SOUTH EAST THAMES SOCIETY OF
ANAESTHETISTS
SETSA MEETING
Promoting Anaesthesia in South East England
Hosted by
DARENT VALLEY HOSPITAL, DARTFORD
9th October 2013
Organising Chairman:
Dr Raman Madan
SETSA Secretary:
Dr Cheng Ong
SETSA President:
Dr Caroline Thompsett
Page 1 of 49
South East Thames Society of Anaesthetists Meeting
Organised by Darent Valley Hospital, Dartford
Venue: Hilton Dartford Bridge Hotel, DA2 6QF
Wednesday 9th October 2013
PROGRAMME
8.30-9.00
8.30-9.00
Set up -Trade Stands
SETSA Council Meeting
9.00--9.30
Registration and Coffee
9.30-9.45
Welcome Address
Dr R Madan, Meeting Organiser
Dr Caroline Thompsett, SETSA President
SESSION ONE
CHAIRPERSON
TBD
9.45-10.15
The Cardiologist and The Anaesthetist in The
Heart Centre
Dr Ed Petzer, Consultant Cardiologist
Dr M Satisha, Consultant Anaesthetist
10.15-10.45
Laser Surgery for Renal Stones and Anaesthetic implications
Mr. S. Sriprasad Consultant Urologist
Dr. Anu Relwani Consultant Anaesthetist
COFFEE
SESSION TWO
11.15-12.45
12.45-13.00
CHAIRPERSON
Dr V Prasad
Trainee Presentations
Prize Quiz
Dr R Madan
LUNCH
SESSION THREE CHAIRPERSON
Dr Mike Protopapas
14.00 -14.30
Microbes and the Anaesthetist
Dr A Gonzalez Consultant Microbiologist
14.30 -15.00
Ultrasound for the Anaesthetist
Dr Richard Beese, Consultant Radiologist
15.00-15.30
Acute Kidney Injury in The ITU and
Anaesthesia for Renal Disease
Dr M Javaid Consultant Nephrologist
Dr T Kaz Consultant Anaesthetist
COFFEE
SESSION FOUR CHAIRPERSON Dr Raman Madan
15.50-16.10
Maternal Sepsis
Dr F Iossifidis. Consultant Anaesthetist
16.10-16.30
Critical Care Update
Dr M Sange Consultant Anaesthetist
16.30 –
Presentation of Prizes
Page 2 of 49
AN AUDIT ON VTE PROPHYLAXIS DURING PREGNANCY AND THE
PUERPURIUM
Dr A. Perham, Dr S. Wade, Dr D. Moor and Dr J. Short
Queen Elizabeth Hospital, Woolwich, South London Healthcare Trust, UK
Introduction
Venous thromboembolism (VTE) remains the 3rd leading cause of direct maternal
death in the UK [1]. The most recent triennium saw a significant reduction in mortality
caused by VTE, which is possibly attributed to the impact of the RCOG green top
guideline (no.37a). 80% of fatal pulmonary embolism in 2003-2005 had identifiable
risk factors [2], and NICE estimates that prophylactic low molecular weight heparin
(LMWH) reduces risk by 60-70% [3].
Aims
1. To audit the compliance of VTE prophylaxis management on labour ward with
the RCOG ‘green top’ guidelines
2. To educate the multidisciplinary team on these guidelines and where
necessary, implement changes to improve compliance.
Standards
 All women should have a completed VTE risk assessment before delivery
 All women scoring 2 or more on the risk assessment should receive LWMH
 All women with scoring 3 or more should receive LWMH plus TEDS
 LMWH showed be dosed correctly for all women
 LMWH is given at least 4 hours after spinal anaesthesia or removal of
epidural catheter in all cases
Methods
Details for patients receiving anaesthetic intervention were recorded, and their notes
were then prospectively audited using a specifically designed proforma. 93 sets of
notes were audited in January and February 2013.
Results of first round
55 patients (59.1%) had a documented VTE risk assessment. Overall, 68 patients
(73.1%) received the correct management for VTE prophylaxis. 9 (9.6%) had LMWH
prescribed but it was not administered. 68% of patients receiving LMWH were
administered the correct dose. All patients had LMWH administered at least 4 hours
after regional anaesthesia. However, 24.5% did not receive the dose for over 14
hours post regional anaesthetic.
Action taken
The results were presented to obstetricians, midwives and anaesthetists at a joint
clinical governance meeting. The presentation involved education on the current
RCOG & NICE guidelines. The green top guidelines were also integrated into the
new Obstetric Anaesthesia guidelines for the hospital, which were distributed to the
multidisciplinary team. An alert sticker was placed on the follow up folders as a
reminder to check VTE prophylaxis as part of the postnatal follow up round. It was
recommended to the maternity department that a standardized VTE risk assessment
form rather than multiple forms for different personnel would lead to improved
compliance and less confusion. A re-audit is planned for February 2014.
Page 3 of 49
References:
1. Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives:
reviewing maternal deaths to make motherhood safer: 2006–08. The Eighth
Report on Confidential Enquiries into Maternal Deaths in the United Kingdom.
BJOG 2011; 118(Suppl. 1):1–203.
2. Reducing the Risk of Thrombosis and Embolism during Pregnancy and the
Puerperium, green top guideline no. 37a, RCOG, Nov 2009
3. Venous Thromboembolism: Reducing the Risk of Venous Thromboembolism
in patients admitted to hospital, NICE Clinical Guideline 2010
Page 4 of 49
ANTIBIOTIC PROPHYLAXIS IN NEUROSURGERY - IMPROVING COMPLIANCE
Dr Pele Banugo, Dr Harpreet Sodhi, Dr Ben Thorpe, Dr Divna Batas, Dr Katy
Laver, Dr Gowri De Zylva
King’s College Hospital, London
Aim:
To assess compliance with local antibiotic prophylaxis guidelines and surgical site
infection (SSI) rate within a major London Neurosurgical unit, and subsequent
influence of targeted education on these endpoints.
Methods:
SSIs are amongst the commonest healthcare associated infections (incidence 520%).1 Prophylactic antibiotics, appropriately timed and dosed, and chosen to take
into account local resistance patterns, play an integral role in reducing the risk of
SSI.2
Phase 1: data proforma used to audit antibiotic administration by anaesthetists
(choice, dose and timing). Phase 2: survey of anaesthetists and neurosurgeons to
assess awareness of existing antibiotic guidelines.
Phase 3: first re-audit to evaluate educational value of phase 2.
Phase 4: 12-month period of targeted education e.g. WHO checklist, laminated
guidelines, trainee induction. Phase 5: second re-audit (retrospective and
prospective limbs) to evaluate efficacy of phase 4.
Results:
Phase 1 (initial audit):
62 cases evaluated.
Correct antibiotic used
in 40% of cases. Eight
percent of patients
developed a surgical
site infection.
Phase 2 (survey): 17
respondents. Only
18% fully aware of
guidelines.
Phase 3 (1st re-audit):
40 cases. Correct
antibiotics: 90%. SSI
rate: 0%
Chart 1. Results summary showing compliance and SSI rates for different phases of the
audit.
Phase 4 (2nd re-audit):
retrospective limb: 40
cases. Correct
antibiotics and timing:
80% and 68%,
respectively. SSI rate:
7.5%. Prospective
limb: 24 cases.
