Reflection made simple - aagbi

The Newsletter of the Association of Anaesthetists of Great Britain and Ireland

INSIDE THIS ISSUE: Join us in Dublin for Annual Congress 2018: Abstract submissions now open Reflection made simple A tale from another health system

ISSN 0959-2962

APRIL 2018

No. 369

Editorial Welcome to April’s issue of Anaesthesia News

Non-Luer Connector in accordance with ISO 80369-6 Non-Luer Connector in accordance with ISO 80369-6

! ! W W E E NN » unchanged needle design » unchanged needle design

Contents

» optimised » optimised hub hub » comfortable handling » comfortable handling » improved » improved grip grip » brilliant chamber » brilliant CSFCSF chamber

RegionalAnaesthesia Anaesthesia Regional

As the days become longer and winter is well and truly behind us thoughts turn to the GAT ASM meeting, to be held in Glasgow in July, and the Annual Congress, which this year is in Dublin’s fair city. Both should definitely be in your diary. These events, along with the Winter Scientific Meeting, are the jewels in the crown of the Association and are always extremely popular. The programmes are already looking pretty special so please book your leave now!

with 80369-6 NRFit™ Non-Luer Connectors with ISOISO 80369-6 NRFit™ Non-Luer Connectors

Patient Safety Patient Safety

Even if you only glance occasionally at the Daily Mail you would think that the NHS is on its knees (or worse). However, spare a thought for Paul Fenton who was unfortunate enough to fall ill abroad, in his adopted country of retiral. His experience will leave you shocked and never knowingly ‘dissing’ our NHS again.

• Reducing of accidental misconnections • Reducing the the risksrisks of accidental misconnections of different supply to different access of different supply lineslines to different access routes routes TM TM NRFit a trademark of GEDSA NRFit is a is trademark of GEDSA andand is is used permission. used withwith theirtheir permission.

Michael Ward, a retired consultant from Oxford, recalls conversations with his father, a pharmacist, who questioned Michael’s decision to become an anaesthetist. Dr Ward clearly had an aptitude and affinity for the specialty and shares his memories with us. I sincerely hope none of you regret becoming an anaesthetist; after 30 years I still believe it is the best decision I ever made and we at the Association are here to support you if ever you have any doubts regarding your career choice. We all like to think we are good trainers and we all recognise a good trainer when we see them in action. Mark Fairbrass devised an online questionnaire which was completed by two different cohorts of trainees. He found consistent results that indicated some trainers were significantly ‘better’ than others. Hopefully constructive feedback will allow those underperforming trainers to ‘up’ their game. In addition to these great articles we also have our regular and popular Anaesthesia Digested, Particles, as well as letters sent in by you. Once again there is something for everyone this month so I really hope you enjoy reading this issue of Anaesthesia News. As always, I and the other members of the Editorial Committee would love to hear from you, so please send in anything you think our members will find entertaining, educational or controversial, and preferably all three! All submissions are very welcome and each is individually assessed on its own merits.

www.sarstedt.com · [email protected] www.sarstedt.com · [email protected] Sarstedt · 68 Boston · Beaumont · LEICESTER LE4 1AW · Tel:+44 116 2359 · Fax:+44 116 2366 Sarstedt Ltd. · Ltd. 68 Boston RoadRoad · Beaumont Leys ·Leys LEICESTER LE4 1AW · Tel:+44 116 2359 023 · 023 Fax:+44 116 2366 099 099

04 Reflection made simple

Craig Bailey Elected Member, AAGBI Anaesthesia News April 2018 • Issue 369

07 The Anaesthesia Trainee Fellowship: what has it done for me?

04

10 A tale from another health system 13 Particles

07

As an appraiser I often have to remind colleagues that they must include their reflections within their appraisal folder. Older anaesthetists such as myself find this particularly difficult because we trained in an era where we were expected to be stoical, not to dwell on the ‘what might have been’ and to get on with our next task. This month we have a piece by Jason Walker that makes the ‘reflection’ part of appraisal easy; simply fill in the appropriate words to complete a statement. This tongue-in-cheek piece is sure to help you! Every year the journal Anaesthesia appoints a trainee editor in open competition for 12 months. In this issue we have the thoughts of Mike Charlesworth, our current talented trainee editor, who reflects on his first four months in post. I hope this will inspire trainees to apply for the next appointment, the advertisement for which is in this month’s issue, with a closing date of the end of May.

• ISO 80369-6: requirements for small • ISO 80369-6: newnew requirements for small borebore connectors in the of neuraxial applications connectors in the fieldfield of neuraxial applications peripheral nerve blocks andand peripheral nerve blocks

03 Editorial

14 Join us in Dublin for our Annual Congress 2018 18 Is the specialty of anaesthesia a waste of medical training? 20 How good a trainer are you? 23 Anaesthesia Digested

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24 Your Letters

14

For the latest news and event information follow @AAGBI on Twitter 20

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The Association of Anaesthetists of Great Britain and Ireland 21 Portland Place, London W1B 1PY Telephone: 020 7631 1650 Email: [email protected] Website: www.aagbi.org Anaesthesia News Managing Editor: Gerry Keenan Editors: Satinder Dalay (GAT), Nancy Redfern, Rachel Collis, Craig Bailey, Tim Meek, Mathew Patteril and Matthew Davies Address for all correspondence, advertising or submissions: Email: [email protected] Website: www.aagbi.org/publications/anaesthesia-news Editorial Assistant: Rona Gloag Email: [email protected] Design: Chris Steer AAGBI Website & Publications Officer Telephone: 020 7631 8803 Email: [email protected] Printing: Portland Print Copyright 2018 The Association of Anaesthetists of Great Britain and Ireland The Association cannot be responsible for the statements or views of the contributors. No part of this newsletter may be reproduced without prior permission. Advertisements are accepted in good faith. Readers are reminded that Anaesthesia News cannot be held responsible in any way for the quality or correctness of products or services offered in advertisements.

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Reflection made simple You went to a conference. You attended most of the talks, you networked, you took notes. You may even have enjoyed yourself.

TABLE 4

•

This was an excellent meeting,

•

and highlighted areas for advancement in

•

This was a worthwhile use of my time,

•

and made me think about the shortfalls within

•

The event was well organised,

•

but forced me to address the limitations in

•

This activity filled a comprehensive remit,

•

and made me proud of what we've achieved in

•

This was a good conference,

•

and helped me to develop a more patient-centred

•

A creditworthy meeting,

paradigm within

•

A fantastic showcase,

•

but threw into sharp relief the contrasts within

•

A pleasurable and productive event,

•

and demonstrated the deficiencies in

•

A very helpful meeting,

•

and allowed me to appreciate the complexities of

•

This opportunity was a positive one,

•

but left me with no illusions as to the steps needed

•

A useful exercise,

•

This conference was valuable,

to improve •

and provided a relaxed forum within which to discuss the needs of

•

and underlined the challenges facing

•

and may help me address productivity within

TABLE 2 •

with many opportunities to network;

•

with lots of opportunity to discuss matters with the

TABLE 5

speakers; •

with a very active social media presence;

•

with a nice balance of didactic teaching and open discussion;

Six months later and you’re faced with that appraisal box titled ‘Reflection’. Previously you’ve put such insights as ‘Good meeting,’ but apparently you need more. Last year’s ‘Educational objectives met,’ earned you a Hard Stare. You need something that sounds meaningful, but what?

•

in a well-appointed venue;

•

with content that dovetailed neatly with my aspirations;

•

in the best traditions of this kind of event;

•

given the subject under discussion;

•

bearing in mind how previous events such as this have disappointed;

•

although the catering was a little lack-lustre;

•

with a good balance of clinical and non-clinical subject matter;

•

Based on previous work [1], we present a system for producing impressivesounding reflections which can win over the most critical of appraisers. Simply take a phrase at random from each of Tables 1 to 5, and put them together in order. This will give you a reflection such as ‘A pleasurable and productive event, with a very active social media presence; it helped me to consolidate my existing knowledge base and highlighted areas for advancement in my practice.’

