and that the blood glucose was 6.0mmol/L. The patient was reviewed by a neurologist who requested MRI of the brain to exclude cerebral venous sinus thrombosis. However, whilst awaiting the MRI the patient had a second seizure which was followed by cardiorespiratory arrest.Defibrillation of VF restored sinus rhythm and spontaneous circulation (ROSC) within three minutes of cardiac arrest. On ROSC the Glasgow Coma Score was 13 (E4, V4, M5). Physical examination was otherwise unremarkable. Blood taken during CPR revealed: potassium 2.7mmol/L and magnesium 0.5mmol/L. An ECG revealed marked prolongation of the corrected QT interval (QTc 550ms). As the ECG recorded on admission to hospital was normal (Figure 5; QTc 380ms) the long QT syndrome (LQTS) was thought to be due to haloperidol, ciprofloxacin, hypokalaemia and hypomagnesaemia. Ciprofloxacin was stopped and replaced with tazocin. Correction of magnesium and potassium over the next 24 hours reduced the QTc to 450ms. The patient was then discharged to the coronary care unit with no significant neurological or cognitive deficit. Two days after the ciprofloxacin was changed to tazocin the QTc returned to the pre-arrest duration of 380ms, confirming that the LQTS was acquired rather than an unmasking of a concealed congenital LQTS. There were no further convulsions or arrhythmias and the patient was discharged home.

DiscussionRisk factors for developing the acquired LQTS are common in critically ill patients. Prevention, detection and treatment of QT interval prolongation must be considered for all patients. Measurement and documentation of the QTc interval is therefore an important aspect of cardiac monitoring in ICU. Predisposing drugs should be avoided if possible and discontinued if the QT interval prolongs. An up-to-date list of that drugs that prolong the QT interval is available at www.qtdrugs.org.[1]Furthermore all patients who have arrhythmias, pre-syncope, syncope,or seizures must have a 12 lead ECG recorded. If the QTc interval is prolonged treatment with magnesium and correction of electrolyte abnormalities is required to prevent TdP.

References1. Arizona Center for Education and Research on Therapeutics. QT

drug lists. QTdrugs www.QTdrugs.org. Accessed 08/08/12.

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Not all smokers who are short of breath have COPD

R. Rajendram1 and R. Parker2

John Radcliffe Hospital 1, OxfordAintree University Hospital 2, Liverpool, UKCorrespondence: rajkumarrajendram@doctors.org.uk

Type II respiratory failure is ventilatory failure causing alveolar hypoventilation. Whilst COPD is a common cause, any part of the respiratory pathway from the cerebral cortex to the respiratory muscles can be responsible. Muscle weakness pre-existing or acquired (e.g. ICU myopathy) should be considered in all patients.

Case ReportA 52-year-old woman with a 38 pack-year history of cigarette smoking presented in extremis. One month earlier a similar presentation had required invasive ventilation for type II respiratory failure. CTPA revealed bibasal collapse and consolidation. She improved with salbutamol and ipratropium, steroids and antibiotics. Weaning ventilatory support was difficult so a tracheostomy was formed. Two weeks later she was transferred to a respiratory ward.The tracheostomy was decannulated and she was discharged home with a diagnosis of COPD. After discharge her breathlessness, weakness and general malaise progressed. One week after discharge, she was found on the floor, cyanosed and unable to stand. On readmission O2, salbutamol and ipratropium, steroids and antibiotics were administered. Arterial blood gases revealed pH 7.07, pCO211kPa, pO2 33kPa and BE 4mmol/l. Hypercapnoea resulted in coma (GCS < 8) so the tracheostomy was recannulated and mandatory ventilation was initiated. Head CT found only cerebral oedema andafter readmission to ICU the patient’s GCS gradually improved to E4,VT, M6. Respiratory effort was limited and ventilatory support was still required. The patient was transferred to a respiratory ward where she weaned onto nocturnal non-invasive ventilation (NIV) and the tracheostomy was decannulated. Spirometry and sniff nasal inspiratory pressure confirmed severe inspiratory muscle weakness. Despite the smoking history, her flow volume loop excluded air flow obstruction. The patient reported progressive weakness over several years and had a waddling ‘myopathic’ gait. A neurologist noted weakness of all muscle groups (4+/5), absent deep tendon reflexes and flexor plantar responses but could not demonstrate fatigability or fasciculation. Cranial nerves were normal and sensation was intact.The diagnosis of acid maltase deficiency (AMD) was confirmed by analysis of peripheral blood lymphocytes, muscle biopsy and enzyme assay. The patient was discharged home seven weeks after readmission. Six months later she was tolerating the nocturnal NIV well with controlled daytime arterial blood gases (pCO2 6.5kPa; BE5.1mmol/l) but unfortunately had to stop working as a domestic assistant due to physical incapacity.

DiscussionAdult onset AMD is autosomal recessive with a frequency of approximately 1:40000.[1] Glycogen accumulates in cells because acid maltase (α1,4 glucosidase) is deficient. This affects skeletal muscle and patients may present with respiratory failure or peripheral muscle weakness. Prognosis is highly variable and presentation is often insidious depending on the enzyme activity. As no cure is available, supportive therapies and screening of family members are the cornerstones of management. However, enzyme replacement is being developed and the results of initial studies are promising.[1]

References1. Winkel LP, Van den Hout JM, Kamphoven JH, et al. Enzyme

replacement therapy in late-onset Pompe’s disease: a three-year follow-up. Annals of Neurology 2004; 55: 495–502.

Cushing’s syndrome: returning to etomidate infusions in ICU

R. Rajendram, S. Schirru and J. Griffiths

Churchill Hospital, Oxford, UKCorrespondence: rajkumarrajendram@doctors.org.uk

Etomidate is a carboxylated imidazole that is a potent inhibitor of the adrenal enzyme 11 β hydroxylase. Etomidate was widely used for sedation of critically ill patients until it was found to increase mortality in these patients due to associated hypoadrenalism.[1] We describe the use of etomidate to treat hypercortisolism.

Case ReportA 57 year old woman with Cushing’s syndrome secondary to adrenal carcinoma with unresectable liver metastasis underwent bilateral adrenalectomy and splenectomy. Prior to adrenalectomy the cortisol had been controlled with an oral block and replace regime of metyrapone and hydrocortisone. This was stopped on the day of surgery but reinstated post-operatively after confirmation of ongoing cortisol secretion from the liver metastases. Two weeks after the initial surgery she was admitted to ICU with intrabdominal sepsis. At laparotomy a large pelvic collection was drained. Three drains were left in situ, the abdomen was packed and left open and i.v. co-amoxyclav and metronidazole were started. Noradrenaline was required to maintain end organ perfusion so hydrocortisone 50 mg qds i.v. was given to ensure that levels of cortisol were adequate.However, 24 hours after admission to ICU the cortisol was very high (2291 mcg/dL). Two days after laparostomy the packs were removed and the abdomen was closed. Metyrapone was then given via a nasogastric tube but absorption was not reliable and so an etomidate infusion was started (2.5 mg/hr i.v.) and seven hours after starting the infusion the cortisol was 1489 mcg/dL. Within 24 hours the patient was weaned off noradrenaline and then extubated. Metyrapone and i.v. boluses of hydrocortisone were initially continued alongside the etomidate infusion but enteral absorption remained erratic and cortisol remained >500 mcg/dL so these were stopped. Unfortunately two daysafter extubation she developed sepsis resulting in type 1 respiratory failure from acute lung injury. She was reintubated and noradrenaline was restarted. Cultures of fluid from the pelvic collection grew Pseudomonas and a Candida so co-amoxyclav was changed to piperacillin-tazobactam and fluconazole was started. The noradrenaline was weaned as she improved. During this time the hypercortisolism was difficult to treat. Various regimens were triedbut the best control was achieved with an i.v. block and replace regimen. A fixed rate infusion of etomidate (1 mg/hr) and a variable hydrocortisone (1-2 mg/hr) infusion were titrated to maintain cortisol levels of 400-500 mcg/dL. Three days after re-intubation she was extubated. When oral intake was established the infusions were replaced with metyrapone and oral hydrocortisone.

DiscussionManagement of unwell patients with Cushing’s syndrome in ICU or HDU facilitates rapid control of cortisol with etomidate if the enteral therapy is unreliable.[1] We recommend the use of an i.v. block and replace regimen using a fixed rate etomidate infusion and variable hydrocortisone infusion. In the present case this controlled cortisol within the target range and was the easiest to monitor and titrate of the various regimens that were tried. In the 21st century experience with the use of etomidate infusions is limited. The complete block of ectopic cortisol production by a low dose etomidate infusion in this case highlights the profound adrenal suppression that occurs if etomidate is used for induction of anaesthesia (0.1-0.2 mg/kg i.v. bolus) or sedation (5-20 mcg/kg/minute i.v.).

Reference1. Preda VA, Sen J, Karavitaki N, Grossman AB. Etomidate in the management of hypercortisolaemia in Cushing's syndrome: a review.European Journal of Endocrinology. 2012;167:137-43.

Spinal anaesthesia for elective caesarean section in a woman with multiple sclerosis.

CL Richardson, R Jones, J Greenwood

Worcestershire Royal Hospitalrhidianjones@hotmail.com

Although obstetric patients with multiple sclerosis (MS) have an increased risk of requiring instrumental/operative delivery, there is little and conflicting evidence in the literature as to the optimal choice of anaesthetic technique. The effects of local anaesthetics on demyelinated fibres and disease progression are not known. Considering the beneficial effects of neuroaxial anaesthesia on mother/neonate, consistent evidence as to whether this may modulate disease is lacking.

The caseA 33-year-old Caucasian female (G1 P0) with active MS underwent aplanned caesarean section pregnancy for breech presentation at 38 weeks. Spinal anaesthetic using 0.5% Marcain was performed with no neurological sequelae or change from baseline symptomatology acutely or over a 3-month telephone follow-up period.

DiscussionTo our knowledge, our case report represents the second reported case in the literature of successful use of spinal anaesthesia for elective caesarean section in a patient with co- existing MS. Nevertheless, most obstetric anaesthetists would preferentially use a regional technique in such a scenario1. Our case demonstrates stability of MS symptoms in the context of active disease over a substantial follow up period. There is a need for further reporting of outcomes in such patients in the form of case series in order to inform practice.

References1. Drake E, Drake M, Bird J, Russell R. Obstetric regional blocks

for women with multiple sclerosis: a survey of UK experience.International Journal Obstetric Anesthesia. 2006 Apr;15(2):115-23

Overdose of ethylene glycol with an unexpected neurological recovery.

W. Rutherford, D. Quemby and T. Guest

Torbay Hospital, Torquay, UK.william.rutherford@nhs.net

Case ReportEthylene glycol (EG) is a readily available poison with highly toxic metabolites which requires rapid treatment. We report a case of EG poisoning with delayed neurological recovery and prolonged unconsciousness.

A 57-year-old male presented to the Emergency Department with adecreased level of consciousness requiring emergency intubation.There was no history to aid diagnosis. He was transferred to the ICUfor ventilation and multiple organ support. Blood results revealed a severe metabolic acidosis (pH 6.89) with an anion gap of 34. The National Poisons Information Service advised initiation of Fomepizolefor likely EG overdose. Continuous veno-venous haemodiafiltration (CVVHDF) was also required to correct the worsening acidosis and to help clear the EG. Blood samples taken on his admission later revealed an EG level of 1138mg/L. We estimate this serum level is approximately 12 hours after ingestion.

Despite correcting his biochemistry and returning the EG levels to almost zero, by day three the patient`s neurological state had not improved and he remained unconscious after sedation breaks. The time course of his recovery was such that withdrawal of support was considered.

On day five he showed significant improvement, opening his eyes but exhibiting no response to painful stimuli. An electroencephalogram (EEG) showed findings compatible with a non-specific encephalitic process. By day six he appeared to be localising to his tracheal tube with the left arm. He remained dependent upon CVVHDF for anuric kidney injury until day 16, by which time he could move both arms and legs to command. A tracheostomy inserted to aid ventilator weaning was removed on day 18 and he was discharged to the general ward on day 21. He has since been reviewed in the ICU follow up outpatient clinic. He has no focal neurological deficit and has made a full renal recovery.

The clinical presentation of EG poisoning is well described in the literature as consisting of three stages. Neurological manifestations are apparent within 0.5–12 hours of ingestion, followed by cardiopulmonary dysfunction and finally renal dysfunction. [1, 2] There are multiple reports of delayed cranial and peripheral neuropathies occurring several days after initial recovery [2], and this is often considered the fourth stage of the clinical presentation. It is expected that after a period of intoxication lasting 24-48 hours, gross neurological recovery should occur if the toxic effects do not prove fatal.

To our knowledge, there are no reports of prolonged depression of consciousness followed by complete recovery. Our case provides evidence of a good clinical outcome and justifies the decision to continue full support. References1. Eder AF et al. Ethylene glycol poisoning: Toxicokinetic and

analytical factors affecting laboratory diagnosis. Clinical Chemistry 1998;44:168–177

2. Rahman SS et al. Autonomic dysfunction as a delayed sequelae of acute ethylene glycol ingestion: a case report and review of the literature. Journal of Medical Toxicology 2012;8(2):124-9.

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Just a little tongue biopsy...

C. Seeley1, I. Driver1, I. Hatcher1

Ipswich Hospital, Ipswich, UK1

cseeley@doctors.org.uk

Case Report

A 55 year old man presented on the elective maxillo-facial list for an EUA and biopsy of base of tongue. Symptoms at referral included dysphasia, a foreign body sensation in his throat, and a recent onset of haemoptysis. An ENT SpR had reported an ulcer on the base of the tongue following microendoscopy. An MRI neck was ordered and the patient was booked for urgent biopsy.

The patient had undergone a pre-operative assessment following referral, where examination was reported as unremarkable. The MRI result had not been followed up by either the maxillo-facial or ENT teams.

On the day of surgery the patient had deteriorated with worsening dysphasia and shortness of breath. MRI images viewed by the anaesthetist showed almost complete airway obstruction by a 35mm supra-glottic mass.

The case was postponed, steroids started and an urgent Consultant ENT review requested. Following a biopsy of the mass, taken under local anaesthetic, he underwent an awake fibreoptic intubation for laser debulking of the tumour. A fibreoptic video available demonstrates the extent of the airway compromise.

This case presentation provides learning points regarding communication between surgical and anaesthetic teams, the importance of thorough pre-operative assessment with follow-up of imaging requests, and the potentially fatal consequences when this fails.

Awake fibreoptic intubation in a patient with isolated laryngeal fracture

S. Shotter and G. Sommerville

Tunbridge Wells Hospital at Pembury, Tunbridge Wells, UKsmshotter@doctors.org.uk

A 61 year old, ASA 1, female nurse presented to Accident & Emergency following a bicycle accident. She had ridden her bicycle into the rear of a stationary lorry with the tail gate down, sustaining an impact to the front of her neck. She presented with a swollen neck, dysphonia and hoarseness. She was maintaining oxygen saturations of 100% on 15 litres of oxygen through a non-rebreathe mask.

MethodsThe patient became frankly stridulous on any palpation of the neck. The neck was swollen and no anterior anatomy was palpable. She was splinting her airway so lying flat for a CT scan was not an option. The patient was transferred to theatre, and the case discussed with anaesthetic and ENT consultants. Flexible nasoendoscopy was performed and showed laryngeal oedema and some supraglottic blood. The patient was remarkably calm despite her pathology, and the decision was made to attempt awake fibreoptic intubation (AFOI). Anurse and ENT surgeon were scrubbed for tracheostomy. The pharynx was anaesthetised with 2% lignocaine using a ‘spray as you go’ technique. A size six cuffed nasal endotracheal tube (ETT) was successfully passed through the vocal cords. 100micrograms of fentanyl and 200mg of propofol were then administered.

ResultsA CT scan showed an isolated fracture of the thyroid cartilage with extensive surgical emphysema. There was extensive oedema, with no space around the endotracheal tube at the level of the lesion. The ENT team felt surgical intervention was not necessary, and so the patient was managed conservatively on intensive care. She remained sedated for 5 days and received high dose dexamethasone and antibioticsbefore a return to theatre for rigid bronchoscopy. This showed the airway oedema had resolved, and demonstrated a healing lesion where the fractured cartilage had pierced her trachea. She was reintubated orally prior to a controlled wean on intensive care. She was successfully extubated with no voice change, and discharged to the ENT ward for further monitoring prior to discharge home.

DiscussionLaryngeal fracture is a rare injury, with incidence reported to be around 1 in 30,000 [1]. Anaesthetic approach is not widely discussed in published literature. The concern with AFOI is that it requires a co-operative patient, which can be difficult in such distressing situations. Furthermore the need to apply local anaesthetic to her vocal cords could have caused laryngospasm of her sensitised glottis. The minimum ETT size is also limited by what can slide over the scope. In this patient she understood what was happening and was co-operative. An alternative approach would have been to insert a tracheostomy under local anaesthetic. This would again have necessitated the patient being able to lie flat, and would have been technically challenging due to extensive surgical emphysema. The risks of giving a general anaesthetic without first securing an airway would be great, as the loss of airway tone could have caused ventilatory compromise with the possibility of being unable to obtain airway access. AFOI is a usefultool for airway management in laryngeal fracture provided careful patient selection is implemented, and an alternative means of securing the airway surgically is also prepared.

References1. Pyeong Kim J., Jae Cho S. Young Son H., Je Park J., Hoon Woo

S.. Analysis of clinical feature and management of laryngeal fracture: recent 22 case review. A 27-year experience. Yonsei Medical Journal. 2012;53(5):992-87

Phaeochromocytoma presenting under anaesthesia for day surgery: the role of magnesium in the patient’s subsequent management and a complication possibly related to its use.

E. Sleap, M. Jenkins, A. Wade and J. Wells.

Basingstoke and North Hampshire Hospital, Hampshire Hospitals Foundation Trust, Basingstoke, UKesmesleap@googlemail.com

Case studyA previously fit and well 55 year old shepherd attended the Day Treatment Centre for inguinal hernia repair. After induction of anaesthesia he developed labile blood pressure up to 180 mmHg systolic, tachycardia and vasoconstriction. Surgery was abandoned and some stabilisation was achieved with esmolol and GTN, allowing transfer to ITU. Initial ITU management of the hypertension and tachycardia was with phentolamine and esmolol infusions. Complications of the adrenergic crisis included pulmonary oedema, cardiac ischaemia, renal failure and digital infarcts. Phaeochromocytoma was confirmed by high plasma metadrenaline and normetadrenaline levels and CT scan showing a left adrenal mass. Introduction of an infusion of magnesium sulphate, targeting plasma concentrations of 2–4 mmol/litre helped achieve enough stability for open adrenalectomy 15 days after ITU admission. Magnesium boluses and infusion were used intraoperatively and the procedure was completed without immediate complication. Two days later, falling haemoglobin concentration prompted a return to theatre. Clotting and platelet count were normal. Two litres of blood clot was removed from the abdomen but no bleeding point was identified. The patient was discharged home two months after admission.

DiscussionPhaeochromocytomas are rare, catecholamine-secreting tumours, usually arising the adrenal medulla. They present a challenge for anaesthetists, both in phaeochromocytoma surgery, and occasionally when an undiagnosed patient suffers adrenergic crisis. In both settings the aim is to gain control of hypertension, usually initially with α adrenoceptor blockade (phentolamine in this case), before proceeding to surgery for tumour resection. A β blocker is often needed to counteract tachycardia. Magnesium can be a useful addition to these therapies; magnesium not only blocks catecholamine receptors, but also has the helpful actions of inhibiting release of catecholamines from the adrenal medulla and peripheral nerves, vasodilatation and antiarrhythmic effect [1]. As this case illustrates, it has a role both in anaesthesia for phaeochromocytoma surgery [2], and in adrenergic crises [3]. However, there is evidence that pharmacological magnesium levels inhibit platelet function in vitro and vivo [4]. The clinical significance of this remains uncertain although bleeding timewas prolonged in a study of pregnant women requiring magnesium infusions [5]. In the case described, we wonder whether magnesium-related platelet dysfunction could have contributed to the post operative bleeding.

References1. Herroeder S, Schönherr M, De Hert S, Hollmann M. Magnesium

– essentials for anesthesiologists. Anesthesiology 2011; 114:971-93.

2. James M. Use of magnesium sulphate in the anaesthetic management of phaeochromocytoma: a review of 17 anaesthetics. British Journal of Anaesthesia 1989; 62: 616-23.

3. James M, Cronje L. Phaeochromocytoma crisis: the use of magnesium sulfate. Anesthesia and Analgesia 2004; 99: 680-6.

4. Gries A, Bode C, Gross S, Peter K, Bohrer H, Martin E. The effect of intravenously administered magnesium on platelet function in patients after cardiac surgery. Anesthesia and analgesia 1999; 88: 1213-9.

5. Fuentes A, Rojas A, Porter K, Saviello G, O’Brien W. The effect of magnesium sulphate on bleeding time in pregnancy. American Journal of Obstetrics and Gynecology 1995; 173: 1246-9.

Regional obstetric anaesthesia in non-surgical scoliosis patients

SL Stobbs1, SJ Cross1 and R Burns1

Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh 1, Edinburgh, UKsarahstobbs@doctors.org.uk

Scoliosis is a common cause for referral to our High Risk Anaesthetic Antenatal Clinic, which serves a unit with >7000 deliveries per year. Referrals can be made by Midwives or Obstetricians and are a heterogeneous group of patients including surgically treated to mild asymptomatic cases. Women with indwelling metalwork are counselled regarding the alternatives to regional anaesthesia andanalgesia and those with untreated scoliosis are informed of the increased difficulty in performing regional techniques and the increased incidence of failure [1]. Our aim was to assess the outcome of neuroaxial blocks in untreated scoliosis patients.

MethodsWith approval from the hospital Quality Improvement Facilitator we searched the clinic database for scoliosis referrals from 2009 to 2012.The maternity TRAK online electronic note system allowed us to identify those women who had had regional techniques performed and our department audit data provided follow-up details for assessing the adequacy of anaesthesia and analgesia.

ResultsOut of the 39 patients with scoliosis who had regional techniques performed, 28 had complete follow up and of these three had inadequate blocks. One spinal did not reach an adequate level prior to emergency caesarean section and was converted to general anaesthetic. Two epidurals were inadequate: one patient required pudendal block for forceps delivery; the second required a resite of a failed epidural which was also unsatisfactory and required entonox for a forceps delivery.

Table 1. Details of findingsNumber of patients

Seen in clinic 2009-2012 85Regional anaesthesia performed 39Follow-up completed 28Lost to follow-up 11Epidural 15Spinal 13Adequate block for delivery 25Inadequate block 3

DiscussionIn this service evaluation we have found a 2/15 rate of inadequate block from epidural anaesthesia for labour and delivery and 1/13 rate of conversion to GA due to inadequate spinal anaesthesia for emergency caesarean section in patients with completed follow-up. This rate is higher than that quoted in the OAA advice leaflets which is 1/8 and 1/100 respectively for straightforward cases, in particular the rate of spinal failure in our study is much higher [2]. However, this study was limited by low patient numbers and a considerable number being lost to follow-up. In our clinic we see a number of patients with scoliosis who are untreated and asymptomatic although these results may indicate they are at a significantly increased risk of regional technique failing and therefore it is appropriate for them to be counselled in this way.

References1 Smith PS, Wilson RC, Robinson APC et al. Regional blockade

for delivery in women with scoliosis or previous spinal surgery. International Journal of Obstetric Anesthesia 2003;12: 17-22.

2 http://www.oaa-anaes.ac.ukhttp://abstracts.oaaanaes.ac.uk//assets/_managed/editor/File/Info%20for%20Mothers/PR_leaflets/2009_ed3_oct_oaa_pain_labour.pdf

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Major Haemorrhage from Scalp Laceration

A. Sykes and P. Dowson

Cumberland Infirmary, Carlisle, UKanna0404@hotmail.com

There are significant time pressures to get patients with a major head injury from the Accident and Emergency (A&E) resuscitation room in to the CT scanner. A concurrent scalp injury, despite being noticed on the primary survey, can be overlooked as potential for causing life-threatening haemorrhage.

Case ReportA 19 year old man fell through a glass door, with a history of heavy alcohol consumption. The ambulance journey from the scene to A&E took one hour and the paramedics were unable to obtain vascular access. The paramedics reported that the patient had a head wound but no other obvious injuries. On arrival the head bandages were saturated with blood. The patient was tachycardic, hypotensive and responded only to pain. The arterial blood gas haemoglobin (Hb) was 12g/dl. Initial fluid resuscitation included 1000ml crystalloid, 500ml colloid and two units of O-negative packed red cells (PRC). His blood pressure normalised but he remained tachycardic. A CT was indicated because of a low GCS. He had a rapid sequence induction and was sedated with propofol. Blood was noted to be soaking through the head bandages when in-line manual C-spine stabilisation was applied for intubation. An arterial line was inserted prior to transfer to CT and a repeat Hb was still 12g/dL. In the CT scanner the patient became increasingly hypotensive. He received a further colloid and cross-matched PRC. The CT showed a massive extracranial haematoma with no intracranial pathology. He returned to the A&E resuscitation bay, had multiple bleeding scalp arteries clamped and received 2 further units of PRC. With the patient stabilised and the bleeding under control he was transferred to theatre for definitive management. In total the patient required 8 units of PRC, 4 units of fresh frozen plasma, 2 pools of platelets and intravenous Tranexamic acid. He was kept intubated and ventilated in the intensive care unit overnight, with uneventful extubation and discharge to the ward later that day.

DiscussionThere can be major haemorrhage from scalp lacerations in adults and their ability to cause shock should always be recognised. It may be argued that the patient should not have been transferred to the CT scanner, despite a period of blood pressure stability, without the source of his initial cardiovascular instability being addressed.

Abdominal hypertension masking propofol infusion syndrome.

E. Traer, R. Rajendram, J. Mandeville, J. Griffiths and J. Westbrook

John Radcliffe Hospital, Oxford, UKCommunications: emilytraer@doctors.org.uk

We describe a patient in whom the propofol infusion syndrome (PRIS)was masked by the coincident development of an abdominal compartment syndrome.

Case ReportA 22 year old man was admitted to the neurointensive care unit(NICU) after a RTA which resulted in petrous bone, facial and cervical vertebral fractures, pneumocephalus and diffuse axonal injurybut no other injuries. The patient was intubated, mechanically ventilated and sedated with propofol and fentanyl. The ICP rose requiring treatment that included sedation (propofol >4mg/kg/hr infusion and boluses), fluid resuscitation, and noradrenaline to maintain a CPP of 60mmHg.Five days after NICU admission the ICP was controlled (<25 cmH2O) but the abdomen distended, the CVP was high (>25cmH2O) and the noradrenaline required to maintain the CPP increased up to 0.3mcg/kg/min. On day six abdominal compartment syndrome developed with a sustained rise in intra-abdominal pressure (>20mmHg) resulting in hypotension and anuric renal failure. Rising ICP impaired CPP despite addition of an adrenaline infusion. Urgentabdominal CT scan revealed colonic distension due to a ‘kinked’ transverse colon. Whilst awaiting colonoscopy, the patient developed profound hypotension secondary to a VT that was refractory to amiodarone. To avert impending cardiac arrest a midline laparotomy was performed on the NICU and the distended transverse colon was decompressed with an 18 gauge needle. Although this immediately restored sinus rhythm, severe right ventricular impairment was seen on transthoracic echo (TTE) and the hypotension remained refractory to noradrenaline, adrenaline, milrinone and vasopressin.Reviewing the events leading up to the cardiovascular collapse revealed that on day 2, lactic acidosis and myoglobinuria had developed but were thought to be due to traumatic rhabdomyolysis (CK 5000iu/dL). On day 4, Brugada-like changes were present on the ECG and right ventricular dysfunction had been seen on TTE. On day 6, potassium was 6.4mmol/L and lactate was 4.0mmol/L before the onset of VT. Blood was also then noted to be lipaemic; PRIS was thus diagnosed and propofol was changed to midazolam and morphine. The patient remained sedated, on haemofiltration, with a laparostomy for seven days. During this time, despite thiopentone, atracurium and hypertonic saline the ICP remained high (>25mmHg) for over 36 hours and CPP was consistently below 50mmHg. However, CT head demonstrated preservation of grey-white differentiation and serial TTE subsequently demonstrated almost complete resolution of the right ventricular dysfunction. The laparostomy was successfully closed, the renal function gradually improved and the inotropic support and vasopressors weaned. On sedation hold the patient recovered rapidly and was extubated. Two weeks later he was discharged home with no significant neurological or cognitive deficitbesides facial nerve palsy related to the initial petrous fracture.

DiscussionIn this case both PRIS and abdominal compartment syndrome caused cardiovascular collapse. It is likely that high dose propofol and noradrenaline contributed to the development of abdominal compartment syndrome. Decompressive laparotomy was life-saving but the concomitant PRIS was initially overlooked. Recognition of the key features of PRIS[1]: elevated lactate, hepatic dysfunction, renal impairment, raised CK and cardiac failure was critical to the subsequent management of this patient.

ReferenceSmith H, Sinson G, Panayiotis V. Vasopressors and Propofol Infusion Syndrome in Severe Head Trauma. Neurocritical Care 2009;10:166-172.

Normoglycaemic diabetic ketoacidosis in pregnancy

S. Vasdev1, J. Salim2 and T. Jovaisa3

Queens Hospital Barking Havering and Redbridge Trust, Romford,UK 1, 2, 3

Email of corresponding author - svasdev@doctors.org.uk

Diabetic ketoacidosis (DKA) is an important complication of pregnancy that can compromise both mother and fetus. Although the clinical presentation is similar as in non-pregnant women, it can occur with normal blood sugars which can lead to a delay in diagnosis and initiation of definitive treatment. We describe two unusual cases of normoglycaemic DKA in pregnancy, which were managed in the critical care department of a district general hospital.

Case ReportThe first case was a 26 year old non-diabetic primigravida of 31 weeks gestation, who was initially admitted under the medical team with suspected pyelonephritis. The urine dipstick demonstrated 2+ leucocytes alone. Subsequently, the patient developed a lower respiratory tract infection fours days following admission. Her arterial blood gas (ABG) demonstrated a severe compensated metabolic acidosis with normal lactate levels, a raised anion gap, a serum glucose of 4.5 mmol/L and normal renal function. She was admitted to the intensive care unit and within 24 hours her acidosis worsened despite intravenous antibiotics and aggressive fluid therapy. At this stage urinalysis was performed which demonstrated significant ketonuria, however she remained euyglycaemic. The second case was a 32 year old primigravida of 23 weeks gestation with established gestational diabetes who was admitted to Labour ward HDU with suspected meningoencephalitis. An ABG was performed which demonstrated a moderate metabolic acidosis, normal lactate levels, a raised anion gap, a serum glucose of 6.6 mmol/L, and normal renal function. Urinalysis revealed 2+ ketones. In each case there was no history of significant starvation or vomiting and both patients appeared clinically euvolaemic. Both patients were commenced on insulin/dextrose infusions and blood glucose levels were maintainedbetween 4 and 10 mmol/L, with a rapid improvement in the metabolic acidosis seen. Once fully resolved the insulin/dextrose infusions werestopped, and both patients were stepped down to ward-based care. During their critical care stay they were assessed with cardiotocography (CTG) with no evidence of fetal compromise. The remainder of their hospital stays were uneventful and were bothdischarged home with ante-natal follow up.

DiscussionNormoglycaemic DKA is a rare complication of pregnancy. A unique set of metabolic changes that occur in women during the late stages of pregnancy can predispose to the development of DKA [1]. There is a decrease in insulin sensitivity due to the production of insulin antagonistic hormones such as cortisol, and insulin requirementsincrease throughout pregnancy due to the high glucose requirements of the placenta and fetus. It can present with normal blood glucose levels which can lead to a delay in diagnosis. The onset of DKA can be more rapid in the pregnant patient with a more severe acidosis seen[2]. Early initiation of insulin therapy should not be withheld despite normal blood sugars and patients should be managed in a critical care area with multidisciplinary input.

References1. Chico M, Levine SN, Lewis DF. Normoglycaemic diabetic

ketoacidosis in pregnancy. Journal of Perinatology 2008; 28: 310-312.

2. Kamalakannan D, Baskar V, Barton DM, Abdu TAM. Diabetic ketoacidosis in pregnancy. Postgraduate MedicalJournal 2003; 79: 454-457.

Chylous ascites: an unusual cause of a pleural effusion

J.Wakeford and P. Farquhar-Smith

Royal Marsden Hospital, London, UKjkwakeford@gmail.com

We present a case of chylothorax post abdominal surgery that presented as a pleural effusion. Chylous ascites is well documented post abdominal surgery, but is most commonly associated with interventions such as resection of abdominal aortic aneurysm and retroperitoneal lymph node dissection [1]. Although chylous acities has been documented after laparoscopic nephrectomy [2], there are no published cases as it presenting as a pleural effusion.

Case reportA 56 year old male presented to the critical care unit post-operatively following a left adrenalectomy and nephrectomy for a non-functioning adrenocortical carcinoma. There had been a small diaphragmatic injury at the time of surgery. Over the course of the first night CPAP was initiated because of increasing oxygen demand. A CXR was done which showed a significant effusion as well as a pneumothorax. The pleural fluid and was found to have a protein content of 33g/dl and an amylase of 13020 U/l (serum amylase 128 U/l). The high amylase content was highly suggestive of an abdominal source. CT was performed and showed some dependent ascites in the abdomen with a small residual pneumothorax and lung consolidation. There was minimal pleural fluid which was consistent with effective fluid drainage. Discussion with the surgeons revealed that they had a suspected chyle leak around the region of the superior mesenteric artery during the operation. The diagnosis of chylous ascities was strengthened by the drainage fluid turning cloudy after eating ice cream. The patient was managed conservatively with a low-fat diet and octreotide infusion.

DiscussionThere are a myriad of causes of pleural effusion. Chyle is well regonised as a cause of pleural effusion but is usually secondary to leakage from the thoracic duct or one of the main lymphatics that drain to it. Our patient however produced copious amounts of chyle from an abdominal site remote to the thoracic duct. The diaphragmatic injury facilitated drainage of the chylous ascites into the pleural cavity thus resulting in a pleural effusion with the pneumothorax. This thesis was supported by the greatly elevated amylase in the chest drain fluid. A low fat diet can reduce the flow of chyle into the lymphatics. If chylous ascites persists despite dietary management, total parenteral nutrition has been advocated [3].Paracentesis can result in immediate symptom relief butreaccumulation of fluid usually follows, and patients may require repeated paracentesis [3]. Octreotide has been described in case reports as useful to decrease lymphatic flow [1]. Management goals focus on maintaining nutrition and decreasing the formation of chyle.[3] This case also highlights the importance of effective communication between surgeons and anaesthetic/CCU staff, since surgical factors can have a direct bearing on the aetiology of post surgical problems.

References1. http://emedicine.medscape.com/article/185777-

overview#a1

2. Aerts J, Matas A, Sutherland D, Kandaswamy R. Chylous

ascites requiring surgical intervention after donor

nephrectomy: case series and single center experience.

American Journal of Transplanation. Jan 2010;10(1):124

3. Aalami OO, Allen DB, Organ CH Jr. Chylous ascites: a

collective review. Surgery. Nov 2000;128(5):761-78.

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Back pain. A cautionary tale…..

C. Williams, T. West, S. Bell, S. Harries, L. De Lloyd and R. BarazUniversity Hospital of Wales, Cardiff, UK

williamscn@cardiff.ac.uk

We present a case of epidural abscess following straightforwardepidural placement for labour analgesia in a healthy primigravida.

Case ReportA 37 year old lady underwent induction of labour at 36+2 weeks for a monochorionic di-amniotic twin pregnancy. She had been commenced on aspirin 75mg daily at 12 weeks gestation as per NICE guidelines. Once in established labour she requested an epidural, which wasinserted uneventfully under strict aseptic conditions at L2/3 and provided effective analgesia for labour and instrumental delivery. The catheter was in situ for 15 hours and the block regressed once analgesia was discontinued. She was asymptomatic on postnatal review. Forty-eight hours after delivery the patient developed back pain and redness at the epidural site. She was apyrexial with no neurological findings and had a normal leucocyte count. A diagnosis of superficial site infection was made and oral flucloxacillin was commenced. The following day her symptoms and signs were improving and the patient was discharged home on antibiotics withappropriate advice. She re-presented two days later with severeradicular back pain shooting into her neck and down her legs, pus discharging from the epidural site, neutrophilia, and raised CRP. There was no neurological deficit. After neurologist review and discussion with a radiologist it was agreed that MRI was warranted but could be delayed to the following morning. Antibiotic therapy was amended to intravenous flucloxacillin and vancomycin. MRI the following morning revealed an extradural mass at L2/3 reported as 'consistent with an infected haematoma'. Neurosurgical reviewrecommended conservative treatment with close neurologicalmonitoring, serial inflammatory markers and repeated MRI scans to monitor progress. Cefotaxime was added as advised by microbiology. Staphylococcus aureus was identified as the causative organism. Follow-up MRI four weeks post-delivery showed complete resolutionof the extradural mass.

DiscussionEpidural abscess is a rare complication of CNB with an incidence of 2.1 per 100 000 and is strongly associated with significant morbidity and mortality [1, 2]. Interestingly this patient was on aspirin which may have contributed to development of an epidural haematoma, although MRI cannot differentiate between blood or pus, so this remains uncertain. Presentation of epidural abscess rarely follows the classical triad of fever, back pain and neurological deficit. Shootingradicular pain appears to be typical whilst neurological deficit is a late sign associated with poor prognosis [3, 4]. Consequently we believe that MRI should be performed without delay in any patient in whom epidural abscess is suspected. In certain carefully selected patients conservative management can achieve a good outcome.

References1. Grewel S, Hocking G, Wildsmith JAW. Epidural abscess.

British Journal of Anaesthesia 2006;96:292-302. 2. National audit of major complications of central neuraxial block

in the United Kingdom. Report and findings of the third national audit project of the Royal College of Anaesthetists. January 2009

3. Danner RL, Harmann BJ. Update on spinal epidural abscess; 35 cases and review of the literature. Review of Infectious Diseases1987;9(2):265-74

4. Darouiche RO. Spinal epidural abscess. New England Journal ofMedicine 2006;355(19):2012-20

TOE scan or not TOE scan (on GICU)Ask and it shall be given to you; seek and you will find…..

C. Williams1 and S. Ahmed2

1University Hospital of Wales, Cardiff, UK. 2Royal Albert Edward Infirmary, Wigan, UK

williamscn@cardiff.ac.uk

This case highlights the role of echocardiography in the general intensive care setting and discusses the differential diagnosis of intracardiac masses.

Case reportIn this case report we describe a 54-year-old previously healthy patient who presented in extremis with abdominal pain. A computerised tomography scan was performed demonstrating features consistent with mesenteric ischaemia. It also revealed a filling defect in the left ventricle, presumed to be a thrombus. The patient underwent emergency bowel resection and was subsequently admitted to the intensive care unit (ICU) as a level three patient. Transoesophageal echocardiography (TOE) was performed to further investigate the left ventricular mass. It showed an intracardiac mass, with appearances consistent with a cardiac tumour. The consensus of opinion between all the specialities involved, was that the features of this mass were consistent with sarcoma, a malignant tumour of the heart, with a very poor prognosis. Despite maximal therapy, the patient deteriorated. Given the improbability of achieving control of her intra-cardiac pathology and her acute abdominal deterioration the situation was deemed unsalvageable and on-going treatment was withdrawn.

DiscussionThis case emphasises the fundamental role of echocardiography in the evaluation of patients with signs and symptoms of cardiac failure, unexplained cardiac murmurs or systemic emboli. It is now considered an indispensable tool for diagnosis and haemodynamic monitoring in critically ill patients and leads to therapeutic changes in approximately 25% of patients [1]. Indications for performing echocardiography (either transthoracic or TOE) in the ICU setting have expanded and it is considered a requirement for critical care physicians to acquire competency as reflected by several recently published guidelines [2, 3]. With careful attention to mass location and morphology along with appropriate application of clinical information, echocardiography can be used to distinguish between the three main intracardiac mass lesions: tumour, thrombus and vegetation. Tumours of the heart are rare with an incidence of 0.0017% [4]. Intra-cardiac sarcomas are highly malignant, rapidly infiltrating all layers of the heart and metastasise widely with a high mortality rate [5]. They have often grown to a considerable size before detection. Presentation may be with systemic emboli and a high index of suspicion is required to achieve timely diagnosis of these patients.

References1. Orme RM, Oram MP, McKinstry CE. Impact of

echocardiography on patient management in the intensive care unit: an audit of district general hospital practice. British Journal of Anaesthesia 2009;102(3):340-344

2. Expert Round Table on Ultrasound in ICU. International Expert Statement on Standards for Critical Care Ultrasonography. Intensive Care Medicine 2011;37(7):1077-1083

3. Neri L, Storti E, Lichtenstein D. Towards an ultrasound curriculum for critical care medicine. Critical Care Medicine2007;35(5):290-304

4. Luper WE, Klima T, Klima M. Angiosarcoma of the heart.Bulletin of the Texas Heart Institute 1977;4(1): 87-91.

5. Silverman NA. Primary cardiac tumours. Annals of Surgery1980;191:127-138

Starting a remifentanil infusion at the end of surgery to facilitate smooth emergence from anaesthesia in a potentially difficult airway

M. Wilson1, C. Burnand2

Salford Royal Hospital, Manchester, UK 1 Salford Royal Hospital,Manchester, UK 2dr_mingwilson@yahoo.co.uk

The anaesthetic as well as the surgical management of a case of profound epistaxis in a patient with Hereditary Haemorrhagic Telangiectasia (HHT) will be discussed, specifically exploring at the use of remifentanil. Remifentanil has been shown to facilitate smooth emergence from anaesthesia. This is particularly useful in situations where coughing or bucking on an endotracheal tube on emergence from general anaesthesia (GA) would be detrimental. In the elective setting, remifentanil would be commenced at induction of anaesthesia or immediately following induction. In this case it was started at the end of the surgical procedure in order to facilitate a smooth emergence and prevention of bleeding. Although this technique has not been recognised yet, it maybe developed for use in emergency cases such as the one presented.

MethodsWe present a case report that introduces a novice method of delivery of general anaesthesia that is specific for ‘difficult’ or ‘challenging’airways. A 52-year-old man with known HHT presented with ahistory of continuous substantial epistaxis. There was significant blood loss and he required resuscitation with intravenous fluids and blood products. He underwent an uneventful GA for attempted cauterisation of the bleeding points and ligation of the sphenopalatine artery. This was challenging surgically due to the extensive bleedingand the procedure was abandoned. Posterior packing with balloon insertion was a temporary means of stemming the bleeding. Due to the high risk of further re-bleeding, the surgeon specifically requested that it was crucial that the patient must not be allowed to cough or strain.At the end of the case, a remifentanil infusion was started at an effect site concentration of 4ng/ml and continued for a further ten minutes. During this time, the patient’s airway was suctioned under direct vision. An orogastric tube was inserted to empty the stomach contents and was then removed. The patient was placed in the head-up position and was not disturbed. Remifentanil effect site concentration was reduced to 2ng/ml, the sevoflurane was discontinued and the fresh gas flow increased.This case has been compiled with the written consent of the patient.

ResultsThe patient emerged from anaesthesia with a ‘clear-head’ and was comfortable. There was no coughing, retching, vomiting, sneezing or straining. The patient was given small boluses of morphine for nasal discomfort. He remained haemodynamically stable throughout the recovery period and there was no further bleeding of the nasal cavity.

DiscussionThe pharmacokinetic and pharmacodynamic properties of remifentanil make it an ideal agent to preserve the surgical site on emergence from anaesthesia. To our knowledge there are no published reports of starting remifentanil at the end of a surgical procedure to facilitate smooth emergence from anaesthesia. Commencing the use of remifentanil at the end of an emergency case should be considered to assist and promote smooth emergence from anaesthesia.

References1. Choi EM, Park WK, Choi SH, et al. Smooth emergence in men

undergoing nasal surgery: the effect site concentration of remifentanil for preventing cough after sevoflurane-balanced anaesthesia. Acta Anaesthesiologica Scandinavica 2012; 56:498-503.

ICU patient pain assessments are often limited, with different factors affecting medical and nursing reviews

S. Alderson1, F. Frame1, C. Goh1, and S. McKechnie1

John Radcliffe Hospital, Oxford, UKs.m.alderson@gmail.com

Pain is common but under-recognised in critically ill patients. Daily pain assessment shortens the duration of ventilation and ICU length of stay, and should therefore be undertaken routinely.[1] We reviewed medical and nursing pain assessment in ICU.

MethodsThe presence and content of a medical and nursing pain assessments, patient length of stay, and barriers to communication were prospectively collected for one month. Significance was determined using chi-squared test.