Correct antibiotics and
timing: 96% and 62%.
SSI rate: 0%.
Conclusions:
Compliance with local antibiotic guidelines and, in turn, reduction of SSIs, can be
improved through education and audit, and maintained through periodic
reinforcement. The anaesthetist’s role is paramount in achieving these endpoints.
References:
1. Gifford C, Christelis N, Cheng A. Preventing post-operative infection: the
anaesthetist role. Continuing Education in Anaesthesia, Critical Care & Pain.
Volume 11, number 5, October 2011.
2. NICE. Prevention and treatment of surgical site infection. Clinical Guideline 74,
2008.
Page 5 of 49
HOW LOW DO WE FLOW?
A. Mussad and M. Puchakayala, asyamussad@doctors.org.uk
Guys and St Thomas’ Hospital, London, SE9 1RT, UK
In a trust where over 50,000 patients are anaesthetised a year the cost of volatile
anaesthetic agents constitutes a significant proportion of the trust’s expenditure. Our
perception was that in our department there is a trend towards the use of moderate
to high fresh gas flow rates. As cost reduction in hospitals is a major objective, we
conducted an analysis of individual theatre performance auditing the total FGF rates,
choice of anaesthetic agents and their consumption. The aim was to feedback the
results and reassess the usage of volatile agents following change in practice as a
means of improving our performance.
Methods
Data from 129 anaesthetised cases was collected from the Dräger Primus
anaesthetic machine at Guy’s Hospital during November 2012 and February 2013.
The following data was recorded: the duration of anaesthetic, the flow rates of
oxygen, air and nitrous oxide and the volatile agent used with its consumption and
uptake. Data was collected from fourteen operating theatres with their corresponding
anaesthetic rooms. Cost expenditure on volatile agents was obtained from the
pharmacy department.
Results
Sevoflurane was the most popular volatile agent used during induction and
maintenance of anaesthesia and was used in 77% of cases compared to usage of
Desflurane in 10% and Isoflurane in 11%. Volatile anaesthetic agent consumption
was noted to be highest in the maxilla-facial, emergency, renal, dental and
orthopaedic theatres. This was demonstrated by a high volatile ratio indicating use of
high FGF in these theatres. The average VR for all agents was 3.6 (VR range of 1.217.8). The average VR for Sevoflurane and Desflurane were 3.9 and 2.4
respectively.
The time taken for the MAC to fall to a value <0.6 or to decrease by more than 30%
was on average 7.9 minutes. This duration was noted to be 8.2 minutes where
Desflurane was used as compared to 7.8 minutes with Sevoflurane.
The trend of expenditure on volatile agents over the last 6 years demonstrated a
continuous gradual rise in the consumption of volatile agents.
Discussion
Utilizing a Volatile Ratio allows assessment of the anaesthetist’s efficiency on a case
by case basis. In addition it allows comparison of performance between various
theatres based on the surgical speciality. The great variation in efficiency in our
study, as measured by the Volatile Ratio, could be partly attributed to differing case
mixture between theatres, which included dental theatres where gas induction is
commonly used.
The high number of VR obtained can also be due to the common practice of
employing higher FGF than necessary via semi-closed circle breathing systems
despite the availability of validated and optimal initial flow and vaporiser setting
regimens as set by manufacturer1,2,3. As such, inclusion of the data from the
anaesthetic rooms may have led to falsely high figures.
Page 6 of 49
In theatres where lower FGFs were utilised notably a lower VR was obtained when
compared to theatres with a higher average FGF. The time to “low-mac”, defined as
the time between switching off a volatile agent to the mac value falling to 80% of the
previous, was higher with Sevoflurane than Desflurane in contrast to their known
pharmacological profiles.
The lack of enthusiasm to the use of low FGF has been affected by technical issues,
which are now largely historical. With the advance in technology, machines with
highly sensitive systems allow accurate use of lower FGF. As such, implementing
change in our practice can lead to a significant reduction in the expenditure of
volatile agents.
Recommendations
1. Utilising a logbook on the anaesthetic machine for each individual anaesthetist as
a reflection of their practice and expenditure. This would be valuable in
determining an operator’s efficiency aiding to improved practice by use of lower
fresh gas flow and subsequently reduction in costs.
2. The use of low fresh gas flows aiming for a Volatile ratio of <3. In the next phase
of the audit, we will aim to feed back the data on individual performance against
departmental standards.
In conclusion, collective change in practice can lead to significant reduction in volatile
drug cost so that we able to maintain a complement of wide range of volatile agent
availability.
References
1. How low can you flow? Dräger 2011.
2. Mapleson WW. The theoretical ideal fresh-gas flow sequence at the start of
low-flow anaesthesia. Anaesthesia 1998; 53: 264–72.
3. erou JG, Verheijen R, Booij LH. Model-based administration of inhalation
anaesthesia. 4. Applying the system model. British Journal of Anaesthesia
2002; 88: 175– 83.
Page 7 of 49
AUDIT OF THE DIFFICULT AIRWAY SOCIETY EXTUBATION GUIDELINES IN A
LONDON TEACHING HOSPITAL
R. Krol ST4
Background
In 2011 the Difficult Airway Society (DAS) produced their extubation guidelines.
During the anaesthetic novice period training is focused on intubation rather than
extubation.
Airway complications during extubation are three times more frequent than those
occurring during intubation (12.6 % verses 4.5%). The Anaesthetic Incidents
Monitoring Society has estimated that 1% of patients require an intervention on
extubation over and above supplemental oxygen.
These findings have been confirmed by the Royal College of Anaesthetist’s National
Audit Project 4 in which 38 per cent of complications were related to extubation
alone, including two deaths.
Aim
To survey the awareness of the DAS extubation guidelines amongst the consultants
of Kings College Hospital (KCH), London and to audit their extubation practice
against the DAS guidelines.
Method
Forty consultants at KCH were asked to describe their extubation practice for a fit
and well patient with no airway concerns. Their responses were compared to the
DAS extubation guidelines.
Results
Ninety per cent of consultants were unaware of the DAS extubation guidelines.
Only fifty per cent of consultants would routinely use neuromuscular reversal and
only thirty per cent would use train of four to assess neuromuscular recovery. Fifty
per cent routinely use a positive pressure breath on extubation and only thirty per
cent would wait until a patient could obey commands to extubate them.
Conclusion
The DAS extubation guidelines are poorly adhered to at KCH. Most consultants
were unaware of their presence. In order to address this, a poster presenting the
extubation guidelines is planned with multidisciplinary teaching of novice
anaesthetists and recovery staff. The local extubation complications should be
audited.
Reference
Karmarker S, Varshney S, Trachel Extubation, Continuing Education in
Anaesthesia, 8 (6), 2008
Page 8 of 49
SURVEY OF GLIDESCOPE USE IN A LONDON TEACHING HOSPITAL
R. Krol ST4
Background
Airway complications are a leading cause of anaesthetic morbidity and mortality
according to UK defence societies and the ASA closed claims data.
The Royal College of Anaesthetists National Audit Project 4 concluded that airway
problems arose when difficult intubation was managed by multiple repeat attempts at
intubation, stating that it is well recognised that a change of approach is required
rather than repeated use of a technique that has already failed. A device such as a
glidescope may present an alternative approach as per the Difficult Airway Society’s
intubation guidelines. Such devices have been shown to improve the Cormack and
Lehane grade of intubation.