•

my Trust.

•

my field.

•

my department.

•

my practice.

•

my work.

•

my daily activities.

•

my specialty.

•

my team.

•

my group.

•

our unit.

•

my discipline.

•

our current approach.

coming as it does at an exciting time in this area;

Jason Walker Consultant Anaesthetist, Ysbyty Gwynedd, Bangor.

TABLE 3

There are 248,832 possible reflections, which should be enough to keep you going.

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TABLE 1

Anaesthesia News April 2018 • Issue 369

•

it fulfilled my educational needs

•

it validated my current practice

•

it helped me to consolidate my existing knowledge base

•

it provided much material for reflection

•

it covered an interesting range of topics

•

it led me to question my thinking

•

the Q and A sessions in particular were most informative

•

the presentations were of an especially high standard

•

the speakers were appropriately challenging

•

it was surprisingly stimulating

Acknowledgements The author is grateful to Dr Hugh Godfrey and Dr Declan Maloney (Ysbyty Gwynedd) who lent their expertise to the tables.

•

the topics were unusually wide-ranging

Reference

•

its approach was refreshing


Conflicts of interest The author is a medical practitioner, with a need for annual appraisal. Make of that what you will.

1.

Caddy J. How to say a lot and still say nothing. Today’s Anaesthetist 1998; 13: 36.

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Apply Now: 2018 Round 1 NIAA Grant The first round of NIAA funding for 2018 is now open to applicants. AAGBI/Anaesthesia research grant – up to £75,000 available The AAGBI research strategy focuses on supporting the following key areas: • Patient safety • Innovation • Clinical outcomes • Education and training • Related professional issues (e.g. standards and guidelines, working conditions, medicolegal issues, etc) • The environment NEW Joint AAGBI/ACTACC research grant – up to £60,000 available The AAGBI and the Association for Cardiothoracic Anaesthesia and Critical Care (ACTACC) are jointly inviting a call for research projects up to the value of £60,000. The AAGBI & ACTACC research strategy focuses on supporting the following key areas: • Cardiothoracic anaesthesia, cardiac intensive care and resuscitation • Patient safety • Innovation • Clinical outcomes • Education and training • Related professional issues (e.g. standards and guidelines, working conditions, medico legal issues, etc) • The environment To have a chance of being successful, applications for funding must clearly demonstrate how the proposed project meets one or more of the above aims, as well as providing value for money. The deadline for applications is 12:00 Friday 20th April 2018

Anaesthesia Trainee Fellowship

The Anaesthesia Trainee Fellowship:

what has it done for me?

Applications are invited for a 1-year Fellowship attached to the Journal, starting at the AAGBI Annual Congress in September 2018. The appointment will run concurrently with the Fellow’s usual anaesthetic training programme. The Fellow’s roles will include involvement in general journal business including handling submissions (but not with direct responsibility). The Fellow must also: • • •

Attend the 6-monthly Editors’ away days and Editorial Board meetings during their term; Attend at least one Committee on Publication Ethics forum/ meeting; Attend the AAGBI Annual Congress in September 2018, AAGBI Winter Scientific Meeting in January 2019, and either the GAT Annual Scientific Meeting in July 2018 or Annual Congress in September 2019, and assist in the programmes as required.

The Fellow will be answerable to and supervised by a designated Editor and thence the Editor-in-Chief and Editorial Board. There will be no payment or honorarium but reasonable travel expenses to attend the above meetings will be met, according to usual AAGBI policy. The Fellow and Editor/Editor-in-Chief will compile a brief report at the end of the Fellowship, to be submitted to the Editorial Board and School of Anaesthesia/Deanery as appropriate. Suitable applicants must: • • • • •

Be post-FRCA (or equivalent); Not have a substantive non-training appointment offered or accepted at the time of taking up the post; Be an AAGBI member; Have an interest in, and commitment to, advancement of the specialty via the areas described in the AAGBI research strategy (http://www.aagbi.org/research); Undertake to maintain strict confidentiality regarding all journal/ AAGBI activities;

Selection will be by a panel consisting of the Editor-in-Chief, an Editor and a GAT Committee representative.

Decisions on these applications will be made at the NIAA grant committee meeting in June.

Applications must be received via email by midnight on 31 May 2018 to [email protected], and should consist of:

For more information and to apply visit www.niaa.org.uk/article.php?newsid=597

1. A brief (max. half-page) CV, to include your current position, AAGBI membership number and CT date; 2. A summary (max. 300 words) of a) how you meet the criteria; b) what you can bring to the Fellowship; and c) what you hope to gain from it; 3. In your covering email, please include: i) the name and email address of your current or immediate past Educational Supervisor, who must be available to respond within a few days if contacted shortly after the closing date; ii) a statement that you hereby commit to informing the Editorial Office if you are offered or take up a non-training position between the date of application and the beginning of the Fellowship.

Getting a paper published is hard-work, even for the most experienced academics and professors. My first ‘accept with revisions’ decision came as a medical student for an article submitted to Anaesthesia News, and a recent browse through the corresponding issue, some eight years old, was fascinating [1].

Firstly, topics such as supervision, working hours and fatigue featured highly then as they do now, though it seems significant progress has been made. Secondly, I should have read the ‘How to design a study’ article by the then newly appointed Editor-in-Chief of Anaesthesia, Steve Yentis, somewhat sooner [2]. More on that later. Last year in Anaesthesia News, Annemarie Docherty wrote of her year as Anaesthesia Trainee Fellow and invited applications for the 2017/18 post [3]. I applied, was successfully appointed, and I have completed my first of three rotations with an editor. Matt Wiles was an obvious first choice, as he has much experience of the role having previously supervised Annemarie and Kariem (Annemarie’s successor). When a manuscript is sent to Matt from the Editor-inChief (Andrew Klein), it is also sent to me for my comments and a decision. I receive around six submissions each month and we aim to get a decision to authors within two weeks. Thus far I have helped several authors get their work accepted for publication, and I plan on subediting at least three accepted articles. Peer review and subediting aside, the roles and responsibilities of the Trainee Fellow continue to evolve. Our projects, which usually focus on aspects of publishing as supervised by one or more editors, have produced some excellent outputs. My project – a review of the reporting, quality and conversion of pilot studies in the anaesthetic literature over the last ten years – is well underway, and we hope to present some preliminary results at Annual Congress in Dublin in September. Social media is an increasingly important area where journals can increase their impact and Anaesthesia is ahead of the game. In addition to running the Twitter and Facebook accounts, myself and Andrew write a popular monthly blog to accompany each issue of the journal [4]. The editors meet four times a year, including two meetings at AAGBI conferences where our popular ‘How to publish a paper’ workshop is delivered. I have also, thus far, contributed an editorial, several letters and a Statistically Speaking Anaesthesia News April 2018 • Issue 369

article. Finally, there will be significant changes at the journal in the coming year (watch this space!) and it has been a pleasure to contribute my thoughts about these. So far the post has provided incredible insight into editorial decisions for submitted manuscripts. Just as I would have preferred to learn the lessons from Steve’s article eight years ago [2] rather than through trial and error, I am now learning through the review of many more manuscripts than I will ever write myself, and through peer review of my own reviews! It is difficult to become an editor without experience, yet this experience is difficult to attain. Anaesthesia is one of a small number of high quality medical publications to offer this valuable experience to trainees and for that it should be congratulated. The advert for the next Trainee Fellow features in this month’s issue of Anaesthesia News and, just as Annemarie did, I wholeheartedly recommend it to all interested in further understanding the research process. Regardless, we must find someone to take over in September, as I will be cycling from London to Dublin with others from the AAGBI and there is a good chance I may need a few months off to recover!