ResultsData for 58 ICU inpatients over 155 patient care episodes (PCE, defined as 24-hour periods of care) was collected. In 64 (41%) of PCEs, patients did not receive a single medical pain assessment. Patients were less likely to receive a medical pain review the longer they remained on ICU (n=5 <24 hours; 15 at 24 hours; 30 at 72 hours; p<0.05). Patient intubation (n=11, 17%), sedation (n=13, 20%), or low GCS (n=8, 12.5%), was not associated with the absence of a medical pain review (p=>0.05). In 31 (20%) of PCEs, patients did not receive a single nursing pain assessment. Patients were less likely to receive a nursing pain review if intubated (n=13, 42%), sedated (n=12, 38%), or had low GCS (n=8, 25%) (p=<0.05). Patient length of stay was not associated with the absence of a nursing pain review (n=1 <24 hours, 7 at 24 hours, 10 at 72 hours; p=>0.05).

DiscussionPatients in this study frequently did not receive a medical assessment of pain, with lack of assessment more likely in patients with longer lengths of ICU stay. It did not appear that recognised barriers to pain assessment were sufficient to account for the absence of medical pain reviews alone. Whilst nursing assessments of pain occurred more frequently, patients who were intubated, sedated, or had low GCS were less likely to have their pain assessed.

References1. Payen, J.F.; Bosson, J.L.; Chanques, G.; Mantz, J.; Labarere, J.;

Pain assessment is associated with decreased duration of mechanical ventilation in the intensive care unit: a post Hoc analysis of the DOLOREA study. Anesthesiology (2009) 111(6):1308-16

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An audit of anaesthetists’ awareness of the contents of the difficult airway trolley

T. Barge and P. Duggleby

Stoke Mandeville Hospital, Aylesbury, UKEmail: tom.barge@doctors.org.uk

The Difficult Airway Society (DAS) has published guidelines for the recommended management of an unanticipated difficult intubation[1]. As part of theses guidelines, DAS recommend certain pieces of airway equipment be available on a dedicated difficult airway trolley(DAT) in any location where an anaesthetic is given [2]. Anaesthetists should be aware of the equipment on this trolley and be familiar with how to use it [2].

MethodsWe audited anaesthetists’ awareness of the contents of our hospitals three DATs. By means of a standardised written questionnaire, 15pieces of airway equipment were surveyed, some of which wereavailable on our hospitals DATs and some of which were not.Responses were “yes”, “no” or “not sure” for each piece of equipment. There was variability in the contents of the three DATs and so ifequipment was available on any one DAT, we allowed a “yes” as a correct response. Initial and re audit results were compared using acontingency table and the Chi-squared test.

ResultsTwelve junior (CT1-2), 16 middle grade (registrars, staff grades and associate specialists) and 22 consultants were surveyed in the initial audit (Table 1). Our standard was 100% awareness of available equipment. After initial audit, we advertised the contents of our hospitals DATs by means of an oral presentation at the local anaesthetic governance meeting, and recommended consideration be given to standardising the contents of the DATs. One month later were-audited 10 juniors, 12 middle grades and 15 consultants using the same questionnaire (Table 1). Awareness of the contents of the DAT increased significantly following intervention (P<0.001).

DiscussionAnaesthetists in our hospital had poor awareness of the contents of the DATs. This improved significantly by advertising what equipment was available. Variability between the contents of the three DATs likely led to some confusion about what equipment was available and contributed to the high proportion of “don’t know” responses.Uncertainty about available equipment on the DAT introduces risk. Anaesthetists may plan to use equipment during a difficult intubation,which they thought was available on the DAT, but is in fact not. We recommend that anaesthetists regularly refresh themselves with what equipment is available on their hospitals DATs. We also recommendthat the contents of a hospital’s DATs be standardised so irrespective of which location a difficult intubation occurs, the same equipment would be available.

References1. Henderson J, Popat M, Latto I, Pearce A. Difficult Airway

Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59: 675-94

2. Difficult Airway Society. Difficult Airway Society Equipment List, 2005. http://www.das.uk.com/equipmentlistjuly2005.htm(accessed 10/01/2013)

Table 1 Anaesthetists’ awareness of the contents of our hospitals difficult airway trollies (DAT) before and after advertising of DAT contents. Values are number of responses (percentage).

Response Before advertising After advertisingCorrect 480 (64.0%) 469 (84.5%)Incorrect 104 (13.9%) 46 (8.3%)Not sure 166 (22.1%) 40 (7.2%)

Delirium in cardiothoracic ICU patients: Is recognition improved with the use of a daily assessment tool and period of education.

Dr Alison Bing1, Dr Jing Wang1, Dr Pete Alston2

Edinburgh Royal Infirmary, Edinburgh, UK.alisonbing@hotmail.co.uk

Methods: The CAMI-ICU delirium assessment tool was used on 42 cardiothoracic ICU patients over three weeks to ascertain the incidence of delirium in CTICU. This was compared to the recognition of delirium by nursing and medical staff as documented in the patient notes and by prescription of antipsychotic medications. Following this there was a ten day period of education with nursing staff and introduction of the CAM-ICU into twice daily nursing assessment. There was then a period of re-audit which included 40 patients over three weeks.

Results: Following a period of education and introduction of a daily assessment tool the recognition of delirium improved from 77% to 92%.

Discussion: This CAM-ICU is now in full time use in the Edinburgh cardiothoracic ICU. There are plans to re-audit following a longer period of education including details on type of surgery and comparisons made with pre-operative mental status.

Continuous venovenous haemofiltration: improving patient safetyin our unitJ A Harrison1, A C Jacques1

Hospital 1, John Radcliffe Hospital, Oxford, UK.jadealiceharrison@doctors.org.uk

Unfractionated heparin is the first choice anticoagulant in 92% of cases of continuous renal replacement therapy (CRRT) in England(1).Anticoagulation is important in maximising filter life to improve treatment consistency, but administration must be balanced against the risk of bleeding complications. Following previous evaluation of heparin use for CRRT in our unit, a new protocol was designed, with target APTT 40-60 in contrast to the previous target of 60-100. Weassessed efficacy and compliance with this new protocol.

MethodsA retrospective analysis of data for all patients receiving CRRT between September and December 2012 was undertaken. Patients were identified as having received heparin according to the new CRRT protocol (target APTT 40-60)(2), the pre-existing trust full anticoagulation heparin protocol (target APTT60-100)(3), or no anticoagulation. Demographic data, prior clotting profile, APTT monitoring and heparin dosing were collected, as well as duration of filtration and reason for discontinuation.

ResultsTwenty eight patients had 70 episodes of CRRT. Of the 70 circuits, 39 received no anticoagulation, 12 were managed on the pre-existing full anticoagulation algorithm (8 patients had documented reason for this)and 19 were heparinised using the new CRRT protocol. Mean length of CRRT was improved using heparin compared to no anticoagulation: 30.67 hours (SD 19.6, IQR 19) and 21.34 hours (SD 14.5, IQR 25) for the full and CRRT protocols, compared to 18.49 hours (SD 18.4, IQR 13.5) for no anticoagulation. Incidence of filter clotting was lower in patients receiving heparin: 21% and 25% for CRRT protocol and full anticoagulation guidelines respectively,compared to 43% with no anticoagulation. Increased filter clottingwithout anticoagulation was seen despite significantly lower pre filtration platelets (87 compared to 219 for heparinised patients, p<0.0001) and prolonged prothrombin time (25.0 compared to 19.4 for heparinised patients, p=0.0026). Pre filtration APTT was alsohigher in the no anticoagulation group (53.8 compared to 50.0), butthis was not statistically significant (p=0.40). Initial bolus doses were administered appropriately in 23.1% and 34% circuits for the CRRT and full anticoagulation protocols. APTT samples were collected at appropriate times in 33% of heparinised patients, were within range in 53% of cases and were acted upon appropriately in 76.7% of cases.

DiscussionThese results demonstrate a new CRRT specific heparin guideline was as efficacious as the pre-existing protocol. There was no significant difference in circuit patency for patients managed on the twoguidelines (p=0.67). In our unit higher APTT targets do not improve filter life but potentially increase the risk of patient haemorrhage.Compliance with elements of both protocols was variable, and could be improved using education programs to improve clinical staff awareness of a specific CRRT protocol and its value.

References1. Sharman A, Gardiner D, Girling K. Anticoagulant use in renal

replacement therapy in the Mid Trent Critical Care Network: A survey of practice. Journal of the Intensive Care Society 2010; 11(2): 138-143.

2. Oxford University Hospitals NHS Trust. New trial of proposed unfractionated heparin protocol for use with renal replacement therapy. 2012.

3. Oxford University Hospitals NHS Trust. Guidelines on when to use and how to monitor Unfractionated Heparin in adults. Medicines information leaflet. 2011.

Low Flow Audit

D. Macrosson,1 R. Brits,2 and Z. Kovacsai3

Royal Blackburn Hospital, Blackburn, UK, and Burnley General Hospital, Burnley, UKduncanmacrosson@doctors.org.uk

The aim of this audit was to monitor fresh gas flows during operations involving general anaesthesia in East Lancashire Hospitals NHS Trust to ensure that the majority were low flows of ≤1L/min.

MethodsOver a two week period in October 2012 proformas were attached to anaesthetic machines in the induction rooms of Blackburn and Burnley hospitals. Anaesthetic staff were encouraged to use these proformas to record fresh gas flow of volatile anaesthetic agent on induction, on entering theatre, and ten minutes after entering theatre. Two months after this data collection period, a repeat spot audit was carried out over the course of one day. This time the data was recorded independently by the audit team who were not involved in theatre on that day, so the data could be used to verify the reliability of the initial audit. The data collected could then be used to compare with previous cycles of the audit to determine whether standards are being maintained and identify any areas of improvement.

ResultsA total of 185 cases were recorded over a two week period, 73 and 112 cases from Blackburn Hospital and Burnley Hospital respectively. Sevoflurane was the most used volatile anaesthetic agent at 83%.Fresh gas flows on induction ranged from 0.6L/min to 10L/min with a mean and median of 6.82L/min and 6L/min respectively. Fresh gas flows on entering theatre ranged from 0.2L/min to 10L/min with a mean and median of 4.63L/min and 4L/min respectively. Finally, fresh gas flows ten minutes after entering theatre ranged from 0.1L/min to 8L/min with a mean and median of 1.01L/min and 0.8L/min respectively with 81.6% of cases ≤ 1L/min. The spot audit yielded slightly better results, a total of 33 cases were recorded with fresh gas flows ten minutes after entering theatre ranging from 0.3L/min to 4L/min with a mean and median of 0.82L/min and 0.5L/min respectively with 90.9% of cases ≤ 1L/min. In comparison to previous cycles of the Low Flow Audit in this trust, a mean fresh gas flow ten minutes after entering theatre of 1.01L/min shows a decrease compared with 1.8L/min when the audit began in 2006, but an increase since last years mean of 0.63L/min.

Discussion3% sevoflurane running at our mean fresh gas flow of 1.01L/min costs £2.87 per hour. At 0.5L/min this cost falls to £1.41 per hour. As the anaesthetic department has spent approximately £138,000 in the past year on sevoflurane, there is potential to halve this cost if target flow rates of 0.5L/min can be met and maintained in theatre. As an approximate 20% improvement has been made on flow rates in the two months between the inital data collection period and the spot audit, it would be of benefit to start a monthly spot audit check by the foundation trainee in anaesthetics to ensure that flow rates continue to be lowered towards the target flows ensuring financial benefit to not only the department, but the trust as a whole.

References1. Baum, J. A. Low-flow anaesthesia. European Journal of

Anaesthesiology September 1996; Volume 13; Issue 5; p123-4. 2. Odin I, Feiss P. Low flow and economics of inhalational

anaesthesia. Best practice and research. Clinical anaesthesiology. September 2005; 22: 399-413

WITHDRAWN BY THE AUTHOR

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Effectiveness of procedure-related pain management during burns dressing changes – is there a need for distraction techniques?

Y. Mustafa, C. Small and M. Bowden

Queen Elizabeth Hospital, Birmingham, UKyassar.mustafa@nhs.net

The changing of dressings in burns patients can be excruciatingly painful, and has been considered as the most painful from amongst all non-surgical procedures.1 The reasons are multi-factorial; in addition to being intrinsically very painful, major burns dressings can take over an hour to change and, furthermore, repeatedly changing them can promote anxiety, thus making subsequent changes even more distressing. This audit was undertaken to investigate whether pain and anxiety were adequately controlled during dressing changes, in burns patients who were not receiving analgosedation by an anaesthetist. The standard employed was that no patient should experience more than mild pain or anxiety at any point during the procedure.

MethodsThis prospective audit was undertaken at a burns centre in a large teaching hospital over a four week period. All burns patients who did not require analgosedation provided by an anaesthetist were investigated, including those who did not receive supplementalanalgesia. The study assessed the levels of both pain and anxiety experienced by these burns patients before, during and after their dressings were changed. An 11-point pain intensity numerical rating scale was employed, with a score of greater than four representing moderate or severe pain/anxiety. Moreover, the body surface area of the burn, age of the burn and number of dressing changes were also recorded.

ResultsForty two burns patients were assessed over the four week period. Of these, seven were excluded from the study as they had received intravenous ketamine by a consultant anaesthetist. Of the remaining 35, eight patients (22.9%) reported an average pain score of greater than four, with a median pain score of 2.5 (1-4 [0-9]). Thirteenpatients (37.1%) reported a worst pain score of greater than four experienced at some point during the procedure, with a median worst pain score of 3 (2-6 [0-10]). Seven patients (20.0%) reported ananxiety score of greater than four during the procedure, with a median anxiety level of 1 (0-3 [0-9]).

DiscussionOur results indicate that pain and anxiety are inadequately controlled in a significant proportion of dressing changes in burns patients. We suggest a review of existing multimodal analgesic regimes, includingoptimising dose and timing of analgesia. We also suggest the use of alternative pain relieving strategies, such as virtual reality (VR) based distraction therapy (e.g. SnowWorld), which intends to divert attention from the painful stimulus, aiming instead to focus on a pleasant virtual world.2 This group plans to trial a novel VR based distraction system and evaluate its efficacy in pain management.

References1. Diamond AW. Analgesia for burns dressing. Journal of the

Royal Society of Medicine 1982; 75(Suppl 1): 33–35.2. Hoffman HG, Chambers GT, Meyer WJ et al. Virtual reality as

an adjunctive non-pharmacologic analgesic for acute burn pain during medical procedures. Annals of Behavioral Medicine April 2011; 41(2): 183-191.

Risk of readmission to intensive care units

A. D Patel1, B. D Young1

1 John Radcliffe Hospital, Oxford, UKCorresponding author: dp606@ic.ac.uk

Readmission to the intensive care unit (ICU) is generally believed to be associated with the same risk factors as death after ICU discharge. The aim of this study was to identify if the risk factors for post-ICU death are associated with readmission to ICU.

MethodsA total of 100 patients readmitted to two ICUs between September 2011 and September 2012 were case matched 1:2 with non-readmitted patients on age, gender, reason for admission and APACHEII score. Risk factors obtained from a systematic review1 of post-ICU death including discharge time from ICU, length of ICU stay, mechanical ventilation, primary disease process, biochemical markers, and GCS were compared between groups.

Results:The mortality of readmissions was 10%. No risk factors for post-ICU death were shown to be associated with ICU readmission.

Discussion:Risk factors identified as predicting post-ICU mortality were not associated with readmission. The assumption that techniques to reduce readmission will also reduce post-ICU mortality may not be valid.

References:1. Rosenberg AL, Watts C. Patients readmitted to ICUs: a systematic review of risk factors and outcomes. Chest 2000; 118(2): 492-502.

Admissions and outcomes of vascular surgery patients admitted to Peter’s Intensive Care Unit before and after service expansion

M. Sweeney1 and M. Parris1

1Ashford and St Peter’s NHS Foundation Trustmark.sweeney@asph.nhs.uk

In August 2011 the vascular surgical service at St Peter’s Hospital was expanded and subsequently the vascular surgery admissions to ICU have increased in line with this. This poster examines the increased activity and the outcomes of vascular surgical patients admitted to St Peter’s Intensive Care Unit before and after this service expansion

MethodsComparison was made of patients admitted in the 12 months preceding service expansion in August 2011 to those admitted in the subsequent 12 months. The electronic ward based system Ward Watcher was used to search for all patients admitted to ICU directly from theatre under the care of a vascular consultant surgeon and electronic discharge summaries were used to determine the mortality and morbidity of patients during ITU admission. Chi squared tests was used to determine mortality significance.

ResultsAdmissions to ITU have increased from 37 to 117 annually since service expansion of which the largest increase is seen in infra-inguinal surgery. (Table 1) Overall mortality is significantly improved post-expansion (p<0.0001) and these improvements in mortality are seen across the entire range of procedures. This reflects an overall reduction in mortality seen among vascular surgical patients at St Peter’s during this time period, demonstrating a genuine improvement in mortality with increased activity [1]. Moreover the length of stay (LOS) in ITU is reduced for almost all types of operation as patients are able to be stepped down to lower levels of care more quickly following surgery. The only exception to this is the LOS for open emergency repair of AAA which increased from 4.5 to 11.7 days.

DiscussionThe expansion of vascular services at St Peter’s Hospital has resulted in greater numbers of vascular patients being admitted to ICU in the year following expansion. The improvements seen in mortality and length of stay demonstrate the advantages that concentrating services and increasing exposure to specialist patients can have on the overall outcomes of an intensive care unit in a District General Hospital.

References1 Personal Data, Vascular Surgery Department

Table 1. Admission and mortality of vascular surgery patients admitted to St Peter’s ITU before and after service expansion in August 2011.(*p<0.0001)

Admissions Mortality2010/11 2011/12 2010/11 2011/12

Elective Open AAA 9 12 11% 0%

Elective EVAR 3 12 0% 0%

Emerg Open AAA 8 15 25% 13%

Emerg EVAR 2 7 0% 14%

Thrombolysis 2 11 50% 18%

Infra-inguinal Surgery 11 34 18% 3%

Carotid endarterectomy 2 10 0% 0%

Other 0 16 - 6%

Total 37 117 16% 6%*

Returning to work after Maternity leave; Are we following the recommendations?Arrow KVictoria Hospital Kirkcaldy, Fife. South East Deanery, Scotland. katearrow@hotmail.com

In 2012, The Academy of Medical Royal Colleges published guidelines for Medical Professionals returning to practice after an extended period of absence. Prolonged absences affect confidence, knowledge and clinical skills, impacting on patient safety. Guidance states that length of time off, reason for absence, age and grade of training should be considered in addressing the returning individuals needs and learning objectives. Guidance states that individuals must take responsibility for their safe return to practice. Key recommendations include structured return to work programmes, mentoring systems, CPD and regular appraisal [1].MethodsSixteen NHS Lothian & Fife Anaesthetic trainees & Consultants who had returned from maternity leave were identified. Survey questions were developed around the AOMRC recommendations and distributed via email. Twelve surveys (75%) were returned and results were compiled and analysed.Results68% of respondents were ST6-7, 16% Consultant, 8% ST3-5 and 8% CT1-2. All had taken maternity leave with 50% taking 9-12 months, 42% 6-9 months and 8% 3-6 months. None had a structured return to work with 16% commenting that initial shifts were out of hours and unsupported. 50% of respondents felt anxious about their clinical skills and knowledge on return to work while 8% felt completely unprepared. The majority felt confident of their non-technical skills. Consultants felt confident in all areas while all the trainees had concerns in at least two areas. 16% returned to a new place of work without any induction, while 50% took part in work related activities during leave. 16% did ‘keeping in touch’ days and stated that these were key to improving confidence. 16% found they were unable to organize KIT days. 42% felt support at work was mediocre while 16% felt ‘unsupported’. DiscussionThe introduction of revalidation and an increasingly female-dominated workforce means guidance on returning to work after maternity leave is a consideration for everyone in the NHS. The returning individual has a responsibility to ensure they are fully prepared while the employing department and deanery must provide a supportive return. This audit demonstrates that the South East Deanery can improve in both areas. Results show that the main issues are at trainee level as Consultants felt their breadth of experience safeguarded them. Planned interventions include the development of a “Return to work” pack for all trainees, provided by the deanery at the start of leave, emphasizing the AOMRC guidance and providing clear advice on organizing KIT days and keeping up to date. The AOMRC guidance has been distributed to departments across the trust. A web based support network for trainees across the specialties is being created, providing a forum for discussion and advice. With the volume of trainees taking maternity leave, phased returns are not compatible with service provision but the above interventions are hoped to improve Practitioner confidence and maintain patient safety.References1. Return to Practice Guidance, April 2012. Academy of Medical Royal Colleges http://www.aomrc.org.uk/committees/item/guidlines.html

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Bispectral Index Monitoring in Patients Undergoing Elective Surgical Resection of Non-Small Cell Lung Cancer; AnObservational Study

M.A. Aslam1, J. Yeung1, M. Wilson1, B. Naidu1, T. Melody1, F. Gao1

1Birmingham Heartlands Hospital, Birmingham, UKmudassar.aslam@doctors.org.uk

Bispectral index (BIS) monitoring is a non-invasive method of quantifying depth of general anaesthesia (GA). Secondary analysis of randomised studies has shown that prolonged “cumulative low BIS”, implying excessive depth of anaesthesia, is associated with excess mortality. [1] However, this relationship is less pronounced when cancer patients are excluded. [2] This may indicate that cancer patients are more sensitive to excessive anaesthesia, or that the presence of cumulative low BIS (BIS<45) is a surrogate for intrinsic increased vulnerability of this patient population. The aim of this study was to investigate depth of anaesthesia of patients undergoing thoracic surgery for tumour resection, and to investigate if this varies withanaesthetic technique and surgical procedure.

MethodsThis was a prospective observational study performed between May and July 2012. The study was classed as a service evaluation and ethical approval was not required. Forty patients undergoing elective resection of non-small cell lung cancer (NSCLC) at Birmingham Heartlands Hospital (BHH), either by video-assisted thoracoscopic surgery (VATS) or by open thoracotomy, were recruited. Prior to induction of anaesthesia, a BIS monitor was attached to each patient and removed at the end of surgery. Intra-operative BIS data werecollected blindly, as well as total anaesthetic and surgical times. Amean BIS value of between 45 and 60 was selected for all operations as the target for optimal depth of anaesthesia. Normality of data was tested with the Shapiro-Wilk test, and relative proportions of patients under, within and over the target range were tested via Chi-squared analysis (p<0.05). Finally, statistical differences in mean BIS were tested via Fisher’s least significance difference test (p<0.05).

ResultsOut of the 40 patients, 15 (37.5%) had a VATS procedure, while 20 (50%) of patients underwent true thoracotomies (excluding VATS conversions). More patients undergoing open thoracotomies (90%,n=18) had a mean BIS of less than 45 (p<0.05) than VATS procedures(60%, n=9). The mean intra-operative BIS for patients undergoing open thoracotomies (39.9; SD 5.71) was lower than for patients undergoing VATS (43.7; SD 8.97). In addition, the ten patients (50% of total thoracotomies) who had open thoracotomy under GA and thoracic epidural had a mean BIS of 39.3 (SD 5.29), compared with 40.2 (SD 4.04) for the five patients (25% of total thoracotomies) who underwent open thoracotomy under GA and intrathecal morphine.

DiscussionOur data show that BIS values were lower in patients undergoingsurgical resection of NSCLC via open thoracotomy compared to those having VATS. Furthermore, this seems to be more pronounced in patients who have their thoracotomy under GA and thoracic epidural.Therefore open thoracotomy patients, anaesthetised under GA and thoracic epidural, may provide a suitable target population for future interventional studies investigating depth of anaesthesia and its effects on post-operative outcomes of surgical lung cancer patients.

References1. Monk TG, Saini V, Weldon BC, Sigl JC. Anesthetic manage-

ment and one-year mortality after noncardiac surgery. Anesthesia & Analgesia 2005; 100: 4–10.

2. Lindholm ML, Traff 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.

Nasendoscopy use in a district general hospitalA. Biffen and A. VarvinskiyTorbay Hospital, Torquay, UKEmail: abiffen@nhs.net

The findings of NAP4 [1] led to a number of recommendations, with the importance of nasendoscopy highlighted. Its use is advocated to assist with planning airway management prior to induction of anaesthesia of patients with head and neck pathology. Torbay Hospitalis a 500 bed district general hospital carrying out 18000 surgical procedures per year. The anaesthetic department acquired a flexible nasendoscope and its use was surveyed over a 19 month period following the publication of NAP4 in March 2011.

MethodsInformation regarding date of use, location and user was gathered via a data collection form stored with the nasendoscope in the anaesthetic department.

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The nasendoscope was used on 45 occasions by twelve different anaesthetists, an average of fewer than three times per month. One individual was responsible for two thirds of the use, while three other anaesthetists used the nasendoscope more than once. Theatres, in particular for maxillo-facial surgery, were the most common site of use (38 instances). The intensive care unit made use of the facility in 13% of the cases. On one occasion the nasendoscope was taken to another hospital in the region for teaching purposes.

DiscussionNAP4 demonstrated that nasendoscopy has an important part to play in the management of the airway, especially where patients exhibit symptoms of airway obstruction or have head and neck pathology, including airway tumours. Nasendoscopy was performed regularly throughout the studied period. High usage by a limited number of individuals may reflect familiarity with the device or the nature of their lists worked on a regular basis. Further study is necessary to determine whether uptake by other users is affected by their awareness of the nasendoscope and its important role. In addition, qualitative research will be beneficial to determine whether effective use of the nasendoscope is guiding airway management.

References1. Cook TM, Woodall N, Frerk C; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. British Journal of Anaesthesia 2011;106: 617-642.

Organ donation survey: assessment of the attitudes and knowledge of appointed clinical leads in organ donation.

J. Blackshaw, J. McCann

Warrington Hospital, Warrington, UK.jonblackshaw@doctors.org.uk

The Organ Donation Task Force was established in 2008 with the aim of improving availability of solid organs and tissues for transplant through the development of a structured and systematic approach to organ donation. The taskforce report highlighted several key areas for improvement including legal and ethical issues, organisation and coordination, training and public recognition and promotion of donation. The as part of the process, every hospital trust was advised to appoint a Clinical Lead for Organ Donation (CLOD) and a Specialist Nurse for Organ Donation (SNOD). This survey explores the attitudes, beliefs and knowledge of those appointed into the CLOD role.

MethodsIn 2010, a questionnaire was emailed to 201 CLODs. The questionnaire was designed to explore the attitudes beliefs and knowledge of the respondents in several key areas relating to personal beliefs, organisational support, process knowledge and ethical issues. It also asked respondents to comment on how organ donation may be promoted to the public.

ResultsFifty CLODs responded to the survey (25%). All respondents supported the notion of organ donation and although only 66% carried a donor card, 100% had either registered on the organ donor register or had given consent to family members. Eighty four percent stated that they believed their trust had made organ donation a trust initiative and 76% stated that their trust had established an organ donation policy. Eighty four percent had been present in theatre during organ harvest. Forty and 43% of respondents wrongly stated that bladder and large bowel respectively could be transplanted. Only 42% of respondents support presumed consent and 40% felt that some religious groups object to organ donation. Seventy percent felt that everyone in their trust should be asked to join the organ donor register and 72% felt that promotion of organ donation by local celebrities would be useful.

DiscussionThis survey highlighted strong support for organ donation among those appointed to promote the process in hospital trusts. It also suggested that, on the whole, organisational support is good. There remains some confusion, even among clinical leads in organ donation, about which organs and tissues are commonly transplantable. Presumed consent remains a controversial issue and other ethical issues relating to promotion and religious beliefs divide opinion. With a further review in 2012, a further survey with wider scope is planned to assess any development in knowledge and attitudes since 2010.

Reducing starvation times and improving the patient experience in elective caesarean section patients: preoperative isotonic drinks

K. Bosworth1, M. Davies1, J. Marriott1 and S. Millett1

Worcestershire Royal Hospital, Worcester, UKkatebosworth50@doctors.org.uk

Women awaiting elective lower segment caesarean section (LSCS) are commonly delayed by emergency cases from the delivery suite unnecessarily prolonging starvation times. The concentration of maternal urinary ketones increases with duration of starvation which leads to longer hospital stay and prolonged recovery [1]. It has been recommended that preoperative administration of carbohydrate rich beverages 2-3 hours before anaesthesia may improve patient wellbeing and facilitate recovery from surgery [2]. This audit aimed to determine the impact of preoperative isotonic drinks for elective LSCS patients. It examined the effect of the drinks on patient fasting times, the presence of ketones in maternal urine and the patient experience. The standard used was the Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidance on preoperative fasting times. This standard states that the minimum time for pre-operative fasting is 2 hours for clear fluids and 6 hours for food.

MethodsAn initial audit was performed to find baseline results. Data was collected from patients undergoing elective LSCS at a UK district general hospital. Data was collected from patients preoperatively using a questionnaire concerning fasting times and satisfaction with preoperative nutrition and hydration. On arrival to theatre, maternal urine was tested for ketones. Following the initial audit, an isotonic drink protocol (500ml still orange carbohydrate drink, costing £0.50) was introduced and given two hours preoperatively to patients having elective LSCS. Following this intervention the audit was repeated. This, once again, examined fasting times, presence of urinary ketones and patient satisfaction.

ResultsData was collected from 36 patients. The implementation of a preoperative isotonic drink for patients undergoing elective LSCS reduced the fasting time for fluids from 11.25 hours (interquartile range (IQR) 10.5-12.25 hours) to 5.5 hours (IQR 4-6.5 hours). The presence of ketones in maternal urine was also reduced from 43% to 25% of patients after implementation of a preoperative isotonic drink. All the pre-intervention patients said that they would have accepted a preoperative drink if offered. All of the post-intervention patients were very satisfied having received a preoperative isotonic drink.

DiscussionThis project demonstrates that an inexpensive simple preoperative isotonic drink protocol reduces fasting times and presence of biochemical markers of starvation in patients undergoing elective LSCS. The new protocol achieved 100% patient satisfaction scoresand may improve patient recovery from surgery.

References1. Braham DL, Patel N, Bell R, Berry M, Columb M, Fernando R.

Maternal and fetal effects of starvation times before spinal anaesthesia for elective caesarean section. International Journal of Obstetric Anaesthesia. 2010; 19: S28.

2. Powell-Tuck J, Gosling P, Lobo D N, Allison S, Carlson G L, Gore M et. al. British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP). Page 6. March 2011. http://www.bapen.org.uk/pdfs/bapen_pubs/giftasup.pdfAccessed on 10/01/2013

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Improving consent in anaesthesia: a simple but effective way

K.Bosworth1, M.Davies1 and S.Risebero1

Worcestershire Royal Hospital, Worcester, UKkatebosworth50@doctors.org.uk

Recent evidence suggests that standards relating to documentation of discussion relating to anaesthetic techniques and associated risks are often not met[1]. The Association of Anaesthetists has produced guidance on consent and states that 100% of patients should have proposed anaesthetic techniques and associated risks explained and documented in the anaesthetic record[2]. The aim of the audit was to assess a whether a simple tick box aide memoire included on the anaesthetic record would improve the documentation of consent foranaesthesia.

MethodsData was collected retrospectively from anaesthetic records of patients on surgical inpatient wards at a district general hospital in the UK over a two week period. Anaesthetic records were included if patients had undergone procedures requiring additional consent e.g. spinal anaesthesia, epidurals, peripheral nerve blocks (PNB), central venous catheters (CVC) and arterial lines. After the initial audit, the anaesthetic chart was re-designed to include a tick box consent section. The consent tick boxes included boxes for serious and frequently occurring complication of anaesthetic procedures. The audit was then repeated three months after the anaesthetic records had been implemented. The data collection was again over a two week period. Data was analysed using chi-squared tests.

ResultsA total of 131 procedures were examined (82 before and 49 after the intervention). Following the introduction of the consent tick box on the anaesthetic record, overall, significantly more patients had consent documented (43/82 versus 42/49 (p<0.0001))Table 1 Comparison of documented consent for procedures before and after the implementation of a tick box consent section on the anaesthetic record

Documented consent p valueNormal

anaestheticchart

Anaesthetic chart with tick box consent section

Spinal 30/39 (77%) 9/10 (90%) 0.33

Epidural 7/9 (78%) 13/13 (100%) 0.05

PNB 3/18 (17%) 7/9 (78%) <0.0001

CVC 1/7 (14%) 5/7 (71%) <0.0001

Arterial line 2/9 (22%) 8/10(80%) <0.0001

DiscussionImplementation of a tick box consent section on the anaesthetic record has significantly improved the documentation of consent for anaesthetic procedures requiring additional consent.

References1. Hilditch, G. RCOA. Raising the Standard: A compendium of

audit recipes: Section 1 Preoperative care. Second edition. RCOA, 2006. http://www.rcoa.ac.uk/document-store/audit-recipe-book-section-1-pre-operative-care-2006 Accessed on 10/01/2013

2. Association of Anaesthetists of Great Britain and Ireland. Consent for anaesthesia. Page 16. 2006. http://www.aagbi.org/sites/default/files/consent06.pdf Accessed on 10/01/2013.

Timekeeping within the Leicester Royal Infirmary operating department.

M. Charlton1, A. Packham2

1. Kettering General Hospital, Kettering, UK. 2. Leicester Royal Infirmary, Leicester, UKMatt.charlton@doctors.org.uk

All doctors are required to keep accurate records of the care they deliver [1]. For the anaesthetist, accurate time-keeping is important for appropriate management of their patient and must be representative of what is sometimes a rapidly changing situation. Trust and government infection control policies recommend that doctors do not wear wrist-watches while treating patients [2, 3]. There are multiple alternative time sources available in each theatre, primarily wall clocks and anaesthetic monitors. In addition, anaesthetic monitors record historical data time-stamped according to their internal clocks. An audit of clock accuracy was performed in 2007 and repeated in 2011 following implementation of various recommendations.

MethodsThis audit was based in a suite of 17 operating theatres. Data was collected during British Summer Time (BST) on both occasions. All wall clocks and anaesthetic monitors were examined in each anaesthetic room and operating theatre within the department. Areference timepiece was used, set accurately to the BT talking clock. Data collected included the type and model of clock/anaesthetic monitor and time deviation from the reference timepiece. The two audit standards were: 1) maximum deviation of any clock from the reference timepiece of 2 minutes (100% target); 2) maximum variation in times displayed by devices in an operating theatre and its adjoining anaesthetic room of 2 minutes (100% target). Simple data analysis was carried out in a Microsoft Excel spreadsheet.

ResultsThe 2007 and 2011 audits examined 76 and 69 timepieces respectively. Data from 2007 demonstrated that 91% of wall clocks in anaesthetic rooms and theatres were accurate to within two minutes, but that only 27% of anaesthetic monitors showed a time that met this standard. The oldest generation of anaesthetic monitors in the department were replaced between the audits. The 2011 re-audit demonstrated that 81% of wall clocks and 44% of anaesthetic monitors were accurate to within 2 minutes. The proportion of monitors accurate to within 10 minutes improved from 42% to 81% between the two audits. In both audits no operating theatre / anaesthetic room met the audit standard of having less than 2 minutes variation between times displayed on the available clocks and monitors.

DiscussionSignificant inaccuracies in time displays carry the potential for confusion in the conduct of an anaesthetic, for example in the timing of doses of neuromuscular blocking drugs. This is especially so when more than one anaesthetist is involved in a case. Inaccuracies in time displays will also feed through to inaccuracies in record keeping which may cause later difficulties. Our audit cycle has demonstrated that despite the implementation of changes prior to the period of re-audit, there remains significant inaccuracies between the timekeeping devices. Further attempts to reduce these inaccuracies may include having a person within the department assigned to maintain clock accuracy at regular intervals.

References1. General Medical Council Good Medical Practice 20062. RCOA / AAGBI Good Practice: A guide for departments

of anaesthesia, critical care and pain management. 2006. 3rd Edition

3. RCOA / AAGBI The Good Anaesthetist: Standards of practice for Career Grade Anaesthetists. 2010.

Sepsis recognition and management at Kettering General Hospital: audit of current practice.

M. Charlton, P. Watt

Kettering General Hospital, Kettering, UKmatt.charlton@doctors.org.uk

Sepsis remains a major cause of mortality worldwide, with death ratesin the UK from severe sepsis (sepsis accompanied by organ dysfunction), estimated between 36000 and 64000 per annum. [1] The surviving sepsis campaign, initially introduced in 2004 and updated in 2008, provided the clinician with internationally accepted guidelines aimed at improving outcomes in severe sepsis and septic shock. [2] Many hospitals around the country have pre-printed pathways to aid in the recognition and immediate management of the septic patient,incorporating the “sepsis six”. The purpose of this audit was to establish our current compliance with these guidelines.

MethodsData collection was carried out retrospectively. Blood cultures over a three-month period were reviewed and patients with confirmed Escherichia coli or Staphylococcus aureus bateraemia were included. Case notes were reviewed and data extrapolated. Date and time of recognition of sepsis and compliance with the immediate sepsis six management bundle within the first hour were ascertained, our standard being 100% compliance (where appropriate). Recognition of features identifying organ dysfunction and therefore severe sepsis were also recorded. Data was inputted and analysed using Microsoft Excel.

ResultsOur selection method yielded 40 patients with a total of 16 of these being excluded (3 neonates and 13 not presenting with features of sepsis). Of the 24 patients included; 4 (16.7%) received supplemental oxygen, 1 (4.2%) received an appropriate fluid bolus, 22 (91.7%) had blood cultures taken appropriately, 7 (29.2%) had a blood lactate measured, 3 (12.5%) had urine output monitored hourly and 12 (50%) received appropriate IV antibiotics within the first hour of recognition. Fourteen patients (58.3%) had one or more features of severe sepsis;whilst in the other 10 (41.7%) this was difficult to establish as not all features had been investigated. Three (12.5%) patients were deceased at the time of review.

DiscussionImplementation of immediate management in the septic patient has been proven to decrease morbidity and mortality. [2] Failure to achieve this standard could therefore be impacting on patient care.The use of pre-printed “bundles” for completion by staff has previously been documented to improve compliance. We plan to implement a sticker for use in the patient notes, as well as an educational programme for nursing and junior medical staff to highlight the importance of early recognition and management of the septic patient. Implementation of such documentation will improve patient care and provide a means of easily disseminating up to date, evidence based guidelines as and when they become available. It will also improve documentation and the audit trail. We plan to repeat this audit post implementation in early 2013, coinciding with planned updates to the surviving sepsis guidelines.

References1. Daniels, R. (2011). Surviving the first hours in sepsis:

getting the basics right (an intensivist’s perspective), J. Antimicrobial Chemotherapy. (2011)66 (suppl2): ii11 ii23.doi: 10.1093/jac/dkq515

2. Dellinger et al. (2008). Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med. 34:17–60 DOI 10.1007/s00134-007-0934-2

A service evaluation on the use and interpretation of ROTEM® six months after its introduction in a regional trauma centre

T. Clarke, B. Batuwitage, and S. Mercer

Aintree University Hospital, Liverpool UKTomClarke@doctors.org.uk

A ROTEM® device was introduced at Aintree University Hospital in June 2012. The use of thrombo-elastometry was recommended in the2010 European guidelines for bleeding following major trauma1. In the six month period following the introduction of ROTEM® data on its use was collected by the transfusion service. On cases triggering the major transfusion criteria there was only documented use of ROTEM® in 16/109 (15%). This indicates that the ROTEM® device is currently being underutilised. The aim of this service evaluation is toinvestigate the possible reasons for this.

MethodsFrom the manufacturers learning package we developed a questionnaire. This asked doctors when they would consider using ROTEM®, which test they would run and to interpret results. Doctors of different grades working in Anaesthetics, A&E and ICU were asked to complete the questionnaire. Following completion a brief tutorial was offered with a learning package using a PowerPoint presentation. Participants were also signposted to a smart phone app available from the ROTEM® website.

ResultsPreliminary results showed 10 (48%) of respondents had receivedformal training in the use of ROTEM®, 20 (95%) had been involved in the management of major haemorrhage in the last 12 months. All respondents would like to use ROTEM® in a major haemorrhage. Thirteen (62%) respondents felt able to interpret ROTEM® results; of these 6 (46%) correctly interpreted all results. There was some variation on the tests that doctors would request in a major haemorrhage; 11 (85%) would request EXTEM, 6 (46%) would request INTEM, 10 (77%) would request FIBTEM and 1 (8%) would request APTEM.

DiscussionData from the transfusion service alongside the results of this service evaluation suggest that ROTEM® use is an area of major haemorrhage management that could be improved. Currently ROTEM® is underutilised despite all of our respondents stating that they would like to use ROTEM® in major haemorrhage. From the results there appears to be inadequate training of staff on ROTEM® usage and this may represent lack of familiarity with the equipment. In order to improve ROTEM® use we plan to implement formal teaching of new starters, develop a protocol to assist clinicians on which ROTEM®

tests to run and encourage the use of a smart phone app available through the ROTEM® website. We will re-evaluate in February 2013 after these changes have been implemented.

References1. Rossaint R, Bouillon B. Management of bleeding following

major trauma: an updated European guideline. Critical Care2010; 14: R52.

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The rate of blood culture contamination in an intensive care unitJ. Clifford-Brown1 and N. Cree2

Royal Berkshire Hospital, Reading, UK, and James Cook University Hospital, Middlesbrough, UKjoanna.e.clifford-brown@doctors.org.uk

Early positive blood cultures provide valuable guidance on appropriate antibiotic prescription. False-positive results have both financial and patient health implications [1, 2]. The Department of Health (DoH, 2007) reported that contamination rates of peripheral blood cultures may be up to 10%. They suggested that rates of peripheral blood culture contamination should be less than 3% and issued supporting guidance on best practice of taking blood cultures. Strategies to reduce contamination are aimed at either prevention or detecting contaminated cultures before clinical decisions are made based upon them[1, 2]. Our audit looked at 12 months of data either side of a change in the Blood Culture Taking Protocol at The James Cook University Hospital Intensive Care Unit.

MethodsWe conducted a complete audit cycle over a two year period examining contamination rates in positive cultures on a sixteen bedded general ICU. Initially, a retrospective audit was conducted examining all positive blood cultures from January to December 2010. They were classified as true positives or as contaminated based on criteria designed in conjunction with Microbiology depending on the site, organism isolated, the number of positive cultures and other potential sites of infection. Each positive culture was independently reviewed by two assessors. These results demonstrated, both, a high number of cultures being taken and high contamination rates andculminated in a change in unit protocol in line with DoHrecommendations. In situ central and peripheral lines were no longer used for sampling routine blood cultures, and specific blood culture taking packs were introduced. All staff were trained in the new protocol. A second prospective audit, from January to December 2011, examined the results of these changes. The total number of blood cultures taken annually was estimated by the Microbiology department.

ResultsTable 1. Results of data collected to establish peripheral contamination rates.

2010 2011

Estimated annual blood cultures taken

1020 950

Total positive cultures 246 120

Contaminated cultures 83 39

Peripheral contamination rate (%)

8.5 4.1

DiscussionIn summary there has been a significant decrease in the rate of peripheral blood culture contamination, to nearer the target set by DoH, following a change in clinical practice. We hope that this has been mirrored by an improvement in the antibiotic prescribing. This yearly audit is to continue on the Intensive Care Unit.

ReferencesHall K, Lyman J. Updated Review of Blood Culture Contamination. Clinical Microbiology Reviews 2006; 19: 788-802.

2. Thompson F, Madeo M. Blood cultures: towards zero false positives. Journal of Infection Prevention 2009; 10: 24-26.

A review of high risk obstetric patients requiring anaesthetic intervention in Middlemore Hospital

M Cockroft 1, C. Matthews2, J. Taylor3, J. Dimech4

Middlemore Hospital, Auckland, New Zealand. Cheltenham General Hospital, Cheltenham, UK. Royal Devon and Exeter Hospital, Exeter, UK.mel_cockroft@hotmail.com

High risk obstetric patients may present to obstetric services in a variety of ways, often requiring anaesthetic input. Middlemore Hospital has one of the busiest obstetric units in Australasia, with over 8,000 deliveries per year (1), and a high proportion of such patients.An anaesthetic clinic was set up alongside the consultant-led obstetric service in accordance with AAGBI and OAA guidelines (2) aiming toreduce perinatal risk for these patients. However, anecdotally many patients were missed. This audit aimed to quantify this, identify reasons for non-referral and review patient outcomes. One of the difficulties in setting up such a clinic in this region was that adjusted referral criteria were required as reviewing all women with a BMI of over 35 for example, would be completely overwhelming given the average booking BMI of 37. Of particular interest therefore was whether the set criteria captured the correct population of women.

MethodsThis was a prospective audit aiming to identify all high risk obstetric patients who had anaesthetic input in Middlemore Hospital over a three month period in 2012. These patients were identified by anaesthetists, recovery nurses and Acute Pain Service with subsequent clinical notes review. Clinical practice was unchanged throughout the audit, all patient information was de-identified and regional ethicalapproval was obtained.