King’s College London has recently invested in ten new glidescope devices across
the trust including remote areas.
Aim
The aim of this project was to survey the current glidescope use across the trust and
to increase awareness of their presence and encourage their routine use to avoid
airway incidents and improve patient safety.
Method
All anaesthetists were asked to complete a proforma each time they used the
glidescope, describing their location and the use of the glidescope and whether it
had helped with successful airway management between March to June 2013.
Results
Twenty seven surveys were returned from three of the trust’s ten sites. During the
period of March to June 2013 the glidescope was used twelve times in an anticipated
difficult airway and three times for an unanticipated airway. Many senior anaesthetic
trainees and consultants were unaware of the presence of the glidescopes. Many of
us were not using them regularly and few of us had had formal training on it.
Conclusion
Despite King’s College Hospital’s recent investment in ten new glidescopes they are
not being routinely used. Teaching and encouragement of glidescope use is taking
place. The survey will then be repeated to demonstrate an improvement in the use
of the glidescope across the trust.
Reference
The GlideScope Video Laryngoscope: randomized clinical trial in 200 patients, D. A.
Sun, C. B. Warriner*, D. G. Parsons, R. Klein, H. S. Umedaly and M. Moult, BJA 94,
381
Page 9 of 49
IMPROVING EFFICIENCY AND REDUCING COSTS IN ELECTIVE CAESAREAN
SECTIONS
R Campbell, S Bapat, S Sharafudeen, N Parry, V Skelton, D Abell
King’s College Hospital, London
Aim
In a time of austerity and increasing financial pressures on the NHS, cost saving
within the bounds of patient safety is paramount. The National Institute of Clinical
Excellence has issued guidelines regarding requirements for preoperative blood
testsi; however there has been little guidance on essential postoperative
investigations. Therefore we felt it was important to retrospectively analyse data
collated during and after elective caesarean sections performed at King’s College
Hospital and the practice of postoperative analysis of full blood count.
Methods
As part of the MASIMO trial, (ethical approval obtained) both pre-operative and postoperative formal laboratory haemaglobin tests and ‘at point of care’ Hemacue tests
were performed on patients undergoing elective caesarean sections. Dats was also
collected regarding intraoperative blood loss, transfusion requirements, and day 1
formal laboratory haemaglobin tests perfomed. Data was collated and analysed in
Microsoft Excel in order to ascertain if guidance could be given on the use of formal
laboratory tests post elective caesarean section.
Results
Estimated Blood Loss <500ml (n=49)
Hb
Preo
p
Hemocu
e pre-op
12.3
(1.33
)
12.4
(1.42)
Difference
between
Lab/Haemoc
ue
EBL/
ml
Hb
Post
op
Hemoc
ue postop
Hb
Day
1
11.0
11.1
10.8
(1.1
(1.3
(1.29)
6)
5)
Estimated Blood Loss >500ml (n=35)
Difference
Hb
Hb
Hemoc
Hb
Hemocu
between
EBL/
Preo
Post ue post- Day
e pre-op Lab/Haemoc
ml
p
op
op
1
ue
11.6
844
9.7
9.7
11.8(1.7
9.8
(1.26
0.6 (0.72)
(308.
(1.2
(1.1
3)
(1.04)
)
4)
2)
4)
All numbers shown as mean (+/- SD)
0.6 (0.81)
424
(83.6)
Difference
between
Lab/Haemoc
ue
Number
transfus
ed
0.4 (0.41)
1
Difference
between
Lab/Haemoc
ue
Number
transfus
ed
0.3 (0.36)
2
Conclusion
There was no significant difference between the haemoglobin measured immediately
in recovery and on day 1 post elective section. . In otherwise uncomplicated, elective
caesarean sections, with minimal postoperative blood loss, it would appear that a
further FBC taken on the first postoperative day could be omitted with little clinical
significance. The benefits of this could be several fold. Hemacue can be taken from
the lower limb while spinal anaesthesia remains effective, thereby avoiding patient
discomfort. Delayed discharge while awaiting laboratory blood tests and time taken
for phlebotomy, analysis and review could also be reduced; potentially reducing
postnatal workload. In addition, each full blood count (FBC) costs approximately
£2.78. In our institution there are approximately 500 elective caesarean sections
each year, potentially saving £1390/year. If a hemocue (£0.5/cuvette + £390/yr for
calibration solution) is taken in recovery and found to be within acceptable limits our
data suggests an additional full blood count could be avoided, saving a further
Page 10 of 49
£750/year. This data is to be presented to the obstetric audit meeting with a view to
developing guidelines regarding the appropriateness of post-operative formal
laboratory tests.
UNUSUAL PRESENTATION OF PENETRATING CARDIAC TRAUMA
V Patle, R Gray, O Boyd.
Brighton and Sussex University Hospitals Trust, Brighton.
Introduction:
A Stab injury to the thorax and upper abdomen may result in serious injuries to vital
organs. We present the case of traumatic mitral regurgitation following stab injury to
chest, with a self-sealing left ventricular entry wound.
Case description:
A 53 year old male patient presented following a self-inflicted stab injury in the left
sub-costal region. The patient was unwilling to provide any type of detailed history
due to personal reasons. He was conscious, alert and haemodynamically stable
throughout. Leucocytosis with white cell count of 30000 was noted on initial
presentation. CT chest revealed a pericardial effusion (18 mm) and airspace
shadowing in both lungs which was reported as possible infection. Transthoracic
echocardiography revealed good biventricular function and moderate mitral
regurgitation. The mitral regurgitation was thought to be chronic in nature due to the
relative haemodynamic stability and small pericardial effusion in the presence of
good cardiac contractility.
Worsening hypoxia on the cardiac HDU was attributed to community-acquired
pneumonia in view of the CT chest findings of airspace shadowing. Two days after
the initial presentation the patient had worsening hypoxia and had developed chest
radiograph changes compatible with pulmonary oedema, raising the suspicion of the
mitral regurgitation resulting from the recent trauma. Pulmonary artery catheter
studies were performed urgently to rule out traumatic septal defect. Transoesophageal echocardiography showed torrential mitral regurgitation with a flail
anterior mitral leaflet. Urgent cardiac surgery was undertaken. During the inspection
of left ventricle, an injury site just lateral to the LAD (not bleeding) was noted.
Anterior leaflet of mitral valve appeared prolapsed with torn chordae tendinae. The
patient made full recovery following mitral valve replacement.
Discussion:
Approximately 20% of cardiac injuries have no obvious signs and symptoms of
cardiac injuries1. In this case, we believe that the development of mitral regurgitation
as a result of penetrating cardiac trauma was masked by the patient’s unwillingness
to provide accurate history, CT scans suggestive of chest infection and the relative
haemodynamic stability. The entry wound on the left ventricle in this patient is likely
to have sealed as a result of the criss-cross arrangement of myocardial fibers thus
preventing the formation of pericardial tamponade or massive haemorrhage.
Conclusion:
A high index of suspicion of cardiac injury should be suspected with all thorax and
upper abdomen trauma. This patient demonstrated that despite his normal
physiology for 48 hours post injury he had a life threatening cardiac injury. This case
also demonstrates the potential delay of diagnosis when the full history of the events
preceding admission are not available for clinical correlation.