Mike Charlesworth Trainee Fellow, Anaesthesia and ST6 Anaesthetics, Cardiothoracic Anaesthesia and ICM, Wythenshawe Hospital, Manchester References

1. Charlesworth M. How green is your gas? Anaesthesia News 2009; 267: 22–3. 2. Yentis SM. How to design a study. Anaesthesia News 2009; 267: 13–4. 3. Docherty A. A year as an editor in training. Anaesthesia News 2017: 356: 5. 4. https://theanaesthesiablog.wordpress.com

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Panel of Quality Assurance assessors for Learn@AAGBI videos

Anaesthesia Study Tour to Japan 12 – 23 September 2018

The AAGBI makes videos from its three major annual conferences (Winter Scientific Meeting in January, GAT Annual Scientific Meeting in May/June, and Annual Congress in September), and occasional other activities, available online on Learn@AAGBI as a powerful educational resource. The AAGBI has a rigorous Quality Assurance process that includes on-site assessment by a member of Council. In addition, all videos are checked and undergo further Quality Assurance before being added to the Learn@AAGBI platform. The Education Committee is now seeking to appoint additional members to its Quality Assurance Panel, to assist with this process. We anticipate 1-3 videos to review per Panel member during the few weeks following each conference, using a standardised assessment template. Training/ support will be available as appropriate/required. We welcome applications from all sections of the membership, but Irish, international and SAS (non-consultant non-trainee) doctors are currently under-represented on the panel. Interested candidates must be AAGBI members and can be of any grade; they should have a clear interest in medical education. Applications should be by email to [email protected] and should include a brief (< 300 words) personal statement describing their suitability for the position. Appointment to the Panel is for three years in the first instance.

For further information please contact Dr William Fawcett, Chair of the Education Committee, via [email protected]. The closing date for applications is 31st May 2018.

The Torii Shrine near Hiroshima

RA-UK ANNUAL SCIENTIFIC MEETING 2018

• Travel through this fascinating country where ancient history jostles with neon modernity and Zen serenity with heaving humanity, while gaining real insight into anaesthesia.

SWANSEA | UK

The

Preoperative Association

SPEAKERS INCLUDE ▌ Dr Michael Barrington (Melbourne, Australia) ▌ Dr Mathias Desmet (Kortrijk, Belgium) ▌ Prof Graeme McLeod (Dundee, UK) ▌ Dr Kariem El-Boghdadly (London, UK)

TOPICS INCLUDE

THURSDAY 10TH MAY 2018 Liberty Stadium Updates and Workshops

The National Waterfront Museum Gala Dinner

FRIDAY 11TH MAY 2018 Brangwyn Hall Scientific Conference Day

▌ Innervation of the hip joint

ADVANCED PREOPERATIVE CARDIAC AND RESPIRATORY INVESTIGATIONS STUDY DAY FOR DOCTORS

17th May 2018

AAGBI, 21 Portland Place, London, W1B 1PY TOPICS TO INCLUDE: Respiratory Function Tests / Transthoracic Echocardiography / Preoperative Biomarkers / Stress Echocardiograms / Interpretation of Cardio-pulmonary Exercise Tests / Preoperative Non-invasive Cardiac Output Measurement

▌ Applications of Fascia Iliaca Block ▌ Safety aspects ▌ Critical evaluation of Quadratus Lumborum Block ▌ Using US Skills Beyond RA

FOR MORE INFORMATION OR TO REGISTER PLEASE CONTACT WWW.RA-UK.ORG

• The tour is led by David Wilkinson, past President of the World Federation of Societies of Anaesthesiology and Vice-President of the AAGBI. • Visit a range of prestigious hospitals in Tokyo, Hiroshima and Matsuyama, meet Japanese anaesthetists and visit the Kobe Japanese Museum of Anaesthesiology. • T ake the bullet train from Tokyo to Hiroshima to visit the Peace Park, cruise across the Inland Sea to Matsuyama and visit the famous castle and gardens, travel via the Naoshima ‘Art Island’ to Kobe and explore traditional Japan in Kyoto. • Partner programme available.

For further details and a brochure, please contact:

All of our Study Days are at a subsidised price of £99 for members and £125 for non-members

Tel: +44(0) 20 7223 9485 [email protected]

For full details and to book your place visit our website or call

www.jonbainestours.co.uk/anaesthesia

W: WWW.PRE-OP.ORG / T: 020 7631 8896

A tale from another health system NHS-bashing is a national pastime in the UK and it’s a popular notion that some other health systems are much better, so I thought your readers might be interested in my own experiences as a patient in one European country. I can report that it’s not always wonderful away from our NHS. For more than 20 years I have had paroxysmal atrial fibrillation (AF) associated with a mitral valve repair done at the Royal Brompton Hospital, London, and have had ablations in both Britain and elsewhere. About a year ago I went to my local GP (in my west European retirement country) with another bout of AF and he referred me to a cardiologist at a hospital about two hours away, a centre of excellence. The door-to-door taxi service, provided by the state, guided me through the ultra-modern reception area, handing over to the nurses on the ward – though this dated from the 1970s and showed it. There was no doctor around and to my surprise I found myself at the end of a list to have coronary angiography, without any explanation. After a 9 hour wait, I was placed on the X-ray table, prepped and draped, and the doctor, meeting me for the first time and noting sternal wires on his screen, asked ‘Oh – have you had an operation?’ I told him I already had a normal angio and had been referred to him for management of my AF. The angio was again normal and, without stents to insert, there was no further interest from this doctor. Before discharge the next day (still in AF), I left a note in the suggestion box recommending they try ‘history – examination – investigation – diagnosis and treatment’ as an excellent method of practising medicine. I got a reply some months later acknowledging my complaint but claiming ‘there was no irregularity found in their billing procedure’. By circumventing the regular channels, I did eventually receive a consultation with another cardiologist at a nearby world centre of excellence to review my AF (which had by then spontaneously reverted to sinus rhythm). He was adamant the AF would return, that I needed another ablation, and should continue the amiodarone (which I had never been on). This time I was first on the list but at this (also 1970s) hospital the ablation, conducted under midazolam, went horribly wrong. A rare event called ‘steam pop’ occurred; if the electrophysiologist lingers too long in one place or tries to do too much during one burn, the irrigating water is explosively vaporised by overheating at the catheter tip, like a steam bubble in a kettle. There is an audible ‘pop’ heard through the chest wall. Even more rarely, this bubble of steam can blow a hole in the atrial wall, as occurred in my case. Tamponade rapidly ensued. Percutaneous aspiration drained half a litre but the blood continued draining, despite reversal of the heparin (this much was in the hospital report), so we proceeded to theatre for an emergency thoracotomy during which 3 litres of blood were drained, the myocardial hole closed, followed by overnight ventilation on ICU with 7 units of blood cells and plasma transfused.

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I woke up intubated, with my arms tied to the bed. Someone eventually took the tube out. (That’s the second time I have woken up with a tracheal tube in place and I urge my younger anaesthetic colleagues to try it for themselves sometime, before insisting on awake extubation for their patients. For the short period before extubation it’s more memorably unpleasant than a thoracotomy incision). A doctor explained there had been some bleeding but no fall in blood pressure and now it was OK. Due to non-sterile techniques on ICU while inserting a urinary catheter, multi-drugresistant E. coli was introduced and septicaemia developed a few days later.