ResultsOne hundred and four patients (of 1774 deliveries) were identified and 97 clinical notes were available for review. Forty six (47.4%) fulfilled clinic referral criteria, with 38 further women (39.1%) not reaching criteria but requiring significant anaesthetic input and considered to be high risk by clinicians involved in their perinatal care, giving a total of 84 high risk women. The median age group was 31-35 years [range 16-44 years], and median parity 1 [0-8+]. Twenty six (31%) were ASA 3 or 4 and the median BMI was 40-44 [range 27-67], with 20.6% ≥ 50, and 6.5% ≥ 60. Eighty percent required an emergency caesarean section with general anaesthetic required in 29.8% of emergency cases. Twenty one (25%) were referred to the clinic, with 15 seen antenatally. The most frequent reason for referral was ‘likely technical challenge’, although comorbidities were also identified.Twenty nine women were reviewed in the clinic for a total of 28 available clinic appointments.

DiscussionDuring this audit clinic utilisation was 100%, but only 33% of those meeting criteria were seen. Nearly as many patients did not reach pre-determined referral criteria but were deemed high risk by clinicians suggesting adjustment of the referral criteria is necessary.Worryingly, the emergency caesarean section and general anaesthesia rates were extremely high. This clinic is clearly greatly needed,however the service requires further improvements if it is to meet the needs of the patients. We encourage other centres with similar clinics to assess whether the referral criteria is capturing the intended women, as clearly adjustments are necessary to fully address the needs of thelocal population.

References1. http://www.deliveringfutures.co.nz/what_we_do.html

2.OAA/AAGBI Guidelines for Obstetric Anaesthesia Services Revised Edition 2005. London: OAA/AAGBI, 2005, p14

A survey comparing Anaesthetic consent between two regions

G. Davenport1,2, Y. Rajendran1,2, G. Yap1,2, S. Halder3 and S. Bates1,2

Lister Hospital1, Stevenage, UK, Queen Elizabeth II Hospital2,Welwyn Garden City, UK, John Radcliffe Hospital3, Oxford, UKGarry.davenport@doctors.org.uk

Anaesthesia has the potential to expose any patient to wide variety of risks, some of these are rare. The AAGBI states in its guidance that information should be provided about “rare but serious complications” [1] and this view is shared by the GMC [2]. The following survey was designed to find out if Anaesthetists routinely give information to their patients about rare but serious complications.

MethodsA survey was undertaken of Anaesthetists working in two regions (Hertfordshire and Oxford). Four open questions asking participants which risks they routinely explain to patients when consenting for Neuraxial blocks, Peripheral nerve blocks, General Anaesthesia and any situations in which the doctors modified their consenting procedure.

Results50 Anaesthetists returned survey forms (49% Hertfordshire, 51% Oxford), with a response rate of 94%. The highest response werefrom Consultants (60%). Any risk which was identified by more than 60% of responders, was defined as ‘commonly explained'. The commonly mentioned risks for Neuraxial blocks were nerve injury, failed or incomplete block and post-dural puncture headache. The commonly explained risks for Peripheral nerve blocks were nerve injury and block failure. For General Anaesthesia the commonly explained risks were dental damage and post-operative nausea and vomiting. In total 23 factors were given as reasons to modify the consenting process. Similar risks are explained in both Hertfordshire and Oxford. However Anaesthetists in Hertfordshire commonly mentioned infection or epidural abscess for neuraxial blocks along with sore throat for General Anaesthesia.

DiscussionIt could be argued that many patients presenting for General Anaesthesia are aware of the risk of death and may have consideredthe possibility of reactions to medications (anaphylaxis, MH etc).Some of the anaesthetist’s time during pre-assessment may be spent reassuring low risk patients. The same may not be true for regional blocks. These blocks are often used in higher risk patients as a way of avoiding the risks of general anaesthesia and the benefits may be highlighted more than the risks. Our results show that aside from nerve injury, the Anaesthetists surveyed are not commonly giving information to patients about the rarer complications. According to guidance by the AAGBI these rare but serious complications should be explained to patients [1]. The RCOA in their leaflet "You and your anaesthetic" [3] lists death as a rare complication. One reason whyAnaesthetists may not mention these risks may be them not wanting to upset their patients. However, not all sources would agree with modifying the consenting process. The NHS choices website states “Healthcare professionals should not withhold information just because it may upset or unnerve the person.” [4]

References1. Consent for Anaesthesia. The Association of Anaesthetists of

Great Britain and Ireland, London, 20062. Consent: patients and doctors making decisions together.

General medical council, London, 2008.3. Risks of anaesthesia. Royal College of Anaesthetists, London,

2008.4. NHS choices. Consent to treatment, 2012.

http://www.nhs.uk/conditions/Consent-to-treatment/Pages/Introduction.aspx (accessed 04/01/2013).

Performance of single-use laryngeal mask airways, an audit.

M. Davies, J. Lee, A. NormanWorcestershire Royal Hospital, Worcester, UKmhdavies@doctors.org.uk

Peer reviewed literature suggests successful first time insertion of laryngeal mask airways (LMAs) is achievable in 95% of insertions.[1,2]

We conducted a full audit loop to evaluate the performance of, and introduce a new LMA into routine use at Worcestershire Royal Hospital.

MethodsFollowing local audit department approval, all grades of anaesthetistswere encouraged to fill out an LMA evaluation sheet following the successful or attempted insertion of an LMA Supra (Intersurgical, UK) during their routine practice. Grade of anaesthetist, patientweight, mallampati score, number of insertion attempts, subjective ease of insertion, device issues encountered, device changes required and the presence or absence of blood on device removal were recorded during an 18 day period. Initial audit results presented to anaesthetics department, and a change in LMA device made – Solus Satin (Intersurgical, UK). The audit loop was completed evaluating the performance of the “new” device.

ResultsTotal of 88 LMA Supra insertions reviewed in initial audit; 48 (55%)by consultants, 11 (13%) by non-consultant career grade doctors (NCCGs), 9 (10%) by registrar grade (SpR), and 20 (23%) core-trainee years one or two doctors (CT1/2). First insertion rate of 69% was achieved, with insertions graded as ‘easy’ in 55% of cases. Device issues were identified in 32% of insertions, LMA intra-operative complications occurred in 15%. Twenty devices (23%) had evidence of macroscopic blood when removed. Fifty Solus Satin LMAs were reviewed in the re-audit; 21 (42%) by consultants, six (12%) by NCCGs, one (2%) by SpR, 21 (42%) by CT1/2 and one (2%) by a medical student. First insertion rate of 88% was achieved, with insertions graded as ‘easy’ in 88% of cases. Device issues were identified in 10% of insertions. LMA related intra-operativecomplications occurred in 2%. Two devices (4%) had evidence of macroscopic blood when removed.

DiscussionThere are many variables which determine successful insertion of an LMA. The findings of this audit suggest that there are advantages of one device over the other, and will aid the local anaesthetist in choosing their supra-glotic airway device.

References1. Zundert AAV, Fonck K, Al-Shaikh B, Mortier B. Comparison of

the LMA classic with the new disposable soft seal laryngeal mask in spontaneously breathing adult patients. Anaesthsiology. 2003 Nov;99(5): 1066-71.

2. Brimacombe J. Analysis of 1500 laryngeal mask uses by one anaesthetist in adults undergoing routine anaesthesia.Anaesthesia. 1996 Jan;51(1): 76-80.

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Emergency Laparotomy at West Wales General Hospital:identification of factors affecting outcome

S. Elgarf,1 S. Jha2 and G. Milne1

1 West Wales General Hospital, Carmarthen, UK, 2 Singleton Hospital, Swansea, UKselgarf@doctors.org.uk

Emergency laparotomy (EL) is a common urgent surgical procedure in the UK [1], defined as any major intra-abdominal surgery carried out laparoscopically or via open incision [2]. Patients undergoing EL generally have a poor outcome (30-day mortality of 18%), with a wide variation in rates between trusts [3]. This audit aims to identify utilisation of resources, determine outcome and compare our provisions to those highlighted in the UK Emergency Laparotomy Network report [4].

MethodsData was collected during October 2011 for EL cases taking place between April 2010 – April 2011. Emergency laparotomy network (ELN) forms were used to record the relevant data, which was then entered into an Excel spread sheet for analysis.

ResultsA sample of 37 cases was identified. Twenty-four (65%) were aged 61-83 years. Twelve (33%) were categorised as ASA grade threephysical status. A consultant surgeon was present in theatre in 91% of cases, compared with 27% of cases for anaesthetists. Goal directed fluid therapy was utilised in 33% of cases. Eleven (30%) of EL’s werecarried out as a complication of surgery in the past 30 days. Level three (ICU) postoperative care was required for 16 (43%) with an average length of stay of one day. The mortality rate at 30 days was 24%.

DiscussionThe majority of patients undergoing EL are aged over 60 years and therefore have a greater likelihood of co-morbidity. This is supported by the majority of cases graded ASA three. The UK ELN report identified a relationship between increasing age of patient and 30-day mortality, and increased mortality associated with higher ASA grade[4]. The audit identified a lack of senior anaesthetist presence in theatre, and significant absence of use of goal-directed fluid therapyfor these high-risk patients.We are currently carrying out prospective data collection on EL cases following dissemination of these initial findings to our department, to add further strength to these results, and ultimately to develop standards for EL in the trust

References1. Association of Surgeons of Great Britain and Ireland.

Emergency General Surgery: The future. A consensus statement, 2007. http://asgbi.org.uk/en/publications/consensus_statement.cfm(accessed 12/12/2012)

2. Saunders DI, Murray D, Pichel AC, Varley S, Peden CJ. The UK NHS Emergency Laparotomy Network Dataset Definitions for the national audit of patients undergoing emergency laparotomy, 2010. http://www.networks.nhs.uk/nhs-networks/emergency-laparotomy-network/audit-documents (accessed 01/10/2012)

3. Clarke A, Murdoch H, Thomas MJ, Cook TM, Peden CJ. Mortality and postoperative care after emergency laparotomy. European Journal of Anaesthesiology 2011; 28: 16-9.

4. Saunders DI, Murray D, Pichel AC, Varley S, Peden CJ; on behalf of the members of the UK National Laparotomy Network. Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network. British Journal of Anaesthesia 2012; 109: 368-75.

A preliminary study to determine predictors of blood product requirements in burns surgery, and whether tranexamic acid reduces perioperative blood product requirement.

A. Fisher1, M.E. Kelly1, Y.M. Foong1, S. Desilva1 and T. Mahambrey1.

1. Whiston Hospital, Merseyside, UK.m.e.kelly@doctors.org.uk

Patients with severe burns often suffer significant peri-operative haemorrhage [1]. Cell savers and blood products are common place in burns theatres. Tranexamic acid (TEA) is an anti-fibrinolytic proven to reduce peri-operative blood product requirement in trauma surgery[2]. To date, studies looking at the use of TEA in burns surgery do not exist. In this preliminary study we aim to identify which clinical variables may predict blood product requirement, before testing the effect of TEA on blood product requirement.

MethodsA retrospective case-control study was executed in a large district general hospital. Patients who underwent burns surgery were identified over the preceding 12 months. The operating surgeon remained the same. Twenty six patients received intraoperative TEA(one gram dose), whilst 16 did not receive any TEA. We collected the following data: patient age, sex, BMI, ASA, bleeding and thrombosis history, anticoagulant use, total burn surface area and thickness, excision and donor site location and surface area, pre- and post-operative haemoglobin concentration, post-operative blood product requirements, mortality, and post-operative deep vein thrombosis/pulmonary embolism. The statistical analysis applied included linear regression and analysis of variance (ANOVA). Ethics committee approval was attained locally.

ResultsForty four patients had burns surgery in the last 12 months; 42 were eligible for statistical analysis, two were excluded because of incomplete data. Twenty six patients had surgery for burns in the first six months and thus did not receive intraoperative TEA. Sixteenpatients had surgery in the following six months and receivedintraoperative TEA. Whole group analysis revealed that burn excision size strongly predicted post-operative packed red cell requirement (p=0.001), as did post-operative haemoglobin concentration (p=0.011). ASA status was found to predict fresh frozen plasma requirement (p=0.045) and fresh frozen plasma requirement strongly correlated with packed cell requirement (p=0.009). The effect of TEAon blood product requirement could not be tested; the distribution of confounders identified above differed between the TEAtreated/untreated groups.

DiscussionThis preliminary study has revealed that burn excision size may be a strong predictor of packed red cell requirement. Furthermore, post-operative haemoglobin concentration may also predict post-operative haemoglobin requirement regardless of whether the patient was transfused intra-operatively. A double blind randomised controlled trial will be executed to look at the effect of TEA on blood product requirement in burns patients, whilst controlling for the confounding variables identified in this pilot study.

References1. Sterling JP, Heimbach DM. Hemostasis in burn surgery—a

review. Burns 2011; 37: 559–65.2. Roberts I, Perel P, Prieto-Merino D, et al. Effect of tranexamic

acid on mortality in patients with traumatic bleeding: prespecified analysis of data from randomised controlled trial.BMJ 2012;345:e5839.

CPR status – can we improve advance planning?

D. P. Hall1, I. Mohamed1, E Buchanan1

1. Cumberland Infirmary, Carlisle, UKd.p.hall@gmail.com

The NCEPOD 2012 review of patients who underwent cardio-pulmonary resuscitation as a result of an in hospital cardiac arrest makes a number of recommendations [1]. The first of these is that “CPR status must be considered and recorded for all acute admissions, ideally during the initial admission process and definitely at the initial consultant review when an explicit decision should be made in this group of patients, and clearly documented (for CPR or DNACPR).”Anecdotal evidence suggested that decisions about CPR status in our institution were poorly documented at the time of initial assessment or first consultant review. We proposed that a simple intervention could improve early documentation of CPR status.

MethodsWe prospectively audited patients admitted as emergencies to the medical admissions unit of a 382-bed district general hospital during one-week in November 2012. We recorded patient age and gender, grade of admitting doctor, whether the admitting doctor had recorded CPR status in the medical notes (“CPR” or “DNACPR”, or alternatively specified limitations of treatment or a ceiling of care) and whether this had been considered or altered at first consultant review.We also recorded whether a formal ‘DNACPR’ form was completed. Following the first audit, we reformatted the ‘take-list’ on which all emergency medical admissions are recorded, such that the admitting doctor and consultant could tick a box by the patient’s entry stating ‘CPR status considered’). We then carried out a prospective re-audit of the same patient group in January 2013 to judge whether there was any change in practice.

ResultsThe notes of 74 prospectively admitted patients were audited in the first round (mean age 71.2 years [S.D. 19.3 years], 60% male). Of these, only 2 patients (1.9%) had documentation of CPR status in their notes (both DNACPR, with the appropriate ‘DNACPR form completed, and decision made at the time of initial assessment and unchanged following consultant review). In the second audit of 106 patients (mean age 71.2 years [S.D. 17.7 years], 53% male], 10 patients (9.4%) had documentation of CPR status at initial assessment (7 [70%] of these were ‘DNACPR’, 3 [30%] were ‘for CPR’). One additional patient (1.0%) had a status of DNACPR documented following consultant review, making a total of 11 (10.6%) patients with a documented CPR status. Where a CPR status had been decided and recorded at the time of initial assessment, this was not changed at consultant review on any occasion.

DiscussionA simple intervention involving change of documentation was able to increase the proportion of emergency medical admissions with a documented CPR status from 1.9% to 10.6%. This still falls short of the recommendations of the NCEPOD report, which recommends CPR status should be recorded on admission for all patients admitted as an emergency. However, our data are comparable to the findings of the NCEPOD audit of nationwide practice, in which 13.2% of audited patients had a documented CPR status following consultant review[1]. We suggest that in some of our patients, CPR was considered but no decision documented, as the default assumption is that a patient is for CPR. However, lack of transparent decision-making and a failure to record such decisions shifts the timing of deciding CPR status to when a patient has deteriorated to the point of requiring advanced life support, which arguably represents sub-optimal care.

References1. Findlay, G. P., Shotton, H., Kelly, B. A. & Mason, M. Cardiac

Arrest Procedures: Time to Intervene? (NCEPOD: 2012).

Extending lifebox beyond the operating room

A. Hewitt Smith1, R. Hallam2

1Lister Hospital, Stevenage, UK, 2Great Ormond Street Hospital, London, UK.adamhewittsmith@gmail.com

Lifebox, a not-for-profit organisation, is providing training and access to robust, low-cost pulse oximeters in order to ensure operating rooms are safer worldwide. The need for this simple but universal standard of care extends far beyond surgery, in the treatment of childhood pneumonia for example or to help prevent neonatal blindness. It is worrying that this vital piece of hospital equipment continues to remain scarce in low-resource countries despite strengthening evidence that it plays a key contribution to improving patient safety.Detection of hypoxia, a recognised risk factor for death in pneumonia, is improved by the use of pulse oximetry [1] where it can decrease mortality by a third [2]. We describe the introduction of lifebox pulse oximetry into a hospital paediatric department in Kampala, Uganda and report on its progress after six months.

MethodsFour lifebox pulse oximeters were introduced to Nsambya Hospital’s paediatric department (ward, outpatient department and special care baby unit) as part of an on-going collaboration to improve acute paediatric care. Concurrent training in pulse oximetry was delivered to 53 paediatric healthcare professionals. During a follow-up visit six months later, a preliminary questionnaire based audit was conducted to support feedback to local staff and provide a focus for further development.

ResultsTwenty five (100%) members of staff were correctly using the lifebox pulse oximeters but only three (12%) had attended a planned training session and knew how to troubleshoot if they ran into difficulties. The majority (21, 84%) felt the pulse oximeters were functioning correctly but five (42%) staff who worked on the ward reported that they were often not available when they were needed. Five (20%) members of staff did not know that oxygen saturations below 90% were abnormal and two (8%) were unaware that, in accordance with the local oxygen use protocol, oxygen therapy should be started if the saturations were 89% or below.

DiscussionAudit is a simple tool that can be used in any setting worldwide and it can play an important role when implemented alongside the informed introduction of new technology. Pulse oximetry has been successfully introduced into the paediatric department at Nsambya Hospital, and this initial audit has allowed us to identify areas that will contribute to further improvements in its use. This will, in turn, improve patient care and reduce mortality and morbidity. Although visiting doctors from the UK conducted this initial audit, a key component of the Nsambya Hospital Project is encouraging local staff to take responsibility for all aspects of paediatric care. This includes data collection, audit (including re-audit in order to complete the cycle) and teaching. The paucity of formal training in the use of pulse oximetry highlighted within the department serves to act as a reminder that with a high staff turnover, regular education is needed. Lifebox pulse oximeters are supplied with a training DVD that enables local paediatricians to include pulse oximetry in their ongoing continuing medical education programme and this must be encouraged.

References1. Subhi R, Adamson M, Campbell H et al. The prevalence of

hypoxaemia among ill children in developing countries: a systematic review. Lancet Infectious Diseases 2009; 9: 219-27.

2. Duke T, Wandi F, Jonathan M et al. Improved oxygen systems for childhood pneumonia: a multihospital effectiveness study in Papua New Guinea. Lancet 2008; 372: 1328-33.

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Pre-operative Assessment Documentation

K. Hill1, M. Moneypenny1

Forth Valley Royal Hospital, Larbert, ScotlandKathrynhill1@nhs.net

Pre-operative assessment by the anaesthetist is an important process that requires adequate documentation as outlined by the Royal College of Anaesthetists [1] and the AAGBI Guidelines 2010 [2]. There havebeen some high profile cases concerning this issue [3, 4] with learning points emphasising the importance of pre-operative documentation. Itherefore conducted an audit looking at our local practice.

MethodsThe Royal College of Anaesthetists have a list of recommended subjects that should be covered and documented in a pre-operative visit (patient details, past medical history, anaesthetic history, medications, allergies, airway assessment, type of anaesthetic, fasting, and results of relevant investigations). I designed a data collection tool with this list and recorded if discussion of these topics had been documented. I collected data on all adult elective surgical cases for five consecutive days. Paediatric, obstetric and emergency cases were excluded due to the different way in which their pre-assessments are documented. I also excluded cases I pre-assessed myself. I took the information from the completed anaesthetic charts. The gold standard is 100% documentation of each of the individual components in the list.

ResultsI collected and analysed the data for 109 out of 140 cases (78%) passing through the theatre complex in a five day period. I calculated a percentage for how often each topic on the above list was documented. Patient details were recorded in 100% of cases, past medical history in 88%, anaesthetic history in 83.5%, medications in 83.5%, allergies in 81.7%, airway assessment in 42.2%, type of anaesthetic in 49.5%, fasting in 75.2%, and documentation of investigations 43.6%. From this data collection there are clearly areas that needed to be improved on, particularly airway assessment, type ofanaesthetic being given, results of investigations, and fasting status.

DiscussionThere have been a number of cases with resulting critical incidents whereby expert opinion has stated that due to the poor documentation at the anaesthetist’s pre-operative visit, it was impossible to defend the case. It was also commented on that inadequate documentation gave a poor impression of professional competence [4]. I presented my findings at our anaesthetic department meeting. As a result of this, awareness was raised throughout the department emphasising the need for better documentation and the reasons for this. The results of the audit also coincided with a reconfiguration of the departmental anaesthetic chart which aims to provide more prompts to aid documentation. This new chart is now in circulation and I am in the process of re-auditing to see if this has improved our documentation.

References1. Royal College of Anaesthetists. Pre-operative Care, 2009.

www.rcoa.ac.uk/system/files/CSQ-GPAS2-Preop.pdf (accessed 10/01/13).

2. AAGBI. Pre-operative Assessment and Patient Preparation -The Role of the Anaesthetist, page 15-18, 2010. http://www.aagbi.org/sites/default/files/preop2010.pdf (accessed 10/01/13).

3. Medical Protection Society. Anaesthetics Update, 2011.http://www.medicalprotection.org/mps-anaesthetics-update-april-2011.pdf (accessed 10/01/13).

4. Medical Protection Society. Casebook, May 2011.http://www.medicalprotection.org/uk/case-reports-may-2011/look-before-you-intubate (accessed 10/01/13)

Audit of timing of emergencies on the 24 hr clock.

H.Lindsay 1, V.Cherian 2

Altnagelvin Hospital, Londonderry ,UKhlindsay@doctors.org.uk

The 1997 and 2003 NCEPOD reports have both shown that out of hours operating, particularly after midnight, results in poorer patient outcomes[1,2]. This has led to recommendations regarding the timing of emergency procedures and level of supervision of non-consultant anesthetists, which are endorsed by the Royal College of Anesthetists[3]. Non-emergency cases should be managed within the extended working day and hospitals should have designated daily theatres for both trauma and emergency cases to facilitate this[4]. Our audit aimed to determine the percentage of cases performed out of hours and whether they were true NCEPOD 1 emergencies. The level of anaesthetic supervision for out of hours, paediatric and complex emergency cases was compared to standards set by the RCoA.

MethodsA list of all procedures classified as emergencies carried out between 01/09/2012 and 30/09/2012 was generated from the hospital theatre management system. The following data was collected; start and end time of procedures, operation performed, NCEPOD classification, age and ASA grade of patient and grade of anaesthetist’s present.

ResultsTable comparing the observed results to the RCoA standards.

Criteria Standards ResultsEmergency cases 08:00 - 18:00 60% 63%Emergency Cases 24:00 - 08:00 <5% 8%Cases after 24:00 are NCEPOD 1 100% 40%Children < 5years with consultant or senior registrar present 100% 100%

100% consultantASA 4 or 5 with consultant or senior registrar present 100% 100%

50% consultantCases after 24:00 with consultant or senior registrar present 100% 100%

10% consultant

DiscussionThe results clearly show that the main area where RCoA standards are not being met is the number of cases being conducted after 24:00 that were not true NCEPOD 1 emergencies. A modification to the emergency list booking form has been made to include the NCEPOD classification. There is now departmental agreement that all cases performed after midnight should be discussed with the consultant on call and the level of senior presence is to be clearly documented on the anaesthetic chart. Only life or limb threatening emergencies are to be undertaken after midnight. Any deviation from the RCoA standards should be documented following consultant to consultant discussion. A re-audit is planned within the next month to determine if clinical practice has improved based on these recommendations.

References1. Campling EA, Devlin HB, Hoile RW et al. Who operates when?

A report of the National Confidential Enquiry into Perioperative Deaths. NCEPOD, London 1997 (http://www.ncepod.org.uk/).

2. Cullinane M, Gray AJG, Hargraves CMK et al. Who operates when? II. A report of the National Confidential Enquiry into Perioperative Deaths. NCEPOD, London 2003 (http://www.ncepod.org.uk/).

3. RCoA response to “Who Operates When II” (http://www.rcoa.ac.uk/rcoa-response-‘who-operates-when-ii’).

4. Calder FR, Jadhav V, Hale JF. The effect of a dedicated emergency theatre facility on emergency operating patterns.Journal of the Royal College of Surgeons of Edinburgh 1998; 43: 17-9.

An audit of anaesthetic machine logbook completion: have new guidelines made an impact?

F. Mazzola and A. Jandziol

Chelsea and Westminster Hospital, London, UKfranci@doctors.org.uk

The Association of Anaesthetists of Great Britain and Northern Ireland (AAGBI) published an updated version of the safety guideline ‘Checking Anaesthetic Equipment’ in June 2012. It highlights that daily pre-session checks and weekly oxygen failure alarm checks should be documented in a logbook kept with each machine, and theprimary responsibility for these checks lies with the anaesthetist [1]. Literature prior to the 2012 guideline suggests poor adherence to logbook completion [2] with difficulty identified internationally adhering to anaesthetic machine checklists [3]. We audited anaesthetic machine logbook completion at our hospital to assess adherence to AAGBI guideline standards and identify areas that may require improvement. We also compared our performance to previous literature, and question the success of implementation of guidelines.

MethodsWe collected data from anaesthetic machines in 17 theatres in 3 theatre complexes (Main Theatres, Paediatric Theatres and the Treatment Centre) for one week starting on 17th September 2012. Logbooks were audited for sessions when theatres were in use. We excluded Saturday, Sunday and lists conducted under local anaesthesia. 252 machine check opportunities were identified. Data was collected with an audit proforma and analysed with Excel. Rates of completion were measured against gold standards set by the AAGBI equipment guidelines [1]. No ethical approval was required.

ResultsThe total number of machine checks documented as having taken place was 113/252 (44.8%). Lists with a trainee present had a higher documentation rate of 53.8% (100/186) compared to 22.8% (13/57) when a consultant was alone. Main Theatres, the Treatment Centre and Paediatric Theatres had documented checks in 54.6% (59/100), 19.7% (15/76) and 57.4% (39/68) of sessions respectively. Morning lists showed documentation on 46.9% (61/130) of occasions compared to 41.3% (52/126) in the afternoon. Documentation of oxygen alarm checks and circuit change was poor at 1.5% (4/252) and 2.6% (7/252) respectively.

DiscussionDocumentation of anaesthetic machine checks in logbooks is poor despite recent updates that highlight the need for accurate records. We noted increased documentation rates on lists when trainees were present and much lower rates in our short stay Treatment Centre. This could possibly be due to increased time pressures when only one anaesthetist is present, as well as time pressures in high turnover areas. Weekly documentation of oxygen alarms and circuit changes were especially poor. Our figures are comparable to an audit performed in 2006 [2], prior to implementation of the updated guidelines, suggesting difficulty adhering to quality assurance aspects of checklists, regardless of the success of the checklist in improving patient safety. Re-audit in planned for September 2013 after further education.

References1. Association of Anaesthetists of Great Britain and Ireland

(AAGBI). Checking anaesthetic equipment 2012: association of anaesthetists of Great Britain and Ireland. Anaesthesia 2012;67(6): 660-8.

2. Sebastian T, Jose Z, Lamb F. J. Record of anaesthetic machine check. Anaesthesia 2006; 61: 817

3. Laboutique X, Benhamou D. Evaluation of a checklist for anaesthetic equipment before use. Annales Françaises d’Anesthésie et de Réanimation 1997; 16(1): 19-24.

Retrospective study of an enhanced recovery programme for total knee replacement patients

L. McLoughlin, N. Airey, S. Fludger

Wirral University Hospital Trust, Wirral, UKme@lauramcloughlin.co.uk

Total knee replacements (TKR) are common and painful operations [1]. A balance needs to be found between maintaining patient comfort and promoting early mobilisation. In December 2011, Wirral University Hospital Trust introduced an enhanced recovery programme (ERP) including the following changes to patient care; high volume local anaesthetic infiltration (LIA) at the surgical site, avoidance of regional or neuraxial blockade, use of total intravenous anaesthesia (TIVA) intraoperatively and an oral postoperative analgesic regime replacing intravenous morphine patient controlled analgesia (PCA). Current evidence regarding the efficacy of LIA for acute post-operative pain relief is inconclusive [2]. The aim of this study was to determine the local impact of this enhanced recovery package on post-operative pain and length of stay within the hospital.

MethodsThe following data was extracted from the casenotes and the hospital computer system of 50 patients before and 50 patients after implementation of enhanced recovery: patient demographics, anaesthetic techniques, morphine administration in theatre and recovery, postoperative pain scores at rest and on movement (scale 0-3), ward administrated analgesia and length of stay.

ResultsComplete data was obtained for 34 patients who receivedconventional management (median ASA 2, mean BMI 31.3) and 28 patients in the enhanced recovery programme (median ASA 2, mean BMI 30.5). Under conventional management 79% of patients received volatile anaesthesia with a regional block and 21% spinal anaesthesia ± sedation. In recovery 24% required morphine (mean dose 6.7mg) compared to 39% (mean dose 8.2mg) in the ERP group. Pain scores were similar in both groups over the 4 days analysed. Patients receiving conventional treatment including regular oral paracetamol and dihydrocodeine self-administered a mean of 36mg of morphine using the PCA over 4 days. Enhanced recovery patients received regular oral paracetamol and tramadol, with Oramorph as required. No Oramorph was required by 29% of patients. Those who did require Oramorph had a mean cumulative oral dose of 33mg. One patient in this group was given a PCA following severe pain in recovery. Meanlength of stay for the patients receiving conventional management was 4.7 days compared with 3.9 days in the enhanced recovery group.

DiscussionMore patients in the ERP group required morphine in recoverysuggesting that immediate post-operative analgesia is less reliable using LIA. Post-operative pain scores on the ward were similar despite lower morphine consumption in ERP patients of whom a significant number required no morphine at all. This is encouraging although morphine was less readily available to the ERP patients. There also appeared to be a reduction in length of stay in the ERP group. This was a simple retrospective study to gain insight into the local impact of an enhanced recovery programme. It describes problems as well as benefits of the package of changes introduced and it would be ideal to supplement this with a patient satisfaction survey.

References1. Puolakka PAE, Rorarius MGF, Roviola M et al. Persistent pain

following knee arthroplasty. European Journal of Anaesthesiology 2010; 27: 455-60.

2. McCartney C, McLeod G. Local infiltration analgesia for total knee arthroplasty. British Journal of Anaesthesia 2011; 107(4):487-9.

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An audit of basic airway equipment

R. Medlock1, S. Webster-Edge1

1Horton General Hospital, Banbury, UKrebecca.m.medlock@doctors.org.uk

Following the Royal College of Anaesthetist’s fourth National Audit Project (NAP4) it has been recognised that preventable deaths are occurring as a result of major airway incidents [1]. In response to NAP4 provision and organisation of airway equipment has been under increasing scrutiny. In our district general hospital there was concern that there was significant variation in provision and layout of basic airway equipment within different areas of the hospital.

MethodsBasic airway equipment layout and content was audited in areas frequented by anaesthetists (main operating theatres, maternitytheatre, emergency department and ITU) over a one day period. A list of equipment in each area was documented as well as a visual record of equipment layout. Following the first cycle of this audit the results were presented to anaesthetic staff and associated healthcare workers. Through discussion a list of equipment and a suggested layout were generated, this was used to create a template that could be reproduced and used throughout the hospital. A basic airway equipment template was introduced to the main operating theatres, maternity theatre,emergency department and ITU. Airway equipment and layout was subsequently re-audited throughout these areas.

ResultsIn the first cycle of the audit data collected demonstrated a wide variety in layout and provision of equipment throughout each area of the hospital. Zero (0%) of areas had the same equipment or layout as any other. In the second cycle of the audit data collected demonstrated 100% compliance; all areas of the hospital had the same airway equipment and layout. Feedback from staff in the areas that the template was introduced was uniformly positive.

DiscussionNAP4 found that poor airway management has resulted in preventable deaths. Poor planning and inadequate provision of skilled staff and equipment were identified as contributing factors to poor outcomes. [1]. Case law has previously criticised lack of organisation and control of equipment placed on airway trollies as contributing factors to poor airway outcomes [2]. To reduce decision making and recall under stress the Difficult Airway Society encourages clear signage of airway equipment [3]. This audit found that there was significant variation in the provision of airway equipment and the layout of that equipment. Through providing a universal template it was demonstrated that we could standardise basic airway equipment throughout all areas of the hospital frequented by anaesthetists. By ensuring that airway equipment is standardised it is hoped that there will be a reduction in poor airway outcomes by improving provision, planning and recognition of equipment in stressful situations.

References1. Royal College of Anaesthetists. 4th National Audit Project:

Major complications of airway management in the United Kingdom. March 2011

2. Scottish Courts Fatal Accident Enquiry into the death of Gordon Ewing, Glasgow. April 2010.

3. Barley M. Anaesthetic Emergency Signage. Difficult Airway Society. Accessed 9th November 2012.

Consent in anaesthesia: an audit of practice

R. Medlock1 and D. Stevenson2

1Horton General Hospital, Banbury, UK2Stoke Mandeville Hospital, Stoke Mandeville, UKrebecca.m.medlock@doctors.org.uk

Consent in anaesthesia is contentious with practice varying widely.Anaesthetists are not currently required to obtain written consent for anaesthesia and related procedures providing that they are done to facilitate another procedure such as surgery [1]. It is estimated that 30% of claims against anaesthetists involve lack of informed consent [2].

MethodsThe anaesthetic charts of all patients (excluding obstetrics) having a general or regional anaesthetic over a two day period at Buckinghamshire NHS Trust were audited. A survey of practice for consent in anaesthesia was carried out amongst anaesthetists within the trust. Following the first cycle of this audit results were presented and discussed with the anaesthetic department. Documentation of consent was re-audited following this presentation. Through consultation with the anaesthetic department changes were made to the anaesthetic pre-operative charts used within the trust. A further re-audit will be carried out once these charts have been introduced.

ResultsNinety-one anaesthetic charts were audited. Most had no documentation of risk. Dental damage was the most frequently documented risk for general anaesthesia (n=29, 32%), and nerve damage for epidural/spinal (n=5, 45%). Of 23 survey respondents 74% (n=17) reported discussing risks of dental damage, post-operative nausea and vomiting, and sore throat for general anaesthetic. More than 83% (n=19) of respondents reported discussing risk of nerve damage, failure and post-dural puncture headache for spinal/epidural anaesthesia. Ninety-nine per cent (n=22) of respondents reported that they documented any risks discussed. This was not concordant with audit findings. In the second cycle of the audit 50 anaesthetic charts were audited, 54% (n=27) of all charts had documentation of risks discussed.

DiscussionOur Trust is not achieving anaesthetic consent standards. The majority of anaesthetic charts did not have any risks documented. Explanations included limited time and fear of frightening patients. Anaesthetists are overestimating the frequency with which they discuss and document risks.

References1. White SM. Consent for anaesthesia. Journal of Medical Ethics

2004; 30: 286-2902. Colvin JR, Peden CJ. Raising the Standard: a compendium of

Audit Recipes. Royal College of Anaesthetists. 2012; 3:70-71

Ability of anaesthetic staff to reliably identify extremely high tracheal tube cuff pressures by palpation of the pilot balloon

S.A. Michlig1

Stoke Mandeville Hospital, Aylesbury, UK, michligsam@doctors.org.uk

High tracheal tube cuff pressures can cause mucosal damage leading to tracheosophageal fistula, scarring and tracheal stenosis[1, 2]. Low cuff pressures are also problematic, causing leak and representing an increased aspiration risk. Whilst low pressures may be recognised by a leak, or unusual ventilatory parameters, high cuff pressures will not be obvious clinically. Previous studies have identified that anaesthetic nurses[3], paramedics[4] and emergency medicine physicians[5] are unable to accurately estimate cuff pressures by palpation. This study seeks to identify if anaesthetic staff are capable of identifying a very high cuff pressure of 120cmH2O (approximately three times the normal range) in a simulated trachea by palpation of the pilot-balloon.

MethodsA size eight tracheal tube was inserted into the barrel of a 20ml syringe and the cuff inflated to120cmH20. Participants were invited feel the pilot-balloon and state if the pressure was “too high, too low, or approximately correct.” 53 people participated: 14 consultants, 11 senior anaesthetists, 11 junior anaesthetists and 17 operating department practitioners (ODP’s). Answers were grouped into correct (too high) and incorrect (too low or approximately correct) and analysed using Chi Squared test with Yates’ correction.

ResultsEighteen (34% believed the pressure too high, 17 (32%) too low and 18 (34%) believed it to be approximately correct. In the sub-groups 6(43%) consultants, 3 (27%) senior anaesthetists, 4(36%) junior anaesthetists and 5(29%) operating department practitioners correctly identified the pressure as too high. Chi squared test revealed a ‘p’value of 0.975 for the study sample, whilst sub groups had p values of 0.9 (consultants) and 0.95 (senior anaesthetists, junior anaesthetists and ODP’s).

DiscussionRegardless of seniority and training no group showed a significant ability to identify an over inflated cuff. Limitations include a small sample size and lack of power calculation, particularly limiting sub group analysis. Despite this I feel it is clear from this data thatassessment by palpation is not reliable.

References1) Pelc P, Prigogine T, Bisschop P, Jortay A. Tracheoesophageal fistula: case report and review of literature. ACTA Otorhinolaryngologica Belgica 2001; 55: 273-278.2) Streitz JM jr, Sharpshay SM. Airway injury after tracheotomy and endotracheal intubation. Surgical Clinics of North America 1991; 71: 1211-1230.3) Stewart SL, Secrest JA, Norwood BR, Zachary, R. A comparison of endotracheal tube cuff pressures using estimation techniques and direct intracuff measurement. American Association of Nurse Anesthetists Journal 2003; 71(6): 443-447.4) Parwani V, Hoffman RJ, Russell A, Bharel C, Preblick C, Hahn IH. Practicing paramedics cannot generate or estimate safe endotracheal cuff pressure using standard techniques. Prehospital Emergency Care 2007; 11: 307-311.5) Hoffman RJ, Rarwani V, Hahn IH. Experienced emergency medicine physicians cannot safely inflate or estimate endotracheal tube cuff pressure using standard techniques. American Journal of Emergency Medicine 2006; 24 (2) 139-142.

A multi-site audit of anaesthetic equipment timing

BH Millette, CM McGlennan

Stoke Mandeville Hospital, Aylesbury, UKbenmillette@gmail.com

Recently released AAGBI guidelines for checking anaesthetic equipment [1] recommend checking that the system clock is set correctly on all anaesthetic equipment. In the course of our anaesthetic training we have observed that the system clock is frequently inaccurate, leading to difficulties in generating an accurate anaesthetic record for the case. This could potentially become a patient safety issue, for instance during a critical incident when accurate timing may be especially important.

MethodsWe audited anaesthetic equipment in any location where an anaesthetic might be administered (encompassing the anaesthetic room, operating theatres, theatre recovery, A&E resuscitation room and the intensive care unit) at two separate sites. Equipment audited included anaesthetic machines, monitors, infusion pumps and haemofiltration machines. Times were recorded as the time difference from Universal Coordinated Time (UTC) to the nearest minute. The gold standard was that the time displayed should be exactly the same as UTC. If the time displayed did not meet this gold standard then we attempted to correct this, recording the corrected time to complete the audit loop. We then compared the data for each site pre and post correction and between the two sites pre-correction. Differences were analysed by means of Fisher's exact test.

ResultsA total of 112 pieces of equipment were identified for analysis (50 and 62 at Site 1 and Site 2 respectively). 31/112 (27.7%) displayed the correct time. 24/112 (21.4%) had a time difference of at least 30 minutes. Of those displaying the incorrect time, 25/81 (30.9%) were successfully corrected. The majority of the remainder (31/56) were machines in intensive care which would cause clinical inconvenience if altered while attached to the patient. We encountered technical difficulties in altering the time on other equipment. There were significantly more machines displaying the correct time at Site 1 following correction (p<0.0001)but no significant change at Site 2 following correction (p=0.468). Site 2 had significantly more machines displaying the correct time than Site 1 on the initial audit (p=0.0053).

DiscussionWe have found substantial inaccuracy in times displayed on anaesthetic equipment with significant heterogeneity between the two sites audited. Although a proportion of these were able to be corrected, with re-audit showing significant improvement at one site, there remains some way to go before we can ensure 100% compliance to the gold standard. Further measures may be necessary, such as incorporating a time check into regular machine maintenance.

References1. http://www.aagbi.org/sites/default/files/che

cking_anaesthetic_equipment_2012.pdf

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Resuscitation equipment checks - are we getting them right?

I. Mohamed1, D. P. Hall1, E Buchanan1, F Dallas1

1. Cumberland Infirmary, Carlisle, UKibrahim.mohamed@nhs.net

The Resuscitation Council (UK) recommends a list of equipment that should be available for use in cardiopulmonary resuscitation in UK healthcare institutions [1]. Hospitals should provide equipment based on these standards and implement regular checks to ensure thestandards are met [2]. Effective advanced life-support is dependent on readily available equipment that is in good working order [3]. Afailure to perform daily checks of this equipment could lead to a lack of operator familiarity with resuscitation equipment, and a failure to identify malfunctioning devices. The potential patient safety implications of a failure to meet these standards are severe [4].

MethodsRoutine resuscitation equipment checks in a 382-bed district general hospital were audited against the Resuscitation Council guidelines, which state that “(a) all clinical areas should contain resuscitation trolleys with an up-to-date and immediately available list of ‘essential’ equipment, together with a record of equipment checks, which includes the date and time of each individual check, and the person undertaking it; (b) there should be a documented check of resuscitation equipment after 100% of resuscitation episodes; (c) the resuscitation trolley should be capable of being moved easily by all members of staff, (d) all malfunctions or deficiencies should be corrected within one working day” [1]. Data were collected on a single day in January 2013. Resuscitation trolleys were checked in all inpatient areas, including medical, surgical, pediatric and obstetric and gynecology wards; critical care areas, the coronary care unit (CCU),and the emergency department

ResultsTwenty-one clinical areas were surveyed. Twenty (95.2%) had a list of essential equipment and record of daily check. Resuscitation equipment was, however, checked only weekly in the paediatric ward.There was no written record to confirm that equipment was checked after each resuscitation event in any ward, although staff anecdotally report that such checks take place. Similarly, no record of a daily check of the mobility of the resuscitation trolley was found. There were no reported malfunctions or deficiencies in equipment recorded.

DiscussionAlmost all clinical areas complied with the guidelines regarding frequency of checks of resuscitation equipment and the documentation of these checks. However, it is concerning that no record exists confirming that equipment is checked after use. The resuscitation of unwell patients could be compromised by missing, used or faulty equipment. These findings were reported to Trust Resuscitation Officer, who plans to revise the written ‘record of daily checks’ in partnership with the audit authors.

References1. Recommended minimum equipment for in-hospital adult

resuscitation. Resuscitation Council (UK), London October2004. www.resus.org.uk/pages/eqipIHAR.htm (accessed 09/01/2013).

2. Dyson E, Smith GB. Common faults in resuscitation equipment – guidelines for checking equipment and drugs used in adult cardiopulmonary resuscitation. Resuscitation 2002;55:137–149.

3. National Reporting and Learning System Quarterly data issue 9. Putting patient safety first (England). NPSA, London 2009.

4. Cummins RO, Chesemore K, White RD. Defibrillator failure. Causes of problems and recom m endations for im provem ent. JAMA 1991;264:1019–1025.

Audit of post-operative analgesia in patients undergoing DIEP flap breast reconstruction.

A. Muirhead-Smith1, N. Bourne1 and J. Myatt1

Charing Cross Hospital, London, UKamuirheadsmith@gmail.com

Deep inferior epigastric perforator flaps are one method of post-mastectomy breast reconstruction with a broad range of possible post-operative analgesia regimens. We performed an initial retrospective audit of 26 patients undergoing DIEP reconstruction and their pain scores and morphine PCA use at Charing Cross Hospital. This demonstrated a low mean total post-operative morphine dose of 25mg (range 18-36mg). Based on this principle audit finding and in discussion with the pain team, patients were instead started on an oral analgesic regime with breakthrough oramorph. Pain scores and analgesic use were re-audited prospectively using the new regime, with encouraging results of low pain scores and average total oramorph use of 20mg (+/- 95% CI). A guideline with the new suggested analgesic regime has been produced and disseminated to the department for ongoing use.