Page 11 of 49
References:
Peter. I. et al. 2013. Stab wound of the heart with unusual sequelae. Texas Heart
Institute Journal. 40 (3); 353-57
QUALITY OUTCOMES IN RECOVERY AUDIT TOOL
J. Gan, E. Dempsey, C. Lanigan
University Hospital Lewisham, London.
Corresponding author: ganjohan@gmail.com
It has become very difficult to measure outcomes in anaesthesia as these are closely
linked to other confounding patient and surgical factors. Traditional mortality
outcomes are unsatisfactory as these events are very rare in anaesthesia. We
studied outcomes in recovery which are patient focused to see if these might be
used to indicate quality of anaesthesia.
Methods
Following local discussion, we set standards for recovery outcomes as follows: <10%
of cases with duration in recovery >2hrs; temperature 36-38C [1]; needing rescue
anti-emetic or analgesia; SpO2<90%; systolic blood pressure <90 mmHg; & <1%
unexpected Level 2/3 admission. Data was extracted using nursing summary ward
chart. The first audit loop was completed in May 2013 and following a feedback
session with the theatre team, the audit was repeated in July.
Results
There were 143 patients in the initial audit and 148 patients in the re-audit. Patients’
demographics and surgical case mix were similar in the audit and re-audit. In the
initial audit, 97 (68%) patients did not have their temperature recorded. Of those that
did, 15 (33%) were recorded as being < 36 o C. One hundred and twelve (76%)
patients had their temperature recorded in the re-audit but 45 (40%) patients were
still hypothermic. In terms of patient comfort, 29 (20%) vs 35 (24%) patients required
rescue analgesia in audit and re-audit respectively. Two (1%) and three (2%)
patients needed rescue anti-emetic in the audit and re-audit. The median (range)
discharge time from recovery was 71.5 (47-97) minutes in the audit and 65 (40-92)
minutes in the re-audit. There was an increase in early discharges (<30 minutes),
five (4%) vs 18 (12%) in the re-audit. One hundred and twenty four (88%) patients
were discharged from recovery under 2 hours compared to 126 (87%) in the re-audit.
For both audits, patients discharged to the Day Surgery ward had the shortest stays
in the first stage recovery area. There were no unexpected Level 2/3 referrals in
either period. There were no records of significant hypotension in the first audit
period although three cases occurred (2%) in the re-audit: while there was one
patient with hypoxaemia in each audit period.
Discussion
The audit criteria were chosen as they reflect morbidity, contribute to patient
satisfaction, and can be directly influenced by the conduct of anaesthesia. The most
striking finding was that having set standards, compliance with temperature
monitoring improved markedly after the feedback process. This may represent
increased staff ‘buy in’ to ensure that standards are met after the group feedback.
Delayed discharges from recovery were postulated to indicate patient complications
and theatre / ward inefficiency. Despite an increase in caseload, there was a quicker
median discharge time in the re-audit period. We found that re-auditing and providing
feedback to the theatre team motivated them to improve their performance. It opened
channels of communication which allowed processes to be streamlined and
problems identified early. We aim to refine this audit tool so that it can be used to
Page 12 of 49
monitor our performance and identify reasons for late discharges through root cause
analysis.
Acknowledgements
L.Ramsey-Powell & T. Emmanuel who led the recovery nurses.
Reference
1. NICE Guidelines CG65 Inadvertent perioperative hypothermia: The management
of inadvertent perioperative hypothermia in adults
http://publications.nice.org.uk/inadvertent-perioperative-hypothermia-cg65
Page 13 of 49
ABSTRACT: AUDIT OF QUALITY OUTCOME MEASURES IN ANAESTHESIA
Dr Smitha Honnesh, Dr Manisha Shah, Dr Kirti Mukherjee
Background/Rationale:
•
•
•
•
•
•
To evaluate the quality of anaesthetic practice and to bench mark our future
performance using following quality indicators in Postoperative recovery
room.
(a) Highest pain score (score 0-10)
(b)Incidence of nausea and vomiting
(c)Maintaining normothermia
To feedback the information from these quality indicators
Ultimate aim is to improve patient outcomes and safety.
Audit criteria & Guidelines:
 There are no set standards or guidelines
 This is a pilot audit to bench mark our practice
Method:
• Prospective audit of 490 patients over a period of 1 month
• All theatre cases requiring Anaesthesia excluding pain blocks.
• Cases performed in Main theatres and Day Surgery Unit.
Key results:
 17.7 % of our patients had a pain score of > 5
 Majority of these cases were minor or intermediate Surgery and these
predominantly were arthroscopies & Gynaecological Surgeries.
 49.9 % of our patients were hypothermic on arrival into recovery. It is a huge
problem.
 9.14% of our patients had nausea and 1.91 % had vomiting.
Recommendations:
 It is a pilot audit to bench marks our practice.
 We should strive to improve on all quality measures
 Attention to Pain Management particularly in minor and intermediate operations.
 Maintaining Normothermia

- Keeping them warm prior to and during Anaesthetic

- Consider Inditherm warming mattress
References:
 Ref(1) Using quality indicators in anaesthesia: feeding back data to improve
care-BJA 109(1):80-91(2012)
 Ref(2) Clinical outcome data, comparative performance reports and
revalidation- A department initiative- RCOA Bulletin 73/May 2012
Page 14 of 49
AN EXPERIENCE OF ANAESTHESIA IN HAWASSA, ETHIOPIA, THE
CHALLENGES, TRIUMPHS AND HOPE FOR THE FUTURE
Dr Shaima Elnour BSc MBChB FRCA
Background: Ethiopia is one of Africa’s poorest states, with 31 percent of its
population of 90 million earning less than $1 per day.1 Due to the prohibitive costs of
healthcare and rural distribution of the population, coupled with poor transport to
access major cities where all secondary and tertiary level care is provided, patients
presented very late in the course of their illness. This consequently translates to a
wide range of pathology that would rarely be seen in the UK. Lack of investment in
healthcare has resulted in weak health care systems and infrastructure. Almost 80
percent of morbidity in Ethiopia is due to preventable communicable and nutritional
diseases, both of which are associated with low socio-economic development.2
Method: I spent 5 months in Hawassa, Ethiopia working in the Referral Hospital
(HRH) which provided care for a catchment area covering 12 million people. During
this time as the only medically qualified anaesthetist, I worked in theatres alongside
the anaesthetic practitioners, supervising their practice and teaching. I was charged
with writing a curriculum for an anaesthesia Bachelor of Science (BSc) programme to
be taught at the university as well as teaching medical students. Time spent outside
of these activities was dedicated to establishing a critical care unit in HRH. I wrote
guidelines, secured grants for staff training, wrote and taught an introductory course
to critical care and set up the unit with funding from the Regional Health Bureau.
Results: I have no statistical evidence to demonstrate whether any of the activities
that I had undertaken have actually improved patient care but I hope they have.
There is now an eight-bedded critical care unit at HRH. The Ministry of Education
has approved the anaesthesia BSc curriculum and the University Board is in the
process of recruiting teaching staff to deliver the course. On a personal development
level, I have been exposed to a wealth of clinical experiences that rarely present
themselves in Britain and have learned a useful lesson from each and every single
one of them.