It seems as though this health system works well if you are on the right conveyor belt and everything goes to plan. My complications seemed to make a nuisance of me. I did not receive good care. The official discharge descended into farce. I was wrapped in sterile paper, strapped to a trolley and taken home in the back of an ambulance, despite my telling them I had been mingling with the crowds down in the foyer drinking orange juice a few hours before. The ambulance became lost so I had to undo all the wrappings to sit up and direct them. Two hours later, we arrived home, the rear door was opened and I walked straight out instead of being carried. The ambulance driver was outraged as I hugged my wife: ‘He’s infectious’ he shouted, waving rubber gloves at her to put on.

However, having been extubated, I was sent to a distant surgical ward and knew only that it was the afternoon of the next day, I had assorted tubes and lines and something must have gone wrong. Thank God for the mobile phone so I could text my wife, who talked to my brother (also a doctor), who then contacted the cardiologist to find out some of what had happened.

I never heard from that hospital again (except for a 4 month routine follow-up appointment) and asked my GP if he had received any report, which he sent to me. There were no surgical notes or record of the thoracic haemorrhage, transfusion, ICU stay, etc. The E. coli infection had never happened; it was all business as usual. After 2 months, I contacted the cardiologist asking about the surgical notes which were ‘Still being typed’. It seemed as though everything would be nonchalantly shrugged off.

Two days of postoperative AF had apparently reverted to sinus rhythm, yet for 4 days no cardiologist came near and there was no monitoring. Somewhat befuddled, I finally realised that I no longer seemed to belong to anyone. I was surgical but the surgeon thought he had just stepped in to help a colleague and stepped back again. He left no record of his operation. On one occasion, he passed the bed on his way to see one of his own valve patients and stopped on the way out. ‘Oh’ he said, surprised, ‘I operated on you’. ‘Really?’, said I, ‘what for?’ ‘I drained 3 litres of blood from your chest cavity and pericardium’. ‘So, I was transfused?’ was all I could think of to ask. ‘Yes, about 6 units’ he said gaily. This explained the excruciating pain in my chest for which, being unable to move and with the dressing out of sight, I had not yet found a cause. After seeing the astonished look on my face, he beat a hasty retreat. Eventually the radial artery line was removed. I counted ten different attempts at cannulation. One was well wide of the mark, somewhere over the median nerve, and worth a photo. Perhaps there had been no pulse at the time. Suddenly a strange realisation dawned – those multiple puncture marks spoke of a period of pandemonium during an episode of shock. The breezy explanation I had received in the ICU had been untruthful. I was, in fact, lucky to be alive and to have an intact cerebrum.


The septicaemia responded to meropenem, which had to be given for 15 days for some reason – ‘multi-drug resistant’ being equated with ‘highly contagious’ or ‘highly pathogenic’. Thus I was declared infectious, moved to a single room and confined there with barrier nursing. In fact the contamination was hospital acquired, since I had come in from the purity of the local countryside. The patients’ showers were permanently out of order in the entire hospital (blocked drains), the food was tasteless and inedible, so, unwashed, I sneaked past the ‘barrier’ to the café on the ground floor to eat. I met the surgeon down here as well – a charming man, and we chatted over a snack. He explained he had diverted me from going on cardiopulmonary bypass and had decided on a lateral incision instead.

Later I went to see the GP for a prescription. He put his head in his hands and apologised on behalf of the health service. He is close to retirement and said that in his entire medical career he had never come across a patient treated so badly. I still have fond memories of my three admissions to the good old Royal Brompton Hospital, even if that was 10 and 20 years ago. It’s a great institution. As is, generally, our National Health Service.

Paul Fenton Retired Professor of Anaesthesia, College of Medicine, Malawi

After a second weekend, wasting away, I said I was going to walk out and take a taxi home unless they discharged me. This was a bluff, but by this time some progress was necessary. Therefore, domiciliary intravenous treatment was quickly arranged and a taxi ordered. The nurses were efficient, professional and pleasant. They said I was a good patient – having put up with it all.


11

Particles Cooper J, McQuilten Z, Nichol A, et al. for the TRANSFUSE Investigators Age of red cells for transfusion and outcomes in critically ill adults New England Journal of Medicine 2017; 377: 1858–67. Background Critically ill patients regularly receive red cell transfusions [1] during hospitalisation. These red cells are stored for up to 42 days or 35 days depending on jurisdiction. At present, routine practice is for blood banks to issue the oldest compatible red cells for transfusion. However, uncertainty exists as to whether the changes these cells undergo during storage, so-called ‘storage lesions’ affect patient outcomes. Two recent studies, the ABLE (Age of Blood Evaluation) trial [2], and INFORM (Informing Fresh versus Old Red Cell Management) trial [3] failed to show any benefit to transfusing fresher red cells; however, a meta-analysis including these studies also failed to exclude harm from current practice. The investigators of TRANSFUSE hypothesised that transfusion of the freshest-available red cells would improve mortality. Methods This was a multi-centre, randomised, double-blind parallel-group trial conduced across 59 intensive care units in five countries (Australia, New Zealand, Ireland, Finland and Saudi Arabia) between November 2012 and December 2016. The primary outcome was 90-day all-cause mortality. Any adult admitted to ICU with an anticipated stay of more than 24 h who their clinical team felt needed a red cell transfusion was eligible. Participants were randomly allocated to receive either the freshest-available compatible red cells or the oldest-available compatible red cells (standard practice) (note, this was 35 days in Ireland, New Zealand and Finland, and 42 days in Australia and Saudi Arabia). The treating medical and nursing staff, statisticians and research team were blinded to the allocations. Two staff members not involved in the direct care of each patient checked the products and concealed the collection and expiration date with opaque stickers.

Call for nominations for the AAGBI & AAGBI Foundation Awards Nominations are sought for the following awards: The AAGBI Award is awarded by the Board of Directors of the AAGBI to those who have made significant contributions to the AAGBI, its objects and goals, or its members. The award is not restricted to members of the AAGBI. The current objectives of the AAGBI are: • To advance and improve patient care and safety in the field of anaesthesia and disciplines allied to anaesthesia. • To promote and support education and research in anaesthesia, medical specialties allied to anaesthesia and science relevant to anaesthesia. • To represent, protect, support and advance the interests of its members. • To encourage and support worldwide co-operation between anaesthetists. The AAGBI Foundation Award is awarded by the Board of Trustees of the AAGBI Foundation, the AAGBI’s charity, to those who have made significant contributions to the AAGBI Foundation, its objects and goals. The award is not restricted to members of the AAGBI. The current objectives of the AAGBI Foundation are: • The advancement of public education in and the promotion of those branches of medical science concerned with anaesthesia, including its history.

• •

The promotion of study and research into anaesthesia and related sciences and the publication of the results of all such study and research. The advancement of patient care and safety in the field of anaesthesia and disciplines allied to anaesthesia in the UK, Ireland and anywhere else in the world.