MethodsRetrospective data was collected from the patient controlled analgesia (PCA) audit sheets filled in by the pain team. Twenty six patients undergoing DIEP flaps between August 2011 to October 2012 received IV morphine PCAs. Their pain scores at rest and on movement at 24 hours and the total morphine use were all recorded. In addition, details of the surgical procedure such as whether the DIEP was uni- or bilateral and whether they had an immediate or delayed reconstruction were noted. An audit form was created to collect further data prospectively with patients started on an initial oral regime (simple analgesics, NSAIDs and weak opiods) with breakthrough oramorph. This was distributed to all lists with DIEPs being performed. Analgesia received intra and post operatively, including local and regional anaesthesia, pain scores and site of worst pain were all recorded. Anesthetists, recovery staff and the pain team all filled in their respective parts of the audit form.

ResultsOf twenty six patients receiving morphine PCAs, 12 had unilateral DIEP, 11 had unilateral DIEP + unilateral mastectomy and 3 had uni/bilateral DIEP + bilateral mastectomy. Their total average post-operative IV morphine use was 18mg, 22mg and 36mg respectively. Their average pain scores at rest were 0.6, 0.7 and 1 and on movement were 1.4, 1.8 and 1 respectively (where 1 = mild, 2 = moderate and 3 = severe). The prospective audit of patients on the oral analgesic regime demonstrated patients used an average total of 20mg (+/- 95% CI) oramorph post operatively. Their average pain score at rest was 1.3 and 2.5 on movement. Over 80% of patients stated the abdominal wound as the site of most pain.

DiscussionThe only current literature on post-operative analgesia for DIEP free flap surgery are assessments of morphine PCA usage. The literature suggests high morphine requirements not consistent with our own anecdotal experience here in the UK. Our restropective audit of morphine PCA usage backed this up with low levels of use that could be adequately replaced by an oral equivalent such as oramorph. Our re-audit, after the change to an oral regime, provided further evidence that oral medications could provide appropriate analgesia, negatingthe need for a PCA. This may have several advantages such as avoiding repeated cannulation, aiding mobilisation and enhancing patient satisfaction. It also suggested the abdominal wound as being the most painful site which may add to the support for transversus abdominis plane (TAP) blocks.

References

Conversion from regional to general anaesthesia for caesarean section: we are meeting the standards? Aretrospective audit of practiceA. Nash1, P. Stevens2 S. Hughes3

Southampton University NHS Foundation Trust, Southampton, UK, Princess Anne Hospital, Southampton, UKandrewnash@doctors.org.uk

Regional anaesthesia techniques widely regarded as safer than general anaesthesia for Caesarean section[1]. Allied to this, the majority of mothers prefer to be awake during their caesarean. The new edition of the Royal College of Anaesthetists guidelines has relaxed the standard in Category 1-3 cases a little to <5% converted from regional to a general anaesthetic[2], accounting for the reduced reliability of epidural top-up anaesthesia utilised in a large percentage of labouring women[3] and variation in time pressures for each category between obstetric units. Over 85% of category 1-3 caesareans should be achieved with regional anaesthesia.

MethodsAll patients having a general anaesthetic for LSCS from 00:01 on 1st

January to 23:59 on 31st December 2011 identified from HICCS database in the Anaesthetic office and data from Linda Campbell, HICCS Maternity Clinical Manager. The HICCS system recorded by theatre staff, midwives and anaesthetists the number of Caesarean sections, urgency category and type of anaesthetic. All possible medical notes of patients who had Regional Anaesthesia converted to General Anaesthesia were reviewed and the results compared to Royal College of Anaesthetists standards [2] and data from previous years.

ResultsThere were 6336 deliveries in PAH during 2011 from 6225 women birthed. 1434 of these were by LCSC. This translated to 455 Elective(Category 4) and 979 Emergency (category 1-3) Caesarean sections. 1281 of these were performed under RA (89.3%) and 153 performed under GA (10.7%). General anaesthesia was used in 48 elective and 105 emergency caesareans (63 category 1 caesarean sections). Forty six regional anaesthetics were converted to general anaesthetics. Three cases (0.65%) were elective caesareans and 43 cases (4.39%) were emergencies. The majority of conversions were failed regional anaesthetics pre-operatively. Twenty three Epidural top-ups were converted to GA, 21 Spinals and 2 CSEs. Within the emergency conversions 15 cases (35%) were intra-operative conversions. Our emergency conversion rate is increased from 2.3% in 2010 whilst elective conversion rates are the lowest to date.

DiscussionAlthough conversion rates are above previous years, this may reflect variations in data recorded and more robust data collection within a busy tertiary obstetric unit. Obstetric preference for general anaesthesia, ‘maternal requests’ and communication difficulties with block assessment especially in ethnic minority or migrant female populations may be a factor in this increase. Our audit has revealed we are complicit with the most recent Royal College of Anaesthetists 2012 standards and advocates recent literature supporting a more relaxed target standard for emergency regional anaesthesia [4].

References1. Confidential Enquiry into Maternal and Child Health. Why

mothers die 2000–2002. RCOG Press, London 2004.2. Dr M Purva, Dr I F Russell, Dr M Kinsella. Royal College of

Anaesthetists | Raising the Standard: a compendium of audit recipes,| 3rd Edition 2012. Section 8.8.

3. Obstetric Anaesthetists’ Association. Regional anaesthesia for unplanned CS. http://www.oaa-anaes.ac.uk/content.asp?ContentID=485 accessed 13/01/2013

4. Pandey R, Gauthama P, Hart E. Conversion from regional to general anaesthesia for caesarean section: are we meeting the standards? Anaesthesia 2012; 67: 550-1.

An audit of analgesia for fractured neck of femur at Darent Valley Hospital

D. Neely1, L. Oswald2, M. Kanagarathnam3 and M. Satisha4

1Tunbridge Wells Hospital, Pembury, UK, 2,3,4Darent Valley Hospital, Dartford, UK1diana.neely@doctors.org.uk

75,000 patients sustain a fractured neck of femur each year in the UK [1], contributing to morbidity and mortality. Darent Valley admits 30 such patients per month, for whom the mean length of stay is 20 days, compared to 16.4 days (national average) [1]. Guidance on ‘Management of Hip Fracture in Adults’ by the National Institute for Health and Clinical Excellence recommends 100% compliance with analgesia standards [2], against which we compared local practices.

MethodsData were collected for 50 consecutive patients admitted with fractured neck of femur from 01/09/11, through review of admission paperwork, Fractured Neck of Femur Proformas, medical/nursing notes, observation charts and drug charts.

ResultsPain was assessed: immediately in 8 patients (16%), 30 minutes after initial analgesia in 1 (2%), hourly until settled in 1 (2%) and routinely throughout admission in 1 (2%). 39 (78%) had no pain assessment. 24 (48%) waited over an hour for initial analgesia (Figure 1).

Fig 1. Time to Initial Administration of Analgesia on Presentation 0-15min (10%), 16-30min (18%), 31-45min (2%), 46-60min (22%), >60min or none (48%)

All were prescribed appropriate oral analgesia pre- and post-operatively, bar 2 (4%) who received a non-steroidal. Analgesia was sufficient in 32 (64%) and unknown or difficult to ascertain in 7 (14%). 12 (24%) received nerve blocks, all performed by an anaesthetist perioperatively, including only three of 11 patients known to have insufficient analgesia – 27% of those in pain.

DiscussionThis first-cycle audit highlighted deficiencies in pain assessment, early administration of analgesia and consideration of nerve blocks. Action taken comprised: education on pain assessments, on early analgesia and training regarding nerve blocks. Designated individuals were identified to perform nerve blocks. A second cycle of the audit (conducted in 2012) aims to show an improvement in these data.

References1. British Geriatrics Society. The National Hip Fracture Database.2011. http://www.nhfd.co.uk/003/hipfractureR.nsf/NHFDNationalReport2011_Final.pdf (Accessed 04/01/12).2. National Clinical Guideline Centre. NICE Clinical Guideline 124: Hip Fracture: The Management of Hip Fracture in Adults. 2011. http://www.nice.org.uk/nicemedia/live/13489/54921/54921.pdf(Accessed 25/08/11).

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Perioperative venous thromboembolism prophylaxis: the anaesthetist’s potential impact on patient safety.W. Shippam1, S. N. Phillips2 and M. Peck3

1. Frimley Park Hospital, Frimley, UK2. Frimley Park Hospital, Frimley, UK3. Frimley Park Hospital, Frimley, UK

Correspondence to: Dr William Shippam (wshippam@doctors.org.uk)

Prevention of venous thromboebolism (VTE) is high profile in both medicine and the media and as such local and national guidelines are in place to enable the prevention of significant morbidity and mortality [1,2]. Completing a VTE risk assessment form does not always equate to providing adequate VTE prophylaxis to the patient. Also, under-treating and over-treating patients can compromise patient safety, increase costs and compromise efficiency. This is an audit ofperioperative VTE prophylaxis in a busy district general hospital aiming to identify any potential improvements in our practice.

MethodsWe collected prospective data during one week in December 2012. Aproforma, filled out by the anaesthetists allocated to the theatre list,collected data regarding VTE assessment, mechanical and pharmacological prophylaxis as patients entered the anaesthetic room.Paediatric, obstetric and short local anaesthetic procedures were excluded.

ResultsOne hundred and seventy six patients were audited out of a total of 450 eligible procedures, however 24 (14%) proformas were only partially complete. The most common surgical procedures wereorthopaedics with 70 (40%) patients. VTE risk assessment was completed for 147 (87%) patients (less than the 90% standard) and 19 (10%) patients had their VTE risk under-estimated. Patients were assessed as high, medium and low risk of VTE as per our local guidelines (60%, 29% and 11% respectively). Pharmacological VTE prophylaxis was correctly prescribed in only 51/164 (31%) patients with the majority of patients having their pharmacological prophylaxispotentially omitted within their first 36 hours of care. Anti-embolism stockings (AES) were worn by 165 (94%) patients and were correctly fitted 95% of the time. Intermittent pneumatic compression (IPC) devices were applied to 81 (46%) patients. Seventy six (43%) patients had both AES and IPC, however this was ‘over-treating’ 49 (28%) patients who were only indicated for monotherapy. Five (3%) patientswere under-treated with mechanical prophylaxis.

DiscussionThis audit highlights a serious failure of pharmacoprophylaxis prescribing on day 1 post-op and a potentially wasteful practice of dual mechanical therapy. Education and increasing awareness for appropriate risk assessment, mechanical and pharmacological VTE prophylaxis is essential. The audit team plans to agree a process for the anaesthetist to minimise missed VTE risk assessments and prescribe (in conjunction with the surgeon) appropriate pharmacoprophylaxis, especially in day surgery. AES and IPC both reduce the risk of deep vein thrombosis but there is a lack of strong evidence available to suggest one method of mechanical prophylaxis is better than another nor any benefit for dual mechanical therapy [2].Our trust can potentially save £43,000 per annum by following NICE guidance and minimising dual mechanical VTE prophylaxis. We aim to re-audit following the implementation of our recommendations toachieve >90% NICE compliance.

References1. Trust VTE Committee. Guidelines for Reducing the Risk of

Venous ThromboEmbolism. Frimley Park Hospital NHS Foundation Trust; Version: 5 January 2011.

2. National Institute for Health and Clinical Excellence. Venous thromboembolism: reducing the risk. [CG92]. 2010.

A simple card makes drug prescription and administration safer.

W. Shippam,1 J. Jackson,2 J. Kirk-Bayley,3 A. Raj4

1. Royal Surrey County Hospital, Guildford, UK2. Royal Surrey County Hospital, Guildford, UK3. Royal Surrey County Hospital, Guildford, UK4. Royal Surrey County Hospital, Guildford, UK

Correspondence to: Dr William Shippam (wshippam@doctors.org.uk)

New anaesthetic trainees are exposed to multiple unfamiliar drugs. The potential for drug errors is high with devastating effects. It has been shown that using an easy to carry drug card reference improves the quality of antibiotic prescribing in a paediatric population [1]. We propose that implementing a similar card for common anaesthetic drugs would improve prescribing practice and safer administration.

MethodsWe surveyed anaesthetic trainees and recovery staff to elicit their confidence at calculating common and emergency drug doses. A paediatric scenario assessed the staffs’ ability to calculate five different drug doses under timed conditions, before and after the introduction of the reference card (Figure 1). The Wilcoxon Signed-Rank Test was used to test the data’s significance.

Figure 1: Front side of the drug reference card.

ResultsIn a survey of 17 staff only 24% felt confident to prescribe drugs for adults and children without using a source of reference. Eighty eight percent felt that a credit card-sized reference tool would be beneficial. The mean scores to correctly calculate five drug doses before and after card introduction were 2.5/5 and 4.7/5 respectively (p<0.0007). The anaesthetic trainees subgroup scored 2.6/5 and 4.6/5 respectively (p<0.0083). No one correctly calculated all five drug doses pre-intervention. The mean time to complete the assessment before and after card introduction was 275 seconds and 131 seconds respectively (p<0.0008). The mean time for only the anaesthetic trainees was 151 seconds and 87 seconds respectively (p<0.0195).

DiscussionThe anaesthetic drug reference card has been demonstrated to be effective at improving prescribing efficiency and safety to statistical significance in anaesthetic trainees and recovery staff. A credit card-sized drug reference tool is desirable and could be applied to other disciplines of medicine.

Reference1. South M, Royle J, Starr M. A simple intervention to improve

hospital antibiotic prescribing. The medical journal of Australia2003; 178: 207-9.

An audit of volatile use and fresh gas flows in a District General Hospital

B. Smith, L. Davis and M.Tindall1

1Russells Hall Hospital, Dudley, UKbensmith@doctors.org.uk

There are many advantages to low flow anaesthesia including economic, environmental and improved patient temperature and humidity [1]. Although there is no universally accepted definition of low-flow anaesthesia it is often quoted as less than 1L/min [1, 2]. The AAGBI also recommend auditing practice with regard to green anaesthesia [3]. We sought to discover the mean flow rate used in our department and the quantity of anaesthetic agents used. The anaesthetic machines have recently been updated to those with an electronic flowmeter and a gas and volatile usage calculator with an internal memory for recent cases.

MethodsOver a six week period we collected data on choice of anaesthetic agent and mean flow rates used. Data was collected from the anaesthetic machine after lists had finished. We collected the length of case in minutes and the volume of fresh gas used in litres in order to calculate a mean flow. Alongside this we collected the grade of anaesthetist carrying out the case and the amount of volatile agent used.

ResultsWe collected data on 149 cases in the time period of the audit with mean flow being 2.31L/min (SD ±1.55). The audit target of 1L/min flow or less was achieved on 22 cases (14.6%). The majority of cases used sevoflurane (65.8%) with 27.5% using isoflurane and 6.7% TIVA. Mean flow was lower in cases involving trainees. Trainees alone had a mean flow of 2.11L/min, when paired with consultants the flow was 2.28L/min and consultants alone had a flow rate of 2.34L/min.

DiscussionA mean flow of 2.3L/min shows overall we do not adhere to low flow anaesthesia but the value is comparable to other hospitals’ results [4,5]. It is interesting that consultants have higher flow rates than trainees. One reason could be that low flow anaesthesia is part of education and training whereas consultants who are used to higher flows are less likely to reduce their flow rates. A survey of consultants practice is ongoing to complement our audit. Combining the results we plan to put in place local guidelines and an education plan before re-auditing.

References1. Nunn G. Low-flow anaesthesia. Continuing Education in

Anaesthesia, Critical Care and Pain 2008;8:1–4.2. Baxter AD. Low and minimal flow inhalational anaesthesia.

Canadian Journal of Anaesthesia 1997; 44:643-6533. http://www.aagbi.org/about-us/environment/possible-avenues-

research-%E2%80%98green-anaesthesia%E2%80%99(Accessed 7th July 2012)

4. Kennedy RR, French RA. An audit of anaesthetic fresh gas flow rates and volatile anaesthetic use in a teaching hospital. New Zealand Medical Journal 2003;116:U438

5. SB Packer, BG Phillips-Bute, HA Muir et al. Evaluating Anesthetic Fresh Gas Flow in a Teaching Hospital.Anesthesiology 2004; 101: A581

Antibiotic duration: can procalcitonin rationalise prescribing in a district general hospital?

F. Tait1, D. Marriott1 and P. Watt1

Kettering General Hospital, Kettering

Frances.tait@doctors.org.uk

Prolonged courses of broad-spectrum antibiotics increase the risk of antimicrobial resistance. The emergence of resistant strains of Pseudomonas within our intensive care population prompted an audit of prescribing practice. We evaluated compliance with trust antibiotic prescribing policy and assessed whether introducing procalcitonin (PCT) testing would be cost effective in shortening courses by changing prescribing habits.

MethodsAn initial audit of prescribing practice was undertaken in a consecutive group of patients admitted to the ICU between August and October 2012 with length of stay greater than three days (n=21). Along with patient demographics and ICU outcome, all antibiotic courses were recorded with course length and any positive microbiological cultures. After introduction of PCT testing, a further audit was undertaken on new admissions anticipated to stay more than three days (n=11) and when new courses of antimicrobials were started. Sixty-six ELECSYS BRAHMS PCT assays were available for the audit. The manufacturer’s recommended ranges were used to determine infection and response to antimicrobials (A fall of 90% from initial level determining cessation of therapy)[1]. Antibiotic course length was recorded along with CRP and PCT on day one, three and five.

ResultsPrior to introducing PCT, antimicrobial prescribing practice was found to be in line with trust policy with a mean course length of 5.2 days (SD 2.4). We found no significant difference in antimicrobial course length once PCT testing had been introduced, mean course length 4.6 days (SD 3.2). No patients had a fall in PCT equal or greater than 90% of the initial value by day five. Nine of the 11 patients (82%) showed a drop in CRP over the five day course. We found two distinct subsets of patients within the PCT group. Group one (n=4) had significantly elevated levels of PCT initially (>10ng/ml). Group two (n=6) had low levels of PCT (<2ng/ml) during the five day testing course. Three (75%) in the elevated PCT group died compared with no deaths in the low PCT group. There was no difference in SOFA or APACHE II scores between these two groups.

DiscussionThis audit of practice in a small group of patients showed overall compliance with trust antimicrobial prescribing policy. Introduction of PCT failed to alter physicians’ prescribing habits to any significant degree. In addition, no patients had a fall in PCT equal or greater than 90% of the initial value by day five, and therefore PCT testing offered no additional value in shortening courses. In contrast CRP fell more reliably over the antimicrobial course. Over the time period 66 assays, at £8 each, were used but only 29 results obtained due to wastage and calibration, representing an increase in cost to £18.20 per result. We feel this audit along with studies of a similar nature [2] calls into question the value of routine PCT testing in the district general hospital intensive care setting.

References1. Bacterial infections and sepsis, procalcitonin testing. Thermo scientific, 2012. 2. Worthington O, Martin-Roberts L, Clayton J, Cunniffe J, Leonard M, Wilson L. Procalcitonin in the intensive care unit: does it answer all our questions? Poster 132. The state of the art meeting 2012. Intensive Care Society. December 2012.

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Theatre simulation training

J. Vedwan, T. Everett, A. Vaughton, R. Jee

Dorset County Hospital, Dorchester, UKjvedwan@gmail.com

Complications in theatre, although rare, are potentially devastating so it is important that staff are able to respond appropriately and in a timely fashion to reduce morbidity and mortality[1,2]. In spite of this a survey of trust theatre staff showed that multi disciplinary training opportunities in theatre emergencies were limited.

MethodsLive simulation and Sim Man 3G scenarios were integrated within theatre Clinical Governance Meetings on a three monthly basis. The theatre simulation training exposed multi-disciplinary staff to adverse anaesthetic incidents. The simulation was run as a “normal” list involving three patients in theatre. Staff were familiarised with SimMan 3G equipment before the list commenced. Local anaesthetic toxicity, Malignant Hyperpyrexia and Anaphylaxis scenarios where performed. Staff were expected to react in real time and use all necessary resources within the department, thus testing clinical, non clinical skills and highlighting latent threats within these processes. Debriefing involved the whole team and the observing staff, any problems and solutions for change were noted. Each scenario was closed with a brief overview presentation highlighting the key learning points.

ResultsSurvey results showed that no attending staff had had any formal teaching within the last two years and only 21% felt they had the appropriate training to assist with management of emergencies in theatre. Post training feedback was excellent. 90% felt it was relevant and 82% felt more aware of how to deal with emergencies and more confident in managing them as a team.

DiscussionIntegrating the use of simulation within theatre Clinical Governance Meetings provides a highly effective educational and training opportunity, within the principles of clinical governance. Increased exposure to infrequent emergencies through simulation enables the rehearsal of delivery of high quality care and improves patient safety.

References1. Brady JE, Sun LS, Rosenberg H and Li G. Prevalence of malignant hyperthermia due to anesthesia in New York state. Anesthesia and Analgesia Oct 2009; vol 109 no.4 1162-11662. Bourne E, Wright C and Royse C. A review of local anaesthetic cardiotoxicity and treatment with lipid emulsion. Local Reg Anesth 2010; 3: 11-19

Elective major joint replacement- an ongoing comfortable journey

M. Yeoh

Whiston Hospita1, Liverpool, UKCorrespondence to: yeohmeifoong@hotmail.com

Effective perioperative pain and nausea and vomiting management improves patient outcome, reduces hospital stay and avoids unnecessary distress [1]. Patient satisfaction is the key indicator of efficient pain and post operative nausea and vomiting (PONV) management [2]. Management of pain and PONV should be guided byindividual patient’s experience [3]. These audits attempt to capture patients’ pain and PONV experiences 24 hours post elective majorjoint replacement.

MethodsData collection of the pilot prospective audit stretched from 15/11/2011 to 18/12/2011. Sample size was 56 patients identified from the daily orthopaedic list at Aintree University Hospital (AUH). Patient questionnaires were used to evaluate patients’ satisfaction with their pain management. A recovery pro forma was used to identify pain score (zero to three) on first eye opening, pain score 30 minutes after eye opening and pain management in recovery. Choice of perioperative analgesia and antiemetics were obtained from patients’ notes. Recommendations were made based on results of the audit. A re-audit stretched from 1/7/2012 to 31/7/2012. Sample size was 19 patients due to reduced number of surgeries performed in July. The same methodology was used with the addition of evaluating patients’ satisfaction with PONV management using the questionnaires. Therecovery pro forma was used to identify PONV score (zero to three)on first eye opening and PONV score 30 minutes after eye opening.

ResultsComparing the re-audit to the pilot, 100% (vs 89%) of patients felt that hospital staff made every effort to control their pain while 10% (vs 16%) would opt for an alternative method of pain relief. In both audits, all patients received preoperative information on pain management. Ninety four percent (vs 89%) of patients had a pain score below two on first eye opening and 94% (vs 87%) had a pain score below two 30 minutes after eye opening. One hundred percent(vs 92%) of patients were prescribed both regular and breakthrough analgesia and antiemetics prior to discharge to the ward. Only 73% of patients were warned about PONV. One hundred percent of patients had a PONV score below two on first eye opening and 95% of patients had a PONV score below two 30 minutes after eye opening.

DiscussionThere has been improvement with patients’ perioperative pain management, judicious prescription of both regular and breakthrough analgesia and antiemetics and the prompt response to patients’ complaints of pain. Informing patients about PONV and its treatment needs addressing. Recommendations made included warning patients about PONV and morphine- induced nausea and vomiting and discussing antiemetic regimes. The audit should be repeated after the AUH elective joint replacement perioperative analgesia and antiemetic protocol commences.

References1. Chumbley GM, Ward L, Hall GM et al. Pre-operative

information and patient-controlled analgesia: much ado about nothing. Anaesthesia 2004; 59(4): 354–8.

2. Dupree E, Martin L, Anderson R, Kathuria N, Reich D, Porter C,Chassin MR. Improving patient satisfaction with pain management using Six Sigma tools. Joint Commission Journal on Quality and Patient Safety 2009; 35(7): 343-50.

3. American Pain Society Quality of Care Committee. Quality improvement guidelines for the treatment of acute pain andcancer pain. The Journal of the American Medical Association1995; 274: 1874–80.

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Quality care in quantity

M. Yeoh

Whiston Hospital, Liverpool, UKCorrespondence to: yeohmeifoong@hotmail.com

Day surgery units can reduce surgical waiting time, improve service provision and may be more cost efficient for hospitals [1]. Patients have the comfort of recovering at home with the reduced risk of hospital acquired infection [2]. This audit evaluates the efficiency and quality of service provided by Aintree University Hospital´s daysurgery unit.

MethodsData collection stretched prospectively from 29/11/2011 to 16/12/2011. Sample size was 99 lists and 124 cases. Patient demographics, grade of anaesthetist and surgeon, type of surgery, anaesthetic administered, choice of perioperative analgesia and antiemetics and intraoperative complications were obtained from patients' notes. The recovery pro forma was used to identify pain and post operative nausea and vomiting (PONV) score (zero to three) at first eye opening, pain and PONV score at 30 minutes after eye opening and management received in recovery. Start and end time of each case, length of stay in recovery and discharge location was obtained from the hospital database. Patients were followed up usingthe hospital database 48 hours post discharge to identify the rate of failed discharges (readmission within 48 hours post discharge). The data was compared against standards suggested by the Royal College of Anaesthetist.

ResultsA defined medical and social day surgery exclusion criteria, protocols for analgesia and antiemesis administration and a discharge protocol existed with 100% of patients meeting the agreed criteria. Ninety seven percent of patients had a pain score below two on first waking,89% had a pain score of below two after 30 minutes of first wakingand 99% had a PONV score of below two on first waking or at 30 minutes. Twenty four percent of lists were >100% utilised and 16% were < 80% utilised. Fourteen percent of lists had >15 minutes start time delay and 10% had an unplanned gap of >10 minutes between cases. There was a two percent unplanned admission rate and a one percent rate of failed discharges.

DiscussionAreas of strength included patient selection, unplanned admission and failed discharge rates and PONV management. However, there was significant under or over utilisation of theatre sessions and unsatisfactory pain management. Recommendations made included judicious use of perioperative analgesia and antiemetics. There should be realistic estimations of surgical time in conjunction with meticulous planning of lists. Thorough pre operative assessments and good communication amongst theatre teams will facilitate optimum theatre utilisation and discharge planning while avoiding cancellations, failed attendance and unplanned admissions.

References1. Mirnezami R, Sahai A, Symes A, Jeddy T. Day-Case and Short-

Stay Surgery: The Future For Thyroidectomy? International Journal of Clinical Practice 2007; 61(7):1216-22

2. Commission for Healthcare Audit and Inspection. Day surgery-Review of national findings. Healthcare Commission 2005.

The prevalence of high obstetric body mass index and its impacton anaesthetic service provision

N. Abu Al-Saad1, C. Williams2

1Peterborough City Hospital, Peterborough, UK, 2Addenbrooke's Hospital, Cambridge, UKEmail: claire.williams@addenbrookes.nhs.uk

CMACE guidelines [1] for the management of obesity in pregnancy state all women with a booking Body Mass Index (BMI) greater than 40kg/m2 should be referred for anaesthetic pre-assessment due to increased overall risk during labour and delivery, including an increased chance of an operative delivery [2]. They also stipulate thatsuch women should have a senior obstetrician and anaesthetist present in cases of an operative delivery (defined as grade ST6 or above). With the rising national prevalence of obesity, it is expected that such recommendations will have significant implications for planning and delivery of obstetric anaesthesia services. Our objectives were, firstly,to assess if the number of women with BMI greater than 40 is significantly increasing with time. Secondly, to estimate the financial and time implications of consultant-led anaesthetic pre-assessment of all women with BMI greater than 40 over time.

Methods:Service evaluation by retrospective analysis of delivery data between 2005-2011 collected on local computer database (PROTOS). Data were collated on total deliveries, BMI, mode and time of delivery and anaesthetic intervention. Chi-squared tests for trend were used to assess data categorised by year and BMI ranges. The annual cost of consultant time required to pre-assess obese women in anaesthetic pre-assessment clinic was estimated based on average figures.

Results:There has been a 15% absolute increase in number of deliveries at our unit during the period studied, with 5853 deliveries in 2011. No significant change in the proportions of deliveries by BMI range wasdemonstrated. Women with BMI over 40 consistently represented between 1 - 1.7% of deliveries during the time period (Chi2 trend test=0.0866, p value > 0.70). Assuming consultant-led anaesthetic pre-assessment clinic appointments for such women, 6 appointments per session and an approximate cost of £150 per session, there is an anticipated increase in cost of consultant time of £570 in 2011 compared with 2005 (unadjusted for inflation and salary changes over time). Women with BMI greater than 40 are more likely to require an operative delivery compared with women with BMI less than 40 (Chi2 statistic 19.9, p < 0.001).

DiscussionThe proportion of obese women delivering at the Rosie Hospital has not changed over time but numbers are gradually increasing as a reflection of the increased number of deliveries taking place annually. Compliance with national guidelines has financial implications which are likely to only increase with time. Prospective assessment of pre-assessment needs for women with high booking BMI, and senior anaesthetic availability during operative deliveries is needed to further assess current compliance with national guidelines, and more precisely assess service provision requirements.

References1. Centre for Maternal and Child Enquiries (CMACE). Maternal obesity in the UK: Findings from a national project. London: CMACE,2010.2. Dresner, M, Brocklesby, J, Bamber, J. Audit of the influence of body mass index on the performance of epidural analgesia in labour and the subsequent mode of delivery. BJOG: An international journal of Obstetrics & Gynaecology 2006; 113: 1178-1181.

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Intensive care glycaemic control, is it optimal?

Dr Adel Al-DujailiStoke Mandeville Hospital, UKadel.duj@gmail.com

Background:The subject of glucose control in critically ill patients is surrounded by controversy due to conflicting data published over the last 10 years. Hyperglycaemia was not routinely controlled in non-diabetic patients as it was considered to an adaptive response to stress in critical illness. Initial studies showed the morbidity and mortality were dramatically reduced when glucose was tightly controlled in ITU patients [1]. More recently, a Meta analysis has shown that mortality does not differ between tight glucose control and usual care, but in fact there is a significant increased risk of hypoglycaemia [2]. The NICE-SUGAR trial is the largest study of glucose control in ITU patients and concluded tight glucose control (4.5 to 6.0 mmol/L) increased mortality, whereas those who were conventionally controlled glucose levels (10 mmol/L or less) had reduced mortality [3]. A more recent study has shown that tight glycaemic control may increase regenerative potential of myocardium during acute myocardial infarction [4].

Objective:To determine whether the Leuven protocol (blood glucose 4.4-6.1 mmol/L) is being followed in ITU at St Peter’s hospital, and whether the protocol should be amended.

Methods:During a two week period every patient who was on the Leuven protocol was included in the study. Data was collected retrospectively for all blood glucose readings during a 24 hour period and the median was calculated. A total of 71 patients were included.

ResultsA total of 626 blood glucose readings were collected over two weeks. Of these only 29.39% were within the Leuven protocol, 56.87% were below 10 mmol/L and 8.79% were above 10mmol/L. A small proportion (4.95%) of glucose readings were less than 4.4 mmol/L.

Conclusions:Our data shows that we are not following the protocol, and this is largely based on the fact that current data shows that tight glycaemic control is detrimental to patients in ITU. Our guidelines need to be updated to incorporate our practice as well as take into account current recommendations.

References:1. Van den Berghe GH. Role of intravenous insulin therapy in critically ill patients. Endocr Pract. 2004;10 Suppl 2:17-20.2. Wiener RS, Wiener DC, Larson RJ. Benefits and risks of tight glucose control in critically ill adults. JAMA 2008; 300(8):933-9443. The NICE-SUGAR Study Investigators. Intensive versus Conventional Glucose Control in Critically Ill Patients. NEJM 2009;360:1283-12974. Raffaele Marfella, Ferdinando Carlo Sasso, Federico Cacciapuoti‘et al’. Tight Glycaemic Control May Increase Regenerative Potential of Myocardium during Acute Infarction. Journal of Clinical Endocrinology & Metabolism March 1, 2012; 97:933-942

‘Be Aware of Air’ The real risks of medical air being supplied on the wards.

Authors: Dr A. J. Allen (KSS Deanery)

Hospital: St Richard’s Hospital, Chichester, West Sussex, UK

drandyallen@hotmail.com

Background

Pipelined air at the bedside has been present in some hospitals, particularly on medical wards for many years. Its use is normally limited to the administration of nebulized medication to patients who may be at risk of carbon dioxide retention, secondary to oxygen therapy.

Introduction

In the National Patient Safety Agency (NPSA) report in 2009 regarding “Oxygen safety in hospitals” it was highlighted that there was often “confusion of oxygen with medical compressed air”. Unfortunately, I have experienced this first hand when I incorrectly attached an ambu bag to air instead of oxygen during an arrest situation. In this particular case it was felt it would not have changed the outcome but I was devastated, and had a real concern it could easily happen again. I was keen to look into the situation and see if mistakes could be prevented. With air and oxygen being administered side by side, the accidental attachment of the ‘air/oxygen giving set’ to the wrong out flow connector is a real risk.

Method

I wanted to establish if there was any inconsistency in the presentation of air and oxygen on the wards at my hospital. I did this by examining and photographing the variety of delivery systems present throughout the hospital.

Results

There was a surprisingly wide variety of different presentations of air and oxygen flow meters seen throughout the Hospital. The flow meters were often of different types and the labelling of them varied in the way they were colour coded and also in the way they were labelled.

Conclusion

Although rare, incidents have been reported of accidental connection to air supplies instead of oxygen, some fatal. There was inconsistency in the way air and oxygen supplies are highlighted on the wards within this one hospital. This was very surprising and worrying at the same time. It was unanimously agreed within the anaesthetic department that this discrepancy increases the risk of a potentially life threatening incident. It was agreed after examining a variety of strategies, that the safest and most economical solution was to remove all the wall attached air flow metres and administer air only via cylinder supplied air. Oxygen is one of our most used treatments. I ask the question how many other hospitals have their oxygen and air supplies set up in an unsafe way, and is removing the air from some wards the best way forward?

References

Oxygen safety in hospitals: National Patient Safety Agency Rapid Response Report, 29 September 2009.

(Situation described below was from time spent working in a different hospital than I am currently working)

Randomised controlled trial data of preemptive analgesia to prevent the development of neuropathic pain after cardiac surgery

S.Anwar, J Rahman, C Sharma, A Hemming, R Langford

Pain and Anaesthesia Research Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London, UKSibtain.anwar@bartshealth.nhs.uk

Persistent postoperative pain (PPP) following sternotomy, either neuropathic or non-neuropathic in nature, is common (30-55%) and difficult to treat once established. Known risk factors such as young age and increased duration of surgery are not modifiable. Evidence is gathering for the role of NMDA receptor antagonists and gabapentinoids in the prevention of chronic pain after various forms of surgery.

MethodsWith research ethics committee approval and written informed consent,we conducted a randomised, triple-blind, controlled trial of 150 elective cardiac surgical patients, assigned to one of three arms:A: Fourteen days of placebo capsule and 48-hour placebo infusionB: Fourteen days of perioperative pregabalin and 48-hour placebo infusionC: Fourteen days of perioperative pregabalin and 48-hour infusion of low dose ketamine

Responses to experimental pain modalities, before and after surgery, were recorded as potential predictors of chronic pain. Pain outcomes were measured in the acute postoperative period and at three and six months following surgery. Results are presented here of a planned interim analysis, following completion of data collection for the first 50 patients.

ResultsThere were significant differences between groups A, B and C respectively, in terms of chronic pain at three months after surgery (50% vs 24% vs 6% p=0.0015) and at six months (31% vs 17% vs 6% p=0.02)Poor responses to Conditioned Pain Modulation (CPM) testing before surgery, as defined by less than 100kPa increase in algometry-derived pain threshold, predicted the development of chronic pain in 75% and 78% of PPP patients, at three and six months respectively.

DiscussionThis is the first study to demonstrate the preventive effect of perioperative pregabalin, alone or in combination with ketamine, on chronic pain following sternotomy. In addition, there is potential to predict the development of PPP by assessing CPM efficiency before surgery. Analysis of the full trial data set is required in order to draw further conclusions.

Use of the Bivona Fome-Cuf tracheostomy and bed head signs

G. Barker and R. RajendramJohn Radcliffe Hospital, Oxford, UKCorrespondence: rajkumarrajendram@doctors.org.uk

Recent guidelines recommend the use of bed head signs to identify hospital inpatients with tracheostomy tubes.[1] The Bivona Fome-Cuf(BF-C) tracheostomy tube (Portex, UK) has a self-expanding foam filled cuff that must be deflated by manual aspiration of air via the deflation line. This is unusual because most tracheal tube cuffs are air-filled and deflate if the inflation line is cut. This is particularly relevant for decannulation because deflation of the foam cuff is not possible if the deflation line is cut. Following an incident in which the pilot balloon of a BF-C tracheostomy tube became disconnected we adapted the recommended bed signage to include information about the type of tracheostomy tube in situ. We performed a survey to find out which hospitals in the Oxford Deanery were using the bed head signs and the BF-C tracheostomy. We also sought to determine doctors understanding of the BF-C tracheostomy.

MethodA Survey Monkey survey was sent to 40 doctors working in the Oxford deanery. They were asked the following questions:• Hospital & ICU, Grade of doctor & Primary speciality?• Does your hospital use bed head signs as recommended by the

national tracheostomy safety project in ICU or the wards?• Does your hospital use the Bivona Fome-Cuf tracheostomy?• How long does the balloon take to deflate if the pilot balloon is cut

or disconnected?• Do you discharge patients to the ward with a Bivona Fome-Cuf

tracheostomy in situ?

ResultsA total of 19 full responses (response rate 48%) were received after three requests. Most respondents worked in one of three different critical care areas [adult general ICU 11 (58%), neuro ICU 2 (11%), cardiac ICU 1 (5%)] in the regional teaching hospital (14; 74%). All four district general hospitals in the region replied to our survey.Consultants were the most frequent responder (8; 42%). The rest were trainees were from a range of ST grades. The primary speciality of respondents was predominantly anaesthesia (90%). Only one hospital in the region used bed head signs on the wards (5%). None of the ICUs surveyed used any signage. Ten respondents (53%) used the BF-C tracheostomy tube in ICU but patients would not be discharged to award with it still in situ. Most responses to the question about pilot balloon disconnection were correct (16; 84%) but three respondents (16%) thought that the BF-C deflates if the pilot balloon is cut.

DiscussionOur survey demonstrates a poor uptake of the recommendations to clearly identify hospital inpatients with c tracheostomies. This is concerning in view of the high risk of airway incidents in this cohort.[1] All five hospitals in our region use the BF-C tracheostomy.It is often used to manage patients with persistent cuff leaks. The foam filled cuff moulds to the trachea and reduces the incidence of leaks atlower cuff pressures than air-filled cuffs. However the foam cuff is self expanding and must be deflated by aspirating air via the pilot balloon connected to the deflation line. If the pilot balloon is detached the cuff remains inflated which presents difficulties with removal. Our survey highlights some lack of understanding about the implications of pilot balloon disconnection from the BF-C. This information should be integrated into teaching programmes to improve awareness ofairway devices commonly used in clinical practice.

References1. McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia 2012; 67: 1025–1041.

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Enhanced recovery after surgery in obstetrics: a regional (West Midlands) survey of current practice.

A. Bodh1, M. Ramamoorthy2 and S. Dinesh3

Birmingham Heartlands, Birmingham, UK 1, 2, 3.

amarbodh@yahoo.com

Enhanced Recovery after Surgery (ERAS) is a perioperative protocol that can improve individual patient recovery [1]. The aim of this protocol is to reduce detrimental effects of stress response associated with surgery and to pre-empt the metabolic changes [2]. There is a reduction in length of hospital stay and the associated cost [1]. Most of this evidence is from colorectal [2] surgeries but it’s applicable to other specialities. The aim of this survey was to explore the role of ERAS in obstetrics.MethodsAn electronic survey questionnaire was distributed to anaesthetists, obstetricians, midwives and operating department practitioners across the West Midlands. Questions were posed on availability of guidelines applicability in obstetrics, the effect of anaesthetic technique, early post-operative oral intake, and early removal of urinary catheter after surgery, and length of hospital stay. Results148 responses were received. There were 106 (72%) anaesthetists, 14(9%) midwives, 11 (7%) obstetricians and 17 (11%) were operating department practitioners. 128 (86%) of responders had more than 5 years of experience.

Survey question(*some responders skipped questions)

Answered yes

1. Do you have a hospital policy on ERAS in obstetric surgery?

8(5%)

2. Do you think it is essential to have written guidelines on ERAS in obstetric surgery?*

108(74%)

3. Should ERAS be used for elective LSCS only?* 52(36%)

4. Should ERAS be used for emergency and elective LSCS?*

19(13%)

5. Should ERAS be used for all obstetric procedures?*

71(49%)

6. Do you feel the choice of anaesthetic has influence on ERAS outcome?*

118(82%)

7. Do you feel patients should have their first oral intake within two hours?

141(95%)

8. Do you feel the urinary catheter should be removed within 12 hours?

123(83%)

9. Do you fell the average length of hospital stay should be no more than two days?*

122(83%)

10. Do you feel there is need for guidelines like ERAS approved by regulating bodies?*

120(81%)

DiscussionThis regional survey demonstrated that there is a definite role for enhanced recovery in obstetric surgery as long as written guidelines are available. The results show there is a clear desire amongst practitioners for establishing ERAS in obstetrics but a barrier to its implementation is a lack of guidance and evidence from research.References1. Sjetne S, Krogstad U, Ødegard S, et al. Improving quality by

introducing enhanced recovery after surgery in a gynaecological department: consequences for ward nursing practice. BMJ Quality and Safety in Health Care 2009; 18: 236-40 (accessed on 24/02/2013).

2. Matthews C. Enhanced recovery after surgery (ERAS) Anaesthesia tutorial of the week 204 2010; 1-9. http://www.frca.co.uk/Documents/204%20Enhanced%20recovery%20after%20surgery%20(ERAS).pdf (accessed on 24/02/2013).

Complete Audit Cycle Of Fasting Times For Children Having Non-Elective Surgery At The Royal Manchester Children’s Hospital

A. Bradley1, S. Rolfe1, D Patel1, V Oshin1 and B Lomas1.

1Royal Manchester Children’s Hospital, Manchester, UKEmail of corresponding author: anthony.bradley@nhs.net

Minimum fasting times prior to surgery have been agreed by The Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland in order to reduce the risk of aspiration whilst under anaesthesia. Excessive fasting may lead to discomfort, potential distress and medical complications. Attainment of these times in elective cases has been established as a key audit recommendation [1]. The Care Quality Commission has advised that periods of starvation in advance of surgery are kept to a minimum.Logistically, non-elective surgery is more difficult to organise and therefore targets are less likely to be achieved.

MethodsPermission to undertake the audit was obtained from the audit department at the Royal Manchester Children’s Hospital. For each cycle (December 2010 and November 2012), one month’s data from children undergoing non-elective surgery was collected. Timings between oral intake and surgery were recorded. The gold standard for maximum fasting times were determined as four hours for oral fluids and 12 hours for solids (i.e. twice the minimum recommended fasting times). The data was processed using Excel. Where possible, Odds Ratios and 95% Confidence Intervals were calculated.

ResultsThe first cycle analysed 83 out of a potential 152 cases (55%). It found that median fasting times for solids and fluids were 11.33 [IQR = 8.33-16] and 10.22 hours [6.5-14.2] respectively. Thirty-nine patients (47%) were fasted in excess of 12 hours for solids and 75 (94%) in excess of 4 hours for fluids. In response to this, the anaesthetist supervising the CEPOD list was provided with a portable telephone to facilitate communication and coordination between the ward and theatres to ensure that excessive fasting did not occur. The second cycle captured 132 out of 164 (80%) cases. Median fasting times were 10.82 [7.25-17.25] and 7.92 hours [4.92-7.92] for food and drink respectively. Despite improvements in the number of patients being fasted for less than 4 hours for fluids; 6% to 18% (OR 3.19 (CI 1.14-8.9)), 94 (82%) still failed to meet this target. There was no change in fasting times for solids. It was also noted that 25 patients (24% of 105 recorded cases) had intravenous (IV) fluid commenced prior to arrival in theatre. Seventeen out of 29 patients who had been without oral fluids for greater than 12 hours (59%, 16% of all patients), arrived without IV fluids being commenced.

DiscussionThe provision of portable telephones to the supervising anaesthetist has significantly reduced the number of children being excessively fasted from fluids. Despite this improvement, 82% still failed to meet the target. This represents the difficulties in organising an ever-changing surgical list with differing specialties competing for the same space. A recommendation for such emergency lists would be for surgeons to commit to an approximate time for each case allowing the child to be starved more appropriately. Of concern is that 16% of patients arrive in theatre at risk of dehydration, having been denied fluids in excess of 12 hours. As well as the long wait times, changing theatre schedules and worry over miss-timing of oral fluids, there may also be a reluctance to cannulate at risk children on the wards.

References1. T Dorman, Preoperative fasting in elective paediatric surgery; Royal College of Anaesthetists. Raising the Standard: a compendium of audit recipes 3rd Edition 2012 234-235.