Discussion: During the time that I spent volunteering in Ethiopia, I was faced with
some challenges that are commonly found in the developing country setting and
were by no means unique to that country. This presentation will outline some of
these challenges, some tips which may help any anaesthetist contemplating a similar
task to survive the experience, perhaps enjoy it and hopefully do some good in the
process.
References:
1) UNData Accessed on 6th September 2013 at
http://data.un.org/Data.aspx?d=MDG&f=seriesRowID%3A580
2) The Earth Institute at Columbia University. Centre for National Health
Development in Ethiopia Accessed on 6th September 2013 at
http://cnhde.ei.columbia.edu/healthsystem/
Page 15 of 49
AUDIT ON CXR REPORTING OF NG TUBE PLACEMENT
EAST KENT HOSPITALS UNIVERSITY FOUNDATION TRUST (EKHUFT)
Dr Sans-Solachi, Dr Hadlow, Dr Kapoor, Dr Strandvik
Background and Aims
NG tube placement has been in focus recently due to being included in the National
Patient Safety Agency (NPSA) list of ‘never events’. The report indicated that there
were problems with misinterpretation of CXRs leading to feed being accidentally
administered into the lung. This occurred at all times but was particularly a problem
‘out-of-hours’ and was also related to the competence/grade of staff confirming NG
positioning.
EKHUFT policy states that reporting of NG tube position should be by consultant
radiologists only both in and out of hours.
This has led to an out-sourcing of reporting out-of-hours (4 Ways Healthcare) and
reports are generated online to confirm NG positioning. There are also sporadic
reports of delays in treatment and feeding across the hospital as a result of untimely
reporting.
The purpose of this audit was therefore to assess whether CXRs were being
reported in a timely manner and to assess the quality of the reporting both in and out
of hours.
Methods
We undertook a retrospective collection of data in 2 intensive care units in East Kent
Hospitals Trust over a 3 month period. Data was anonymised and collected using
our on-line system of Patient Centre (CXR ordering service) and PACS (Radiology
review system). We looked at the number of individual patients undergoing CXRs as
well as whether they were repeated in these patients both in and out-of-hours. We
reviewed whether the report was satisfactory i.e. NG in correct position or whether
further intervention was required e.g. advance NG tube and repeat CXR. We also
reviewed the time taken for the CXR to be performed and how long it subsequently
took for the CXR to be reported both by our on-site radiologists and the off-site
radiologists and subsequently whether this could have an impact on patient
treatment.
Results
The total number of patients undergoing CXRs across the 2 sites was 99 with a total
of 161 CXR being performed on this patient group. In total 123 were satisfactorily
reported in terms of NG position. The time taken to report the CXRs in these
patients were as follows:-
Day Time Hours
Out-of-Hours
<30 minutes
40.19%
11.86%
30-60 minutes
19.6%
35.59%
>60 minutes
40.19%
50.8%
Page 16 of 49
Conclusions
Despite guidance for time frames for NG reporting, NG tube reporting time was
delayed both on site and off site. Particularly of note was more than 50% of reports
took more than 1 hour out of hours. This does not include time for CXR to be
requested and performed and so can visibly cause a significant delay in patient
treatment administration and establishment of feeding and so may have a negative
impact on patient care.
New ways of NG placement confirmation such as electromagnetic devices may help
to minimise patient exposure to irradiation and improve NG confirmation times. In
addition to this, it may be viable to consider specialist radiology training for clinicians
such as ITU Consultants in our trust to minimise delays in reporting.
References
National Patient Safety Agency Alert – published March 2011
Page 17 of 49
OBSERVATIONAL STUDY OF TRANSFUSION PRACTICE IN KING’S COLLEGE
HOSPITAL CARDIAC THEATRES AND RECOVERY
Dr Andreas Zafiropoulos1, Dr Shital Patel2, Dr Saif Baluch3, Dr Desire
Onwochei1, Dr Stephen James4, Dr Daniel Krahne4
Specialist trainee anaesthetics and intensive care, King’s College Hospital, London;
Specialist trainee anaesthetics, King’s College Hospital, London; 3Specialist trainee
intensive care medicine, King’s College Hospital, London; 4Consultant cardiac
anaesthetist, King’s College Hospital, London
1
2
Institution:
King’s College Hospital NHS Foundation Trust
Aim of the study:
Cardiac surgery and cardiopulmonary bypass carry a significant risk of blood loss
and blood transfusion. Transfusion of blood products itself carries significant risks
(infection, transfusion reaction, lung injury and fluid overload)i,i and is associated with
increased morbidity, length of stay, higher mortality and overall costs in cardiac
surgical patients.i,i Evidence suggests that transfusion guidelines as well as point-ofcare (POC) thromboelastometry may reduce transfusion requirements as well as
assist in the decision making process of what and when to transfuse.i
There is currently no transfusion guideline in place and there is significant variability
in the use of POC techniques and transfusion triggers at our institution. Therefore we
sought to investigate transfusion practice in our cardiac theatres and cardiac
recovery to assess whether improvements could be made to our practice. We
defined a high-risk group as those with a pre-op Hb <12g/dL, use of anti-platelet drug
therapy or warfarin within 5 days before surgery, a measured coagulation defect,
those having complex surgery and a time on cardiopulmonary bypass of >180min.
We looked at transfusion intra-operatively and post-operatively up to 24 hours.
Method:
We collected data on 100 patients undergoing cardiac surgery at King’s College
Hospital cardiac theatres between May and September 2013. 6 patients were
excluded due to missing data. Analysis was performed on the remaining 94 patients.
Data was collected on pre-operative blood count, clotting parameters, drug therapy,
intraoperative haemoglobin levels and blood product administration as well as postoperative blood count, blood loss and blood product administration. POC
thromboelastometry was done with TEG® (Haemonetics®, Massachusetts, USA).
Intra-operative heamoglobin level and blood gases were analysed with the i-STAT®
1 Analyzer 300 (Abbott, Illinois, USA). Full blood count and coagulation tests were
performed in the central laboratories at King’s College Hospital.
Results:
Of the 94 patients undergoing cardiac surgery, 60 (63.8%) had coronary artery
bypass grafting (CABG), 28 (29.8%) valve replacements, 8 (8.5%) CABG & valve
replacements and 5 (5.3%) aortic repair.
Page 18 of 49
Overall 62 (66.0%) patients received blood products, 43 (45.7%) red blood cell
transfusion (RBC), 39 (41.5%) fresh frozen plasma (FFP) and 36 (38.3%) platelets
(PLT).
51(54.2%) patients were defined as high-risk and within the first 24 hours, 30
(58.8%) received RBC, 24 (47.1%) received FFP and 23 (45.1%) received PLT. In
the low risk group the numbers were 13 (30.2%), 15 (34.9%) and 13 (30.2%)
respectively.
Of the 62 patients receiving blood products, 20 (32.3%) were transfused intraoperatively, 21 (33.9%) post-operatively and 21 (33.9%) patients received blood
products both, intra and post-operatively.
A total of 379 units blood products were transfused (119 RBC, 187 FFP and 73 PLT)
of which 42 (35.3%) of RBCs, 68 (36.4%) FFP and 37 (50.7%) PLT were transfused
intra-operatively with the remainder transfused post-operatively in the cardiac
recovery unit.