Nominations should take the form of a short description of the nominee’s contributions (no more than one side of A4 paper*). Self-nomination is acceptable. If you nominate someone else, you should gain their approval for your nomination. The closing date for nominations, which should be sent to [email protected], is 25 May 2018. The AAGBI’s Honours and Awards Committee will consider nominations at its meeting on 08 June 2018, and will make recommendations to the Board of Directors of the AAGBI and the Board of Trustees of the AAGBI Foundation, which will determine the recipients of the 2018 AAGBI Awards and AAGBI Foundation Awards. The successful nominees will be informed shortly afterwards. The awards will be made at the AAGBI’s Annual Congress in Dublin (26-28 September 2018) or at WSM London 2019 (09-11 January 2019). * Minimum font size = 12 pt

Results Of 6363 eligible patients, 4994 were randomised and 4919 were included in the primary analysis, with roughly equal proportions in each group. The baseline characteristics of each group were similar, and the groups received 4.1 and 4.0 units of red cells, respectively. The mean storage duration of red cells was 11.8 +/- 5.3 days in the intervention group, and 22.4 +/- 7.5 days in the control group. In the intervention group, 90-day mortality was 24.8%, and 24.1% in the control group (absolute risk difference 0.7% [95% CI, -1.7–3.1]; unadjusted odds ratio, 1.04 [95% CI, 0.91–1.18]; p = 0.57). There was a small statistically significant increase in non-haemolytic red cell reactions in the intervention group. Subgroup analysis showed a small increase in mortality in the intervention group among patients with an APACHE-III score >21.5% Discussion There was no benefit for critically ill adults with transfusion of the freshestavailable red cells. There was a small increase in febrile non-haemolytic reactions with fresh red cells, but its clinical significance is uncertain. This trial therefore supports current standard practice of transfusing the oldest compatible red cells first. This is significant, as a finding in the other direction would put blood banks across the world under huge pressure to deliver the freshest-available red cells to critically ill patients, with significant resource implications. Thus it puts to rest the question over whether fresh red cells are better. Eoin Kelleher SAT 3, University Hospital Galway, Ireland References 1. Walsh TS, Garrioch M, Maciver C, et al. Red cell requirements for intensive care units adhering to evidence-based transfusion guidelines. Transfusion 2004; 44: 1405–11. 2. Lacroix J, H.bert PC, Fergusson DA, et al. Age of transfused blood in critically ill adults. New England Journal of Medicine 2015; 372: 1410–8. 3. Heddle NM, Cook RJ, Arnold DM, et al. Effect of short-term vs. longterm blood storage on mortality after transfusion. New England Journal of Medicine 2016; 375: 1937–45.

Anaesthesia News News April April 2018 2018 •• Issue Issue 369 369 Anaesthesia

Sessler DI. Decision support alerts: importance of validation Anesthesiology 2018; 128: 241–3. Background Electronic anaesthetic records are now widely used and it seems likely that in the near future all hospitals will have them. It is relatively easy to add decision support functions to them, providing interpretation of the recorded variables and thus giving clinicians’ guidance about patient management. This paper looked at an evaluation of one of these systems used in clinical practice. Methodology This paper critically appraises the evaluation of a Decision Support System, called AlertWatch and designed by Kheterpal et al. [2]. This system aims to provide the clinician with advice on avoiding hypotension, limiting tidal volumes and guiding appropriate fluid management. The investigators used two different control groups: one from 22 months prior to the system being available and a contemporaneous one where clinicians did not use the AlertWatch system for advice. The chosen end-points for evaluating the system were various process measures, myocardial and kidney injury, hospital length of stay and mortality. Use of the system during the study period was left to the discretion of the treating clinician. Results Three main sources of bias in the study design were identified. First, timedependent confounding, where outcomes improve over time with subtle, unquantifiable changes in management and so attributing improved outcomes to one single change, i.e. the decision support system, is unfounded. Second, the Hawthorne effect, where the investigator has a vested interest in improving the study outcomes and so the subject is affected by the awareness of being observed. Third, regression to the mean can give a false result when the intervention is implemented in response to a random increase in the study outcomes that happened prior to the intervention and would have reverted to baseline incidence anyway. Discussion The author comments that before and after studies are often invalid due to these sources of bias, but this study did include a contemporaneous control which could have been randomised. Unfortunately, this was not done, leaving the study open to selection bias because allocation was decided by the clinician present. The apparent benefit of this system was much greater when compared with the historical control, but it showed little difference when compared with the contemporaneous control group. This highlights how unreliable the before and after study design is. In the contemporaneous control group, there were small improvements in process measures, but none in the outcome measures. The lack of outcome benefit does not necessarily mean the system does not work and the system presents physiological data in ways that may help clinicians manage more subtle aspects of anaesthesia. Conclusion This paper gives an interesting appraisal of study design for evaluating a new clinical decision tool. Validation of a new decision support system should be based on robust study design and therefore randomisation would have been more appropriate. The author comments that this may have been too onerous because of the number of patients required to demonstrate significance. The author suggests use of an alternating intervention approach, with multiple cycles of alternatively using and excluding use of the system. Changes in practice over time would then be comparable during the crossover period and the Hawthorne effect can be averaged out. In summary, while decision support systems like this may intuitively seem to provide benefit, the guidance provided by this system only provided modest benefit, which supports the author’s assertion that they should be formally tested in the same way as any other medical interventions. Bence Hajdu1, Andrew Selman2 Peri-operative Medicine Fellow, 2ST6 Peri-operative Medicine Fellow, University College Hospital London 1

References 1. Kheterpal S, Shanks A, Tremper KK. Impact of a novel multiparameter decision support system on intraoperative processes of care and postoperative outcomes. Anesthesiology 2018; 128: 272–82.

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ANNUAL CONGRESS DUBLIN, IRELAND

26-28 Sept 2018

for Annual Congress 2018

Convention Centre Dublin

AAGBI’s flagship meeting for the international anaesthesia community comes to Ireland Discounted rates for AAGBI members

Join us in Dublin

BOOK TODAY

Time to shine There are many ways to be recognised and rewarded at Annual Congress 2018.

Abstract submission is now open

Have you worked on an interesting project or clinical case? This is your chance to present your findings at Annual Congress 2018. You can submit an abstract in the following categories: audit and quality improvement, case reports, original research and survey.

SAS audit prize

Roddie McNicol safety prize

Calling SAS anaesthetists to submit an abstract for the AAGBI SAS Audit Poster Prize.

Showcase how you and your team have improved safety in anaesthesia. The prize is open to members of the AAGBI. Your project could involve an individual, department, medical students or allied health care professionals, provided the project lead is a member of the AAGBI.

Barema and AAGBI environment award Demonstrate how your project related to anaesthesia, intensive care or pain management has had and will continue to have a measurable beneficial effect on the environment. The winner will receive a cash prize and a grant for further support and development of the project.

High-profile Keynote speakers, anaesthesia topics, abstracts, workshops, social events and more

www.annualcongress.org

Remember…The winners and runners up will receive cash prizes, and all accepted abstracts will be published in an online supplement of the international journal Anaesthesia.

"Being able to publish my abstract in Anaesthesia is a great accomplishment and winning the first prize is the jewel in the crown". Dr Eid M M Hussein, SAS Anaesthetics, South Tyneside NHS Foundation Trust

The deadline to submit is 23:59 on Tuesday 8 May 2018.

European Accreditation Council for Continuing Medical Education (EACCME) applied for.

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The winner will receive a cash prize and will be invited to make a 3-minute presentation about their safety project at Annual Congress 2018.

www.annualcongress.org/content/abstracts Anaesthesia News April 2018 • Issue 369

Anaesthesia Anaesthesia News News April April 2018 2018 •• Issue Issue 369 369

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GAT in Scotland

ANNUAL SCIENTIFIC MEETINg

04 - 06 JULY 2018

Location: Hilton Glasgow

Trainees, medical students and first year consultants, BOOK NOW!

Association for Cardiothoracic Anaesthesia and Critical Care

Annual Scientific Meeting Joint Meeting with Congenital Cardiac Anaesthesia Network

Bristol

Thursday 14th – Friday 15th June 2018

www.gatasm.org

Call for nominations for the Featherstone Professorship Nominations are sought for the AAGBI’s 2018 Featherstone Professorship, which is awarded to practising clinicians and scientists who have made a substantial contribution to anaesthesia and its related subspecialties in the fields of safety, education, research, innovation, international development, leadership, or a combination of these. Applications should be submitted using the application form available on the website www.aagbi.org/about-us/awards/featherstone-professorship. The closing date for applications, which should be sent to [email protected], is 25 May 2018. The AAGBI’s Honours and Awards Committee will consider nominations at its meeting on 08 June 2018, and will make recommendations to the Board of Directors, which will determine the recipient of the 2018 Featherstone Professorship (if any) at its meeting on the same date. The successful nominee will be informed shortly afterwards. The award will be made at the AAGBI’s Annual Congress in Dublin (26-28 September 2018). Featherstone Professorships are held for two years, during which the holder will be required to deliver a Featherstone Oration at a major AAGBI meeting.