Raising the alarm again

S. F. Campbell

John Radcliffe Hospital, Oxford, UKdrscampbell@gmail.com

Setting appropriate alarm limits is a key part of the anaesthetic machine check [1]. No published advice exists concerning the lower limit of the inspired oxygen (FIO2) alarm. This is often set at 21% or lower; many anaesthetists do not routinely check or change this limit. There are theoretical advantages to having a limit set higher than the concentration of oxygen in air (21%).

MethodsWe have previously discussed [2] our practice of raising the default inspired oxygen alarm on our anaesthetic machine (GE Heathcare, Chalfont St Giles, Bucks, UK) from the default of 18% to 24%. This allowed detection of an overlooked disconnection of the fresh gas flow from the circle breathing system. This occurred as the common gas outlet was disconnected in order to use a Hudson mask for the previous patient.

We have attempted to identify other scenarios where setting this alarm above 21% would provide early warning of problems. Additionally, we have surveyed awareness of this issue at our institutions.

DiscussionAttempted preoxygenation, while neglecting to turn on the oxygen, will be ineffective at denitrogenating the patient. Additionally, with a circle system it will rapidly expose the patient to a hypoxic gas mixture, with obvious benefit to early identification.

Disconnection of the patient circuit between the machine and the gas sample line in a spontaneously breathing patient will continue to show an end tidal CO2 trace and may show minute ventilation to be unchanged (depending on the location of the flow monitor). However, the sampled FIO2 will rapidly drop to 21% and hence cause an alarm with appropriate limits set.

This same scenario is seen when the “Auxiliary Common Gas Outlet” is accidentally selected when the intention is to use the circle system, or indeed if a “T-piece” or “Water’s circuit” is connected but not provided with oxygen flow.

The drawback to this higher alarm limit is the possibility of unwanted alarms. These are likely to occur in when the machine is not in use (and therefore the gas sample system is exposed to air) unless the standby mode inhibits alarms (all GE machines tested could be silenced).

A local survey (unpublished) of 60 anaesthetists of various grades across three sites showed that most (87%) denied ever having checkedthe default level for this alarm, and 60% erroneously thought that it was set at 21% or higher by default. Changes have been made, as when audited locally in 2009 all machines were set at 18%. A repeat audit this year showed that newer GE machines have arrived with a default limit set at 21%.

We would urge all anaesthetists to consider raising the alarm level default for the FIO2 alarm to 24% to avoid some of the scenarios described. Do you need to raise the alarm?

References1. Association of Anaesthetists of Great Britain and Ireland.

Checking Anaesthetic Equipment 2012. Anaesthesia 2012; 67: pages 660-68. doi: 10.1111/j.1365-2044.2012.07163.x

2. Campbell, S. F. and Sellers, W. F. S. (2009), Raise the alarm. Anaesthesia, 64: 687. doi: 10.1111/j.1365-2044.2009.05947_1.x

Data driven healthcare; right under our noses?

S. F. Campbell

John Radcliffe Hospital, Oxford, UKdrscampbell@gmail.com

The third healthcare revolution, according to Sir Muir Grey, involves the flow of data and medical knowledge [1]. We are continuously trying to improve patient outcomes and resource utilisation. By using data that we already routinely collect we can find patterns to inform resource decision making.

MethodsWe have an obstetric database that is used to record interventions (for example epidurals) and identify patients requiring follow-up the next day. This data has not been previously used to identify service demand. Using simple data manipulation and visualisation we used fully anonymised data to search for temporal trends in caesarean section carried out under general anaesthesia (GA). A list of dates and times of emergency caesarean sections was normalised by day of year relative to the first Wednesday of August (trainee rotation effect), day of week (weekend effect) and time of day (shift change effect). This created a temporally summed dataset, which was then plotted as a cumulative frequency curve.

ResultsThe cumulative frequency curves for caesarean sections under general anaesthesia matched the linear regression line for day-of-year normalisation and day-of-week normalisation. However variation was seen in the time-of-day curve (figure 1).

Figure 1. Cumulative frequency graph of GA caesarean sections normalised by time of day. Variation from linear regression line (dotted line) seen at 08:00 and 20:00 (dotted arrows).

DiscussionClear increases in workload due to GA caesarean section can be seen at 08:00 and 20:00. This corresponds with shift changeover times, when no consultant is present on the unit, with potential increase in stress and poor handover. Potentially increased senior cover could be targeted at these times to ensure good clinical decisions are being made. This very simple technique can easily be expanded to other datasets. For example, shifts could be altered to allow for an overlap at busy times. High numbers of cancelled elective cases at certain times of year could lead to a change in list booking strategy. This data is already being collected; we must ensure that we make the best use of it.

References1. Muir Grey, The Third Healthcare Revolution.

http://muirgray.net/ (retrieved 13/1/2013)

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A audit of emergency theatre delays in a district general hospital. L. Carrick1 and K. Szypula1. Lincoln County Hospital, Lincoln, UK lcarrick@doctors.org.uk Delays are a regular occurrence in the running of the emergency theatre list. An audit of emergency theatre delays was completed to determine the cause of these delays and the findings were compared to AAGBI standards as stipulated in the guidance on theatre efficiency1.The findings were presented at the local joint surgical and anaesthetic audit meeting and are presented here with the agreed recommendations.

Methods:The audit was conducted over a one month period. A proforma was completed daily by the emergency anaesthetic team. Data collectedincluded the number of cases waiting on the emergency list at 08:00, 18:00 and 22:00 and the duration and reason for any delay that arose.It was determined than an acceptable theatre turn around time in between cases was 30 minutes. Information from ORMIS was collected including patient statistics and the times the patient arrived within the theatre suite, anaesthetic room, into and out of the theatre and into and out of recovery.

Results:93 cases were completed during the audit period, 39 males and 54 females. The average age was 41.4 years; the youngest was two and the oldest 95 years of age. The median start time of the first case was 10.08hrs. The list started at or around 09:00 on only 4 days. 68.3% of the cases were completed between 08:00 and 18:00. 25.8% between 18:00 and 22:00, 4.3% during 22:00 and 24:00 and 1:08% between 24:00 and 08:00. The average number of cases per day was 4 with a range of 0 to 7.

A delay was quantified as the time elapsed between the preceding case leaving the theatre and the following case arriving within the theatre suite. 62 delays arose. The average delay was 78.6 minutes and the longest delay was 486 minutes. Reasons for a delay were documented in 25 out of the 62 cases. The unavailability of the surgeons was the cause of nine delays (14.5%). Clinical reasons such as the patient not being fasted accounted for 5 delays (8%). Poor communication was afactor in 3 delays (4.8%). A lack of consent resulted in 2 delays (3.2%). Ward delays contributed to 2 delays (3.2%), a lack of porters resulted in 2 delays (3.2%) and theatre issues including equipment and staff availability accounted for 2 delays (3.2%).

Discussion.The AAGBI guidance on theatre efficiency1 states that for the efficientrunning of an emergency theatre list senior anaesthetists and surgeons are required without any other commitment to routine work. Aefficient emergency list should enable up to 80% of emergency cases to be completed within normal working hours. Yet currently between the hours of 08:00 and 18:00 we are falling short at 68.3%. The availability of surgeons needs to be improved. The number of cases on the emergency list at 08:00, 18:00 and 22:00 was poorly documented and no significant inference could be drawn. Currently a paper booking system is used and due to inefficiencies in this system accurate data on this could not be gleaned. At the local anaesthetic and surgical joint audit meeting, it was agreed to update the booking system to use an electronic system and the implementation of this is now under review.

References.1. AAGBI. Theatre Efficiency. Safety, quality of care and optimal use of resources. 2003.

Urinary catheterisation in elective hip and knee arthroplastiesfollowing introduction of the enhanced recovery protocol.

S.S.Chauhan1, F.Ismail1 and L.Handcock1

Raigmore Hospital , Inverness, UK (1)satvinder.chauhan@nhs.net

The rate of urinary catheterisation in patients undergoing hip & knee arthroplasties in Raigmore Hospital was the highest in Scotland at 90% according to the Enhanced Recovery After Surgery (ERAS)Musculoskeletal Audit report 2011[1]. Since the majority of patients undergoing elective hip & knee replacements are well ASA 1 & 2 patients, avoiding urinary catheterisation is one of the interventions that can significantly improve patient comfort, reduce catheter associated urinary tract infections and assist them to return to their normal function. The introduction of local Enhanced Recovery Protocol (ERP) guidelines in Raigmore Hospital during October 2011 which recommends omission of intrathecal opiods and restriction ofamount of fluid given intraoperatively amongst others aimed to reduce this number. This retrospective audit aimed to assess if the implemented protocol was successful in reducing the rate of catheterisation in line with the recommended standard of 5% [1]

MethodsCase notes of patients who underwent elective primary hip & knee arthroplasties during the month of December 2011 were reviewed.The number of patients catheterised, timing and reasons for catheterisation were reviewed. Fasting times, intrathecal local anaesthetic and opioid use, peri-operative fluid administration and incidence of post-operative renal impairment were also recorded.

ResultsThirty three case notes were reviewed; twenty one cases were hip arthoplasties and twelve were knee arthroplasties. Only one of thirty three patients received intrathecal opioid. The mean volume of intraoperative fluid given was 1100 millilitres (SD200) for hip arthroplasties and 844 millilitres (SD221.67) for knee arthroplasties.Two patients (6%) required to be catheterised; one intraoperatively due to intrathecal opioid use and one post-operatively due to anuria and subsequent renal impairment. The first patient also developed vomiting post-operatively and subsequently had renal impairment. Of note, there were another three patients who also developed a decline in renal function (15%).

DiscussionThis audit has shown that we have managed to reduce the rate of catheterisation from 90% to 6% following implementation of our local ERP protocol with overall minimal detrimental effect. This is close to the standards set out in the national Scottish audit of 5%. Additionally, we also highlighted the incidence of post-operative renal impairment in this group of patients which was higher than desirable. Our local ERP protocol was then amended to increase the amount of fluid given intra-operatively and a re-audit is currently under progress to assess the effects of this.

References1. NHS National Services Scotland. Optimal patient pathways for

hip and knee arthroplasties: Use of Enhanced Recovery After Surgery principles in Scotland in April-June 2011 – A one-year review of practice. Page 18 Available from: http://www.18weeks.scot.nhs.uk/service-redesign-and-transformation/enhanced-recovery/orthopaedics/

The North West Airway Management Database (NWAD) - a reporting system to improve patient safety and airway management training (www.eanaesthesia.com/nwad).

C. Conlon and JP. Lomas

North West Deanery, UK.clareconlon@doctors.org.uk

Demonstration of exemplary airway management is the most fundamental skill of the anaesthetist. Of all complications related to anaesthesia, airway complications most commonly lead to death or brain damage [1]. Advancement of airway skills requires exposure to challenging airways but direct clinical experience is inconsistent and inadequate due to a paucity of clinical cases [2]. NWAD compensates for this and improves patient safety by enhancing clinical performance through shared experiential learning.

MethodsParticipants register at www.eanaesthesia.com/nwad, allowing them to submit and review case reports. Submitted cases are examined prior to publication by regional airway management experts. Reported cases are published online and in magazine format. NWAD complies with The National Information Governance Board (NIGB) standards. RCOA CPD points are awarded for each report submitted.

ResultsSeventy one registered participants. The cases reported to NWAD have improved the fidelity of simulation and airway management training.

Discussion Advancement of airway skills requires exposure to challenging airways - experienced anaesthetists recognise problems sooner and start treatment in response to problems faster. However, patients with complex airway disease present to non-specialist consultants and trainees whose exposure is inconsistent and inadequate due to apaucity of appropriate clinical cases [2]. NWAD compensates for the lack of direct clinical experience. Participants share their direct experiences and reflect on these as well as those of others, delivering lifelong learning and the development of expertise.Mental representations built from experience are more easily and reliably recalled upon in crisis situations than protocols and algorithms [3]. NWAD achieves sustained deliberate mental practice in the management of infrequent and challenging situations. It allows clinicians to mentally rehearse management of these real life examples and reduce the inherent delay and reluctance to perform rescue techniques when necessary.Poorly-performing pieces of equipment feature repeatedly in adverse events. NWAD provides an evidence base by identifying frequently failing pieces of equipment.Case reports or 'patient stories' have a profound effect. NWAD is a vehicle to share 'patient stories' and experience in an easily digestible, accessible way, providing a more powerful and meaningful driver for learning than other forms of academic work.Analysis of adverse events illustrates inexperience, poor judgement,and education and training to be frequent contributory causes in airway misadventure. NWAD reduces the risk of similar events by enhancing understanding of the factors that influence patient outcome.

References1. Cook TM, Bland L, Mihai R, Scott S. Litigation related to anaesthesia: An analysis of claims against the NHS in England 1995–2007. Anaesthesia 2009; 64:706-18.2. Clarke RC, Gardner AI. Anaesthesia trainees’ exposure to airway management in an Australian tertiary adult teaching hospital. Anaesthesia and Intensive Care 2008; 36: 513–5.3. Ericsson, K. A., & Charness, N. Expert performance: Its structure and acquisition. American Psychologist 1994; 49(8): 725-747.

Review of a new “DNACPR / Acute Care Limitation of Treatment Plan” form

S. Dunlop1, R. Ferrie2 , T. Birke2 , P. Smith2

Northampton General Hospital 1, Northampton, UK, Kettering General Hospital 2, Kettering, UK sallydunlop00@hotmail.com

New documentation to record patient CPR (cardiopulmonary resuscitation) status in association with an acute care limitation of treatment plan was introduced at Kettering General Hospital in February 2012. This review was undertaken at three months, with the aim of identifying issues relating to completion of the form.

MethodsA single assessor (SD) reviewed the first 10 (all if less than 10) forms completed on each ward from carbon copies. Data relating to how the forms were completed was collected on a proforma.

ResultsData was collected from 162 forms (74 male, 70 female, 18 unknown) across all hospital wards, with 72% being over 70 years of age (on 13% of forms, the age was not stated). An appropriate grade of doctor had completed the form in 91% of cases, and 86% had a documented review period. There was documentation of discussion with the patient on 35% of forms and with the patient’s family or power of attorney on 28%. Of great concern, 35% of forms failed to identify if the patient was for CPR. Nearly half of all forms had some level of potential clinical inconsistency within the acute care treatment plan.

DiscussionIn the majority of cases the form was being used correctly. However in 35% the CPR status question had not been answered. “Is the patient for cardiopulmonary resuscitation?” was the last of 12 questions. It was in a different font and colour to the other questions. We suspect that those who failed to complete it may not have realised that it needed to be answered separately, believing that the form itself implied a DNACPR status. The formatting of this question needed to be changed immediately. Discussion with patients and/or family was frequently not being documented on our form (though may have been so elsewhere in the patient notes which were not examined for this review). GMC guidelines [1] state that discussion should be documented, or if discussion does not take place that the reason why should be documented. We are encouraging doctors to use this section of the form, in an attempt to ensure that there is appropriate patient and/or family involvement in these decisions.

The NCEPOD report, Time to Intervene? [2] states that the use of a ‘ceilings of care’ document would facilitate decision-making and clarity of intent. However, it recognises that health care professionals often fail to understand that a patient can remain for active treatment but in the event of cardiac arrest that CPR would be futile. There were numerous cases of such inconsistencies within the acute treatment plan section of our form. We are educating medical staff to try to rectify this issue. The report also states that a national project is required to lead work into ceilings of care documents [2]. Our form is in its early days and further audit and review are on going. As evidenced from our initial results the introduction of any new documentation requires ongoing education and review.

References1. General Medical Council. Treatment and care toward the end of

life: good practice in decision making. London: GMC, 20102. Findlay GP, Shotton H, Kelly K, Mason M. Time to Intervene?

National Confidential Enquiry into Patient Outcome and Death 2012

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Substantive Locum Anaesthetic jobs are said to be the normal route for post CCT trainees: a glimpse at jobs for the last five years

C E Fiandeiro, J E Petrie, N Eltom and S. Yentis

Anaesthesia, Chelsea and Westminster Hospital, London, UK

As a trainee approaching CCT there is a constant reminder that jobs are few. Many trainees take up locum consultant jobs until they find the job that they want. The NHS is moving towards a fully Consultant led service, which places great pressure on Trusts to employ and create substantial posts to ensure the highest possible standard is delivered. The role of the Locum consultant is to fill this gap, but is also a costly measure. We aimed to quantify this suspected expansion with the current jobs advertised over the last five years.

MethodsWe searched the BMJ archives between 12.01.2008 (online start) to 31.01.2012 for substantive and NHS full time advertised locum consultant posts (duration ≥ 6 months) in all regions.

ResultsNumerous jobs were advertised ranging from weeks to several months. Larger teaching hospitals were not always clear on the number of posts available, and many of the jobs for 2009 and 2010 stated that there was a 3-month trial period with possible extension. There has been a marked decline in number of full time locum consultant jobs from 198 in 2008 (29.95%) to 86 in 2012 (18.9%).This trend parallels the drop in substantive consultant jobs until 2012 where there was a slight increase in full time consultant jobs.

Figure 1: Trends in substantive (☐) and locum consultant ()posts (2008 – 2012): % locum posts compared to total

DiscussionDespite the growing workload on the NHS the available number of advertised locum and substantive consultant jobs advertised aredecreasing. Of note is that some posts advertised are of shorter duration, with the possibility of extension. This could be to try save costs or due to an increase in bank staff available to fill these theatre sessions. As many anaesthetists post CCT take this route prior to getting their substantive consultant posts is this increasingly leading to a period of insecurity amongst our newly qualified colleagues, despite seeming like a requirement to get the job they want?

References 1. BMJ. BMJ Careers; careers.bmj.com (accessed 10/01/2013)

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Development of a multidisciplinary simulation programme based upon the Royal College of Anaesthetists curriculum. Forbes L, Eitel C, Melville D, Turner J St Richards Hospital, Chichester lyndseyforbes@doctors.org.uk

Simulation plays an integral part in Anaesthetic training and is widely used for the practice of emergency drills. The Royal College of Anaesthetists (RCoA) have a structured curriculum for the training of core and higher trainees. [1]

MethodsUsing twelve basic units of training from the RCoA curriculum we have developed a monthly simulation program. Each month a different unit of training is the focus of our simulation session. We have involved other specialties. Both the Emergency and Paediatric Departments have been involved in order to make the scenarios as realistic and educational as possible. In the Intensive Care Unit, we used our high fidelity mobile simulator to simulate emergencies that commonly occur in this environment and involved both Anaesthetic trainees and Intensive Care nurses as candidates.

ResultsUsing the RCoA curriculum has allowed us to focus our Anaesthetic simulation teaching; structuring it towards multidisciplinary based teaching sessions. It also allows the Anaesthetic and Simulation Departments to produce a repeatable simulation programme for annual teaching. The feedback we have had from all candidates has been extremely positive. We believe multidisciplinary modular guided simulation is an essential element in trainee medical education.

Reference:

1. Royal College of Anaesthetists. Curriculum for a CCT in Anaesthetics (2010) http://www.rcoa.ac.uk/document-store/curriculum-cct-anaesthetics-2010

Learning from NAP 4 - multidisciplinary simulation training in airway emergencies

V.Fox, P.Patel, O.Boomers and I.Sockalingham

Lister Hospital, Stevenage, UK,Prabir.patel@doctors.net.uk

The 4th National Audit Project of the Royal College of Anaesthetists (NAP 4) highlighted poor judgement, lack of skills, confidence and equipment as factors contributing to adverse airway events in theatres, emergency departments (ED) and intensive care units (ICU) [1]. At least one in four major events reported was from ICU or ED, and the outcome of these events was more likely to lead to permanent harm or death than events in anaesthesia. Displaced tracheostomies were the greatest cause of major morbidity and mortality in ICU. The report found a 60% failure rate of emergency cricothyroidotomy. Wepresent the findings of multidisciplinary simulation training centred around these findings. The objectives in accordance with NAP 4 recommendations, were to improve knowledge, confidence and skills in staff that may be involved with airway emergencies

MethodsThe sessions were attended by anaesthetic trainees, operating department practitioners (ODPs), anaesthetic nurses and ICU nurses. The session content included a presentation of NAP 4 data, Difficult Airway Society guidelines and displaced or blocked tracheostomy algorithms. This was followed by workshops on fibreoptic intubation, videolaryngoscopes, the intubating LMA and emergency cricothyroidotomy. Attendees then participated in simulated scenarios including ‘failed intubation’, ‘failed ventilation’, ‘the displaced tracheostomy’ and ‘the blocked tracheostomy’. Each scenario started with a first responder who was able to call for help from other participants. A facilitated debrief followed each scenario. Pre and post session questionnaires were completed by all participants.

ResultsTwenty nine participants attended including eight anaesthetic trainees, 15 anaesthetic assistants (ODPs and nurses), and six ICU nurses. Inpre-session questionnaires, all anaesthetists were aware of NAP4 findings in contrast to only 10% of nurses and ODPs. Interestingly more than half of anaesthetists and all nurses felt under confident inmanaging tracheostomy complications. Post session ratings are presented as mean scores (SD) out of five. The course was globally rated as relevant 4.5 (0.63) and realistic 4.3 (0.66) and all participants enjoyed the training. All participants learnt from observing others even when not actively participating. The workshops were viewed as extremely useful 4.5 (0.68). 88% of anaesthetists, 60% of anaesthetic assistants and 50% of ICU nurses felt more confident in managing a ‘cannot intubate, cannot ventilate’ scenario. Encouragingly all ICU nurses, 75% of anaesthetists and 60% of anaesthetic assistants felt more confident at managing the dislodged tracheostomy as a result of the training. All anaesthetists, anaesthetic assistants and ICU nurses staff felt more confident in using or preparing difficult airway equipment. Good communication, situational awareness and confidence were the most valuable human factors rated 4.7 (0.43), 4.7 (0.45) and 4.6 (0.48) respectively. All agreed that such sessionsshould be carried out at least twice a year.

DiscussionOur data suggests that multi disciplinary airway training is enjoyable and beneficial for all staff groups. Participants were able to develop more confidence, and build on technical and non-technical skills required to manage airway emergencies. There is perceived benefitparticularly for nursing staff, in doing such sessions regularly.

References1. Cook TM, Woodall N, Frerk C. Major complications of airway management in the UK. NAP4. British Journal of Anaesthesia 2011; 106: 617-31.

How the use of a non invasive cardiac output monitoring device influenced fluid management in major colorectal surgery - a retrospective audit

P. Garry1, S. Menon1

1 Milton Keynes General Hospital, Milton Keynes, UKpeesh222@yahoo.co.uk

Targeted fluid administration may improve the postoperative outcome in patients underdoing surgery. [1] Studies have shown that use of devices such as the oesophageal Doppler may lead to decreased hospital stay and morbidity in patients undergoing elective colorectal resection [3]. Newer devices based on bioreactance such as the Cheetah NICOM (Non Invasive Cardiac Output Monitor) may provide a less invasive method of estimating cardiac output. This audit aimedto determine the number of cases where cardiac output monitoring was being used, and if this influenced the amount of fluid given peroperatively.

MethodA retrospective audit of 96 patient notes who underwent major elective colorectal surgery over a 1 year period (Sept 2011-Sept 2012) was performed using the hospital electronic document management system. Data was collected on the type of device used and the amount and type of fluid that was given over the case. The data was analysed using simple descriptive statistics and the student’s t test was used to determine whether there were significant differences in the amount of fluid given.

ResultsThe 96 patients had a mean age of 64.7 (SD 12.6) and mean ASA grade of 2. A cardiac output monitoring device was used in 17 of the 96 cases (12 cases NICOM, five cases Doppler). The mean amount of fluid given in the no cardiac output device group was 3.05 litres (SD 0.95). The mean amount of fluid given when the Cheetah NICOM was used was 2.62 litres (SD 0.88), and the mean amount when the Doppler was used was 3.2 litres (SD 0.84). These results were not statistically significantly different from each other but the trend seems to be towards using less fluid with the NICOM.

DiscussionOnly 17% of cases used a monitoring device, with the NICOM being used in the majority. This may be due to the fact it is non invasive and relatively simple to set up. There have been several studies suggesting targeted perioperative fluid therapy can improve outcome after major colorectal surgery [1]. It may also reduce critical care admissions [2]. ‘Restrictive’ fluid regimens may also confer improvement in pulmonary function and post operative hypoxaemia [3], however morbidity may also be increased by this approach highlighting the need for ‘goal-directed’ fluid administration strategies, as patients undergoing colorectal surgery often have multiple co-morbidities. Our audit suggests a need to improve the number of cases where these devices are being used. A re-audit in 6 months is planned after presentation of results at the monthly departmental audit meeting.

References1. S Noblett, C P Snowden, B K Shenton, A F Horgan. Randomised clinical trial assessing the effect of Doppler-optimized fluid management on outcome after colorectal resection. British Journal of Surgery 2006; 93: 1069-10762. D Conway, R Mayall, M Abdul-Latif, S Gilligan, C Tackaberry. Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Anaesthesia 2002; 57: 845-8493. K Holte, N Foss, J Andersen, L Valentiner, C Lund, P Bie, H Kehlet. Liberal or restrictive fluid administration in fast-track colonic surgery: a randomized, double-blind study. British Journal of Anaesthesia 2007; 99 (4): 500-508

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An audit of malignant hyperthermia crisis management.D. Glasgow, D. Hughes

Ulster Hospital, Dundonald, UKdenverglasgow@doctors.org.uk

Malignant Hyperthermia (MH) is an important anaesthetic emergency with an estimated incidence of 1:3000. The observed MH morbidity rate is 35%. Morbidity increases with each 2oC increase in maximal temperature and doubles with every thirty minute delay in dantrolene administration.1,2 Robust emergency planning will increase the likelihood of a positive patient outcome.

MethodsAn audit comprising a review of resources and an emergency drill was carried out to assess the drugs, equipment and procedures in place to deal with an MH crisis in core anaesthetic areas across four district general hospitals within the same NHS Trust.

Standards were primarily based on the Association of Anaesthetists of Great Britain & Ireland MH Management Guidelines.3 Standards were grouped into four categories:

1. Immediate care: Guidelines and dantrolene stocks 2. Supportive care: Emergency drugs and cooling provision3. Investigation & Monitoring: Lines and blood sampling

equipment.4. Organisational: Implementing guidelines and transfer

considerations.100% compliance was expected in all categories.

ResultsA summary detailing the presence of core elements of MH management across the trust in both the initial audit and subsequent re-audit are detailed in figure 1.

Important organisational problems were also identified such asstaffing numbers and difficulty in the emergency transfer of stocksand equipment to remote sites.

DiscussionThere were significant deficiencies in the ability to respond to an MH crisis which were multi-factorial. Consequent changes included the updating of protocols and drug stores as well as the development of amobile crisis management kit and task card system. This audit illustrates the necessity of the regular audit of emergency protocols and importance of emergency drills in identifying organisational deficiencies.

References1. KPE Glahn, FR Ellis, PJ Halsall, et al. Recognizing and

managing a malignant hyperthermia crisis: guidelines from the European Malignant Hyperthermia Group. British Journal of Anaesthesia. (2010) 105(4): 417-420

2. M. Larach, SJ Dirksen, KG Belani, et al. Creation of a Guide for the Transfer of Care of the Malignant Hyperthermia Patient from Ambulatory Surgery Centers to Receiving Hospital Facilities. Anaesthesia & Analgesia. (2012) 114:94-100

3. AAGBI. MH Crisis Management. (2011)

Daily sedation holds in the intensive care unit: an audit of local practice following introduction of a sedation protocol

C. Goh, G. Barker, S. Alderson and S. McKechnie

Oxford University Hospitals NHS Trust, Oxford, UKcyndi.goh@gmail.com

Continuous intravenous sedation is an independent predictor of prolonged length of mechanical ventilation and ICU stay [1]. Daily sedation holds have been shown to reduce these complications [2] and the Society of Critical Care Medicine recommends use of a protocol to incorporate the assessment of sedation, setting of sedation targets and institution of daily sedation holds [3]. In 2010, an audit carried out in the adult ICU of our hospital revealed poor implementation of sedation holds. In response, a sedation protocol was introduced.

MethodsIn 2012, one year after the introduction of the sedation protocol, aprospective audit was carried out over 10 days. Clinical practice was audited against the standards set out by the sedation protocol. This reflected the Society of Critical Care Medicine guidelines [3]. Patients were included in the audit if they met all three inclusion criteria: (1) age ≥ 18 years, (2) infusion of sedative agent administered in the preceding 12 hours, (3) expected length of intubation/ventilation ≥ 24 hours. Data was collected included type/dosing of sedative infusions, implementation of a daily sedation hold, and Richmond Agitation Sedation Scale (RASS) score before, during and after sedation hold.

ResultsTwenty-five patients were included. Of these, 19 (76%) were over-sedated prior to the beginning of a sedation hold, with an actual RASS below target RASS. The most common sedative regime was acombination of propofol and fentanyl, which 16 patients (64%)received. Only 15 patients (60%) had had a sedation hold that day.Two patients (8%) who were eligible for a sedation hold did not receive one whilst the remaining eight patients (32%) were appropriately excluded from a sedation hold, in line with the protocol. This was an improvement on the findings of the 2010 audit where out of the 27 patients studied, only five (19%) had had a sedation hold that day, 18 (67%) of patients eligible for a sedation hold did not receive one and only four (15%) patients were appropriately excluded from a sedation hold. However, the effectiveness of our sedation holds isquestionable. Our 2012 audit found that the improvement to RASS score following a sedation hold was not sustained. Two hours following a sedation hold, eight (53%) of the 15 patients had the same or increased levels of sedation compared to before the sedation hold. This may be because none of the 11 (73%) patients requiring sedation rescue had their sedation restarted as recommended by the sedation hold pathway (bolus sedation with a restarting of infusions at 50% the initial rate if requiring >3 boluses per hour).

DiscussionThe introduction of a sedation protocol has improved the numbers of patients receiving daily sedation holds and provided standards against which practice can be audited. However, our practice of sedation rescue following a sedation hold needs to be addressed and re-audited.

References1. Kollef MH, Levy NT, Ahrens TS, Schaiff R, Prentice D,

Sherman G. The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation. Chest 1998; 114:541-8.

2. Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. New England Journal of Medicine 2000; 342: 1471-7.

3. Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Critical Care Medicine 2002; 30: 119-41.

High Fidelity Simulation Training for the Primary FRCA OSCE.Harvey R1, Gillan C1 and Edgar S1

St Johns Hospital, Livingston, UKrachel.edwards@doctors.org.uk

High fidelity simulation is used as an assessment component in the Primary FRCA Objective Structured Clinical Examination (OSCE).Simulation training is well established in anaesthesia, as aneducational tool (1), developing technical and non-technical skills (2). The use of simulation for assessment, in an OSCE setting is a compensatory summative which is reliable and valid (3). In the Primary FRCA OSCE, candidate performance, in the simulator station, is marked out of 20 against a checklist, reflecting competence. Evidence shows that performance following simulation trainingimproves following reflective debriefing (4), leading us to investigate if pre exam simulation training with structured debriefing could improve scores in subsequent simulation sessions.

MethodsOver a period of 18 months, 40 anaesthetic trainees in SE Scotland attended a simulation training session, 4 weeks prior to the Primary FRCA exam, divided into groups of 5. In each group, individuals completed simulated scenarios in turn, whilst being observed by other candidates. Each candidate was awarded a mark out of 20 by 2 independent researchers, based on a checklist, followed by a structured reflective debriefing session. Marks were recorded in each group, and examined to see if scores improved as each session progressed.

ResultsIn total 40 candidates completed 40 scenarios. In scenario 1, the average score was 50%, which increased to 96% by scenario 3. The final scenario had an average mark of 98%. In analysing mark breakdown, candidates in scenario 1 performed a structured A to C approach to the critically unwell patient, in 20% of cases. Following a structured debrief, 83% of candidates performed a structured A-Cassessment from scenario 3 onwards. Analysing marks given for knowledge, candidates scored an average of 80% with no significant differences as scenarios progressed.

DiscussionOur results have shown that although candidate knowledge was consistently scored highly, approach to a critical incident improved markedly with simulation training and debriefing, reflected in the improvement of overall scores. We conclude that in order to prepare for a practical OSCE exam, simulation training with structured reflective debriefing is necessary for candidates to improve performance in future simulated critical incidents. Theory learned needs to be practiced in the setting in which it is going to be examined, in order for performance in the examination setting to be optimal.

References1. Ross AJ, Kodate N, Anderson JE, Thomas L, and Jaye P.

Review of simulation studies in anaesthesia journals, 2001–2010: mapping and content analysis. British Journal of Anaesthesia. 2012; 109(1): 99-109.

2. Riem N, Boet S, Bould MD, Tavares W, Naik V. Do technical skills correlate with non-technical skills in crisis resource management: a simulation study. British Journal of Anaesthesia. 2012; 109(5): 723-728.

3. Forrest FC, Taylor MA, Postlethwaite k, Aspinall R. Use of a high-fidelity simulator to develop testing of the technical performance of novice anaesthetists. British Journal of Anaesthesia. 2002;88:338-44.

4. Rudolph JW, Simon R, Raemer DB, Eppich WJ. Debriefing as formative assessment: closing performance gaps in medical education. Academic Emergency Medicine 2008,15:1010-1016.

Use of preoxygenation and recruitment manoeuvres during general anaesthesia: A survey of anaesthetic practice in the UK

D.L. Horner1 and A.B. Lumb1

1. St James’s University Hospital, Leeds, UKEmail: debbiehorner@doctors.org.uk

Few studies have addressed what constitutes ‘best care’ for the lungs during general anaesthesia (GA). Two strategies used as part of lung care during GA, preoxygenation and recruitment manoeuvres (RMs),are particularly controversial [1]. To further inform this debate we conducted a survey to gauge current use of these strategies.

MethodsWe surveyed UK anaesthetists using three hypothetical clinical cases:1, an ASA 1 patient having an elective hysterectomy, 2, an ASA 2 obese patient having an elective laparoscopic cholecystectomy and 3,an ASA 3 patient with lung disease having an emergency laparotomy.An email was sent to every UK anaesthetic department, providing alink to the survey for distribution to anaesthetists. The survey was conducted via Survey Monkey®, using Mail Chimp® software to distribute the emails and track the results of the mail contact.

ResultsA total of 253 departments were emailed, of which 119 (47%) cascaded the email to individual anaesthetists within their department. The email was opened a total of 3155 times and 740 useable responses returned. Table 1 shows the results of the preoxygenation questions.

Table 1. Face mask used and FIO2 on induction (% of respondents):Airway management: Case 1 Case 2 Case 3

No face maskLoosely applied maskTight fitting rebreathing mask

12.657.130.3

3.238.558.2

0.512.387.2

FIO2 before induction (%)10030-9921-29

78.013.38.8

85.912.31.8

89.79.80.5

The number of anaesthetists using RMs regularly during the case increased with the higher risk cases at five, 13 and 19% for cases 1, 2, and 3 respectively. Approximately two thirds used RMs when worried about the patient’s oxygen saturations. When using a RM, techniques varied widely with only 15% of anaesthetists using one of the two RMs proven to have a beneficial effect intra-operatively [2,3], the remainder selecting unproven manoeuvres fabricated for the survey.

DiscussionOur findings show widely differing approaches to the use of pre-oxygenation and RMs during GA. A third of anaesthetists formally preoxygenated case 1 with a tight fitting mask, which may be regarded as overly cautious, while a substantial minority did not fully preoxygenate case 3, which may be regarded as poor practice. RM use seemed appropriate except for the third of anesthetists who did notconsider a RM to be necessary in a hypoxic patient. Knowledge of the proven RM techniques was poor.

References1. Lumb AB. Just a little oxygen to breathe as you go off to sleep...

is it always a good idea? British Journal of Anaesthesia 2007; 99: 769-71.

2. Tusman G, Böhm SH, Vazquez de Anda GF, do Campo JL, Lachmann B. ‘Alveolar recruitment strategy’ improves arterial oxygenation during general anaesthesia. British Journal of Anaesthesia 1999; 82: 8–13.

3. Rothen HU, Sporre B, Engberg G, Wegenius G, Hedenstierna G. Re-expansion of atelectasis during general anaesthesia: A computed tomography study. British Journal of Anaesthesia1993; 71: 788–95.

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Text message reminder to prompt administration of pain relief after children’s day surgery – a proof of concept initiative.

L. Hulatt1, O. Hussain1, V. Allen1 and D. Mason1

1. Oxford University Hospitals NHS Trust, Oxford, UKlaurence.hulatt@doctors.org.uk

Could a text message help improve children’s pain after day surgery?Research and local audit has shown that although children experience significant pain after day surgery, many children receive very few doses of pain relief medication [1]. Short message service (SMS) text messages are used by the NHS for appointment reminders and have been used clinically for diabetes education [2]. There is no literature describing their use for pain relief reminders. This proof of concept initiative explored whether SMS text messaging could be a practical method of improving pain relief administration. The primary outcome was whether carers consider that receiving an SMS text acts as a useful reminder to administer pain relief medication to their children.

MethodsThe initiative was deemed not to be research by the Trust Research & Development Department and formal Ethics Committee approval was not required. Agreement to participate was gained from children’s carers. After discharge from the Day Ward, an NHS.net account was used to send an SMS text message to carers stating: “Don’t forget to give your child pain relief medicine regularly. For help or advice, call the Day Ward 01865234148”. On the first postoperative day, carers were telephoned and asked: whether they had received the message; whether it was a good time to receive the message; and whether themessage was a useful reminder to administer pain relief medication.Information relating to pain and analgesic dosing was also collected.

ResultsThirty-four messages were sent: the earliest at 18:39, the latest at 19:40pm (mean 4:14 hours post discharge). Two were delivered late (21:02 and 16:33 the following day) due to network issues - including the recipient’s phone being turned off or without network signal.Thirty-three (97%) carers could be contacted. All had received the reminder message. Thirty (91%) carers stated that the reminder was useful. Four (12%) carers did not think the message was received at a good time – two of these were the recipients of delayed messages. Carers expressed a preference for receiving the message in the evening, before their child’s bedtime.

DiscussionAs regards the primary outcome of this initiative, the majority of children’s carers (91%) considered that receipt of an SMS textmessage was a useful reminder to administer pain relief medication. It would be possible to create a secure, automated system to send this message. Further research should be undertaken to assess whether this improves administration of pain relief medication and children’s pain.

References1. Fortier M, MacLaren J, Martin S, Perret-Karimi D, Kain Z.

Pediatric pain after ambulatory surgery: where’s the medication? Pediatrics 2009; 124: e588-95.

2. Wangberg S, Arsand E, Andersson N. Diabetes education via mobile text messaging. Journal of Telemedicine and Telecare2006; 12: 55-6.

Anaesthesia and the environment: an audit of anaesthetic waste disposal in the operating theatre

C. Ivermee and T. Katawala

Kingston Hospital, London, UK.clareivermee@doctors.org.uk

The National Health Service (NHS) has a carbon footprint of 18 million tonnes of carbon dioxide per year [1]. As anaesthetists, we make significant contributions towards these emissions and the environmental burden of the NHS with extensive use of disposable equipment and single-use devices, medicines, volatile anaesthetic agents, heating and lighting. Approximately 2.3 tonnes of anaesthetic waste is produced annually per theatre [2]. The climate change act requires the NHS to cut carbon emissions by 26% by 2020 [3]. At present, carbon emissions are continuing to rise but appropriate disposal and recycling of anaesthetic waste is a cost effective step towards reducing our footprint.

MethodsA prospective audit of the waste produced by the anaesthetic team during 60 theatre sessions at Kingston hospital was performed. Standards used were the Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidelines on ‘Green Anaesthesia’ [2] and local guidelines for clinical waste disposal. Data was collected on the quantity of anaesthetic waste produced and method of disposal. The waste was segregated retrospectively to ensure compliance with the identified standards. The environmental impact and costs were then assessed.

ResultsAll anaesthetic waste was disposed of as clinical waste except on one occasion where a domestic waste bag was used. None of the anaesthetic waste produced in theatre was recycled. Forty-four large clinical waste bags were used in total. The median weight of waste per clinical waste bag was 1.5kg. The median weight of waste produced during a full day list (2 theatre sessions) was 2.25kg per theatre. This costs our hospital £1.03 to dispose of as clinical waste. Segregation of the waste retrospectively identified that 80% could have been disposed of as domestic waste or recycling, with only 20% of thewaste being appropriately disposed of as clinical waste. This would reduce the cost to less than £0.48 per theatre per day.

DiscussionFollowing education of anaesthetic and theatre staff, provision of easily accessible domestic waste and recycling facilities are being introduced in our main theatre complex, before re-auditing practice.Appropriate disposal of anaesthetic waste is simple and efficient, with potential for significant cost savings. In our hospital, clinical waste disposal costs £0.46/kg, compared with £0.15/kg for domestic waste and £0.05/kg if waste is recycled. Some hospitals are even paid for recycling. Implementing this change would cut costs by more than half, which equates to a saving of £750 a year in the main theatre complex. There is also the potential to make substantial savings in day surgery and obstetric theatres, as well as in the disposal of surgical theatre waste and sharps. More importantly, implementation of small changes like this in each department of every hospital will help the NHS reduce its carbon footprint in line with targets. It increases staff awareness of our environmental impact and highlights other areas where simple changes, for example turning unnecessary lights off and re-using equipment where appropriate, can be made.

References1. Sneyd J, Montgomery H, Pencheon D. The anaesthetist and the

environment. Anaesthesia. 2010; 65: 435–437.2. The Association of Anaesthetists of Great Britain and Ireland.

http://www.aagbi.org/about-us/environment/what-can-you-do-reduce-environmental-impact-anaesthesia (accessed 08/08/2012)

3. Climate Change Act (2008). London: HMSO, 2008.

The projected cost savings with the use of recycling bins on an ICU in the UKB Ivory1

1. Derriford Hospital, Plymouth, UKbenivory@doctors.net.uk

The NHS in the UK produces an average of 5.5kg of waste per patient per day, with a disposal cost of more than £37M [1,2] and the government has adopted a policy of increasing recycling rates in hospitals[3]. Derriford Hospital ICU started using receptacles for clinical and non-clinical waste in each bed space in 2009 but at present has no facilities for recycling waste from clinical areas, despite paper waste being removed from the hospital at no cost. Locally, clinical waste costs £294 per tonne to dispose of and domestic waste £76[4]. Previous work has examined the amount of recyclable waste in ICU, but not the cost implications[5].

MethodsThe waste produced from the bedspaces of all non-infective patients in the ICU was prospectively collected for one twelve hour daytime nursing shift. The waste was weighed, manually sorted into clinical, domestic non-recyclable and domestic recyclable (paper and card) and these subsets were re-weighed. According to local guidelines, any matter that had come into contact with the patient was classified as clinical waste. Bed occupancy data was used to extrapolate these data to give approximate annual costings.

ResultsWaste was collected from 7 bed spaces. A total of 25.25kg of clinical waste was collected (median per bedspace 3.8kg, IQR 2.13-4.43kg) and 4.69kg of non-clinical waste (median per bedspace 0.75kg, IQR 0.53-0.84kg). 2.5kg (10%) of the waste in clinical bins was domestic non-recyclable and 2.13kg (8.4%) was domestic recyclable. 1.9kg (53%) of domestic waste was recyclable. No clinical waste was found in the domestic waste stream. Extrapolating these data to yearly bed occupancy, optimal use of domestic waste bins and the addition of recycling bins could save this 26 bedded ICU £3950 (18%) per annum.

Discussion The use of domestic and recycling bins alongside clinical waste bins could significantly reduce disposal costs in the ICU. This study did not identify any contamination of the doemstic waste stream with clincal waste indicating that the addition of a recycling stream would be unlikely to pose a significant infection control risk.

References 1. Tudor TL, Marsh CK, Butler S, et al. Realising resource efficiency in the management of healthcare waste from the Cornwall National Health Service (NHS) in the UK. Waste Management 2008; 28: 1209–182.Waste - Department of Health - Management Resourceswww.dh.gov.uk/en/Managingyourorganisation/Estatesandfacilitiesmanagement/Sustainabledevelopment/DH_4119635 Accessed 10th January 20133.House of Commons Hansard Written Answers for 16 June 2008 (pt 0032). http://www.publications.parliament.uk/pa/cm200708/cmhansrd/cm080616/text/80616w0032.htm#08061641003213 Accessed 10th January 20134. Local data5.McGain F, Story D and Hendel S. An audit of intensive care unit recyclable waste. Anaesthesia 2009; Vol 64 (12): 1209-1302

Setting up a regional trainee committee and teaching programme in the Oxford Deanery.

Janes CSG1, Rowland M1, Shorthouse JR2 and Dyar OJ1

1Oxford University Hospitals NHS Trust, Oxford. 2Reading General Hospital, Reading. Email correspondence: carolinejanes@gmail.com

Post-fellowship teaching for trainee anaesthetists in the Oxford Deanery was previously hospital-based and inconsistent in quality and quantity. In August 2010, a small group of trainees set out to re-structure and centralise post-fellowship teaching with the support of the Deanery.