Thromboelastometry was used in 34.0% of patients intra-operatively and 4.3% of
patients post-operatively. The transfusion threshold for RBCs appeared to be
between 7-9 g/dL intra-operatively and 7-11g/dL post-operatively.
Discussion:
This observational study was designed to characterise transfusion practice in cardiac
theatres and cardiac recovery to assess whether improvements could be made to
our transfusion practice. We demonstrated a very high transfusion rate (66.0%)
within our patient group with the majority of blood product units (61.2%) being
transfused post-operatively.
A wide transfusion threshold for RBCs was identified both pre and post-operatively
and although thromboelastometry was used more frequently in theatre than the postoperative period, it was only used to guide a minority of non-RBC transfusions.
This prospective audit was relatively small and although the aim was to include
consecutive patients this was not achieved. However we were concerned to see our
suspicions confirmed by the data we collected. These figures appear to be clinically
significant in their difference to other published studies. We feel that there is great
room for improving our transfusion practice and aim to do this with the following
interventions. We have developed a blood transfusion guideline based on existing
and well published recommendations, adapted to our local requirements. We will
commence the use of a TEG-guided transfusion protocol including functional
fibrinogen testing and, a soon to be acquired platelet function analyser. We have
asked our surgical colleagues to propose a RBC transfusion trigger for use on the
post-operative cardiac recovery unit which they run without the assistance of 24/7
critical care support. Finally we will re-audit of transfusion rates six months after the
introduction of this approach.
i
Knowles S (ed.), Cohen H on behalf of the Serious Hazards of Transfusion (SHOT)
steering group. The 2010 Annual SHOT Report 2011. www.shotuk.org.
i
Shaw RE, Johnson CK, Ferrari G, et al. Balancing the benefits and risks of blood
transfusions in patients undergoing cardiac surgery: a propensity-matched analysis.
Interactive cardiovascular and thoracic surgery 2013; 17: 96-103.
i
Galas FR, Almeida JP, Fukushima JT et al. Blood transfusion in cardiac surgery is a
risk factor of increased hospital length of stay in adult patients. Journal of
Cardiothoracic Surgery 2013; 8: 54.
i
Horvath KA, Acker MA, Chang H et al. Blood transfusion and infection after cardiac
surgery. Ann Thorac Surg 2013; 95: 2014-201.
Page 19 of 49
i
Weber CF, Gorlinger K, Meininger D et al. Point of care testing: A prospective
randomised clinical trial of efficacy in coagulopathic cardiac surgery patients.
Anaesthesiology 2012; 117(3): 531-547.
SALBUTAMOL INHALER IDENTIFIED AS HALOTHANE DURING TOTAL
INTRAVENOUS ANAESTHESIA.
Salota V*, Parras T**, Lanigan C**
*Anaesthetic SpR, ** Consultant Anaesthetist.
University Hospital Lewisham, London SE13 6LH
Purpose/Objective
We report a false positive anaesthetic vapour signal in a patient receiving inhaled
salbutamol during total intravenous general anaesthesia.
Material and Methods
Forty-three year old male smoker, BMI 29.4 kg/m2, ASA I with no known allergies
admitted for a daycase knee arthroscopy. Following the application of standard
monitoring of ECG, NIBP, SpO2 and ETCO2, we induced general anaesthesia with
Alfentanil 1 mg and Propofol at 200 µg/kg/min before inserting an I-gel size 5.
Dexametasone and Ondansetron were also given. Anaesthesia was maintained with
Propofol 120 µg/kg/min with an FiO2 of 50% oxygen in air, allowing spontaneous
ventilation throughout.
Oxygen saturation fell to 93% around ten minutes into the procedure. When
auscultation revealed bilateral wheeze, we administered salbutamol from a metered
dose inhaler (“Ventolin”) through a 50 mls syringe connected with a T-piece to the
breathing circuit (fig 1). We were then surprised to see a screen display on the
Aestiva/5 suggesting an endtidal halothane concentration of 8%, which rapidly
decreased to 0% (figs 2 & 3). This coincided with the salbutamol administration and
was repeated on several occasions. Oxygen saturation rose to 98%, and the
remainder of the procedure and recovery were uneventful.
Result
The Aestiva/5 gas monitor failed to recognise the carrier gas norflurane in a
salbutamol inhaler and mis-attributed it to halothane. Had we not been using TCI
propofol, we might erroneously have reduced the anaesthetic vapour concentration,
risking awareness under anaesthesia or worsening bronchospasm due to inadequate
anaesthesia.
Conclusion
Some inhaled devices have the potential to interfere with infrared anaesthetic gas
monitors1,2.
References
1. Sellers WFS. Ventilator delivery systems for asthma inhalers. Br J Anaesth 2013;
110(5): 871P-872
2. Levin PD, Levin D, Avidan A. Medical aerosol propellant interference with infrared
anaesthetic gas monitors. Br J Anaesth 2004; 92(6):865-9
Page 20 of 49
Figures
Fig 1: Salbutamol inhaler connected to breathing system
Fig 2: Anaesthesia monitor showing “Halothane” waveform while salbutamol is
administered.
Page 21 of 49
Fig 3: “Halothane” decreases to 0% following completion of administration of
Salbutamol.
Page 22 of 49
A SERVICE EVALUATION OF THE MONITORING OF SENSORY BLOCKADE IN
LABOUR EPIDURALS
Dr Swinda Esprit & Dr Francoise Iossifidis
Background:
Labour epidurals are commonly performed by Anaesthetists on Labour wards, but
they are monitored by Midwives whilst in use providing analgesia for mothers in
labour. At Darent Valley Hospital, patient observations whilst the epidural is in use
are recorded on a proforma. The proforma gives guidance for the frequency of
assessing the level of the sensory block achieved by the epidural. There is concern
that the best practise is not being followed, and sensory block height is neither being
assessed nor recorded. It is necessary to quantify this because there is a risk that
“high blocks” will go unidentified, which is especially a risk if the patient goes to
theatre and has the epidural “topped-up” with high dose local anaesthetic for an
emergency procedure. A baseline assessment is also a necessary consideration
before expanding the epidural provision to include “walking” epidurals, during which
sensory block height monitoring is essential.
Aims & Objectives:
Aim – Is there best practice, in the monitoring of sensory blocks achieved by Labour
Epidurals?
Objectives- Quantify: 1. How often is the initial sensory block level check
performed?
2. Is the sensory block checked whilst the epidural is in situ? If
so, how often?
3. Average length of time labour epidural is in situ
4. Mode of delivery of baby for the women with epidural
Design:
Fifty-one sets of notes were randomly selected from women who had Labour
epidurals placed in June 2012 on the Labour ward at Darent Valley Hospital. The
labour notes were examined and data from the proforma recorded.
Results: total of 51 notes examined. Full data recovered in 40/51 for duration of
epidural and mode of delivery.