© Dave Pratt

CPET debate Modern Management of Endocarditis Paediatric Failing Heart Physiology in CICU Prehabilitation

www.actaccbristol.co.uk

Pulmonary Hypertension Risk in Cardiac Surgery Thoracic Update Trainee Presentations Using IT for Change

@ACTACCBristol

Is the specialty of anaesthesia a waste of medical training? My father was a successful retail pharmacist, and had a shop in High Road, Leyton, East London. In the 1960s when I was about 15, he told me he had wanted to be a doctor, but as the son of immigrants who had a corner grocery shop in the East End of London, there was no way the family could afford the fees. He settled for an apprenticeship at Timothy Whites & Taylors, a chain of high street pharmacy shops, since taken over and merged into Boots, and then he entered the Chelsea School of Pharmacy, and qualified as a Member of the Pharmaceutical Society of Great Britain.

Living away from home I still saw my parents frequently and often met them on a Thursday evening, my father’s half day closing day, when he and my mother would drive to the West End to see a show or film, and I would join them for a meal. My father was always asking about my courses, and what I had seen, and wanted as much detail as possible so he could vicariously enjoy his youthful ambition to some extent through me. I tried to oblige. Dad still felt I shouldn’t decide too soon what my future should be until I had seen it all, but it became clear he secretly hoped I would become a general practitioner, as this is the field he came into contact with most frequently and felt comfortable with. He was delighted when I told him I had turned my back on psychiatry.

Dr Ward and his father

Pharmacy suited my father as a close fit to being a doctor. He certainly had a bedside manner and empathy which came out when he was in the shop, and there were many patients who would come in to see him rather than have to face the dragon receptionists and the crowded waiting rooms of the nearby GPs’ surgeries. He had an excellent knowledge of treatment and had picked up enough about diagnosis so that he could generally give sound advice and find an over the counter remedy for most complaints. I never heard of him making a bad mistake, so I suspect he was a cautious lay physician.

After the first year of clinical work, we began a rotation of specialty subjects, for a month at a time. When it came to anaesthesia, each student was allocated to one consultant for the entire month, and the idea was that we would trail around the individual lists with him or her (though then it was almost exclusively a ‘him’). If there was no list, either we would be advised by our trainer to go to another theatre or we had time to spend in the library. I was to be attached to Dr Charles James. He had a reputation as being a very gentle and genial person. He provided anaesthesia for several different specialties on several sites, and additionally had started a very embryonic pain clinic. Dr James was an enthusiastic teacher and we hit it off from the onset. He was happy to chat during those long tedious gynae cases on any subject that came to mind, be it anaesthesia or model railways or even current affairs. I thoroughly enjoyed every minute with him. He was a patient instructor who was always happy to let you have a go, once he saw you knew what needed doing, and were able to be taught. He was also a heavy smoker, who needed to go out of theatre for a quick cigarette ever 30 minutes or so, leaving his anaesthetic trainees or students in charge. We always knew where he was and he would return immediately he was called. At the end of a month I was hooked on anaesthesia.

My earliest memories are of living over the shop and walking through it on my way to school, and home again in the evening. I suppose one could say I inhaled medicine from my earliest years so it was no surprise to anyone when I announced that I wanted to become a doctor, and it may have been that very decision that made my father admit his own, unachieved, youthful ambition. I did well enough at school, and my interests were tilted towards the sciences, so it fitted me well. The government of the time required no contribution to the medical school fees, and even gave all students a grant to support them, even if the level of grant was subject to parental means testing. It was not until after my own sons went to college that the idea of parents or students making a contribution to the fees was reintroduced, and that state has moved forward to the sad position we are in now.

Stung by his thoughts

I did well enough in my A levels to take up an offer I had received in response to my application to King’s College Hospital Medical School, with the preclinical five terms leading to the 2nd MB exam being taken at King’s College London. I enjoyed my time at the ‘Strand’, as we referred to KCL, but couldn’t wait to start clinical studies.

When I next saw my father and told him I thought I had found what specialty I wanted to pursue, he went quiet and then said to me, ‘Don’t you think, Michael, doing anaesthesia will be rather a waste of your medical training?’ Looking back, I was stung by his thoughts but I suspect that this would have been a fairly common reaction at the time, with little understanding of our specialty outside the medical profession (and sometimes inside too). Fortunately I did not take his words too much to heart, and as I never felt as drawn to any other specialty I made plans to begin my anaesthetic training as soon as I had finished my preclinical year. I was able to get a post as a Senior House Officer at King’s College Hospital from July 1970.

The course was very structured and exposed us in rotation to most, if not all, specialties. At that time there is no doubt that surgery and medicine were the areas most of us felt were the chief subjects. I remember at that very early stage of my training being attracted to psychiatry, largely I suspect because in my younger years I had really enjoyed a television series about a psychiatrist, who seemed to be able to achieve miracles with his soft voice and demeanour alone. However, this ambition was sadly wrecked when the first real psychiatrist I came across was giving us a lecture on psychosomatic illness and fell asleep at the lectern!

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Fellowship exam (Fellow of the Faculty of Anaesthetists of the Royal College of Surgeons), and got a post as Lecturer in Anaesthetics and Hon Senior Registrar until December 1976. However after 18 months or so I felt that my future lay back in clinical rather than academic anaesthesia, and successfully applied for a post which began at Queen Victoria’s Hospital, East Grinstead, and rotated after 6 months back to King’s. Finally I was appointed Consultant at the Nuffield Department of Anaesthetics, Oxford from July 1977 until I retired in May 2007. The day I was appointed Consultant I called my father to tell him I had been given a post at what I believed to be the most important anaesthetic department in the country, if not the world. He was very happy for me but I remember him saying, ‘Wonderful Michael,’ then there was a pause, a beat too long, before he went on ‘What’s next, will you be a Professor?’ Looking back 40 years to that moment, I wonder whether our profession has managed to educate the public adequately so that my father’s anaesthetic blind spot has been eradicated. Sadly, though I believe it may have cleared a little, I suspect it has not been fully erased.

Looking back 40 years to that moment, I wonder whether our profession has managed to educate the public adequately so that my father’s anaesthetic blind spot has been eradicated. Sadly, though I believe it may have cleared a little, I suspect it has not been fully erased.

Michael E Ward Consultant Anaesthetist (Retired), Oxford

I stayed at King’s for several years, becoming a Registrar there in May 1971, where apart from a 6-month stint in Västerås, Sweden as an underläkare, I continued until September 1973. I then had my Anaesthesia News April 2018 • Issue 369


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How good a trainer are you?