MethodsFirstly, a series of informal, open meetings were held to discuss theoverall structure and location of the teaching programme. A chairman and secretary were appointed and a name was chosen for the working group – Oxford Deanery Anaesthetic Trainees (OXDAT). The Head of School approved the format and agreed that trainees should be released from clinical duties for all teaching days (excluding out-of-hours work). Confirmation for the project to go ahead was received at the Deanery School Board meeting. This information was relayed to all anaesthetic departments within the region together with teaching dates for the upcoming year. A committee was officially nominated and elected during the first OXDAT teaching day. A committee meeting was to be held during each teaching day and minutes of the meeting were to be circulated to all trainees and members of the school board. Terms of reference were constructed and a graphic designer approached to produce a logo for administrative purposes. Abusiness plan was formulated and submitted to the Deanery and asmall sum of money was granted to provide refreshments and reimburse travel expenses for speakers.

ResultsSuccessful, monthly teaching days have now been taken place in the Oxford Deanery for the past two years. Teaching days follow the RCOA curriculum but also include topics such as NHS management, preparing to be a consultant, and out of programme experiences. Feedback on the teaching days has been consistently positive. Discussion of specific training issues during the committee meetings have led to significant improvements in the way training is delivered throughout the region. A buddy system has been set up to provide all newly-appointed specialty trainees with a senior trainee as a point of reference for informal advice and support and regular social events have taken place. All these implementations have helped build morale and camaraderie between trainees of different levels within the Deanery.

DiscussionWe present our experience of setting up OXDAT in order to assist trainees in Deaneries who would like to set up a similar programme and trainee committee. We have found OXDAT to be an invaluable addition to our training experience, not only in providing regular, quality post-fellowship teaching but also as a platform for trainees to voice training issues and in improving communication amongst each other.

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Implementation of Thromboelastography® Platelet Mapping™ to reduce cancellations in surgical patients on antiplatelet therapy.

R.Kasivisvanathan1, K. Mitchell2 and S. Mallett3

1,2,3Royal Free London NHS Foundation Trust, London, UK.correspondence:r.kasivisvanathan@nhs.net.

An Audit into last minute elective surgical cancellations at our centre between May 2005 and April 2008 showed that patients who were most likely to be cancelled were those who had inadvertently failed to stop antiplatelet therapy (APT). This was because of the perceived increased risk of perioperative bleeding they presented to the clinician. Perioperative bleeding in patients on APT has been shown to correlate with the extent of their platelet inhibition [1]. Thirty percent of patients taking APT have no platelet inhibition [2] suggesting not all these patients will be at increased risk of perioperative bleeding.Platelet function analysers measure platelet inhibition and raise the possibility of rapid risk stratification of perioperative bleeding in patients who fail to stop APT. They have the potential to reduce cancellations by predicting which patients do not present an increased risk of bleeding.

MethodsFollowing a quality improvement grant and ethics approval a service to measure platelet function using Thromboelastography® Platelet Mapping™ (TEG®PM™) (Haemoscope Corporation, Niles, IL, USA)was introduced in May 2008. All elective surgical patients who had inadvertently not stopped Aspirin and or Clopidogrel and where there were concerns that the potential for perioperative bleeding would lead to cancellation of surgery were referred to this service. Less then 30% platelet inhibition in patients on APT is associated with minimal bleeding [2] and this threshold was used to indicate safety to proceed to surgery. Re-audit of cancellations and transfusion requirementstook place after 3 years of service implementation.

ResultsThe implementation of TEG®PM™ resulted in a significant reduction in cancellations in patients from 85 patients (94% of total patients at risk of cancellation) between May 2005 and April 2008 to 12 patients(16% of total patients at risk of cancellation) between May 2008 to April 2011 (student’s t-test p = 0.03) There was no significantdifference in packed red blood cell, fresh frozen plasma and platelet(p= 0.65, p =0.54, p =0.43 t-tests) requirements between the patients who had surgery following TEG®PM and those of matched patients having the same surgical procedure not on APT or anticoagulation.

DiscussionMeasuring platelet function presents clinicians with a useful tool in reducing last minute cancellations in patients who have inadvertently failed to stop APT. This service met the standards set out by the Department of Health’s recommendations in ‘Tackling Last Minute Cancellations’ resulting in improved patient satisfaction, reduced wasted theatre time and allowing clinicians to make more informed decisions about patient care. The fact there was no difference in transfusion requirements in patients who had surgery followingmeasurement of platelet function suggests TEG®PM™ and a thresholdof 30% platelet inhibition are valid in predicting the patients taking APT who do not present an increased risk of perioperative bleeding.

References1.Chen L, Bracey AW, Radovancevic R et al. Clopidogrel and bleeding in patients undergoing elective coronary artery bypass grafting. Journal of Thoracic Cardiovascular Surgery. 2004 September;128(3):425–31.

2.Ferreiro JL, Angiolillo DJ. Clopidogrel response variability: current status and future directions. Thrombosis Haemostasis. 2009 July;102(1):7–14.

Safety cannulas - one cannula to rule them all?R.Khirwadkar 1 , A. Bhalla 2 ,C. Dragomir 3, C. Chevanesse4

Liverpool Women’s Hospital, Liverpool UKrashmikhirwadkar@aol.com

The European Union Directive [1] recognises that the work of healthcare staff puts them at risk of serious infections, with exposure to more than 30 potentially dangerous pathogens. Needle stick injuries are a serious occupational hazard with an estimated one million needle stick injuries occurring in the European Union each year. Emotional impact of sharps injury can be severe and even when a seriousinfection is not transmitted. Healthcare workers and their families can suffer many months of anguish as they wait to discover whether theyhave contracted a potentially fatal infection. We evaluated safety cannulas from five companies in our Trust, in order to implement the change and be fully compliant with EU guidelines.

MethodsA survey questionnaire was devised to evaluate these safety cannulas. Each company was given a two week trial and each user was asked to complete an evaluation form which covered a wide range of assessment criteria such as the ease of insertion, reliability, potential benefits such as reduced incidence of needle stick injury, any difficulties experienced during insertion and overall rating.

Results185 members of staff (anaesthetists, nurses, midwives and doctors) completed the questionnaire for each trial. Two out of five safety devices trialled had an immediate accepantance from the majority of staff members in terms of patient and staff benefits. One device evaluated poorly from the start of trial, ironically causing sharp injury to a staff member. The remaining two devices were moderately rated and did not offer any additional benefits. Full results pending.

DiscussionOur survey has reinforced EU recommendations. The introduction of these safety cannulas will benefit our Trust in many ways. It will eliminate to a great extent incidence of needle stick injury and promote safe sharps disposal practice. This in turn will reduce occupational health referrals, the subsequent expense associated with it thus resulting in positive patient care outcome.

References1. European Biosafety Network Prevention of Sharps Injuries in the Hospital and Healthcare Sector Implementation Guidance for the EU Framework Agreement, Council Directive and Associated National Legislation. 2010.

‘A pain in the neck’: establishing a safe system for changing tracheostomy tubes in hospitalised patients.

M. Kigozi, S. Espirit, T. Moorthy, C. Bradley, L. Clarke, R.Yorke, J.Dunne, C. Holland and S. Uddin

Kings College Hospital NHS Foundation Trust, London, UK,.mkigozi@nhs.net

The National Tracheostomy Safety Project[1] has highlighted ways healthcare professionals can improve the care and safety of ‘neck breathers’[1,2]. This is particularly relevant when changing tracheostomy tubes(TT), a predictable ‘high risk’ time during tracheostomy care[2,3].In light of this, we report on a multidisciplinary analysis on the system of TT change in our institution and on the changes that have been instituted to address issues relating to patient care.

MethodsRetrospective analysis of discharged intensive care unit (ICU) patients referred to the duty ICU registrar for TT change whilst on the general ward was carried out. Only patients who had a tracheostomy performed (surgical or percutaneous) as part of their ICU stay were included. Data collected included:a) Indication for changeb) Referring practitionerc) Reasons for delaysd) Available equipment (using ICS guidelines as a standard[3])

ResultsFifteen changes were indicated as the TT had been indwelling for 30 days or more. 13 referrals (87%) were received from physiotherapists and the majority of these (80%) were made on or after day 30 (i.e on the day the change was required).Thirteen patients (87%) experienced a delay of 6 ± 5 days (mean ± SD) between referral and TT change. The commonest reasons for delay were:i) Patient not starved (46%)ii) Unpredictable workload of duty registrar (38%)iii) Registrar called away to an emergency (16%)Survey of the ICU doctors (n=10) revealed varying experience with tracheostomy management. Survey of the wards revealed that available equipment was poorly compliant with recommended standards [3].

DiscussionThe following measures have been instigated in response to this• A referral pathway with advance identification of patients by the

weekly physiotherapy-led tracheostomy ward round • An electronic referral form • A ward checklist, that includes nil by mouth policy• A TT change guideline to standardise registrar practice• A nominated registrar (not on duty) to undertake the procedure in

coordination with the ward staff• A portable ‘tracheostomy bag’ to include routine and emergency

equipment and drugs. This will be stored on ICU and maintained by the ICU technicians and doctors.

A re-audit to review the impact of these changes is in progress.References1. National Tracheostomy Safety project. www.tracheostomy.org.uk.

Accessed October 2012.2. Protecting patients who are neck breathers. National Patient Safety

Agency, March 2005. http://www.nrls.npsa.nhs.uk/resources. (Accessed October 2012)

3. Intensive Care Society (2008) Standards for the care of adult patients with a temporary tracheostomy

Shared Mental Models, Team Expertise and Patient Safety in Anaesthesia

N. Lau1, S. Malhotra2, M. Burtscher3 and N. Sevdalis4

1-Lister Hospital, Stevenage, UK, 2-Imperial College Healthcare Trust, London, UK, 3-Department of Social and Economic Psychology, University of Zurich, Switzerland and 4-Department of Surgery and Cancer, Imperial College London, UK

Correspondance: norlan.lau@gmail.com

The ‘shared mental model’ (SMM), defined as knowledge that team-members share about each others’ roles [1], has been postulated to describe effective team working within high risk industries. Building on work previously done under simulated environments [2], the aim of this study was to explore the feasibility of assessing SMMs within anaesthetic teams under real time in theatres.

MethodsParticipating teams comprised an anaesthetist and an anaesthetic nurse/technician. Data was collected at the beginning and end of the first case of the day. SMM was assessed using a previously validated nine-item self-report scale. Patient safety was assessed via self-reporting of “non-routine events” (NREs) – including excessive stress levels, equipment problems or miscommunications. All data was submitted to descriptive and correlational analyses.

Results51 teams were assessed (52% anaesthetists; 48% anaesthetic nurses/technicians); age range 27-62 years, experience in specialty 0.5-42 years. 39 NREs were reported (37% of participants) –including airway problems (n=12), team problems (n=12), equipment issues(n=11). Senior anaesthetists were more likely than juniors to report a NRE (p<0.05). Assessment of SMM was reliable (Cronbach alpha=0.93). Teams who had worked together longer had better SMMs. No relationship was obtained between the quality of the SMM and NREs.

DiscussionSMMs in the anaesthetic environment can be reliably assessed. Teams with experience of working together showed better understanding of each other’s roles. In our data, however, this was not directly related to patient safety assessed via NREs. These findings should be replicated with larger samples, as they carry implications in light of increased team instability (with shiftworking) and medical emergencies where anaesthesia teams are often ad hoc.

References1. Team mental models and their potential to improve teamwork and safety: A review and implications for future research in healthcare. Safety Science 50 (2012) 1344–1354. M Burtscher, T Manser

2. Interactions of Team Mental Models and Monitoring Behaviors Predict Team Performance in Simulated Anesthesia Inductions. Journal of Experimental Psychology: Applied © 2011 American Psychological Association 2011, Vol. 17, No. 3, 257–269. M Burtscher, M Kolbe, J Wacker, T Manser

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Total knee arthroplasty: local infiltration of anaesthetic versus other methods of analgesia

S. Liddle and V. Annam

Colchester University Hospital, Colchester, UKEmail: sliddle@doctors.org.uk

There is an increasing focus on reducing recovery times and improving outcomes in major joint surgery in the UK by using Enhanced Recovery programs, similar to more established practice in other specialties[1, 2]. Analgesia is an important part of this, and we noticed an increasing incidence of local anaesthetic infiltration for total knee arthroplasty at our institution. This is low concentration, high volume local anaesthetic injected into and around the knee joint towards the end of surgery. There is evidence that this technique may be superior to other forms of analgesia, in particular reducing time to mobilisation and time to discharge[1, 2]. We wanted to know if this was true for our patients.

MethodsWe performed a retrospective case note review for any patient who had a total knee arthroplasty in 2011. We recorded data on demographics, dates of surgery and discharge, anaesthetic technique, details of block (if any), post operative analgesia, duration and dose of patient controlled analgesia, pain and nausea and vomiting scores on days one, two and three, time of first attempt at mobilisation, any reason for failure, time to first successful mobilisation, and time to medical fitness for discharge.

ResultsWe examined 106 sets of notes out of 460 total knee arthroplasties in 2011. Thirty three (31%) had local infiltration of anaesthetic (LIA). The remaining 73 (69%) had either general or spinal anaesthetic with or without a nerve block. The non-LIA and LIA groups were similar with regards age, ASA and BMI. Mean length of stay was 4 days overall, with no difference between groups. They also had similar times to first attempted mobilisation. Mean (SD) time to first successful mobilisation was 30 (12.8) hours for the LIA group and 38.5 (19.3) hours for the non-LIA group (p-value 0.04). Duration of PCA morphine was also less at 44 (12.5) hours for the LIA group and 58 (20) for the non-LIA group (p-value 0.002). Zero patients in the LIA group had severe pain on day 1, compared to 13 (17%) in the non-LIA group, however mean pain scores were similar.

DiscussionThis audit highlighted the wide variation in anaesthetic and surgical practise for total knee arthroplasty at our institution in 2011. We have shown that patients who received LIA mobilised quicker and had less severe pain on day one. They also used less morphine post operatively. Analgesia is only one part of reducing recovery time and since collecting this data we have implemented guidelines. These advise spinal anaesthetic without opioid, pre and post-operative gabapentin, LIA, oral analgesia (rather than patient controlled analgesia), aggressive early physiotherapy, and many other recommendations. Early data suggest a trend towards much faster mobilisation (often on the day of surgery) and even faster time to discharge of around 3 days.

References1. Ian Starks, Tom Wainwright and Robert Middleton. Local

anaesthetic infiltration in joint replacement surgery: what is its role in enhanced recovery? International Scholarly Research Network Anesthesiology 2011; doi:10.5402/2011/742927

2. Ajay Malviya, Kate Martin, Ian Harper, Scott D Muller, Kevin P Emmerson, Paul F Partington and Mike R Reed. Local infiltration analgesia in joint replacement: the evidence and recommendations for clinical practice. Acta Anaesthesiologica Scandinavica 2011; 55: 778-784

Audit of anaesthetic volatile use at a large tertiary referral centrein Northern England

S. Lobaz, M. Hamilton and A. SweenieRoyal Victoria Infirmary (RVI), Newcastle upon Tyne, UK.Email correspondence: Stevelobaz@doctors.org.uk

During these times of economic hardship, every NHS department has a role to play in reducing costs, and anaesthesia is no exception. Paying meticulous attention to volatile use, type and fresh gas flow (FGF) rates can have a significant impact on reducing budget andenvironmental costs1. We conducted an audit at a tertiary referral hospital in the North of England to assess both actual and perceived anaesthetic volatile usage, appropriateness of desflurane use and whether anaesthetic chart documentation was complete.

MethodsPart One (actual volatile use): Anaesthetic chart documentation was assessed in four post-operative recovery areas. Information collected included: case demographics, documented volatile (isoflurane, sevoflurane, desflurane), FGF rates and duration of operation. Using the formulae proposed by Dion2, anaesthetic volatile cost per case was estimated. Part Two (perceived use): a survey was undertaken to assess each anaesthetist’s perceptions regarding their volatile practice and chart documentation.

ResultsFour hundred and twenty one anaesthetic cases were assessed over an eighteen day period in June 2012. Three hundred and twenty seven(78%) cases were reported as consultant led with the remaining casesdelivered solely by trainees. Induction and maintenance volatile was recorded in 358 (85%) and 381 (91%) of cases, respectively. FGF was documented in only half of the cases, with 224 (53%) caseshaving complete documentation for cost analysis. An estimated minimum total volatile cost for 224 cases was £600: isoflurane 1% (151 cases) £26.68; desflurane 6% (25 cases) £373.57; sevoflurane 2% (48 cases) £196.67. Compliance with formulary indications for desflurane was met in 14 (56%) of desflurane cases. The remaining 11 cases using desflurane 6% are estimated to have cost £173.79. Acost saving of £169.81 could have been made if isoflurane had been used instead. £134.37 could have been saved if desflurane 12% was used at a low FGF of approximately 0.2 l/min. A survey of 23 anaesthetists’ perceived practice estimated a mean maintenance FGF of 0.76 l/min. Isoflurane was preferred in most cases, with sevoflurane being predominantly used for gas induction and paediatric practice. Fourteen anaesthetists (60%) reported “never” or “sometimes” considering FGF rates during induction, with 21 (91%) considering FGF “mostly” during volatile maintenance. FGF rates were only regularly recorded by 17 (75%) of those surveyed.

DiscussionOverall documentation of volatile use, including FGF rates, has the potential to be improved. Attention to appropriate volatile type is paramount. Despite indications for desflurane being well known, 44% of the desflurane cases could have been performed using isofluranewith a 97% cost reduction. Increased compliance with desflurane formulary indications is needed. Mean perceived FGF rate was 0.76 l/min. Significant cost savings could be made if further reductions in FGF rate are undertaken. Re-audit is planned after recommendations using the more accurate Volatile Ratio technique3. There are no formulary indications for sevoflurane in our trust, and we plan to work with our pharmacy and anaesthetic department to develop guidance.

References1. Nunn, G. Low-flow anaesthesia. Continuing Education in

Anaesthesia, Critical Care & Pain 2008;8(1):1-4.2. Dion, A. The cost of anaesthetic vapours. Canadian Journal of

Anaesthesia 1992;39(6):633.3. www.draeger.com/media/50/00/24/50002458/how_low_can_yo

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Have lessons been learnt? An audit of difficult airway planning and experience in anaesthetists.

J. Longbottom1 and S. Varshney2

Royal Manchester Children’s Hospital, Manchester, UK1 and North Manchester General Hosptial, Manchester, UK2

jesslongbottom@doctors.org.uk

Major airway complications are rare, estimated at 1 in 10,000 [1], yet each incident has the potential to have a significant patient impact. The recent 4th national audit project (NAP4) identified 184 major airway complications which contributed to 56 deaths and non-recoverable injuries [1]. Closed claims data from the US has suggested that up to 90% of these incidents are preventable[2]. The failure to act on anticipated difficulties, absence of prior planning, limited airway skills and equipment and human factors have all been suggested as avoidable contributory factors by NAP4 [1].

MethodsA paper survey of 21 anaesthetists of all grades was conducted to evaluate clinical experience and familiarity (self assessed, 0-10/10) with the use of difficult airway devices and adjuncts, to assess difficult airway planning using four scenarios including ‘can’t intubate, can’t ventilate’ (CICV), and to identify any need for further training.

ResultsSeven (33%) trainee, two (10%) non-consultant grade and twelve(57%) consultant anaesthetists completed the survey of which 17 (81%) had completed a formal airway module. All participants had experience using rigid indirect laryngoscopes (RILs) in patients and scored the familiarity with one or more of the various RILs as at least 7/10. Eighty-six percent of participants had experience of second generation supraglottic airway devices in patients and the mean familiarity score was 6.8/10 (SD 2.6). All had experience in flexible fibreoptic laryngoscopy and the mean familiarity score was very high at 8.9/10 (SD 1.5). Only 43% of participants had clinical experience in cricothyroid airway placement in patients and the mean familiaritywas only 4.4/10 (SD 3.3). Of the four difficult airway scenarios, 21%of proposed plans did not include a back-up plan in event of failure. In the proposed CICV scenario, 20 participants (95%) had a cricothyroid or transtracheal airway as their plan A and all included this within plans A to C. However, only three (14%), suggested a surgical cricothyroidotomy. Seventy-six percent requested further training.

DiscussionThe management of difficult airways is an essential skill for all anaesthetists. Despite the lessons and recommendations of NAP4, the same issues repeatedly feature. Preparation for failure is highlighted as one of the key components of preventing avoidable complications. Yet in 21% of cases this has not taken place. After poor judgement, education and training is the second most contributory factor towards adverse airway events [1]. Following training, emergency airway skills are retained for just six-nine months [1]. The vast majority of the participants agreed they would benefit from further training. Ofparticular note, both clinical experience and confidence in performingemergency cricothyroidotomy was poor and there was still areluctance to perform surgical cricothyroidotomies. This is in spite the high failure rate of needle cricothyroidotomies (approximately 60%[1]). We have introduced a regular emergency airway training scheme and the inclusion of airway plans into anaesthetic documentation. A resurvey will be conducted after twelve months.

References1. Cook T, Woodall N, Frerk C. Major complications of airway

management in the UK. 4th National Audit Project of the RCoA and DAS. March 2011.

2. Popat M. The unanticipated difficult airway: The ‘can’t intubate, can’t ventilate’ scenario. AAGBI Core Topics in Anaesthesia.2012; 44-55

Aseptic precautions in paediatric caudal anaesthesia

A. Maddock1, P. Jefferson2 and D.R. Ball3

1 Forth Valley Royal Hospital, Larbert, UK, 2 Warwick Hospital, Warwick, UK,3 Dumfries & Galloway Royal Infirmary, Dumfries, UKalistair.maddock@nhs.net

Despite national guidelines [1] recommending maximal barrier precautions in caudal epidural blockade, our experience and previous studies [2] suggest that these are not universally performed.

MethodsWe performed an online survey (SurveyMonkey.com) of members of the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI). We enquired about anaesthetists’ usual aseptic precautions, including skin preparation, in caudal injections and caudal catheterisation. We investigated asepsis in adult caudals and inimmunocompromised children, and the wearing and removal of rings.

ResultsOne thousand and twenty-four members of the APAGBI were invited to respond. There were 452 responses (response rate 44.1%); 422 (41.2%) were suitable for inclusion. All 422 included respondents performed single-shot caudal injections; 158 inserted caudal catheters.

Table Aseptic precautions used by respondents in caudal procedures

Precaution Single shot injection CatheterSterile gloves 393 (93.1%) 157 (99.4%)Surgical scrub 192 (45.5%) 148 (93.7%)Sterile gown 32 (7.6%) 142 (89.9%)Surgical cap 244 (57.8%) 141 (89.2%)Surgical mask 127 (30.1%) 133 (84.2%)Sterile drape 188 (44.6%) 142 (89.9%)Full compliance with the Association of Anaesthetists of Great Britain and Ireland (AAGBI) Infection Control in Anaesthesia Guideline [1]was reported by 23 (5.5%) respondents for single shot caudals, and 101 (63.9%) for caudal catheters. For skin preparation 255 (48.6%) used 0.5% chlorhexidine, 180 (42.7%) used 2% chlorhexidine and 36 (8.5%) used povidone-iodine. Two hundred and forty-four respondents normally wore a ring to work. Thirty-six (14.8%) routinely removed their ring prior to undertaking a caudal procedure.

DiscussionIn a survey carried out prior to the publication of the AAGBI Guideline [1], Menzies et al [2] found that 10% and 92% of respondents used “a full aseptic technique” (defined in the survey as sterile gloves, mask and gown) for single shot and catheter techniques respectively. Our data suggest that compliance with the AAGBI Guideline is poor, and there seems to be a divergence of opinion about the level of aseptic precautions required for caudal procedures. This may be because the incidence of complications is low: there were no cases of epidural abscess after caudal anaesthesia reported in one year to a national UK survey [3], despite an estimated 18,050 procedures. The degree of aseptic precautions recommended in the AAGBI Guideline [1] may not be required for paediatric caudal anaesthesia.

References1. Gemmell L, Birks R, Radford P, Jeffries D, Ridgway G, McIvor

D. Infection Control in Anaesthesia. Anaesthesia 2008; 63:1027-36.

2. Menzies R, Congreve K, Herodes V, Berg S, Mason DG. A survey of paediatric caudal extradural anesthesia practice. Pediatric Anesthesia 2009; 19: 829-36.

3. Cook TM, Counsell D, Wildsmith JAW. Major complications of central neuraxial block: report on the Third National Audit of The Royal College of Anaesthetists. British Journal ofAnaesthesia 2009; 102:179-90.

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End-of-life care in four adult intensive care units in the Oxford University Hospitals Trust.N. Makris1, T Kauhanen1 and W. Seligman1

1John Radcliffe Hospital, Oxford, UK.nikosvmakris@hotmail.com

A significant proportion of patients admitted to Intensive Care Units with critical illnesses do not survive them. Around 70% of deaths on ICU usually follows recognition of the dying process and withdrawal of active care.1 It as is important that the physical and emotional needs of the dying patient and their relatives are attended to as those of the critically ill that are expected to survive.MethodsWe aimed to evaluate the quality of end of life care across the four adult Intensive Care Units (ICUs) within the Oxford University Hospitals NHS Trust. Using quality indicators from the Liverpool Care Pathway, we prospectively audited all deaths in the John Radcliffe Adult ICU, the Churchill Hospital ICU (both mixed medical and surgical units), the Neurosurgical ICU and the Cardiothoracic ICU. All expected deaths in the 4 month study period were included in the analysis. In addition to documentation of communication, patient care and daily assessments, the method of withdrawal of care was recorded. Statistical analysis of categorical data was performed using the Chi square test, using a P value of 0.05 as significant.ResultsIn the 4 month period from August to December 2012, there were a total of 52 deaths. Of these, nine (17%) were unexpected and excluded from further analysis.The median age was 66 years [IQR 52-74years], 29 patients (69%) were male and the median length of stay on the ICU was 3 days [IQR 1-8days]. Median time from documentation of withdrawal of active treatment to death was 2 hours [IQR 1-5 hours].The withdrawal plan was discussed with the patient in 2 cases (5%) and with relatives of the patient in 40 cases (93%).Ventilation was weaned in 20 patients (40% of ventilated patients), the patient extubated in 13 (42% of intubated patients) and inotropes discontinued in 17 (77% of patients on inotropic support.) There were no significant differences between withdrawal practices across the ICUs.DiscussionDocumentation of the plan for withdrawal of active treatment and the plan for the mode of withdrawal were for the most part clearly documented. Similarly, prescription of “comfort” medications and documentation of resuscitation status were well attended to.We were surprised to find that, once a decision to withdraw active treatment was made, the time to death was a matter of a few hours. This reflects the severity of the underlying physiological derangement that has led to the decision to withdraw active care in most cases.The Liverpool Care Pathway (for Hospital Intensive Care Units)2 is divided into sections detailing initial assessment, ongoing daily assessment and verification of death. It is our conclusion that improvements in planning and documenting the withdrawal of active treatment could be made by the introduction of a checklist for the dying patient which would encourage the treating team to consider the physical, emotional and spiritual aspects of the patients’ care.However, since the period of time from withdrawal to death was in the majority of cases less than one nursing shift, our findings do not support the need for ongoing daily assessment of these needs.

References1. Winter B, Cohen S. ABC of Intensive Care; Withdrawal of

treatment. British Medical Journal. 1999. Vol 319 pp306-308. 2. Intensive Care Units and the Liverpool Care Pathway for the

Dying Patient Version 12, 2011. Marie Curie Palliative Care Institute Liverpool.

Cost-effectiveness of regional anaesthesia: An audit of money saved with a new ultrasound machine

J. Mathers1, D. Patel1, A. Hayward1

1. Royal Free Hospital, London, UKjonathanmathers@me.com

Modern ultrasound technology has led to increased block efficacy and performance with reduced early complication rates [1]. However, new ultrasound machines can cost up to £30,000. We undertook an audit of usage of a new ultrasound machine purchased in our department and aimed to see how much money had been saved by it’s use based upon costs saved by avoiding a general anaesthetic [2, 3].

MethodsAll blocks performed using the new ultrasound machine were recorded prospectively in a written record that was attached to the machine. After 40 weeks, from March 2012 to January 2013, the log was analysed and only those cases where regional anaesthesia alone was the primary anaesthetic were included. Cost savings were calculated using the estimated cost saving versus general anaesthesia as £7.34 [2] for disposables alone and £695.94 [3] when factoring in reduced need for admissions, general anaesthestic complications and increased theatres throughput from regional anaesthetic techniques.

ResultsDuring the 40 weeks 193 cases of regional anaesthesia only surgery were identified. Table 1. Case mix of regional anaesthetic blocks

Specialty Number Block Type NumberPlastics 125 Axillary 95Orthopaedics 57 Interscalene 60Renal 10 Supraclavicular 36

Vascular 1Superficial Cervical Plexus 1Ulnar 1

Total 193 Total 193This led to cost savings of between £1,417 to £134,145 during the 40 weeks or £1,771 to £167,681 for a year (assuming a 50 week working year).

DiscussionThe benefits of regional anaesthesia – swift discharge, optimal analgesia – are offset by capital costs. Our audit shows that even with the most conservative estimations that a single ultrasound machine can save £1,771 per year. However, once the additional factors of time saved and early discharge are accounted the savings can be much higher - up to £167,681 per year.

References1. Abrahams M, Aziz M, Fu R, Horn J. Ultrasound guidance

compared with electrical neurostimulation for peripheral block: a systematic review and meta-analysis of randomized controlled trials. British Journal of Anaesthesia 2009; 102: 408-417

2. Gonano C, Kettner S, Ernstbrunner M, Schebesta K, Chiari A, Marhofer P. Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery. British Journal of Anaesthesia2009; 103: 428-433

3. Horn J, Swide C, Gaebel B, Cross Jr R. Comparison of efficiency, recovery profile and perioperative costs of regional anaesthesia vs. general anaesthesia for outpatient upper extremity surgery. European Journal of Anaesthesiology 2007; 24: 557-559

Audit of preoperative fasting times for elective caesarean section: Are we compliant with new guidelines?

V Nalawade1, RCC Thompson2

1 James Cook University Hospital, Middlesbrough, UK2 James Cook University Hospital, Middlesbrough, UKvaishalinalawade2003@yahoo.co.in

Appropriate preoperative fasting reduces the risk of lung damage from regurgitation/aspiration. However, prolonged fasting has a number of detrimental effects. The catabolic response to prolonged fasting includes increased insulin resistance, increased stress response to surgery and delayed wound healing. Dehydration exaggerates the hypotensive response to anaesthesia. Prolonged fasting is distressing to patients and leads to headache, hunger, thirst, nausea and increased anxiety levels. This is especially true in obstetric population. Focus in preoperative fasting has shifted to encourage oral intake for as long as possible so that the minimal fasting times are achieved. The aim of this audit was to establish if our local practice was compliant with recently published international guidelines on the preoperative fasting for women undergoing elective caesarean section.[1]

MethodsThis audit was registered with and approved by the hospital audit committee. Data was collected prospectively from 50 patients between March 2012 and May 2012 by the anaesthetist or anaesthetic nurse from patients scheduled for elective caesarean section immediately prior to commencing anaesthesia using a standard questionnaire.

ResultsOur audit demonstrated an average (mean) fasting time for solids of 15 hours (audit standard 6 - 10 hours) and for clear fluids the average was 13.6 hours (audit standard 2- 4 hours). The average thirst score was 6.6 (scale 1-10). Seventy six percentage (76%) of patients would have liked to drink clear fluids on the morning of surgery.

Figure: Fasting time (hours) for solids and clear fluids

DiscussionThis audit identified an area for improvement in our practice by demonstrating that many of our patients were excessively fasted compared to our audit standards. This is both clinically unnecessary and has a negative impact on patient experience. After local presentation of audit results, a new preoperative fasting policy for elective caesarean section has been designed and implemented. This includes guidance for clear fluid intake up to two hours preoperatively. The new guidance has been incorporated into patient information leaflets and the changes have been highlighted to midwifery, healthcare, obstetric and anaesthetic staff. We intend to re -audit in March 2013, to identify whether reduced fasting time have been achieved by these changes and whether this has positively impacted on patient experience.

References1. Ian Smith, Peter Kranke, Isabelle Murat, et al. Perioperative fastingin adults and children: guidelines from the European Society ofAnaesthesiology. Euro J Anaesthesiology. 2011 Aug; 28(8):556-69

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Prospective caesarean section GA audit: Are we compliant with revised RCOA standards?

V Nalawade1, U Misra2 and Z Arfeen3

1 Sunderland Royal Hospital, Sunderland, UK, 2 Sunderland Royal Hospital, Sunderland, UK, 3 Sunderland Royal Hospital, Sunderland,UK,vaishalinalawade2003@yahoo.co.in

The reports of the confidential enquiry into maternal deaths in the U.K. clearly demonstrate that direct deaths related to anaesthesia are usually attributable to emergency general anaesthesia (GA).[1]

Regional anaesthesia (RA) for caesarean section (CS) has a considerable chance of failing especially when performed under stressful conditions of an emergency CS particularly a category 1. The RCOA has recently revised the recommended standards for percentage of caesarean sections carried out under RA and those requiring RA to GA conversion separately for category 1, 1-3 and 4 CS.[2] The aim of our on-going prospective audit is to see if we are compliant with the revised RCOA audit standards.

MethodsAfter gaining approval from the hospital audit committee data was prospectively collected over two years [Jan2011-Dec2012]. This included CS category, grade of anaesthetists, indication for primary GA and details of epidural in-situ which included top up started in room or theatre, top up drugs used, use of a single shot spinal (SSS), height of block with testing modality and timing of GA (before or after delivery).

ResultsThere were 1511 caesarean sections during above two year period. The following table shows the comparison of RA CS rates and RA to GA conversion rates at our hospital against proposed standards(Std.) by RCOA. CS Category Cat 1

Our percentage(RCOA std.)*

Cat 1-3Our percentage(RCOA Std.)*

Cat 4Our percentage(RCOA Std.)*

CS carried outunder RA

74.4%( > 50% )*

87.9%( > 85% )*

99.1%( > 95% )*

RA to GA conversion 9.5%( < 15% )*

4.9%( < 5% )*

0.4%( < 1% )*

The most common reasons for GA were urgency of CS due to fetal compromise followed by sepsis, APH, low platelets and maternal request. Seventeen (34.7%) failed spinal and 32 (65.3%) failed epidural top-up contributed towards RA to GA conversion. The reasons for conversion to GA were: insufficient analgesia intra-operatively (n=27), insufficient time to top-up the existing epidural (n=6), inadequate block height (n=6) and failed spinal due to technical difficulty (n=10). Other contributory factors were not topping up epidural in room leading to insufficient time for top up to work and failure to identify non working epidurals beforehand.

DiscussionThis prospective audit demonstrates that our GA CS rate and RA to GA conversion rates are compliant with standards proposed by the RCOA in 2012. Strategies to further reduce the RA to GA conversion may include early recognition of inadequate labour epidural analgesia, starting top-ups in labour room and reliable assessment of adequacy of block height.

References1.. Lewis G, ed., CEMACH. Saving Mothers’ Lives: Reviewing Maternal Deaths to make Motherhood Safer—2003–2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in theUnited Kingdom. London: CEMACH; 2007. p. 107–11.2.. Purva M, Russell IF Caesarean section anaesthesia: technique andfailure rate, Chapter8.8. Raising the srandards: A Compendium ofAudit Recipes. 3rd ed. RCOA; 2012. p. 220-221.

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Anti-convulsant use in traumatic brain injury (TBI).

G. Nickols1, D. Janssen1 and A. Manara1.

Frenchay Hospital, Bristol, UK.gemmanickols@doctors.org.uk

Early (<1 week) post traumatic seizures (PTS) are common after TBIand can lead to secondary neuronal injury through increased cerebral metabolic rate, excitatory neurotransmitter release and raised intracranial pressure. Current guidelines recommend anticonvulsants to prevent early PTS after severe TBI [1]. Anticonvulsants have not been shown to be effective in preventing late (>1 week) PTS, so prophylaxis beyond one week is not recommended. As PTS is not associated with worse outcome after TBI, there is an argument that potential benefit of prophylactic anticonvulsants may be outweighed by side effects. There is considerable variation in practice: some authors have stated that prophylactic anticonvulsants should be used only in certain high-risk groups [2], whilst others advocate anticonvulsant use only after documented clinical or EEG evidence of seizure activity [3]. We set out to describe current practice in anticonvulsant prophylaxis after TBI by conducting a survey of Neurocritical Units to ascertain unit policy and practice in the UK.

Methods.A ten question survey created on Survey Monkey® was emailed onceto the lead intensivist for each hospital in the UK with an adultneurocritical service managing patients with TBI. Responses, which were anonymous, were collected through Survey Monkey®’s website.

Results.The survey was emailed to 32 consultant intensivists representing theadult neurosurgical centres in the UK. There were 24 responses (75%). Of these, nine (37.5%) were dedicated neurocritical care units and 15 (62.5%) mixed units. Of the respondents, nine (37.5%) only answered the first question (type of unit) and omitted the remaining nine questions. A further one survey had answers for the first seven questions only. Fourteen (58%) were fully completed. The number of patients admitted with TBI per annum was between 10 and 500. All units had a policy for the management of TBI and in 12 of these it addressed the use of anticonvulsants. Two out of 15 units gave prophylactic anticonvulsants to all patients with TBI. In the remainder the use was limited to patients having one or more seizures, case by case decision, penetrating head wound or low GCS. The agent of choice was phenytoin for all units. The range of duration for prophylactic anticonvulsants was one to four weeks and for use after seizure activity from two weeks to 12 months. Seven out of 14 units used EEG monitoring to exclude fitting, with two units using it for barbiturate coma and a further two units using it routinely.

Discussion.The anticonvulsant agent of choice in 100% of cases was phenytoin. The variability in prophylactic or targeted use and the wide variety of duration shows that there is no current consensus on anticonvulsant prescribing in TBI in the UK.

References.1. Brain Trauma Foundation, American Association of Neurological Surgeon, Congress of Neurological Surgeons et al. Guidelines for the management of severe traumatic brain injury: XIII Antiseizure prophylaxis. Journal of Neurotrauma 2007; 24 (Suppl 1): 83-6.2. Temkin NR. Risk factors for posttraumatic seizures in adults. Epilepsia 2003; 44(Suppl 10): 18-203. Helmy A, Vizcaychipi M, Gupta AK. Traumatic brain injury: intensive care management. British Journal of Anaesthesia 2007; 99 (1): 32-42

Elective asleep fibreoptic intubation for teaching. A retrospective analysis of 136 cases.

C. Oscier, T. Pepall, P. Sidebottom

Frimley Park Hospital, Camberley, UKChrisoscier@gmail.com

Fibreoptic intubation is an essential skill for anaesthetists. Learning the technique, however, is often difficult for trainees. It is performed relatively infrequently in the majority of UK hospitals, and cases where fibreoptic intubation is indicated maybe technically challenging and not always appropriate for junior staff. At our institution, elective asleep fibreoptic intubation is used in appropriately selected patients as a way of teaching the technical aspects of the procedure.

MethodsOver a 5 year period, 136 adult patients due to undergo elective dental, oral/maxillo-facial, orthopaedic and general surgery were intubated by supervised trainees using a fibreoptic bronchoscope once asleep and paralysed. All patients were predicted to be easy to intubate and ventilate, and contraindications to fibreoptic intubation were excluded. Intubation was performed via the oral or nasal route, and through a laryngeal mask in a number of cases. 92 (68%) intubations were performed by ST1-ST2 level anaesthetists, while 44 (32%) were performed by trainee anaesthetists of ST3 level or above. Supervision was from experienced consultant anaesthetists with an interest in airway management. Difficulties and complications with each procedure (immediate and approximately 1 hour post extubation) were recorded.

ResultsDifficulties included passing the tracheal tube through the vocal cords (23 cases (17%)), disorientation (14 (9%)), equipment failure (8 (6%)), oesophageal intubation (4 (3%)), desaturation (4 (3%)). Complications included sore throat (20 (15%)), cough (13 (11%)), minor nasal bleeding (11 (8%)), stridor at intubation (1 (0.7%)). All patients were extubated at the end of surgery.

DiscussionNo patients in this series suffered significant morbidity directly attributable to the use of fibreoptic laryngoscopy. The difficulties reported are consistent with the varying skill and experience of the operators, while the complications occurred with a frequency similar to that reported in previous literature [1, 2, 3]. Asleep fibreoptic intubation allows junior anaesthetists to become familiar with the technical aspects of fibreoptic intubation and in selected patients is likely to have a similar complication rate to direct laryngoscopy.

References1. Woodall N, Harwood R, Barker G. Complications of awake

fibreoptic intubation without sedation in 200 healthy anaesthetists attending a training course. British Journal of Anaesthesia 2008; 100: 850-855

2. Blanc V, Tremblay N. The complications of tracheal intubation: A new classification with a review of the literature. Anaesthesia and Analgesia 1974; 53: 203-213

3. Christensen A, Willemoes-Larsen H, Lundy L, Jakobsen K. Postoperative throat complaints after tracheal intubation. British Journal of Anaesthesia 1994; 73: 786-787

SMART-COP score for patients admitted with community acquired pneumonia (CAP) to an ICU in a district general hospital: A smarter way of identifying patients with severe CAP?

Marcin Pachucki1, Fiona Kelly2, Andrew Padkin2

1Frenchay Hospital, Bristol, UK; 2Royal United Hospital, Bath, UK

marcinpachucki@gmail.com

British Thoracic Society guidelines on CAP [1] advocate ICU referral for patients with CURB65 score of 4 and 5. A recently developed scoring system, SMART-COP, designed to identify patients at need of intensive respiratory or vasopressor support (IRVS), has been validated in a variety of settings [2, 3]. It predicts the need for intensive care unit (ICU) admission (defined as need for IRVS) with greater accuracy than CURB65 [4] but is not used routinely in our UK institution.

MethodsWe retrospectively analysed critical care admissions of patients with a diagnosis of CAP in a UK district general hospital - ICNARC coded diagnoses of pneumonia (bacterial, viral, no organisms isolated) over a seven month period (Aug 2011 – Jan 2012). We ascertained the CURB65 and SMART-COP scores on referral to ICU and matched them in relation to the need for IRVS, length of inotropic and ventilatory support and ICU length of stay.

ResultsOur search revealed 28 potential matches. Five patients were excluded (not CAP) and the notes for seven patients were not available for analysis. We analysed the notes of 16 patients matching our criteria. In this small sample, there was a strong association between increasing SMART-COP score and the need for IRVS (correlation coefficient r=0.96). There was also a strong correlation with longer inotropic support (r=0.85) and longer ventilatory support (r=0.96) with increasing SMART-COP scores but a weaker correlation with length of ICU stay (r= 0.49). Moreover, none of the patients admitted to ICU had CURB65 score higher than three at the time of ICU referral.

DiscussionIn our small sample, higher SMART-COP score was associated with increased likelihood of IRVS. This suggests that a further study with a larger sample size should be performed to investigate whether SMART-COP is an improvement on CURB65 in predicting the need for IRVS in UK intensive care patients.

References1. The British Thoracic Society Guidelines for the management of

Community Acquired Pneumonia in Adults Thorax 2009; 64:Supplement III: 1-61

2. Charles PG et al. SMART-COP: A Tool for Predicting the Need for Intensive Respiratory or Vasopressor Support in Community-Acquired Pneumonia Journal of Clinical Infective Diseases2008; 47: 375-84

3. Robins-Browne K et al. The SMART-COP score performs well for pneumonia risk stratification in Australia’s Tropical Northern Territory: a prospective cohort study European Journal Tropical Medicine and International Health 2012; 7:914-919

4. Fang et al. Application and comparison of scoring indices to predict outcomes in patients with healthcare associated pneumonia Critical Care 2011, 15:R32

Improving access to critical incidents management guidelines in district general hospital theatres

M. Pachucki1, P. Hersch2

1Frenchay Hospital, Bristol, UK, 2Royal United Hospital, Bath, UK

marcinpachucki@gmail.com

In order to reduce fixation errors in anaesthetists and empower anaesthetic assistants in the management of critical incidents we designed and implemented a wall mounted critical incidents management folder sharing a view that this would provide a safer environment for all patients undergoing an anaesthetic in our Trust.

MethodsUsing departmental mailing list we surveyed all anaesthetists working at our institution about the critical incident guidelines they would consider useful to have to hand in an event of critical incident. After a period of consultation we compiled a list of 10 items of interest including: Anaphylaxis treatment, Adult and Paediatric Life Support Algorithms, Malignant Hyperthermia, Local Anaesthetic toxicity, Major haemorrhage, Tachycardias and Bradycardias treatment algorithms, Difficult Intubation guidelines, Paediatric drug doses and equipment formulae.

ResultsWe assembled identical wall mounted A4 size document holders for each anaesthetic room comprising the guidelines on critical incidents encountered during anaesthesia. They each have 10 leaves all of which are detachable allowing urgent and easy access in case of an unexpected incident. The new critical incidents management folder offered an organized and practical solution that replaced previous attempts to make adherent aide-memoires available around the anaesthetic room and operating theatre.