1. Initial block level check performed in 2/51 (4%)
2. Regular block level checks performed in 5/51 (10%)
3. Average length of epidural in situ- 4.8hrs, median length of epidural in situ5hrs
4. Outcomes:
a. SVD 15/40 (37.5%), 1 went to theatre for MROP
b. LSCS 13/40 (32.5%)
c. Forceps delivery 7/40 (17.5%)
d. Ventouse delivery 5/40 (12.5%)
Number of epidurals “topped up” in theatre 26/40 (65%)
Page 23 of 49
Conclusions:
The sensory blocks of Labour epidurals are not being checked adequately and so
there is the potential risk of a high block being missed. This is a particular risk when
the epidural is “topped-up” with stronger local anaesthetic for an emergency
operative procedure. Out of this audit’s population, 65% of epidurals ended up being
topped-up. The absence of adverse events related to high blocks and labour
epidurals may in part be due to the patient-controlled delivery system of the
epidurals, so the epidural will only be topped up if pain is felt during labour. However,
the emergency top-up risks respiratory compromise and complete spinal anaesthesia
in the mother with an unrecognised spinal catheter. Therefore, best practise should
be observed. Anaesthetists should also be aware of this risk when they are
performing the top-up.
As a result of the findings of this survey, we recommend re-education of the
Midwives and Anaesthetists working on the Labour ward at Darent Valley Hospital, to
explain the importance of monitoring sensory block height whilst an epidural is in
situ. The epidural proforma should also be re-launched, and documentation of
sensory block height emphasised. “Walking” epidurals have been shown to increase
maternal satisfaction1. However if they were to be introduced, a culture where the
epidural sensory block is recorded regularly is essential for safe maternal
ambulation. Motor blockage would also need to be assessed formally; the Bromage
scale2 would be suitable.
References
1. McGrady, Elizabeth, and Kerry Litchfield. "Epidural analgesia in labour."
Continuing Education in Anaesthesia, Critical Care & Pain 4.4 (2004): 114117.
2. Vallejo, Manuel C., et al. "Effect of epidural analgesia with ambulation on
labor duration." Anesthesiology 95.4 (2001): 857-861.
Page 24 of 49
AIRWAY MANAGEMENT IN THE EMERGENCY DEPARTMENT: LESSONS
LEARNED FROM NAP4
A. Medniuk*, R. Grimaldi, P. Westhead
Royal Sussex County Hospital, Brighton , UK
gingerabb@yahoo.co.uk
Purpose
The 4th National Audit Project of the Royal College of Anaesthetists (NAP4)
identified airway management outside of theatres as being high risk, with at least one
quarter of reported adverse events occurring in the Emergency Department (ED) or
Intensive Care Unit [1]. This finding prompted our institution to look into current
practice in our ED.
Method
A retrospective case note review of all patients admitted through the ED as a
“Trauma Call” over an eight month period was conducted. Inclusion criteria were
adult patients (aged over 18), requiring intubation in the ED. Use of our ‘challengeresponse’ Rapid Sequence Induction (RSI) checklist was investigated along with
data regarding airway management technique [2].
Results
Thirty five patients out of 465 trauma calls (7.5%) required intubation in the ED, of
which documentation was found for 22 (63%). No adverse airway events were
documented as per NAP4 criteria [1].
Documentation of Airway Management
Documented in the correct place
18/35 (51%)
Documented somewhere in the case notes
22/35 (63%)
RSI Checklist used
4/22 (18%)
Difficult airway trolley present
5/22 (23%)
Difficult intubation
9/22 (41%)
Manual in line stabilisation used
13/22 (59%)
Cricoid pressure applied
11/22 (50%)
Capnography used
10/22 (45%)
Discussion
1. Implementation of the RSI checklist is inadequate [2]. Awareness of it was found
to be lacking, so formal training sessions have been arranged.
2. Incidence of difficult intubation is far more common than previously realised. It is
hard to find concordance for a definition of difficult intubation, however the literature
quotes a range of the order of 0.5-15% [3], which is significantly lower than our
incidence. Planning for difficult/failed intubation [1], with available advanced airway
management tools is required.
3. Adherence to standard practice and monitoring guidelines during RSI is not
evident from the current documentation.
4. Currently, documentation of RSI undertaken in the ED is ad hoc. A new
anaesthetic document has been produced to give efficient and clearly structured
documentation of anaesthesia provision outside of theatres, for which formal training
sessions are planned.
Page 25 of 49
References
1. Cook T, Woodall N. 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–
42
2. First do no harm: a multifaceted study focusing on the use of checklists within
the emergency department. Swann F, Brighton & Sussex Medical School,
University of Sussex.
3. Emergency airway management: a multi-center report of 8937 emergency
department intubations. Walls R, Brown C, Bair A, Pallin D, J Emerg Med.
2011;41(4):347.
Page 26 of 49
CONVERSION OF EPIDURAL ANALGESIA DURING LABOUR TO SURGICAL
ANAESTHESIA FOR EMERGENCY CAESAREAN SECTION: AUDIT OF
CURRENT PRACTICE OF EPIDURAL TOP-UPS
Buchanan Dr Salota V and Agarwal M
Labour Ward, Maternity Unit, University Hospital Lewisham, London SE13
Introduction:
Epidural mixtures containing local anaesthetic [LA] solutions with or without adjuncts
are commonly used to extend labour epidural analgesia to surgical anaesthesia for
emergency C-Section. There is still no consensus about the most appropriate choice
of local anaesthetic solution[LA]despite previous studies[1,2]and guidelines. Given
the rising C-Section rate in UK[3] and establishment of enhanced recovery
programmes for elective C-sections[4], we sought to establish how extension of
epidural blockade was achieved in a busy outer London Maternity Unit at University
Hospital, Lewisham, London, UK.
Aims
The aim of this study was to determine current management and choice of Local
Anaesthetic solutions with/without opioids for “topping-up” epidural analgesia to
provide surgical anaesthesia for emergency C-section given the large number of
rotating trainees who have been trained in other units. We aimed to discover which
local anaesthetic solutions were used, volumes used, where they were administered,
whether a test dose was used, whether an epidural opioid was given and where they
were removed
Methods
4 week observational study using a simple postal/e-mail questionnaire and sent to all
Obstetric Anaesthetists covering Labour Ward { Consultants, Trainees comprising
SpR/ST3-6/CT1-2 and Clinical Fellows[CF]/Staff Grades[SG]}
Results
Response Rate: 25/32 replies [>78% response rate] 5/10 CT1-2; 11/12 SpR; 4
CF/SG
Test Dose: All Anaesthetists except 2 SpR’s gave a test dose before giving
remainder of the dose
Range of LA solutions and volumes
16 Trainees[SpR &CT1-2]
5/7 Consultants
65% 0.5% Bupivacaine alone/+2% Lignocaine[10-18mls] 0.75 % Ropivacaine [ 510mls]
35% 0.75% Ropivacaine [10-15mls] Incremental Doses
Epidural Opioids: Most Anaesthetists usually/sometimes administered epidural
Diamorphine at end Emergency C-Section. Fentanyl not used.
Location Epidural Top-Up : All administered in Delivery Room or Theatre
Removal Epidural: All removed Theatre or Recovery
Findings
Topping-up a working epidural gives good surgical anaesthesia for emergency CSection
Majority of Consultant Anaesthetists used 0.75% Ropivacaine in small incremental
doses 5-10ml
Page 27 of 49
Majority Trainees still used 0.5% Bupivacaine either alone/or in combination 2%
Lignocaine in larger doses [10-18ml]. Choice Local Anaesthetic solution depended
on operator familiarity & preference
Combination of adrenaline-bicarbonate-lignocaine not used.