Figure 1. Spread of average score for each trainer 2016, anonymised and in ascending order

21st Anaesthesia, Critical Care and Pain Forum Da Balaia, The Algarve 1 - 4 October 2018

Figure 2. Spread of average score for each trainer 2017, anonymised and in ascending order

www.doctorsupdates.com education in a perfect location®

As trainers we are asked to provide evidence of ‘teaching and facilitating learning’ and reflect upon it; this is part of our annual appraisal and our revalidation. It may become part of our personal development plan. We are all involved in training, be it on-call, in theatre, outpatients, intensive care etc. There is a lack of feedback from these areas which provide the majority of a trainee’s learning experiences. There are initiatives to provide two way feedback following a teaching episode to both trainer and trainee, but none are widely used or ready to use at this stage. Having given all our consultants and Associate Specialists the option to opt out, I devised a SurveyMonkey questionnaire to score each individual on how good a trainer they were. I used a star ranking, 1 star rated as poor and 6 stars as excellent. The questionnaire was emailed to all trainees and responses anonymised during collection. Data collection was carried out for two consecutive years using different cohorts of trainees. Each individual trainer was emailed their own score, the average for the whole department, and where they were in the ranking from top score to bottom score. The email included a graph showing distribution of scores, no details were given on anyone else’s score to maintain confidentiality; the email also included the RCoA Anaesthetists as Educators booklet as a gold standard against which to reflect (Fig. 1). Using their own score, trainers could easily see if they were an outlier from the graph, thus providing information for appraisal and reflection. The cut off for 'poor performers' was done at two standard deviations from the mean score, although the data is not normally distributed it did fit nicely with the clear visual fall off point on both graphs and provided some justification in highlighting the 'poorest' performers to themselves (Fig. 2).

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Given that the scoring was from two completely different groups of trainees, the spread of trainer’s ratings have been very consistent over the two years, giving reassurance the results are reliable. There has been good correlation between scores for each individual over the two years. Unfortunately, this has meant that the poorest three performers from 2016 were still in the bottom four places for 2017. This indicated that simply giving a score and access to written information on how to teach, along with the appraisal system had not improved performance. This form of feedback has been well accepted, people are keen to have evidence for their annual appraisal to support their educational responsibilities. I discussed the poor results with the poorer scoring individuals and this was taken as a constructive interaction. A further questionnaire was carried out to collect more detailed feedback for those who had scored poorly and had requested more detail on their overall score following the original round. Scores on credibility, approachability, communication skills, enthusiasm, mutual respect and willingness to meet training needs were gained. This supplemental questionnaire was done after feedback to the trainer which may explain why the results were good and did not indicate poor performance in the areas trainees considered important. This aspect of timing will be altered next year to make the results more pertinent. The survey will be repeated annually in an attempt to raise training standards. It does require trainers who are open to being assessed and ranked, something we may have become far removed from as consultants and may therefore not be suitable for all departments or individuals. Some may see it as criticism, which it is not – it is a device to identify areas where individual training may be improved. The feedback has always been constructive including support on how to improve training. Anaesthesia News April 2018 • Issue 369

ANAESTHESIA HERITAGE CENTRE

Anaesthesia Heritage Museum in London Free entry

A unique medical science museum devoted to the history of anaesthesia and pain relief. The GMC National Training Survey and summative assessment of trainees gives us one measure of how a department is performing as a group of trainers; but how we perform as individuals is more difficult to assess. It seems appropriate that we ask the trainees themselves to suggest what qualities a good trainer should have and be able to give feedback based on those qualities while we in turn assess them on an RCoA curriculum on both formative and summative formats.

Mark J Fairbrass Consultant Anaesthetist, Bradford Teaching Hospitals NHS Foundation Trust *Declaration of interest: I am a clinical and educational supervisor

Brave Faces

Exhibition open until November 2018

Powerful stories of facial reconstructive surgery during World War I

Opening hours: Monday to Friday 10am-4pm (last admission 3:30pm). Closed on Bank Holidays. Booking recommended.

Visit www.aagbi.org/heritage Find us at: The Anaesthesia Heritage Centre, AAGBI Foundation, 21 Portland Place, London W1B 1PY Registered as a charity in England and Wales no. 293575 and in Scotland no. SC040697.

Africa

Digested April 2018 Pilot multi-centre randomised trial of the impact of pre-operative focused cardiac ultrasound on mortality and morbidity in patients having surgery for femoral neck fractures (ECHONOF-2 pilot) Canty BJ, Heiberg J, Yang Y, et al. This pilot study examined the feasibility of providing focused cardiac ultrasound for all patients having surgery for femoral fractures, an elderly group that typically have multiple comorbidities, and a high incidence of postoperative morbidity and mortality. There is obviously a balance to be struck between ordering extensive investigations (which may delay surgery) or rushing patients to theatre, hoping that the advantages of early surgery outweigh the risks of suboptimal patient preparation. Echocardiography is a technique that has potential to improve the accuracy of diagnosis and to guide physiological optimisation, but formal evaluation

See next month's article to find out how your money is helping SAFE Africa

of cardiac function typically depends on the availability of specialist equipment and cardiologists. Focused cardiac ultrasound is a more rapid goal-directed technique that has fewer barriers to implementation. In a twocentre retrospective cohort analysis of Melbourne patients with femoral neck fracture, the use of focused cardiac ultrasound was associated with a change in patient management in 17 out of the 49 patients, and a three-fold reduction in 30-day mortality (compared with a matched control group). This result provides encouragement for a larger prospective study, but there is also the usual note of caution about using retrospective data.

A systematic review of the incidence of and risk factors for postoperative atrial fibrillation following general surgery Chebbout R, Heywood EG, Drake TM, et al.

Saving lives in Africa through safer anaesthesia In Africa millions lack access to safe anaesthesia. AAGBI’s fundraising campaign, SAFE Africa aims to: Raise £100,000 over two years to improve anaesthesia education and care in Africa, by

Atrial fibrillation (AF) is the most common arrhythmia in the UK, and is associated with increased morbidity and mortality from thromboembolic events. The incidence of AF is known to be increasing along with the average age of the population. It is often diagnosed for the first time following surgery; the reasons for this are obscure, but may be related to ‘postoperative inflammatory response’ or individual predisposition. Chebbout et al. carried out a systematic review that aimed to assess the incidence of new peri-operative diagnosis of AF in a general surgical population (as the majority of reports of new AF are after cardiac or thoracic surgery). A secondary aim was to identify risk factors and outcomes for newonset postoperative AF. Patients were included in the study if they did not have a previous diagnosis of AF but developed it within 30 days of surgery.

Because of large variations in the way the condition has been diagnosed, categorised and recorded in published studies, and the intermittent nature of the condition, this turned out to be a difficult task. The data analysed were from 13 publications that included 52,959 patients. The incidence of postoperative AF was calculated as 10.94% (although this was regarded as a conservative estimate), and a consistent association between newly-diagnosed AF and postoperative complications was also identified. Perhaps predictably, there was a higher incidence following thoraco-abdominal procedures such as oesophagectomy. This is an important paper, establishing baseline data for a condition is increasingly common in postoperative patients.

A new retrograde transillumination technique for videolaryngoscopic tracheal intubation Biro P, Fried E, Schlaepfer M, Kristensen MS.

Scaling-up three-day SAFE obstetrics and paediatrics training courses.

Donate today www.aagbi.org/SAFE-Africa

Finally, for those of you who still find intubation difficult despite assistance from the latest technologies, Biro et al. have described and assessed tracheal transillumination as an aid to intubation with a videolaryngoscope. Mention of tracheal transillumination may provoke symptoms of déjà vu among older readers, but previously published methods have used it to confirm correct tracheal positioning of intubation guides such as light wands. The

new technique uses a disposable ‘Infrared Red Intubation System’ which is placed on the front of the neck and generates a blinking light to help identify the tracheal lumen and increase contrast between the glottis and surrounding structures. Initial results were encouraging, but we also know that visualising the glottis during videolaryngoscopy does not guarantee successful intubation.