DiscussionSuccessful escape from fixation may be provided by insight from other people, from the environment or by ‘knowing how’ in practical terms. The standard operating procedures folder described above is intended to ease the burden of managing the rare but life threatening emergencies. Storing together these reference items required to manage critical incidents will likely reduce the time spent searching for safety guidelines/glossies and hence expedite initiation of successful treatment.

References1. E. Fioratou, R. Flin, R. Glavin; No simple fix for fixation errors:

cognitive processes and their clinical applications Anaesthesia2010; 6: 61–69

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An integrative review of physical rehabilitation on ICU

R. Parker1, J. Halliday2, R. Rajendram2 and J. Griffiths2

Aintree Hospital 1, Liverpool, UK John Radcliffe Hospital2, Oxford, UKCommunications: rajkumarrajendram@doctors.org.uk

Interest in the incidence, aetiology, consequences and treatments for ICU acquired weakness is growing, as emphasised by the recent publication of UK national guidelines on rehabilitation after critical illness.[1] The aim of this study was to perform an integrative review of the published literature to assess the feasibility, safety and benefits of physical rehabilitation on the ICU and make recommendationsabout current best practice of physical rehabilitation on the ICU.

MethodsSystematic electronic searching using Ovid platform and hand searching of reference lists of Medline (1950-June 2009), Embase (1980–June 2009) and the Cochrane Collaboration electronic databases for original research papers that reported on the feasibility, safety and benefits of physical rehabilitation on the ICU. Studies without an English title or abstract were excluded. Studies were identified using predefined inclusion and exclusion criteria. Those that were suitable for inclusion in the review were subjected to an integrative review with a predefined framework for data collection, extraction and analysis.

ResultsOf the 6336 studies identified, 437 were selected for further review. After full text evaluation of 29 studies ten were suitable for inclusion in the review and were subjected to an integrative review. The integrative review found that the following conclusions can be drawn from the existing literature: Physical rehabilitation can be delivered in the ICU. It is particularly important to note that patients receiving mechanical ventilation via an endotracheal tube can safely participate in physical rehabilitation. Physical rehabilitation can be safely started at an early stage of an individual patient’s admission to ICU. A variety of interventions are possible depending on the patients’ clinical condition, ranging from passive limb movements to ambulation with a portable ventilator. Physical rehabilitation improves outcome measures across a range of domains, including physiologic variables, muscle strength, transfer and mobility, time to wean from mechanical ventilation, and ICU and hospital length of stay. To date no study has assessed the effects of critical care unit initiated physical rehabilitation on short or long term mortality rate or any potential benefits beyond hospital discharge.

DiscussionBasic physical rehabilitation therapy should be given to all patients expected to remain on the ICU for more than four days, and should start as soon as it is safe to do so. However, this review highlights the paucity of data available to guide this therapy. The majority of published studies were conducted at a single centre and only 60% are randomised controlled trials. Furthermore there was no standardisation of the therapies applied, outcome measures or times of assessment in these studies.

Reference1. Rehabilitation after critical illness. National Institute for Health

and Clinical Excellence. March 2009.

Assessment of how well the safer surgery WHO theatre checklistis completed

J. Parmar1, N. Hickman2 and T. Bourne3

Glenfield Hospital 1, Leicester, UK, Leicester General Hospital 2, Leicester, UK, and Leicester Royal Infirmary, Leicester, UKjainaparmar@hotmail.com

The safer surgery checklist has been designed to improve theatre communication, team work and provide a consistent level of care. Most importantly it has been shown to reduce rates of morbidity and mortality post surgery [1]. The WHO checklist has to be completed fully at integral parts of a patients’ peri-operative journey. The aim of this audit is to assess how well the checklist is carried out within our hospital.

MethodsDesigned a proforma incorporating all parts of the checklist and assessed whether they were all completed over a one week period. It was carried out within one of the hospitals part of a large university teaching hospital. Specialities included general surgery, gynaecology, urology and orthopaedics.

ResultsA total of 34 responses were obtained. Only 16 (47%) lists carried out a team brief. Where it was done well there were many positive comments including introductions, identifying issues and resolving them. Reasons for it not occurring included not all staff members present or list running late. Regarding the sign in there was 100% compliance by operational department practitioners (ODPs), but out of the anaesthetists only nine (26%) took part. This seems to occur as ODPs do a checklist prior to bringing the patient to the anaesthetic room and therefore seems as a repetition for them. However this leads to the majority of anaesthetists not being involved at the sign in stage.During the time out stage the team member that consistently fully engaged were ODPs, with surgeons least likely to. Issues identified varied from the checklist being rushed, done quietly, approaching individuals, not all questions being asked, other members interrupting the flow, completed after incision and not all members being attentive e.g. surgeon scrubbing, anaesthetist busy with patient, scrub nurse working on set. However in areas where it was done well positive comments included members fully engaging and staff members wanting to do it properly and completely. A sign out was carried out in 23 (88%) lists. A debrief only occurred in seven (21%) lists.

DiscussionUnfortunately there was not a 100% compliance rate within all parts of the checklist. Issues raised were that all staff members have their individual roles and are busy preparing for them and therefore it can be difficult for members to fully engage during checks. It is important that this is a team exercise and all members see the importance and participate as this makes the checklist effective and ensures safer care for the patient.

References1. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety

checklist to reduce mortality in a global population. The New England Journal of Medicine 2009; 360: 491-9.

Survey of anaesthetists’ preferred methods for postoperative oxygen supplementation following simple general anaesthesia

J. Parmar1, W. Russell2 and O. Williams3

Glenfield Hospital 1, Leicester, UK, Leicester Royal Infirmary 2, Leicester, UK, and Leicester General Hospital 3, Leicester, UKjainaparmar@hotmail.com

Most anaesthetists transfer patients to the recovery room with alaryngeal mask airway (LMA) in-situ following simple general anaesthesia. There are several methods of providing oxygen supplementation via an LMA e.g. via a t-piece, t-bag or the use a heat-and-moisture exchange filter (HME). This survey looks at anaesthetists’ preferred methods within our hospitals and if they have any particular concerns regarding specific methods. Our aim is toselect a cost effective and safe method of oxygen delivery in theatre recovery. In particular we would like to determine anaesthetists’ opinions regarding the use of the HME filter as an oxygen delivery device attached to a laryngeal mask airway as there is evidence indicating this provides effective oxygen supplementation, achieving mean end-tidal oxygen concentrations of 36.2% (+/- 6.2%), at an oxygen flow rate of 4l.min-1 [1].

MethodsA prospective electronic survey in a large multi-site teaching hospitalwas sent to anaesthetists at all grades. Data collected included their normal practice regarding LMA use when surgery has completed,their preferred method of oxygen administration via the LMA including the oxygen flow rates used and if they routinely use the HME filter in recovery. The survey also asked whether anaesthetists had experienced any adverse events, had any concerns regarding safety and if they were aware of any evidence or guidelines for or against any particular techniques of oxygen administration.

ResultsThere were 75 responses in total of which 38 (50.7%) were consultants, nine (12%) staff grades and 28 (37.3%) trainees. Forty-four (59.5%) anaesthetists attach a t-piece to the LMA with no HME filter and only eight (10.8%) would attach the oxygen tubing directlyto the sampling port of the HME filter. Sixty-six (90.4%) had not witnessed any adverse events with any of the methods of supplementing oxygen. Concerns raised regarding the use of the HME filter included risk of obstruction e.g. from secretions, increased resistance at expiration with use of high flow rates and that themanufacturer does not state this as a use for the filter. Majority of anaesthetists, 67 (93.1%), were not aware of any guidelines for or against these techniques of oxygen supplementation. If there was conclusive evidence that a different method of oxygen supplementation showed increased efficacy and safety then 70 (94.6%) anaesthetists would be willing to change their practice.

DiscussionAnaesthetists use a variety of techniques for oxygen supplementation and a range of flow rates that are safe. The preferred method within our hospitals is the use of a t-piece with no HME filter attached. Most anaesthetists are willing to change practice provided there is evidence that another method is safe and efficacious. This allows us to promote alternative techniques such as the use of the HME filter for oxygen supplementation with appropriated monitoring if the manufacturer supports this, as this has been shown to be safe and cost effective [1, 2].

References1. Orme RM, Williams M. Supplementary oxygen and the

laryngeal mask airway-evaluation of a heat-and-moisture exchanger. Anaesthesia and Intensive care journal 1999; 27:509-11.

2. Wilkes AR, Vaughan RS. The use of breathing system filters as3. oxygen-delivery devices. Anaesthesia 1999; 54: 552-558.

Intraoperative CPR in the prone position, would you perform it? S Phillips1, FJ Lamb2, M Mackenzie2

1,Frimley Park Hospital, Frimley, UK, 2,East Surrey Hospital, Redhill, UK

Sioned.phillips@doctors.org.uk There are no guidelines on cardiopulmonary resuscitation (CPR) for patients in the prone position. However there are risk factors for cardiac arrest during surgical procedures in the prone position and there have been several case reports of successful intraoperative CPR of patients in the prone position [1,2,3]. We surveyed opinions on the management of a patient in cardiac arrest during prone surgery. We produced a video,distributed via the intranet, and a teaching session with a literature reviewwas presented within the department. Management opinions were then canvased again.

MethodsAfter providing a short clinical scenario we asked anaesthetists how they would start chest compressions and where they would place the defibrillation pads on a prone patient in cardiac arrest. The same questions were repeated after distribution of the educational video and teaching session.

Results The initial survey showed a wide range of opinions. With regards to performing CPR, 20/37 said they would turn the patient into the supine position, 11/37 would commence CPR in the prone position, 4/37 in the lateral position and 2/37 did not know which position they would commence CPR in. The landmarks described to perform prone chest compressions varied as did defibrillator pad position: 17/37 stating the anterior apical position, 12/37 anterior–posterior, 5/37 apical-posterior, 2/37 bi-apical and 2/37 did not know. On repeating the survey 25/25 of responders said they would start CPR with the patient in the prone position and knowledge on accepted land marks for hand position and defibrillation pads had improved with every respondent giving a valid answer.

DiscussionStudies have shown that prone CPR is efficient [4,5]. We believe that there will be a significant delay in commencing CPR if the intraoperative patient is repositioned to the supine position. The American Heart association recommends “CPR in the prone position is a reasonable alternative for intubated hospitalized patients who cannot be placed in the supine position” [6]. We have improved knowledge in this area and produced a consensus within the department on the management of CPR in a prone patient. Both of which will lead to more efficient management of a patient if this critical situation occurs.

References

1. Brown J, Rogers J, Soar J. Cardiac arrest during surgery and ventilation in the prone position: a case report and systematic review. Resuscitation. 2001; 50: 233–2382.Tobias JD, Mencio GA, Atwood R, Gurwitz GS. Intraoperative cardiopulmonary resuscitation in the prone position. Journal of PediatricSurgery. 1994; 29: 1537–1538. 3.Dequin PF, Hazouard E, Legras A, et al. Cardiopulmonary resuscitation in the prone position: Kouwenhoven revisited. Intensive Care Medicine. 1996; 22: 12724.Mazer SP, Weisfeldt M, Bai D, et al. Reverse CPR: a pilot study of CPR in the prone position. Resuscitation. 2003 June: 57(3); 279-285.5. Wei J, Tung D, Sue S et al. Cardiopulmonary resuscitation in the prone position: a simplified method for out patients. Resuscitation. 2004;62:120-121 6. Adult basic life support. Circulation. 2005; 112:III-5-III6

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Prevention of cough at tracheal extubation:A meta-analysis of six techniques

R. Rajendram1, A. Joseph2 and S.K. Ramachandran3

John Radcliffe Hospital1, Oxford, UK, Princess Alexandra Hospital2,Harlow, UK and University Hospital3, Ann Arbor, USA,Correspondence: rajkumarrajendram@doctors.org.uk

Cough at tracheal extubation increases the risk of post-operative morbidity through acute increases in blood pressure, heart rate, intrathoracic, intracranial, intraocular and intraabdominal pressures.[1]Little is known of the comparative effectiveness of available techniques to prevent cough. The aim of this meta-analysis was to evaluate six techniques to prevent cough at tracheal extubation.

MethodsSeveral electronic databases (1966 to Sep 2010) were systematically searched (AJ, SKR) for original research papers that reported the interventions to reduce cough at emergence from anaesthesia. Data were evaluated using standardized methods.[2] Meta-analyses were performed using fixed or random-effects models based on presence or absence of heterogeneity. Bias was evaluated by observing funnel plots and control event rates (CER). The risk difference (RD; the absolute change in risk attributable to the intervention) was employed as a summary measure of efficacy, and heterogeneity was quantified using the I2 statistic. Number needed to treat (NNT) was calculated from the pooled data to provide a visual estimate of both clinical value and heterogeneity of effect.

ResultsFrom 1114 articles screened, 22 articles with a median sample size of 50 (interquartile range 40-60) were chosen for the final analysis(Table 1). Significant bias (CER 0.15-0.96) and heterogeneity (I2>75%) were observed. Pooled subgroup estimates are presented to provide summary data on effectiveness, but the small numbers of studies in each subgroup limits any generalization.

Table 1: Techniques for prevention of emergence coughTechnique (studies) Pooled data

N RD (CI) NNT (CI)i.v. L (7) 390 -0.22(-0.31,-0.14) 4.5(3.3, 7.2)Cuff alkaline L (5) 270 -0.27(-0.20,-0.37) 1.7(1.5, 2.0)Cuff plain L (4) 197 -0.27(-0.37,-0.26) 3.8(2.7, 6.3)Mucosal L LITA™ (2) 80 -0.43(-0.59,-0.26) 2.4(1.7, 3.8)Dexmedetomidine (2) 100 -0.45(-0.62,-0.28) 2.2(2.6, 3.5)Remifentanil (2) 110 -0.46(-0.62,-0.29) 2.2(2.6, 3.4)All Techniques (22) 1147 -0.38(-0.42,-0.33) 2.6(2.4, 3.0)

Legend: Abbreviations; lidocaine (L), intravenous (i.v.), laryngotracheal instillation of topical anaesthesia tube (LITA™),pooled number of patients (N), risk difference (RD), Number needed to treat (NNT), 95% confidence intervals (CI).

DiscussionThis meta-analysis demonstrates that several techniques reduce emergence cough with an overall modest effect size (RD -0.38) and low NNT (2.6). No single technique dependably prevents cough; i.v.lidocaine and tracheal cuff inflation with plain lidocaine have the least clinical value. However, subgroup analyses are hampered by study biases, inadequate sample size and study heterogeneity.

References1. Leech P, Barker J, Fitch W. Proceedings: Changes in intracranial pressure and systemic arterial pressure during the termination of anaesthesia. British Journal of Anaesthesia 1974;46:315-62. Liberati A, Altman DG, Tetzlaff J et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. British Medical Journal 2009;339:b2700

A randomized, crossover, observational simulation-based survey comparing use of a needle-guide with the freehand technique for in plane US guided regional anaesthesia.

R Rajendram1, J McGrath2

John Radcliffe Hospital1, Oxford, Royal Free Hospital2, London, UK.Correspondence: rajkumarrajendram@doctors.org.ukIn plane US guided placement of nerve blocks is widely accepted as the gold standard for safe practice. However, this is technically difficult. Recently, a new needle guidance device (Infiniti) has become available to facilitate in plane techniques. We hypothesized that the use of a needle guide (NG) paired with the in plane approach would facilitate regional anaesthesia in a simulation model more effectively than free-hand (FH) in plane techniques.

MethodsA prospective randomised single blind crossover observational study was conducted using a partial-task training device (Blue Phantom, Sonosite, UK). Each anaesthetist localised a specific ‘nerve’ in plane with a 10 cm nerve block needle (B Braun, Germany) used either FH, or with a NG. Each attempt was performed under the observation of a specialist in regional anaesthesia who was blinded to the technique used by the anaesthetist. The supervisor could only see the screen of the US machine (Micromaxx, Sonosite, UK). The fraction of time the needle tip remained in view of the ultrasound was recorded and compared. Time required for completing the task and the number of needle passes and needle re-directions were compared. The anaesthetist was asked which technique was easier to use and which technique made them feel more confident. The blinded supervisor was also asked to note which attempt he felt most confident whilst supervising. The primary end point was the fraction of time the needle tip remained in view. This was defined as 100% or less than 100%. The anaesthetist reported which technique was easier to use and made them feel more confident. The blinded supervisor noted which attempt he felt most confident supervising. Statistics: Parametric data wasanalysed using the paired t-test. Non-parametric data was analysed using the Chi-squared test. Ethical approval was not required as the audit department considered that this was a service evaluation project to determine whether the department should purchase this device.

ResultsTwenty two anaesthetists participated in the study. The NG did not increase 100% needle visibility in comparison to the FH technique (100% visibility: FH 8; NG 5; ns). There was no significant difference in time to the target (NG 23.0 s ± 16.3; FH 17.9 s ± 11.7; p=0.17). The numbers of needle passes did not differ between the groups. Ten anaesthetists (45%) preferred to use the NG and felt more confident using the NG. One anaesthetist preferred the FH technique but felt more confident using the NG. Eleven anaesthetists (50%) preferred the FH technique and felt more confident with the FH technique.There was no difference in the anaesthetist’s or their supervisor’s preference or confidence whilst performing the simulated nerve block with either the NG or FH techniques. The supervisor’s confidence correlated with the preference and confidence of the anaesthetist performing the block. On only 2 occasions when the anaesthetist preferred the FH technique and was more confident with the FHtechnique did the supervisor prefer their NG technique.

DiscussionThe NG did not improve needle visualization or facilitate in plane nerve blockade in this simulation model when compared with FH techniques. Approximately half of the anaesthetists surveyed preferred to use the NG. The supervisor was usually more confident supervisingthe anaesthetist when the anaesthetist used the technique preferred by the anaesthetist.

AcknowledgementsNo external funding and no competing interests declared

The provision of an on call service for regional anaesthesia

R. Rajendram, J. McGrath, S. Stamatakis, A. Joseph

Royal Free Hospital, London, UKCommunications: Rajkumarrajendram@doctors.org.uk

‘Regional anaesthesia (RA) is only beneficial if the right dose of the right drug is put in the right place.’[1] However, not all anaesthetists possess the necessary skills, confidence or inclination to formulate an appropriate plan for RA and then consistently execute this effectively. Many patients could potentially benefit from regional techniques for anaesthesia or analgesia. At the Royal Free Hospital 17 patients with renal failure listed to have complex vascular access surgery under general anaesthesia were surveyed after performance of this surgery under brachial plexus blockade either alone or with sedation.[2] These patients reported excellent post-operative analgesia and had short stays in the recovery area (<30 minutes).[2] Although these patients were invariably discharged from hospital on the same day of surgery, those patients who have similar procedures under general anaesthesia require at least overnight admission. Unfortunately for many reasons only a handful of these patients are ever even offered RA. We describe the use of a RA on call service to improve the access of patients and anaesthetists to RA.

MethodsIn order to increase the availability of RA at the Royal Free Hospital the first RA fellow was appointed in 2010. However many opportunities were missed as there was no formal referral pathway and it was often difficult to contact the fellow. In 2011 it was agreed that the RA fellow would provide a formal on call service during normal working hours (8 am to 6 pm, Monday to Friday) and a bleep was obtained to facilitate this. When contacted the RA fellow would formulate a plan for RA with the anaesthetist responsible for the patient and then discuss all the options for anaesthesia with the patient. After obtaining informed consent the fellow would either perform the chosen technique or supervise the responsible anaesthetist or another trainee performing this. If required the RA fellow would then support the patient and the responsible anaesthetist throughout the peri-operative period and review the patient 24 hours later (by telephone if the patient had been discharged). The uptake and effectiveness of the RA on call service was evaluated 6 months later.

ResultsOver 12 months the RA fellow was called to review 45 patients who would otherwise have had surgery under general anaesthesia alone. These patients appreciated the opportunity to discuss all the available options for their anaesthetic in more detail. All of these patients accepted RA; 12 had surgery under RA alone; 33 patients received RA as part of a balanced anaesthetic technique.

DiscussionIn carefully selected patients the use of RA can improve patient satisfaction and reduce length of stay in the recovery area and in hospital. This novel on call service has increased the provision of RA at the Royal Free Hospital and is greatly appreciated by patients, anaesthetists and surgeons.

References1. Denny NM, Harrop-Griffiths W. Location, Location, Location!

Ultrasound imaging in regional anaesthesia. British Journal of Anaesthesia 2005;94:1–3.

2. Rajendram R, Batra R, Lindsey B, Joseph A. Regional anaesthesia in haemodialysis patients undergoing complex arterio-venous fistula surgery. Anaesthesia 2012; 67(suppl 1):22.

No external funding and no competing interests declared

Optimising fasting of children prior to elective cardiac surgery

R Rajendram1, B Clevenger2, E Haxby2

John Radcliffe Hospital1, Oxford, UK,Royal Brompton Hospital2, London, UKCommunications: rajkumarrajendram@doctors.org.uk

Fasting prior to elective surgery reduces the risk of aspiration under general (GA).[1] The specific minimum fasting times recommended for children[1] are:

Low-residue food allowed up to 6 hours pre-opFormula milk allowed up to 6 hours pre-opBreast milk allowed up to 4 hours pre-opClear fluids allowed up to 2 hours pre-op

Despite clear guidelines, these recommended pre-anaesthesia fasting times are often greatly exceeded. In 2010 an audit of 858 patients having cardiac catheter labs (CCL) procedures under GA at the Royal Brompton Hospital 72% were starved > 6h, for food and fluid; 27% were fasted 2-6h for fluid. Only 8 patients fasted <2h (<1%). Children are distressed by prolonged fasting and dehydration which also increase risks of hypoglycaemia, difficulty obtaining intravenous access, and cardiovascular instability at induction of GA. We aimed to reduce the number of children fasting more than 6 hours prior to elective procedures under GA by 10% over 3 months.

MethodsOur approach evolved through several Plan, Do, Study, Act (PDSA) cycles. Educating staff about the fasting guidelines was unnecessary. Although most were keen to reduce fasting times there were several barriers; the greatest of which was lack of communication. The lists were frequently reorganised without informing staff. Attempts to finalise the list the evening before and ‘empowering’ parents to request fasting times were fruitless. Trying to update several ward nurses on the day of the list was frustrating and time consuming. To improve communication we supported the introduction of a team brief and an adapted WHO safer surgery checklist. Fasting times and the order of the list should be confirmed at the team brief and then communicated to the ward staff. A ward nurse bleep holder was appointed to disseminate this information to the other nurses on the ward.

ResultsAn audit one month later found that the adapted WHO safer surgery checklist was used in 75% of cases but a team brief only took place before 50% of lists. We audited paediatric fasting times with a parental questionnaire. Over the week 8 children had elective CCL procedures. Five (62.5%) were fasted > 6 hours (mean fluid fast 7 hours). However, 3 (37.5%) had been given fluid between 2 and 6 hours of induction of anaesthesia. We therefore appear to have achieved our target. Accurate starvation times had been given to nurses and parents verbally, but none were given in writing. This is the next target for a PDSA cycle.

DiscussionAfter each intervention we reviewed the impact and discussed this with the team involved. After several failures we focused on the team as a whole and tried to enhance communication between the CCL teams and ward staff. The use of the team brief and an adapted WHO safer surgery checklist in the CCL will ensure that these improvements are sustained and increase.

References1. Perioperative fasting in adults and children – an RCN guideline

for the multidisciplinary team. RCN publications 2005.http://www.rcn.org.uk/__data/assets/pdf_file/0009/78678/002800.pdf. Accessed 12/12/12.

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Survival to ICU & hospital discharge after small bowel transplant

R. Rajendram, I. Edmond, T. Thomas, and J. Millo

Churchill Hospital, Oxford, UK, Correspondence: rajkumarrajendram@doctors.org.uk

Experience in small bowel transplantation (SBT) is very limited. Arecent case series of 20 SBT in children reported that 95% survived to ICU discharge.[1] The survival to ICU discharge and rate of readmission to ICU prior to hospital discharge has not previously been reported in adults. This data was obtained as part of a service evaluation project.

MethodsAll adult patients who had SBT at the Churchill Hospital between April 2009 and December 2012 were identified from the transplant programme database. The dates of admission and discharge form ICU were determined from the electronic patient records (Intellivue Clinical Information Portfolio, Philips Medical Systems, The Netherlands) and used to calculate readmission rate and length of stay.

ResultsOver the 45 month period assessed 14 SBT (4 Female; mean age 44.4±14 years) were performed (3.7/year) and 13 (93%) survived to discharge to the ward and 12 (86%) survived to hospital discharge.The 30 day post-operative mortality was 0; however, one patient was never discharged from ICU and died 33 days after SBT. The mean length of the initial ICU admission was 8.8 days (SD 10.8 days; mode 3 days; median 3.5 days; range 2-33 days; inter-quartile range 3-5.5days). Of the 13 patients who were discharged to the ward three were readmitted to ICU prior to discharge from hospital (25%; 23% of all patients). Of the patients readmitted to ICU before discharge, the mean length of stay on the ward prior to the first readmission was 7.3 days (SD 3.5; range 4-11 days). Only one patient was readmitted to ICU more than once before discharge from the hospital. This patient died in ICU on their 3rd readmission, the other two survived to ICU discharge and hospital discharge.

Table 1. Number of SBT performed and re-admitted to ICU prior to hospital discharge from April 2009 until December 2012.

Year Months SBT ICU days

ReadmissionsN(pts, ICU days)

Deathsin ICU

2009 9 4 37 3 (1; 27 days) 12010 12 2 8 1 (1; 3 days) 02011 12 5 39 1 (1; 3 days) 02012 12 3 39 0 1Total 45 14 123 5 (3; 33 days) 2

Legend. Abbreviations: number of readmissions, N; patients, pts.

DiscussionSurvival to ICU discharge and re-admission rates to ICU after SBT have not previously been reported in adults but survival to PICU discharge is excellent (95%) after SBT in children.[1] Survival to ICUdischarge in our adult cohort was comparable (93%) and survival tohospital discharge was good (86%). Of the 13 patients who survivedto discharge to the ward three (23%) were readmitted at least once.The early postoperative period after SBT is a high-risk phase that requires significant input from intensivists but refinement of peri-operative management has significantly improved survival to ICU and hospital discharge. Small bowel transplantation is a low volume procedure and we hope that dissemination of our experience will open discussion on how to improve outcomes.

References1. Rowan CM, Vianna RM, Speicher RH, Mangus RS, Tector AJ, Nitu ME. Post-transplant critical care outcomes for pediatric multivisceral and intestinal transplant patients. PediatricTransplantation 2012;16:788-95.

Improving use of the WHO Surgical Safety Checklist

R. Rajendram1 and A. Joseph2

John Radcliffe Hospital1, Oxford, UK, and Princess Alexandra Hospital 2, Harlow, UKCorrespondence: rajkumarrajendram@doctors.org.uk

The aim of the Safe Surgery Saves Lives Challenge is to improve the safety of surgical care by increasing adherence to proven standards of care. The WHO surgical safety checklist improved compliance with standards and decreased complications from surgery in eight pilot hospitals where it was evaluated.[1] The checklist was introduced at the Royal Free Hospital in February 2010. In 2011 an audit of 520 patients over a 3 week period (15/4/11-6/5/11) revealed poor compliance (57% complete; 6% not started). Several serious untoward incidents also highlighted the potential benefits of using the checklist. However, despite disseminating this information widely, compliance remained poor. The aim of this quality improvement initiative was to improve utilisation of the WHO surgical safety checklist.

MethodOur approach evolved through several Plan, Do, Study, Act (PDSA) cycles. The key stakeholders within each theatre team were identified and surveyed informally. The key reasons cited for the failure to complete the WHO checklist were; lack of understanding, perceived lack of time and overall lack of communication, co-ordination and defined responsibility. A program of education on the principles and aims of the WHO safer surgery checklist was delivered to theatre staff. Thereafter various initiatives were implemented using plan, do, study, act (PDSA) cycles to gauge their effectiveness. After each intervention the effect was discussed with the key stakeholders and aspot audit of 50-100 patients over a week was undertaken.

ResultsIn October 2011 a spot audit of 50 patients over a week found that utilisation of the checklist was still low (67% complete). Repeating the 50 patient spot audit unexpectedly detected a fall in use of the checklist (50% complete). In each audit the greatest deficiency was in completion of the surgical time out. However, highlighting this to theatre staff and allocating responsibility for the sign in, time out and sign out to the anaesthetists, surgeons and circulating scrub staff respectively resulted in an improvement (100 checklists; 94% complete). Whilst encouraging this improvement was unlikely to be sustained without the repeated audits which were too labour intensive to be continued indefinitely. Of the many initiatives that were subsequently tried, the most successful was to refuse access to the theatre recovery area without a complete checklist. A spot audit of 100 patients performed one month later found that the adapted WHO surgical safety checklist had been completed for all cases. Subsequent spot audits have confirmed that this improvement has been sustained.

DiscussionThe WHO surgical safety checklist is a global standard of care that has saved many thousands of lives. However, despite clear evidence of benefit in the published literature, explicit guidelines and serious untoward incidents at our own institution, human factors still resulted in failure to utilise this checklist. Several different strategies were attempted to incentivise theatre staff to complete the checklist. The ‘stick’ philosophy of refusing entry to the theatre recovery area without a complete checklist was the key to its successful implementation at our institution. Regular spot audits are no longer required as a strategy to maintain compliance and so these have been stopped.

References1. Haynes AB, Weiser TG, Berry WR et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population.New England Journal of Medicine 2009;360:491-499.

Readmission to ICU after kidney and pancreas transplantation

R. Rajendram, G. Hadjipavlou, and C. Author

Churchill Hospital, Oxford, UK, Correspondence: rajkumarrajendram@doctors.org.uk

Simultaneous kidney-pancreas transplantation (SKPT) is a promising treatment for patients with type 1 diabetes mellitus and end stage renal failure. The incidence of early complications is not well described [1] and the level of care required to support patients who suffer these complications of SKPT has not previously been reported. At our institution all patients are admitted to the ICU immediately after SKPT and usually discharged to the transplant ward 2 days later. The aim of this survey was to determine the readmission rate to ICU in this cohort after initial discharge to the ward.

MethodsAll SPKT performed at the Churchill hospital between March 2009 and the end of November 2012 were reviewed. The ICU admissions register was reviewed to determine the number or SKPT performed over this period. The number of patients who were then readmitted to the ICU after SKPT was also determined from the ICU admissions register and used to calculate the monthly ICU readmission rate.

ResultsOver the period assessed 225 SKPT (60/year; 5/month) were performed. The average number of readmissions to ICU after SKPT was 9.6 per year (0.80 per month). The monthly readmission rate was therefore 16% i.e. 1 in every 6-7. The number of SKPT performed and the re-admissions to ICU during 2011 are shown in figure 1.

0123456789

10

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Figure 1. Number of SKPT performed (shaded; 72) and re-admitted to ICU (black; 15) in 2011

DiscussionRe-admission rates to ICU after SKPT have not previously been described, but one series reported that 44% required re-laparotomy.[1] These patients are likely to have been re-admitted to ICU and our re-admission rate (16%) compares favourably to this. The early postoperative period after SKPT is a high-risk phase for complications which require re-admission to ICU and impair long-term outcomes.These patients require meticulous review to reduce the risk of failed discharge from ICU but research should focus on the refinement of peri-operative management to reduce the risk of early complications after SKPT.

References1. Page M, Rimmelé T, Ber CE et al. Early relaparotomy after simultaneous pancreas-kidney transplantation. Transplantation.2012;94:159-64.

Agreement on ECG rhythm strip interpretation by anaesthetists

R. Rajendram1, S. Kale2, S. Patel2 and V. Nangalia2

Churchill Hospita1l, Oxford, UK Royal Free Hospital2, London, UKCorrespondence: rajkumarrajendram@doctors.org.uk

Continuous electrocardiographic (ECG) monitoring is a core standard of care for patients undergoing general anaesthesia. Anaesthetistsshould be expert at the interpretation of this data. The initial aim of this project was to audit anaesthetists’ ability to interpret a single Lead 1 ECG rhythm strip to diagnose sinus rhythm (SR) and atrial fibrillation (AF). However as significant differences between the anaesthetists’ reports was noticed this was investigated.

MethodsOne thousand and two anonymous 30 second Lead 1 ECG recordings, on standard ECG paper, from 501 patients attending a clinic for influenza vaccination were obtained from an ECG device manufacturer. Three post FRCA anaesthetists (A, B, C) interpreted these single lead ECG recordings and were asked to report therhythms as either AF, SR, another rhythm or uninterpretable. The anaesthetists’ diagnoses and their agreement were compared by an independent analyst as described in the legend to Table 1. Differences between anaesthetists’ ECG interpretations were compared using the Wilcoxan signed rank test for paired data.

ResultsTable 1. Agreement between anaesthetists reporting ECGs rhythm as AF, sinus rhythm, or indeterminate.

Anaesthetists’Reports

Rhythm (%)AF SR Uninterpretable

0 657 (66) 120 (12) 741 (74)1 269 (27) 243 (24) 160 (16)2 54 (5) 237 (24) 53 (5)3 22 (2) 402 (40) 48 (5)Agreement (0+3) 679 (68) 522 (52) 789 (79)Disagreement (1+2) 323 (32) 480 (48) 213 (21)

Legend: For AF, a score of 3 indicates that all 3 anaesthetists agreed that the ECG showed AF whilst a score of 0 indicates that the anaesthetists all agreed that the ECG did not show AF. They disagreed if only 1 or 2 anaesthetists made a diagnosis of AF on an ECG. This analysis was repeated for the diagnoses of SR and uninterpretable.The individual anaesthetists’ diagnoses of AF were significantly different (p<0.001). The diagnoses of SR by anaesthetist A were significantly different to those of B and C (p<0.001). However diagnoses of SR by B and C were not significantly different (p=0.25).

DiscussionThe significant variability between the anaesthetists’ interpretation of these single lead paper ECG rhythm strips on was surprising. This may simply reflect differences in the way these anaesthetists diagnose cardiac rhythms. For example, AF may be diagnosed by the absence of p waves or by irregularly irregular variation of the RR interval or both. Previous studies have suggested that the accuracy of the reports of 12 lead ECGs by non-cardiologists is poor.[1] However this has not previously been investigated on single lead ECG data or in anaesthetists. In clinical practice less variation between anaesthetists is likely because data from pulse oximetry and palpation are usually also available when continuous single lead ECG monitoring is used invivo. However, our observations suggest that further investigations on the interpretation of single lead ECG data are required.

References1. Tsai TL, Fridsma DB, Gatti G. Computer decision support as a source of interpretation error: the case of electrocardiograms. Journal of the American Medical Informatics Association 2003; 10: 478-83.

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Prolonged clear fluid fasting times on the gastroenterology suite: the unintended consequence of the recommended fasting time.

K.J. Richardson1, J. H. Smith1,2, A. Pearson1

1 Great Ormond Street Hospital, London, UK, 2 Portex Department of Paediatric Anaesthesia, ICH, UCL, London UK.drkaterichardson@gmail.com

Great Ormond Street Hospital recommends a four hour clear fluid fasting time for gastroenterology procedures in view of the possibility of decreased gut motility. We audited clear fluid fasting times on the gastroenterology suite to investigate if patients were adhering to current local guidance. Prolonged fasting times in children can lead to thirst, irritability, patient distress, hypoglycaemia, and dehydration. Much research has been done to rationalise fasting times in order to minimise these potential side effects. Overwhelming evidence now supports a two hour fasting time for clear fluids [1]. The Royal College of Anaesthetists recommends fasting times for clear fluids should be no longer than 2-3 hours for elective paediatric surgery [2].

MethodsWe conducted the audit over a three week period using a form which was completed by the gastroenterology suite nurses. Data collected included the last time of clear fluid and the time of induction of anaesthesia,. Other patient information was accessed through the PIMS database retrospectively. Exclusion criteria included patients having video capsule endoscopy, diabetics, or if overnight intravenous fluids were given. Excel spreadsheet was used for data analysis.

ResultsSixty-two patients were included in the study. We found that only nine (16.1%) patients were within the recommended fasting time of four hours, and that over 25 (40.3%) exceeded eight hours or more. By reviewing the morning and afternoon lists separately, we found that the morning lists had more prolonged fasting times. Sixteen (72.6%) of the patients on the morning list fasted for more than eight hours, compared with only eight (20.6%) of patients on the afternoon list. Interestingly, of the 29 day stay patients we found that six (20.6%) stayed within the four hour fasting rule, compared with only four of the 33 (9.1%) overnight stay patients. A telephone survey was conducted to various national and international paediatric gastroenterology units which showed that the 2-3hr fasting guidelines was followed by the majority of units.

DiscussionThe vast majority of patients exceeded the recommended four hour clear fluid fasting time. Of these, a greater proportion of the patients on the morning list compared with the afternoon list, had prolonged fasting times. This can be explained by the fact that it is an overnight fast, and that parents are reluctant to wake sleeping children to offer them fluid. This is the unintended consequence of a four hour fasting time. The finding that overnight stay patients were less likely to adhere to the four hour fasting guidance than day stay patients may indicate that clearer information needs to be given to ward staff. Clearer information also needs to be given to parents, the list order needs to be more predictable, and the four hour fasting time needs to be reviewed. Plans for quality improvement include text to parents, a checklist for ward staff and prescribed fluids for afternoon patients.

References1. Brady MC, Kinn S, Ness V, O’Rourke K, Radhawa N, Staurt P.

Preoperative fasting for preventing perioperative complications in children. Cochrane Database of Systematic Reviews, 2009;Issue 4. No: CD005285

2. Pre-operative fasting in elective paediatric surgery. Raising the Standard: a compendium of audit recipes. RCoA 2012; 9.2: 234-235

Regional anaesthesia for facial plastic surgeryA. Riskalla1, P. Modayil1, A. Joseph2

, R. Rajendram3, A. D’Souza1

University Hospital1, Lewisham, UK, Princess Alexandra Hospital2,Harlow, UK, and John Radcliffe Hospital 3, Oxford, UKCommunications: rajkumarrajendram@doctors.org.uk

Nerve blocks are widely used in facial plastic and reconstructivesurgery.[1] The aim of this survey was to determine whether effective regional anaesthesia was being provided for facial plastic surgery. We aimed to assess completion of consent forms, patient acceptance, which blocks were commonly used, their effectiveness for surgery under local anaesthesia (LA) alone and need for conversion to general anaesthesia (GA).

MethodsData on 350 patients who had facial plastic reconstructive surgery under LA alone over a four-year period (May 2004–2008) at University Hospital Lewisham was obtained from patients’ health records. The parameters analysed included; consent, diagnosis, surgical procedure, LA technique and volume used and outcome.Patients who underwent cosmetic surgery for rejuvenating the ageing face were excluded from the study.

ResultsThe study group included patients with melanoma (n=10), Squamous cell carcinoma (n=38), basal cell carcinoma (n=256) and other lesions (n=46). Lidocaine hydrochloride 2% with adrenaline 1:80,000(Lignospan) was used in all patients. In addition to the nerve blocks shown in Table 1 all patients received local infiltration with Lignospan. All patients offered LA consented to surgery under LA alone and signed consent forms. No untoward effects were recorded. Although some patients required sedation, conversion to GA was never required.

Table 1. Nerve blocks for facial plastic surgeryTechnique Cases

Number (%)Field block only 38 (10.8)Infraorbital 82 (23.4)Mental 26 (7.4)Supraorbital + supratrochlear 42 (12)Dorsal nasal 41 (11.7)Zygomatic 21 (6)Great auricular 29 (8.3)Mandibular 8 (2.3)Combination 63 (18)Total 350 (100%)

DiscussionThe use of LA in facial plastic surgery has many advantages and benefits particularly when administered correctly. Depending on the intended area of surgery, the nerves supplying it can be blocked effectively and securely resulting in a painless, bloodless field ideal for facial plastic surgical procedures. It is cost and time efficient with 100% patient acceptance in this cohort. We therefore recommend that anaesthetists and surgeons familiarise themselves with these techniques and offer them routinely.

References1. Salam GA. Regional anesthesia for office procedures: part I. Head and neck surgeries. American family physician 2004;69:585-590.

Northern deanery primary FRCA trainee survey.

T.E Sams1 and C.F Dickson2

1Freeman Hospital, Newcastle, UK. 2Royal Victoria Infirmary, Newcastle, UK.tesams@hotmail.com

Increasingly core anaesthetic trainees are being required to achieve numerous competencies as well as complete the challenge of the Primary FRCA prior to ST3 appointment. First time pass rates for both examinations of the Primary FRCA have been falling over the last few years [1]. Examiners have expressed concern that candidates are underprepared and struggle to pass the examinations within a two year training programme [2]. We attempted to get a consensus on revision practices and to assess trainee satisfaction with the current fortnightly regional teaching course in our region with an aim of improving the information and teaching available to core trainees about the examination.

MethodsA 12 question internet based survey was sent by email from the authors to all CT2, CT2+, ST3 and ST4 trainees in the Northern deanery in August 2011.

ResultsFifty six trainees were sent the questionnaire of whom 40 (71.4%) replied. Nineteen (47.5%) had failed at least one section on one or more occasion. Four (10%) had taken three or more attempts to pass a section of the examination. Of the trainees who failed a section of the exam, eight (42%) felt pressurised into sitting the exam before they were ready and 12 (63%) felt they just hadn’t worked hard enough.Trainees first sat the exam a median of 10 months after starting training (inter-quartile range (IQR) 7-10) and revised for a median of six months (IQR 4-6) spending a median 15 hours a week revising (IQR 10-20). Asked to attribute one factor most likely to lead to success in the examination 17 trainees (50%) picked hard work or knowledge, eight (23.5%) selected planning or preparation and seven(20.5%) selected practice questions as the main factor to passing the exam. Trainees were asked to assess our regional teaching course using an 11 point numerical rating scale over five domains and suggest improvements. The course received a mean overall rating of 4.4 (standard deviation (SD) 2.1) with variety of topics scoring highest at 6.8 (SD 1.9) and value for money lowest at 4.0 (SD 2.3). When asked for suggested improvements, 16 (80% of responders) felt that more exam practice and greater involvement of senior trainees would be beneficial.

DiscussionThe results of the survey have given us an excellent insight into current revision practice in our region for the Primary FRCA. The results of the questionnaire are now presented to all new CT1 traineesto inform them of how much work is required to pass the examination and which books or courses have been recommended by previous trainees. In conjunction with the school of anaesthesia, the primary course has been improved with exam practice sessions on each day and a dedicated revision day for each of the examination sections included at no further cost. We hope to survey again later this year to see if it has impacted on trainee satisfaction and exam pass rates.

References1. McCahon R, Joannides C. Is all well with training in

anaesthesia? Bulletin of the Royal College of Anaesthetists 2012;76: 16-18.

2. Report of the Examination Review Working Party 2011. Royal College of Anaesthetists (www.rcoa.ac.uk/node/3312) (accessed December 2012).

Data storage and backup: an audit of trainees’ habits

A. Simpson

Royal Infirmary of Edinburgh, Edinburgh, UKalistair@asdesign.org.uk

This audit sought to identify the use of different logbooks within the anaesthesia trainee population in the South East Scotland deanery and to assess trainees’ habits regarding data storage and data backup.Since no guidelines currently exist, this work sought to provide evidence for the establishment of guidelines for national approval.

MethodsAn online survey was created which used check box and free text boxes to gain information on trainee demographics, logbook use, computer and portable device use, data storage, data backup and data loss. The resultant data was then analysed to assess trends.

ResultsSixty-five trainees responded to the survey and represented a spread from CT1 to ST7/SpR5. All logbooks were in electronic format. Most trainees used a mobile device for logbook or other work data entry (47; 74.6%); for many this was their primary device for data entry (38; 62.3%). Twenty-four percent of trainees backed up their mobile device every week; 40% every 8-30 days, 18% less than every 30 days, 18% never backed up. For computer backup, these figures were 11.5%, 26.2%, 37.7% and 24.6% respectively. Nearly 40% of trainees have suffered data loss (24; 39.3%).

DiscussionThe results of this audit illustrate that electronic logbooks are nowubiquitous amongst trainees. As expected, the use of portable electronic devices for data entry and data storage is now very common, with almost 75% of trainees using such a device and nearly two-thirds of trainees using such a device as their primary platform for data entry. Data backup is clearly important; losing or damaging an electronic medium can result in permanent loss of data. This can have significant implications, particularly since the maintenance of a logbook of cases is a requirement of training in the United Kingdom and since production of a summary of cases is a requirement at annual review of competency progression (ARCP) [1]. Nearly 40% of trainees have suffered some form of data loss. However, 18% never back up the data from their mobile device and 24.6% never back up their desktop or laptop. A further 18% and 37.7% respectively backup less often than once per month. As such trainees are vulnerable to loss of data. At present there are no recommendations for data storage and backup from the major anaesthesia bodies (Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Northern Ireland). It is proposed that guidelines are produced for trainees on methods of data storage and backup. Such guidelines must be simple, safe, reliable and cost-effective. Available techniques include a separate data drive (external hard drive) and a web-basedsystem or cloud. Of these, the cloud system has the advantage of being remote to the user’s device and thus safe from theft and physical damage (e.g. fire). Cloud storage may also be safer, although this could be a matter for technical debate. All patient-sensitive data must also be anonymized [2]. A proposed guideline has been produced and will be submitted to the Royal College of Anaesthetists for their consideration. Regardless of the means of data backup, it should be on a separate device and should be performed regularly.