N.B. the articles referred to can be found in either the latest issue of Anaesthesia or on Early View (ePub ahead of print) Anaesthesia News April 2018 • Issue 369

B. J. Jenkins, Editor Anaesthesia

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Dear Editor CoRSU is a rehabilitation hospital in Uganda which specialises in orthopaedic and plastic reconstructive surgery with a special emphasis on rehabilitation for disabled children. Although it provides a multidisciplinary approach to rehabilitation, the power house of the hospital is the theatre suite. Many children require repeat surgeries and it is important to endeavour to make the experience in theatre as pleasant as possible. There is also reticence to use opiates on the ward and so the use of regional anaesthesia is an excellent means for providing postoperative pain relief. Until recently, blocks were done by using a nerve stimulator or a landmark technique; however, in the last few months we have been lucky enough to acquire an ultrasound scanner. One of our anaesthetists has also just completed a 6 month WFSA fellowship in regional anaesthesia at Ganga hospital in India. The combination of these two factors (local expertise and appropriate equipment) meant that we found ourselves able to administer nerve blocks safely and effectively, improving our intra- and postoperative analgesia. Local expertise also means that other staff have a mechanism by which to become trained and develop their own ultrasound skills. Since we acquired the ultrasound scanner it has been used on over 50 occasions, primarily for nerve blocks but also for vascular access. As time passes we are expecting its use to increase further. While we are in possession of an ultrasound scanner, not all associated equipment is readily available or cost-effective in the low resource setting in which we practise. Ultrasound probe covers are an important associated piece of equipment as they protect the ultrasound probe, keeping it clean and prevent the probe becoming damaged or contaminated while in use. In lieu of these, our institution has elected to use condoms to cover the ultrasound probe, a strategy used by Ganga Hospital and learnt there by our colleague during his fellowship. These provide an excellent interface between the probe and the patient,

Dear Editor giving a high-quality image on the ultrasound screen (a tightly fitting probe cover with no air bubbles between probe and cover is essential for a good image). In addition, they are cheap, widely available and well designed for this purpose.

your Letters

Our experiences have found that the best way to fit a condom to the probe is as follows:

SEND YOUR LETTERS TO:

1. 2.

3.

Remove the condom from the packet and stretch it horizontally to a greater width than the top of the ultrasound probe Apply gel to the top of the ultrasound probe and roll the condom downwards over the top of the probe. Ensure the tip of the condom does not end up sitting on top of the probe as this will distort the image by introducing air bubbles. We have found that condoms can often split at this stage if inadequately stretched or rolled inside out. A two person technique (as shown) can be helpful The probe should now be tightly covered and ready to use

While the condom thickness may affect the likelihood of it splitting, we have not found the condom colour or presence of contouring/studs to have any effect on ease of application, image quality or overall experience! Anne Kendall1, Sarah Hodges2 Anaesthetic trainee, 2Consultant, CoRSU Rehabilitation Hospital, Kisubi, Uganda

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

The Archies are the 130 mountains in Scotland over 1000 m, with a drop of 100 m on all sides (this differs from the 3000 feet – or 914.4 m – Munros which rather surprisingly have no clear separation criteria). The charitable journey was completed by a group of medical staff from Ninewells Hospital, Dundee, with their family and friends. This included 11 anaesthetists and it turned out to be a very effective team building exercise.

Dear Editor Incorrectly assembled catheter mount We would like to report a problem with GVS Filter Technology catheter mounts. During patient use, a circuit disconnection occurred at the level of the catheter mount due to a loose connection. The 15 mm female/22 mm male connector at one end of the catheter mount was found to be insecurely pushed into the concertina tubing (Fig. 1), leading to a less secure assembly.

Consent given by all to include photographs, which were taken by the authors I was recovering from a ‘minor’ head injury at the time of the Challenge [2], and the event was very helpful for me. Two weeks of fresh air and exercise in the mountains of what Rough Guide readers describe as ‘the most beautiful country in the world’ [3] turned out to be a great form of rehabilitation. However, once the challenge had finished and the dust had settled, I realised I could only really put the whole thing to bed by writing a book. Fig 1. Right hand catheter mount shows incomplete insertion of top connector

Further examination of our stock found a further 88 pieces to be affected and these were removed from clinical use immediately. We contacted GVS Filter Technology and it confirmed that assembly was not performed correctly on the product. On examining a sample of 50 pieces of the same lot number as ours, GVS found them all to be affected. Subsequently, it placed 1775 pieces into quarantine and are awaiting production rework. We raised this as a safety issue using the hospital’s incident reporting system and scheduled discussion at our local Morbidity and Mortality meeting. We also recorded this as a national adverse incident at the Scottish Incident Reporting and Investigation Centre. No patient harm was caused. Pooja Hartley1, Ian Broome2 1 ST4 Anaesthesia, 2Consultant Anaesthetist, Forth Valley Royal Hospital

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Last year, Anaesthesia News published my account of the Archie Mountain Challenge [1].



This turned out to be an interesting journey in itself. The painful process of putting thoughts, ideas and memories into the written word is a craft that takes time, and time is not something that full-time anaesthetists tend to have in abundance. Thankfully I could cheat a little and used contributions from 28 other people who gave their personal accounts of their parts of the journey, but these accounts still had to be edited and spun together in a way that flowed and gave a cohesive story of the entire event. World-record-breaking round-the-world cyclist Mark Beaumont had been very supportive of the original challenge, and kindly added a Foreword. I also had a huge file of original photos of wonderful mountain scenery which needed sorting. Even once the book was written, the process of self-publishing with the help of a professional graphic designer was all consuming. In total the book took over a year to complete. I found it as least as much of a challenge as the original event, but it was also hugely rewarding. The Archies is available at good bookshops and outdoor shops in Scotland. You can also buy it online at the new ARCHIE website: https:// archie.org with all proceeds going to The ARCHIE Foundation. Paul Fettes Consultant Anaesthetist & Honorary Senior Lecturer, Ninewells Hospital & Medical School, Dundee References 1. 2. 3.

Fettes P. The ARCHIE Mountain Challenge – bagging Scotland’s 1000m mountains. Anaesthesia News 2017; 355: 12–4. Fettes P. Reflections on a ‘minor’ head injury. Anaesthesia News 2016; 353: 28–9. Rough Guide. The most beautiful country in the world – as voted by you. 2014. https://www.roughguides.com/gallery/most-beautiful-country-in-the-world

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New London Venue

EBPOM 2018: Annual London Peri-Operative Medicine Congress IET Savoy Place, London, 4-6 July 2018 6th July - POETTS Annual Meeting 6th July - TRIPOM Annual Meeting

Key Speaker’s include:

Professor Paul Myles

Alfred Hospital, Melbourne and Monash University, Australia

Ramani Moonesinghe Professor of Peri-Operative Medicine, UCLH, London

www.ebpom.org 18th Peri-Operative POETTS CPET Course: London, 2nd & 3rd July 2018 see www.EBPOM.org

20th Dingle Congress: Current Controversies in Anaesthesia and Peri-Operative Medicine Dingle, County Kerry, Ireland Monday 8th to Friday 12th October 2018 8th -11th October - UCL & Southampton 20th Annual Congress 12th October - ICSI & SIAA Joint Annual Congress Call for Abstracts - €1000 in Prizes - Deadline 20th July

Current Controversies in Anaesthesia and Peri-Operative Medicine Dingle, County Kerry, Ireland Monday 8th to Friday 12th October 2018 8th -11th October - UCL & Southampton 20th Annual Congress 12th October - ICSI & SIAA Joint Annual Congress Call for Abstracts - €1000 in Prizes - Deadline 20th July



Anna Batchelor

Royal Victoria Infirmary, Newcastle, UK

Ross Kerridge

John Hunter Hospital, Newcastle, Australia

www.ebpom.org 26


My

®

Follow RCoA guidelines by implementing MyPreOp: • It is preferable for one-stop arrangements to be implemented • Electronic systems should be considered • Information from the patient’s PreOp assessment should be readily available, ideally as part of an EPR • Details of websites that provide reliable, impartial and evidence-based information should be made available to patients Royal College of Anaesthetists, 2017

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