References1. Royal College of Anaesthetists. CCT in anaesthetics –

assessment guidance (2010 curriculum), 2nd edn. London: The Royal College of Anaesthetists, 2010.

2. General Medical Council. Confidentiality: disclosing information for education and training purposes. London: General Medical Council, 2009.

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The impact of electronic prescribing in a district general hospital intensive care unit on medication error rates – an audit cycle

J. Strachan1

Royal Berkshire Hospital, Reading, United KingdomStrachan.jamie@gmail.com

Prescribing errors are common in hospital, and in intensive care, with its collection of complex patients on multiple medications via a variety of routes, the risk increases, bringing with it the risk of serious patient harm. In the UK, several groups working in teaching hospitals have shown that electronic prescribing decreases the number of medication errors in intensive care. [1, 2] Others have shown that whilst electronic order entry means that instructions are clearer, ICU prescription error rates are not decreased. [3]. In our district general ICU in order to assess the impact of electronic prescribing on medication error rates I audited the number of medication errors with traditional hand written prescriptions and re-audited following the introduction of a computerised prescribing system.

MethodsDrug charts were reviewed on a daily basis collected over a 17 day period between the 29th of July 2011 and the 14th of August 2011 (period 1) whilst paper drug charts were in use. It aimed to count the number of prescriptions, and the number of prescription errors, as defined by validated categories likely to lead to harm. Additional data collection techniques included asking nursing staff at the bedside about any drug incidents that may have been unrecorded and review of the critical incident database for this period for forms relating to medication errors. Electronic prescribing was then introduced via the existing IntelliVue Clinical Information Portfolio (Phillips). All patients admitted after 00:01 on the 23rd of August 2011 had solely electronic prescriptions made. The audit was then repeated over a second 17 day period between the 29th of October and the 8th of November 2011, again by reviewing the electronic prescriptions, reviewing critical incident forms and asking ICU staff for any unrecorded events. The audit was registered in line with trust clinical governance procedures.

ResultsIn period 1 there were 30 patients and 382 individual prescriptions (mean 13 prescriptions per patient). There were 8 serious errors in 8 patients in this period giving a prescription error rate of 2%, or 27% of patients affected. In period 2 there were 32 patients and 749 individual prescriptions (mean 23 prescriptions per patient). There were 6 serious errors in 6 patients in this period giving a prescription error rate of 0.8% or 19% of patients affected. There was a significant drop in error rates (p< 0.05) per prescriptions ordered.

DiscussionThe decrease in medication errors associated with electronic prescribing supports previous data from studies in intensive care. [1, 2] Further work should evaluate (ideally on a national scale) the longer term harm associated with these errors, and try to quantify what the remaining types of errors equate to in terms of quality of patient care, with the ultimate goal of minimising the harms associated with the treatment of critically ill patients.

References1. Shulman R, Singer M, Goldstone J, Bellingan G. Medication

errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit. Critical Care. 2005, 9:R516-R521

2. Went K, Antoniewicz P, Corner D, Dailly S et al. Reducing prescribing errors: can a well-designed electronic system help? Journal of Evaluation of Clinical Practice. 2010 16: 556–559

3. Evans KD, Benham SW, Garrard CS. A comparison of handwritten and computer-assisted prescriptions in an intensive care unit Critical Care 1998 2(2):73-78

Informed consent for general anaesthesia – an audit of risks discussed with patients.

L. Talbot, G. Paddle

Salford Royal NHS Foundation Trust, Manchester, UKltalbot@doctors.org.uk

It is not currently mandatory to obtain specific written consent for anaesthesia, verbal consent being sufficient. Several guidelines exist to support the consent process [1, 2, 3]. Consent should be informed, with patients being made aware of common and significant risks. In those cases where patients decline to discuss risks, it is advised that the patient is advised of the importance of the discussion and that this is fully documented.

MethodsRetrospective case-note audit was undertaken of 50 patients presenting for surgery, of any surgical subspecialty, under general anaesthesia. Standards stipulated that patients should receive an information leaflet about their anaesthetic or, alternatively, be informed of non-specific risks (sore throat, PONV, dental damage and anaphylaxis) and any additional patient or procedure specific risks.Documentation of anaesthetic risks discussed with patients was assessed from the pre-operative assessment proforma, accessed in recovery post-operatively.

ResultsThe mean patient age was 50 years (range 17-82 years) – 24 (48%) female, 26 (52%) male. Each of the surgical subspecialties present within the trust were represented in the sample. The majority, 19 (38%), had undergone neurosurgery. Consultants performed 32 (64%) of pre-operative consent discussions, PA(A)s 10 (20%), specialty doctors 4 (8%), and trainees 4 (8%). Anaesthetic risks discussed were documented as demonstrated in the figure below. Where ‘other’ risks were discussed with patients these included chest complications [9 (37.5%)]; cardiac complications [9 (37.5%)]; pain [4 (16.7%)]; headache [3 (12.5%)]; CVA [4 (16.7%)]; venous thromboembolic complications [3 (12.5%)]; positioning associated risks [3 (12.5%)]; death [3 (12.5%)]; and further patient-specific risks [8 (33.3%)].

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DiscussionThe informed consent process could be improved by making patient information leaflets more readily available on the day of surgery and by increasing awareness of these amongst trainees. Addition of pre-printed generic risks to the pre-operative assessment proforma would further facilitate documentation of this consent process.

References1. Association of Anaesthetists of Great Britain and Ireland.

Consent for anaesthesia. 2006.2. General Medical Council. Consent: patients and doctors making

decisions together. 2008.3. Department of Health. Reference guide to consent for

examination or treatment. 2009.

Setting up an ‘introduction to tracheostomy management’course for health care professionals in the west of Scotland

K.Tober1 , K.Owen1

Royal Alexandra Hospital, Paisley, Scotlandkatherina@doctors.org.uk

Tracheostomy patients have always been complex to deal with, and following NAP 4, shortcomings in the management of emergencies in this group have been brought to light. As a result of the National Tracheostomy Safety Project (NTSP), algorithms for managing patients with tracheostomies and laryngectomies have been created and arebecoming widely publicized [1]. Intensive care units across the UK oftenhave junior staff that may lack experience in dealing with difficult airways due to many factors, including a reduction in training opportunities. As two senior anaesthetic trainees based in a district general hospital in Paisley, we decided that, after establishing the baseline knowledge of staff that manage tracheostomies, we would runan introductory course for junior ACCS, anaesthetic trainees and nurseswho may have to deal with emergencies in these patients. The aim of the course was to familiarize staff with the NTSP algorithms.

MethodsAs part of the pre-course assessment, twelve anaesthetic and ACCS trainees ranging from ST1-ST3, working at the Royal Alexandra Hospital in Paisley,were given a questionnaire regarding their prior experience in managing patients with tracheostomies. Questions included how well equipped they felt to deal with a tracheostomy emergency. Trainees were also asked to describe their management of patient with a displaced tracheostomy tube and to identify pictures of equipment that can be used in managing a tracheostomy emergency, such as a Mapleson C circuit.The questionnaire exposed a significant need for further education regarding management of tracheostomy emergencies. Using our experience gained by teaching on the NTSP courses, we set up a free ‘Introduction to tracheostomy management’ pilot course in Paisley. The trainees then attended this course, which included a review of relevant NAP4 cases, an introduction to the NTSP and both algorithms.Candidates had an opportunity to practice the algorithms using simulated scenarios. The course also included interactive stations to facilitate the use of airway equipment and had an ENT surgeon discussing anatomy and types of surgical tracheostomies.

ResultsCandidates were given the same questionnaire following the course. Regarding management of a displaced tracheostomy after the teaching,100% of candidates applied high flow oxygen and requested capnogaphy compared with 10 (83%) and three (25%) pre-training. Trainees establishing patency of the tube by passing a suction catheter improved from one (8%) to seven (88%).

DiscussionPrior to the course the trainees did not feel adequately prepared to deal with a tracheostomy emergency and in the case scenario many trainees did not assess the patency of the tracheostomy or suggest a definitive measure for managing the airway.The management of the case scenario improved after training and there was increased familiarity with airway equipment that might be required in the algorithms.Candidates felt that it was a valuable course and rated themselves as more prepared to deal with tracheostomy emergencies in the future.

References1) B.A.McGrath, L.Bates, D.Atkinson, J.A.Moore. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia 2012; 67:1025-1041.

Improving morbidity and mortality in the emergency laparotomy patient

A. Vaughton, S. Baker

Dorset County Hospital, Dorchester, UKavaughton@doctors.org.uk

Recent reports from the Royal College of Surgeons, NCEPOD and the laparotomy network have highlighted a high complication and mortality rate of the emergency general surgical patient [1, 2, 3].Although complications and deaths may be inevitable there are indications that outcomes are much poorer than they should be.

MethodsTo improve outcomes in this group of patients we made a number of interventions. A survey of trust staff to pin point key concerns and recommendations. A review of case notes for emergency laparotomy admissions to highlight areas for improvement and key learning points. The running of live ward based multi disciplinary simulation training in the sick surgical patient focusing on recognition, management and escalation. The design of a simple acronym (TARGET) that encompasses the main clinical needs of this group built on recommendations from the Royal College of surgeons. This was designed into a poster format for display on the surgical wards and trust Network. The design of the TARGET course for junior doctors and nursing staff comprising a series of lectures, low fidelity simulation (based around real cases) looking at uncommon presentations / pitfalls of the sick surgical patient, communication (SBAR) workshop, risk assessment workshop and high fidelity simulation into acute emergency surgical patients. A prospective audit of all emergency laparotomys in the trust.

ResultsFeedback from the course was excellent. 100% of candidates felt the course was relevant, 95% were more aware of the problems when dealing with the sick surgical patient. 96% felt more confident in recognizing and managing this group of patients. 89% felt the TARGET principle would help them approach these patients in a more systematic way. Knowledge of the TARGET principle was measured via a case assessment pre and post course. This showed marked improvements in all key learning points. The prospective audit has shown a decrease in mortality rate (30 day) for emergency laparotomy from 16.67% to 10.5% post interventions.

DiscussionA Combined approach of Multidisciplinary simulation training, implementation of recommendations and a targeted systematic approach to the emergency surgical patient has shown early promising results. Ongoing audit, training and continued implementation of guidelines through the TARGET bundle will aim to continue this current improvement.

References1. NCEPOD—POC: Knowing the Risk Report (2011).2. The Royal College of Surgeons of England/DoH. The

Higher Risk General Surgical Patient: towards improved care for a forgotten group (2011).

3. Saunders D, Murray D, Pichel A, Varley S, Peden C.Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network.British Journal of Anaesthesia 2012; 109 (3): 368-375

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Audit of timing of epidural top-ups prior to delivery; a completed audit cycleJ.K. Wakeford1, and M. Stevens2

Hillingdon Hospital, London, UK, and Hillingdon Hospital, London,UKjkwakeford@gmail.com

The National Institue of Clinical Excellence provides guidelines for the management of epidurals on labour ward. They recommend that “Once established, regional analgesia should be continued until after completion of the third stage of labour and any necessary perineal repair” [1]. The NICE guideline also recommends “Hourly assessment of the level of sensory block should be undertaken”. We were concerned through our follow-up of women post epidural that these guidelines weren’t being adhered to and midwifes were letting epidurals wear off in the mistaken belief that it better enabled women to push.

MethodsFor a six week period from January to February 2012, all women who had epidurals for labour and had a normal vaginal delivery had their epidural chart examined. Time of birth and the timings of epidural top-ups were noted. It was also noted whether the sensory level was recorded. From this average time of epidural top-ups was calculated and time calculated from last top-up to delivery. The audit was repeated in June to July 2012.

ResultsIn January to February, 69 women were identified as having vaginal deliveries with epidurals in situ and had notes available. For these women the average time between top-ups was 68minutes (SD 19min)and the average time between last top-up and delivery was 71minutes(SD 47mins). Out of 69; 51% had a shorter period of time from top-up to delivery than their average time between top-ups. In June to July 2012, 54 patients were identified. The average time from last top-up to delivery was 68 minutes (SD 24mins) and the average time between top-ups was 72minutes (SD 49mins). Out of the 54 women, 65% had a shorter period of time from last top –up to delivery than the average time to between their top-ups. With regards to documentation the block height in the first cycle 61% had their block documented before each top-up. In July 81% had documentation of block height.

DiscussionOur first audit suggested that many women were giving birth in pain despite the presence of a working epidural. From follow-ups on the ward we found out that this was because some of the midwifes were purposely letting the epidural wear off for the second stage. In order to re-educate the midwifes to the evidence that this has no benefit to mother or child we introduced a period of education. For a two week period the midwife in charge for the day at shift handover fed back the results of our audit and encouraged the continued use of epidurals during second stage. We also published the results of the audit in the monthly midwifes bulletin newsletter and produced a poster of the audit results that was placed in the midwifes coffee room. The repeat audit showed that the topping up of epidurals in the second stage is much improved. This time the average length of time from last top-up to delivery, 68 mins, was less than the average duration between top-ups, 72mins. There was an increase from 51% to 65% in women who had shorter times from last top-up to delivery than their average top-up duration. Documentation of sensory levels improved from 61% to 81%. Although of note these checks were done prior to top-up rather than every hour as NICE guidance suggests. We believe this is acceptable practice.

References1. National Institute for Health and Clinical Excellence 2007. Intrapartum care (CG55). London: National Institute for Health and Clinical Excellence.

An audit of hydrocortisone use in the treatment of septic shock

D. Whitmore1, L. Wilson2

1Countess of Chester Hospital NHS Foundation Trust, Chester, UK, 2Countess of Chester Hospital NHS Foundation Trust, Chester, UK.dwhitmore@doctors.org.uk

Corticosteroid treatment in patients with septic shock is controversial. Large multicentre randomised controlled trials demonstrate conflicting results regarding the role of hydrocortisone therapy in septic shock [1, 2]. The 2008 Surviving Sepsis Guidelines [3] provide little clarification on the subject, with the 2012 update still awaited. As such it is the author’s experience that the prescription of hydrocortisone for the treatment of septic shock varies greatly between practitioners, often deviating from what may be considered ‘best practice.’

MethodsIn this retrospective case note audit, we looked at the use of hydrocortisone for the treatment of septic shock in a seven bed ICU ata district general hospital. Ethics approval was not required. In a six-month period we identified 19 patients meeting the inclusion criteria. We evaluated the vasopressor/inotrope requirement upon initiation of hydrocortisone, the duration of hydrocortisone therapy in relation to the duration of vasopressor/inotropic support, along with the clinical response to therapy. The primary aim of the audit was to identify inappropriate initiation and continuation of hydrocortisone.

Results15 (79%) patients had septic shock ‘resistant’ to fluid and vasopressors prior to the initiation of hydrocortisone therapy. Of these only six (40%) patients were prescribed vasopressin, with five (33%) prescribed dobutamine. Four (26%) patients were deemed to have ‘non-resistant shock’ (single vasopressor therapy with noradrenaline <25mcg/min) prior to hydrocortisone therapy. Twelve (63%) patientsresponded to hydrocortisone therapy, as judged by a significant reduction in vasopressor/inotropic support. In this cohort the mean duration of cardiovascular support was 4.4 days (SD 2.2), with a median of four days (IQR 2). In comparison the mean duration of hydrocortisone therapy was 11.5 days (SD 6.8), with a median duration of 10 days (IQR 6.5). The overall mortality for our cohort of patients prescribed hydrocortisone for septic shock was 61%.

DiscussionThere needs to be greater consideration to the type of vasopressor/inotrope used in the management of septic shock, with possible earlier introduction of vasopressin or dobutamine prior to hydrocortisone therapy. Greater attention needs to be paid to the duration of hydrocortisone therapy, as inappropriate continuation can be associated with significant adverse effects. We recommend the production of local guidelines to assist in the management of escalating cardiovascular support, which we will implement following presentation of this audit. A re-audit will then be undertaken.

References

1. Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. The Journal of the American Medical Association 2002; 288: 862-871.

2. Sprung CL, Annane D, Keh D, et al. Hydrocortisone therapy for patients with septic shock. The New England Journal of Medicine 2008; 358: 111-124.

3. Dellinger RP, Levy MM, Carlet JM, et al. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock. Critical Care Medicine 2008; 36: 296-327.

Anaesthesia For Organ Donation In Brainstem Dead Patients: A UK National Survey

M. Wilson1, J. Cupitt2

Salford Royal Hospital, Manchester, UK 1, Blackpool Victoria Hospital, Blackpool, UK 2dr_mingwilson@yahoo.co.uk

The concept of ‘brainstem death’ has emerged both to establish futility and to enable heart-beating cadaveric organ donation. For the purposes of organ donation, brainstem death is considered equivalent at law to death. So, therefore organ retrieval in a brainstem dead patient would be analogous to organ retrieval from a non-heart beating donor. Why do we administer anaesthesia to legally dead people? Are we making a mockery of the brainstem death criteria? There are no up-to-date guidelines on ‘anaesthesia’ for organ donation in brainstem-dead patients. This survey aims to determine the current UK practice. The results will be used to consider the publication of future guidelines.

MethodsAn anonymized electronic survey was created and was approved by the Chair of the Research Committee and Executive Committee of the Intensive Care Society (ICS) and was displayed on their website for two months. The survey link was also emailed to all Clinical Leads for Organ Donation (CLOD) in the UK for them to distribute within their departments. An electronic questionnaire was created using SurveyMonkey®. Responses were imported into a Microsoft® Excel spreadsheet for further analysis.

ResultsThere were 249 respondents, of which 73.1% were Consultants. All respondents have been involved in the administration of anaesthesia for organ retrieval in brainstem dead patients. Half of respondents had been involved in less than five cases of organ retrieval surgery.Thirteen (5.2%) of respondents stated that they do not administer anaesthesia in these cases. Where anaesthesia/analgesia is provided, practices differ so much in the fact that drugs administered and the dosages in which they are given differ tremendously.

DiscussionOrgan retrieval surgery in the brainstem dead can be envisaged as a pre-mortal surgical procedure on a paralysed patient who is undoubtedly irreversibly unconscious. Anaesthetists may suppress the possibility of distress and pain by administration of general anaesthesia; and in addition providing physiological support of the donor during the retrieval stage. We are relatively ‘inexperienced’ in this modus operandi and serious consideration should be given to issue national guidelines for these infrequently occurring cases. The arguments for and against anaesthesia in organ retrieval surgery in brainstem dead patients are most unequivocally going to be an infinite parley.

References1. Conference of Medical Royal Colleges and their Faculties in the

United Kingdom. Criteria for the diagnosis of brain stem death. Journal of the Royal College of Physicians, 1995; 29(5): 381-382

2. Anon. A definition of irreversible coma. Report of the ad hoc Committee of the Harvard Medical School to examine the definition of brain death. Journal of the American Medical Association 1968; 205: 337

3. Dunne K, Doherty P. Donation after circulatory death. ContinuingEducation in Anaesthesia Critical Care Pain 2011; 11(3): 82-86

4. Young PJ, Matta BF. Anaesthesia for organ donation in the brainstem dead – why bother? Anaesthesia 2000; 55: 105–6

Re-audit of management of fracture neck of femurs. Are we improving?

C. Yeow, P. Poh, E. Pillai and J. Dedhia

Lincoln County Hospital, Lincoln, UKcyeow01@qub.ac.uk

Guidelines from AAGBI [1] recommend that hip fractures should be surgically fixed within 48 hours of hospital admission whereas NICE[2] recommends surgical fixation on the day of admission or the day after. The recently published NHFD’s [3] annual national report recorded almost 60,000 cases from 180 hospitals in the UK. Hip fractures occur in patients over 60 years old in at least 95% of cases with 66% having either ASA grade 3 or 4 and associated 30-day mortality of about 10%. The perioperative care of these patients remains a challenge to anaesthetists. Hence, these patients require a multi-disciplinary team in managing their hip fractures.

MethodsA prospective study covering a period of two months was conducted. Pre-operative investigations such as FBC, U&E, Coagulation and ECG and management such as IV fluids, thromboprophylaxis and Orthogeriatrician review were collected. Timing of surgery, ASA grades, anaesthetic techniques and 30-day mortality rate were analysed. Results were compared from the previous audit cycle conducted a year ago.

ResultsFifty patients were admitted with hip fractures. Of these, 66% were females and 34% males. Mean age was 85 years old (SD 7.3). Majority of these patients (72%) were either ASA grade 3 or 4. For pre-operative investigations, all (100%) had FBC and U&E performed but only 86% and 94% had Coagulation and ECG performed respectively. Majority (86%) received IV fluids, 100% was prescribed a thromboprophylaxis and Orthogeriatrician review was conducted in 86% of cases. Forty-nine (98%) patients were surgically fixed. Timing of surgery is shown in Figure 1. Regional anaesthetic was performed in 26 patients (53%) and 23 patients (47%) received general anaesthetic. We had a 30-day mortality rate of 10% in this cohort.

Figure 1: Timing of surgery from admission. Current audit (dark shade) and previous audit (light shade).

DiscussionOur hip fracture patients population reflects national findings. An Orthogeriatrician Consultant was appointed following recommendation from the previous audit. This has resulted in patients having surgical fixation in a more timely manner. We aim to introduce an admission pathway proforma to further enhance the management of hip fracture patients.

References1. Management of Proximal Femoral Fractures 2011. AAGBI

Safety Guideline. June 2012. Association of Anaesthetists of Great Britain and Ireland.

2. NICE Clinical Guideline 124. The Management of Hip Fracturein Adults. June 2011.

3. The National Hip Fracture Database, National Report 2012.

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Provision for the higher risk surgical patient, the Royal Cornwall Hospital perspective.

D. Bunce

Peninsula College of Medicine & Dentistry, Royal Cornwall Hospital, Truro, UKdaniel.bunce@students.pcmd.ac.uk

In 2011 both the Royal College of Surgeons (RCS) and NCEPOD produced updated recommendations for the care of higher risk non-cardiac surgical patients. These both highlight the fact that a large proportion of those who die post-operatively in the general surgical population are considered higher risk patients. It is therefore of great importance to ensure that these patients are readily identified and treated in accordance with the recommendations.

MethodUtilising the RCS recommendations, a patient with “a predicted mortality of ≥5%” was identified on the critical care unit of the Royal Cornwall Hospital [1]. The predicted mortality was calculated using the P-POSSUM score, which the RCS considers one of the “best validated methods” for commencing risk assessment [1]. The patients’wife was approached for consent due to the patient being under sedation. After consent was obtained the patients’ notes were analysedfrom initial presentation through until critical care admission, and compared against the new recommendations to identify points of success and failure.

Case ReportThe patient identified, Mr W, had a final post-operative predicted mortality of 36.903% which is markedly higher than that outlined in the recommendations. Mr W had undergone an emergency, open appendicectomy and had a subsequent admission to critical care. Unfortunately Mr W was not admitted to critical care until more than 36 hours post-surgery at which time he had poor oxygen saturations on 15 litres of oxygen, worsening cardiorespiratory effort and evidence of a small bowel ileus. Following admission to critical care and stabilisation of his hypoxia, Mr W encountered further complications over the nest 17 days including hospital acquired pneumonia, agitation when not sedated and atrial fibrillation that required cardioversion.

DiscussionWhat this case clearly demonstrates is the importance of following recommendations for patients with a high risk of mortality.Disappointingly the Royal Cornwall Hospital was only successful in achieving two of the recommendations provided by the RCS. These were both emergency service provision recommendations which can be considered applicable to all surgical patients, not only those who are considered high risk. There was no documentation of predicted mortality in the notes of Mr W. Furthermore no discussions took place to determine where Mr W should receive his post-operative care –which given his predicted mortality should automatically have been the critical care unit. The Royal Cornwall Hospitals Trust does not currently have a documented care pathway for high risk surgical patients. Therefore it is imperative that the Royal Cornwall Hospital implements a care pathway for higher risk surgical patients as a matter of urgency. This must include a mandatory requirement for the completion of pre- and post-operative risk assessment to aid in determining the optimal location for patient care in line with the RCS and NCEPOD recommendations.

References1. The Royal College of Surgeons of England and Department of

Health. The Higher Risk General Surgical Patient – Towards Improved Care for a Forgotten Group. London. 2011

Are their faces really smiling? - Paediatric pain assessment

H. Donaldson1, Dr H. Laycock1,2, Dr C. Bantel1,2

1. Imperial College Medical School, London 2. Chelsea and Westminster Hospital, LondonE.mail: Hannah.donaldson11@imperial.ac.uk

Children and infants perceive pain[1] and it affects their health, contributes to suffering and prolonged behavioural consequences[2,3]. Pain relief in children is often inadequate[4,5],yet assessing pain improves analgesic provision, reduces pain experience and improves patient satisfaction[6]. Pain assessment in children should be completed with tools appropriate for age, clinical situation and the child’s ability to self-report[7].Are we assessing acute pain accurately in paediatric patients related to local guidelines?

MethodsThirty children admitted to an acute paediatric ward completed self-report pain scores using the Wong Baker Faces Pain Rating Scale. In addition they answered a questionnaire with parents on their pain assessment experience. Medical notes were consulted for data on pain scores and frequency of assessment. These were compared to local guidelines for paediatric acute pain assessment.

ResultsResponder rate was 100%. Children ranges from ages 2-16yrs with mean of 9.7yrs. Equal split male and female, with eight medical and twenty-two surgical patients. Eighty seven per cent did not recognise the Wong-Baker Face Pain Rating Scale. Half self reported pain scores higher than those recorded in the notes, and for all of these patients the pain score recorded in the notes was of “no pain”. All children had regularly documented pain scores, although 33% reported they were not asked regularly about their pain. Ninety per cent of children and parents felt the pain was adequately treated.

DiscussionLocal guidelines recommend the Wong-Baker Faces Pain Rating Scale for paediatric pain assessment. Eighty seven per cent did not recognise this tool suggesting its lack of use clinically. Half the sample had inaccurate pain assessments documented. Reassuringly most children and parents felt pain was adequately managed, despite low use of the recommended assessment tool and inaccurate pain scoring. Recognising pain is important, enabling rapid and appropriate management. This preliminary data suggests the need for a re-education program in paediatric pain assessment, with the aim to improve adherence to local guidelines and assessment accuracy.

References1. Fitzgerald M. The development of nociceptive circuits. Nature Reviews Neuroscience 2005;6(7): 507-520.2. Weisman SJ, Bernstein B, Schechter,N.L. Consequences of inadequate analgesia during painful procedures in children. Archives of Pediatrics & Adolescent Medicine 1998;152(2): 147-149.3.Taddio A, Shah V, Atenafu E, Katz J. Influence of repeated painful procedures and sucrose analgesia on the development of hyperalgesia in newborn infants. Pain 2009;144(1): 43-48.4. Ellis JA, O'Connor BV, Cappelli M, Goodman JT, Blouin R, Reid CW. Pain in Hospitalized Pediatric Patients: How Are We Doing? The Clinical journal of pain 2002;18(4). 262-269.5. Groenewald C, Rabbitts J, Schroeder D, Harrison T. Prevalence of moderate-severe pain in hospitalized children. Paediatric anaesthesia 2012;22(7): 661-8.6. Treadwell MJ, Franck LS, Vichinsky E. Using quality improvement strategies to enhance pediatric pain assessment. International Journal for Quality in Health Care 2002;14(1): 39-47.7. RCN. Pain in Children, 2nd edn. London: RCN. Report number: 2; 2009.

Privacy and dignity in the recovery room after surgery audit, at the Bradford Royal Infirmary (BRI)

T. Foulcher1 and S. Griffin1

Bradford Royal Infirmary 1, Bradford, UK.um09twf@leeds.ac.uk

The recovery room is an area within a theatre suite which allows patients to be closely monitored by specialist staff when they are recovering from anaesthetic. There are many guidelines that advise on recovery room practice [1, 2] which state there should be the provision of curtains and screens for patient privacy [1, 2, 3]. Do patients get enough privacy in the recovery room? Would they benefit if further privacy was provided? With the current guidelines in mind, this study looked at privacy and dignity in the recovery room. It focused on two recovery areas in the BRI, each serving 4 theatres: the ENT recovery area has 5 bays and nucleus has 6 bays. Screens were introduced intothe recovery areas last year; but are these being used to their full potential? Males and females are recovered in the same areas and children recover along side adults.

MethodsA questionnaire was given to consenting patients which asked about their most recent experience in the recovery room (n=114). Questions were split into three main areas: 1) Patient options, 2) medical questions and 3) communication questions. Each question had a tick box answer, and patients could either: strongly agree, agree, neither agree or disagree, disagree, strongly disagree, or N/A. Two researchers collected the data. Patients were approached after they had returned to the ward after recovery. In addition, data already being collected by the anaesthetics team about how long each patient stays after they are fit to leave was analysed (n=269). Ethics approval was not required for this study. The study sample was patients recovering in nucleus or ENT recovery areas of the BRI between 06/06/2012 and 12/06/2012 inclusive.

ResultsNinety six (60%) participants said that they knew before surgery what to expect from the recovery room. Thirty three (29%) participantswere anxious or worried in the recovery room. One hundred and seven(94%) participants said they had enough privacy and 112 (98%) said they felt they had been treated with dignity in the recovery room. Twenty three (20%) participants would have liked more screens or curtains to be used in recovery. One hundred and twelve (98%) said they were overall satisfied with their experience in recovery. The average time spent in the recovery room after the patient was declaredfit to leave was 7 mins (0 mins to 1 hr 14 mins).

DiscussionThe patients overall were satisfied with their experience in the recovery room. Recommendations were made and they include: a new policy for screen use and to provide information for patients about recovery before going to surgery (to increase knowledge and also reduce anxiety in recovery). A re audit would take place to see if the changes enabled the BRI to conform with current guidelines.

Acknowledgements The authors would like to thank Dr Jane Bembridge, Dr Paula Boyle, Carol Close and the staff in the operating theatre departments at the BRI for their help.

References1. Immediate Post Anaesthetic recovery, The Association of

Anaesthetists of Great Britain and Ireland: London 20022. Health Building Note 26. Operating Department. HMSO:

London, 1991.3. The Anaesthesia team (revised edition), The Association of

Anaesthetists of Great Britain and Ireland: London 2005

Epidural anaesthesia and analgesia in hepatic resection

T. Jarbawi1

University of Leeds um09tj@leeds.ac.uk

The use of epidural anaesthesia and analgesia has become increasingly popular in liver resections. However, there remains a concern whether this procedure is safe to use in patients undergoing hepatic surgery due to the risk of coagulopathy and spinal haematoma [1]. Intra-operative hemodynamic instability and post-operative coagulation are difficult to predict and may be unavoidable [1, 2]. This study alsolooks at the prevalence of post-operative shoulder pain after liver resection, which is not compensated for by epidural analgesia.

MethodsThis literature review was done as part of a student selected component (SSC) project. It looks at articles published after the year 2000 which were found using the key words “epidural anaesthesia”, “liver resection” and “shoulder pain”. Studies where patients were not given epidural anaesthesia or analgesia were excluded from the paper.

ResultsResults show significant decrease in platelet count (p<0.001) and significant increase in prothrombin time (p<0.001), activated partial thromboplastin time (p<0.001) and International Normalized Ratio (INR) (p<0.001) post-operatively [3]. There appears to be a relationship between changes in the coagulation profile and the extent of the liver resection [2, 4]. Furthermore, Akpek et al (2003) and Shumann et al (2004) reported a prevalence of post-operative shoulder pain of 5.3% and 75% respectively [5, 6].

DiscussionIt is difficult to comment on the relation between shoulder pain and liver resection and why epidural analgesia is not effective enough to eliminate it, as there is limited literature on the topic. Despite a change in the post-operative coagulation profile, there were no reports of spinal haematoma [2, 3, 4, 6] as an adverse outcome of epidural analgesia. However randomized studies with a larger size sample are needed in order to reflect the risk of spinal haematoma in the hepatic resection patient population.

References1. Feltracco, P, Brezzi, ML, Barbieri, S, Serra, E, Milevoj, M and

Ori, C. Epidural anesthesia and analgesia in liver resection and living donor hepatectomy. Transplantation Proceedings 2008;40: 1165-1168.

2. Matot, I, Scheinin, O, Eid, A and Jurim, O. Epidural Anesthesia and Analgesia in Liver Resection. Anesthesia and Analgesia 2002; 95: 1179-81.

3. Stamenkovic, DM, Jankovic, ZB, Toogood, GJ, Lodge, PA and Bellamy, MC. Epidural analgesia and liver resection: postoperative coagulation disorders and epidural catheter removal. Minerva Anestesiologica. 2011; 77(7): 671-679.

4. Siniscalchi, A, Begliomini, B, De Pietri, L et al. Increased prothrombin time and platelet counts in living donor right hepatectomy: Implications for epidural anesthesia. Liver Transplant 2004; 10(9): 1144-1149.

5. Akpek, EA, Arslan, G, Erkaya, C et al. 2003. Anesthetic risks for donors in living-related liver transplantation: analysis of 30 cases. Transplant International 2003; 16:584-588.

6. Schumann, R, Zabala, L, Angelis, M, Bonney, I, Tighiouart H and Carr, DB. Altered hematologic profiles following donor right hepatectomy and implications for perioperative analgesic management. Liver Transplant 2003; 10(3): 363-368.

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Audit on the emergency induction checklist

M. G. Jones,1 D. Maloney2 and R. M. Knights2

1Cardiff University, Cardiff, UK.2Ysbyty Gwynedd, Bangor, UK.Jonesmg5@cardiff.ac.uk

The Fourth National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society reports that at least a quarter of all major airway events occur in intensive care units (ICU) or emergency departments (ED), and are more likely to result in permanent harm or death than those occurring in anaesthesia (1). In order to address this, it was recommended that ‘an intubation checklist should be…used for all intubations [of ED] and critically ill patients’. Such a checklist was developed and introduced at Ysbyty Gwynedd, Bangor. This audit project aimed to quantify the uptake of the checklist in clinical practice and to evaluate its effect on preparation for intubation.

MethodsTrainee anaesthetists and other healthcare professionals were asked to anonymously fill a 10 question survey for every intubation they attended in critical care areas over a six week period. Data was analysed on one Excel® spreadsheet. Statistical analysis was performed on Minitab® 16. All intubations were scored on a scale of one to seven according to the participant’s response concerning aspects of preparation. A Mann-Whitney test was used to compare the median scores of intubations occurring with and without the checklist. Ethical approval was unnecessary.

ResultsThe checklist was used for 23 (69.7%) intubations. The median score of preparation for intubation was seven (6-7 [3-7]) when the checklist was used and four (4-5 [1-6]) when the checklist was not used. The difference between the median scores was statistically significant (p<0.0001, 95% CI 2-3). For each of the seven measured aspects of preparation for intubation, the proportion of those achieving the standard was higher when the checklist was used. Even when the checklist was used, the discussion of a failed intubation plan was omitted on eight (34.8%) occasions. The checklist identified a problem with six (26.1%) intubations. Twenty-two (95.7%) users did not believe using the checklist caused a significant delay of intubation.

DiscussionAlthough this audit was a small-scale project, the results suggest that using the intubation checklist improves preparation of the patient, equipment and team. The patient’s condition affected the decision to use the checklist; if very unwell, the team decided to proceed urgently to avoid delay of intubation. A difficulty in implementing the checklist may be resistance from doctors. Understanding the role of human factors in errors can help doctors to adapt their practice to minimise risk to patients. Future research into this area should review the effects of introducing an intubation checklist on the complication rates in the ED and ICU, however any prospective study would require a very large number of patients. Recommendations: the team’s clinical judgement should override the recommendation if risk outweighs benefit for the patient; training sessions should encourage use of the checklist and demonstrate its role in reducing human error; training should also provide experience and opportunity to familiarise with the checklist and to improve efficiency of its use.

References1. Cook, T, Woodall N, Harper, J, Benger, J. Major complications

of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. British Journal of Anaesthesia 2011; 106 (5): 632-642.

In-situ patient simulation as a tool for prehospital training

R.McCarthy1 and S.Mitra2

Cardiff University, Cardiff, UK, and Ysbyty Gwynedd Hospital,Bangor, UKmccarthyr@cardiff.ac.uk

Patient simulation is increasingly becoming an essential tool used in medical education, with the most advanced set-ups utilizing wireless computer-controlled manikins1. However, simulation training for prehospital staff is currently limited to part-task simulation (such as intubation manikins), with few centres using computer-controlled manikins2. In this case study we aimed to conduct and evaluate a training simulation located in a community setting and designed for prehospital staff.

MethodsWe designed a simulation scenario using simplicity, realism, and challenge as criteria. The resulting scenario comprised leg trauma complicated by haemorrhagic shock in a young farmer located on his farm. The software was programmed with multiple likely physiologic states, and appropriate props were gathered. The simulation was then carried out with two off-duty paramedic participants equipped with an ambulance. A subsequent feedback session provided qualitative data on the efficacy of the session and recommendations for improvement.

ResultsThe major points made during the feedback session were as follows. Firstly, both paramedics perceived the simulation to be enjoyable and beneficial, and indicated a wish to participate in similar training in future. Secondly, the participants agreed that although the situation was realistic, it was also too “run-of-the-mill” and lacking challenge.Thirdly, the introduction to the manikin was not comprehensive enough and gave away the scenario, precluding the suspense of disbelief. Lastly, limitations of the simulator included overly difficult venous cannulation, due to thick skin and lack of flashback.

DiscussionThat the two participants perceived the simulation session as beneficial overall is of little scientific value alone, especially without quantitative or objective data. However, we hope that this case study will provide a basis for a more expansive pilot prehospital training programme in future, which may provide an opportunity to gather objective data on the efficacy of prehospital simulation training. These results may also provide valuable pointers into the nature of any future prehospital simulation training. One of the most important learning points is that that simulation training uniquely offers a risk-freesolution for training prehospital staff in how to deal with extremely challenging scenarios. This should not be forsaken on grounds of “realism”, as these situations do occur, albeit infrequently.Additionally, it is clear that a thorough introduction on the manikin’s functions is vital in order that the simulation run smoothly. Perhaps running a short example scenario in this session would also improve familiarity. Limitations of using simulated patients such as unrealistic cannulation are difficult to avoid considering the technology currently available. However, as technology develops and newer models become available this may well become less of an obstruction.

References1. Ker J, Bradley P. Simulation in medical education. In:

Swanwick T, editor. Understanding Medical Education. Evidence, Theory and Practice. Chichester: Blackwell Publishing 2010: 164-80

2. Alinier G. Skills benefits of advanced simulation training. Journal of Paramedic Practice 2009; 1(9): 369-75

A cry that can’t be heard

Savage I, Sheng Z, Macpherson B, Connell C, Kennedy G, Marshall C, Mckerron S, Ross IAll at Edinburgh University Medical School, Edinburgh, UKiainsavage@hotmail.co.uk

According to a multi-centre US study, the incidence of awareness is 0.1-0.2%, regardless of where an individual resides and potential differences in anaesthetic agents, administration and monitoring [1]. A group of Edinburgh University medical students investigated the risk factors for, the monitoring techniques that detect, and the professional and patient consequences of, intraoperative awareness.

MethodsThis project was performed by reviewing a variety of primary research and review articles. These articles were critically appraised and conclusions were drawn about the validity of the research material.

ResultsOur review of the literature, suggested a higher incidence of intraoperative awareness amongst cardiac patients, procedures involving neuromuscular blockade and in particular children, with astudy [2] stating the awareness incidence in children under anaesthesia is 0.8%, compared to 0.1%-0.2% in adults. There are contrastingopinions on the Bispectral Index monitor (BIS), with some studies finding BIS guided anaesthesia reduced awareness risk by 82% [3] in those who had a high risk of experiencing intraoperative awareness. However a recent prospective study concluded that there was no superiority of the BIS protocol over a standard End-Tidal Anaesthetic Agent technique, with the incidence of awareness and mortality greater in the BIS group [4]. It was found in one study that 71% of patients, who were aware, had Post-Traumatic Stress Disorder [5]. The group found that there is a low incidence of awareness claims.

DiscussionThere is a significant risk of ‘Awareness under Anaesthesia’, which anaesthetists should consider when selecting techniques especially in patients with risk factors. Once the group had compiled and discussed all of our findings, the practical value of BIS monitoring was considered. During our project, we witnessed the administration of anaesthetics and talked to the anaesthetists about their work. What was interesting was that many were unsure about the value of the BIS monitor, with one describing it as a "random number generator". This illustrates the point that although BIS monitoring has been involved in many clinical studies and has undergone thorough scientific research, it is only relevant if physicians themselves find it useful. This leads to the question of whether the National Health Service should spend large amounts of money on equipment that may only benefit 1 out of 1000 people, and which the anaesthetists may not even use?

References1. Sebel P. S, Bowdle T. A, Ghoneim et al. The Incidence of Awareness During Anesthesia: A Multicenter United States Study. Economics, Education, and Health Systems Research. Anesthesia and Analgesia 2004; 99: p833-8392. Davidson A.J., Huang G.H., Gibson M.A., Jamsen K. Awareness During Anaesthesia in Children: A Prospective Cohort Study.Anesthesia & Analgesia 2005; 100(3): p653-613. Myles P. S, Leslie K, McNeil J, Forbes A, Chan M. T. V. Bispectral index monitoring to prevent awareness during anaesthesia: the B-Aware randomised controlled trial. The Lancet 2004; 363: p1757-17634. Avidan M. S., Jacobsohn E., Glick D et al. A. Prevention of Intraoperative Awareness in a High-Risk Surgical Population. The New England Journal of Medicine 2011;365(7): p591-6005. Leslie K., Chan M. T.V., Myles P.S., Forbes A., McCulloch T.J. Post-traumatic Stress Disorder in Aware Patients from the B-Aware trial. Anesthesia & Analgesia 2010; 110(3): p823-8

The relationship between stigmatization and self-esteem in chronic pain patients

M. Wall1, D. Hegarty2

South Infirmary Victory Hospital, Cork, ROI, Cork University Hospital, Cork, ROImary.wall@umail.ucc.ie

Self stigma, or the internalized cognitive, emotional, and behavioural impact of others’ negative attitudes on a person who possesses a devalued characteristic such as chronic illness, has been associated with lowered self esteem, depression, anxiety, and decreased service utilization [1]. The relationship between self stigma and self-esteem, with chronic pain has not been examined.

MethodsWith ethical approval, chronic pain patients (n=160) completed a set of validated questionnaires: Stigmata Scale for Chronic Illness (SSCI), Rosenberg’s Self-esteem Scale (RSES); Hospital Anxiety Depression Scale (HADS); Brief Pain Inventory short form (BPI); and the General health survey (SF12v2). Data was recorded using Microsoft Excel and analyzed using SPSS.

ResultsOur study population (n=160) was 69.1% female. Table 1 reports the mean age, chronicity of pain, and pain intensity. 77% of patients (123/160) had a lowered self-esteem (RSES score = 17.2 + 14.5) with a mean SSCI score of 50.85 + 19.02 (normal range 24-120). An inverse relationship between stigmatization and self-esteem (Pearson correlation, r = .58, p<0.001) and self-esteem and pain interference (r=.48, p<0.001) was identified. Partial correlation analysis failed to demonstrate a statistically significant relationship between stigmatization and self-esteem (r= .174, p = .040). A positive correlation between stigmatization and anxiety (r=.228, p<.05) and an inverse relationship between self-esteem and depression existed (r=.234, p<.05).

Table 1 shows the mean (+/- SD) age, pain duration, pain intensity (VAS), Hospital Anxiety and Depression (HADS), general health score (Sf12) for chronic pain patients (n=160) attend outpatients clinics.Item Mean (+ SD) RangeAge 53.9 (15.2) 24 – 100Duration of Pain 7.7 (8.5) 0.5 – 56Pain Intensity (VAS) 6.1 (1.7) 2.5 – 10HADS: Anxiety 10.79 (4.72) 0 – 21HADS: Depression 8.65 (4.23) 1 – 19SF12v2: Mental Component 41.51 (10.96) 8.48 – 70.61SF12v2: Physical Component 32.23 (8.23) 17.77 – 53.46

DiscussionPatients with chronic pain are stigmatized, which may contribute to poor health outcomes and act as a barrier to recovery. A significant number of chronic pain patients (77%) report a lowered self-esteem, which was associated with higher levels of anxiety and depression. Preventative interventions targeted at those with low self-esteem may influence clinical outcome in chronic pain patients.

AcknowledgementsThis project received funding from the Health Research Board under the Summer Student Scholarship Scheme.

References1. Rao D, Choi SW, Victorson D, et al. Measuring stigma across

neurological conditions: the development of the stigma scale for chronic illness (SSCI). Quality of Life Research. 2009;18(5):585-95