All epidural top-ups were undertaken in Delivery Room or Theatre
Test Dose usually administered prior to giving full dose of top-up
All epidural catheters removed theatre or Recovery
Conclusions & Recommendations
A working epidural facilitates provision of anaesthesia for surgery avoiding need for
general anaesthesia, even for Category 1 C-sections with the appropriate & timely
choice and volume of local anaesthetic solutions and opioids. There are advantages
to enhanced recovery pathways even following emergency C-section in women
without complications[4]. Given recent safety warnings about NSAID [especially
Diclofenac] and Codeine in pregnancy, expression in breast-milk and effect on foetal
respiration, every opportunity should be taken to maximise regional analgesia &
anaesthesia.
References
Extension of Epidural Blockade for Emergency Caesarean Section: A Survey
of Current UK Practice.
Regan K.J. and O’Sullivan G.O. Anaesthesia 2008:63:136-142
Extending Epidural Blockade for Emergency Caesarean Section. A
Comparison of Three Solutions
Lucas DN, Ciccone GK, Yentis SM. Anaesthesia 1999:54:1173-7.
Office for National Statistics; Births and Deaths in England and Wales 2011;
Http:// www.ons.gov.uk/final 2012
Enhanced Recovery in Obstetrics: A New Frontier: Editorial
Lucas DN, Gough KL. International J. Obstetric Anaesthesia 2013:22:92-95
Page 28 of 49
INVASIVE LINE INSERTION – DOCUMENTATION & CARE PRACTICE
Dr M Kanagarathnam, Dr S Sparkes, Dr C Anderson
Kings College Hospital NHS Trust
Aim of the study: To identify and improve our standard of care in invasive line
insertion
Background:
A 2006 prevalence survey showed 42% of blood stream infections are central line
related in England. Introducing Matching Michigan principles and care bundles
reduced Catheter related blood stream infections CRBSI from 7.7 to 1.4 per 1000
central line insertions. But this requires an audit to ensure the key policies and
practices are implemented appropriately1. We are aware that there are a lot of care
bundle packages used in several trusts across the country2. We also had recent
critical incidences of arterial cannulation, misplaced guide wires, pseudo aneurysm
and retroperitoneal haematomas.
Method:
After registration in our audit department we evaluated our critical care units looking
at our invasive lines with details of documentation and visual inspection of the lines
in a day. We used a standardised proforma to fill the details of the line type, site of
insertion, date of insertion, documentation details, etc.
Results:
Out of the 82 invasive lines on the day of our study 27% of them had no
documentation at all. 75% of the arterial lines which accounts to 50% of the lines are
not documented. There was better documentation with central lines. 97% of the lines
were secured appropriately. Complications were recorded in very few cases. 48% of
the lines had no operator identifiable. All the subclavian and central lines have chest
x-ray requested but only quarter of them being documented as checked.
Page 29 of 49
Conclusion:
This was presented in an interdepartmental meeting to raise the issue and formulate
a solution. We debated about the reasons for poor documentation and the need for
education with good support measures. For immediate impact this was presented to
the trainees on induction every 3 months to raise the awareness of the problem.
There is a future plan to create an invasive line documentation proforma to be filed
into the notes with vision to extending this into our existing electronic record when
intensive care is fully integrated into a paperless system. Our changes will be
evaluated at regular intervals to improve the standard of care in line with General
Medical Councils Good Medical Practice guidelines3 .
References:
1 http://www.his.org.uk/files/3813/7088/0820/4_epic2_National_EvidenceBased_Guidelines_for_Preventing_HealthcareAssociated_Infections_in_NHS_Hospitals_in_England_2007.pdf
2 http://www.sicsag.scot.nhs.uk/HAI/SICSAG-central-line-insertion-bundle120418.pdf
3 http://www.gmc-uk.org/static/documents/content/GMP_2013.pdf_51447599.pdf
Page 30 of 49
ASSESSING THE IMPACT OF TWO SIMPLE INTERVENTIONS TO IMPROVE
POSTOPERATIVE BETA-BLOCKER AND STATIN ADMINISTRATION AND
TROPONIN MEASUREMENT FOLLOWING MAJOR VASCULAR SURGERY
H Arunachalam and M Harper
Department of Anaesthetics, Royal Sussex County Hospital, Eastern Rd,
Brighton, BN2 5BE
European Society of Cardiology(ESC) guidelines recommend continuing betablockers and statins postoperatively and monitoring troponins following major noncardiac surgery 1 as raised levels are associated with worse outcomes 2. Following a
baseline audit of local practice we now report the findings of a re-audit after the
implementation of two simple interventions to improve compliance with the
guidelines.
The aim of the interventions was to ensure all patients taking statins and betablockers preoperatively received them on the first two days following their operation
and to quantify the numbers of patients at a higher risk of morbidity by measuring
postoperative troponin levels. We therefore affixed stickers to the drug charts
exhorting ward staff to ensure beta-blockers and statins were administered
postoperatively and provided pre-filled blood request forms for postoperative troponin
measurements on the front of the patients’ notes. Data was collected for 100
consecutive elective major vascular patients.
Improvements were seen in both drug administration and postoperative troponin
monitoring. These are summarised in the table below.
This audit indicates that simple interventions can lead to better compliance with the
ESC guidelines for patients undergoing major vascular surgery. A high proportion of
patients had raised troponins postoperatively but at which level this warrants
intervention and what interventions are appropriate remain unclear.
Preop Beta blocker
Beta blocker administered post op
Initial audit
%(number)
32% (16)
12% (6)
Re-audit
%/(number)
32% (31/97)
65% (14/22)
Preop Statin
Statin administered post op
Tn measured Day 0
Tn measured Day 1
Tn measured Day 2
Tn >14 ng/L d1
Tn >14 ng/L d2
Tn increase
80% (40)
60%
0
10% (5)
2% (1)
NA
NA
NA
90% (87/97)
79% (58/74)
1% (1/91)
89% (71/80)
70% (52/75)
56% (41/73)
58% (30/52)
52% (27/52)
Change
+53%
+10%
+19%
+1%
+79%
+68%
Reference(s)
1. Poldermans D, Bax JJ, Boersma E, et al. Guidelines for pre-operative cardiac risk
assessment and perioperative cardiac management in non-cardiac surgery: the Task Force
for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Noncardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European
Society of Anaesthesiology (ESA). Eur Heart J 2009;30:2769-812.
2. Winkel TA, Schouten O, van Kuijk J-P, Verhagen HJM, Bax JJ, Poldermans D.
Perioperative asymptomatic cardiac damage after endovascular abdominal aneurysm repair
is associated with poor long-term outcome. Journal of Vascular Surgery 2009;50:749-54.
Page 31 of 49
TRAINING PROFESSIONALS: A NOVEL APPROACH TO EDUCATIONAL
SUPERVISION AND NON CLINICAL LEARNING
Dr Andrew Pool1, Dr Oliver Long2, Dr Simon Lambden3
1Kings College Hospital, 2Croydon University Hospital, 3University College
Hospital
Introduction
The Training Professionals project was one of 9 winners selected nationally from
over 200 applications to the Inspire Improvement competition and is receiving
funding from Health Education England (HEE) as part of the Better Training Better
Care initiative. We believe it could represent a future model for non-clinical teaching
and educational supervision for trainees. Making the Trainee the centre of their own
training and responsible for their own successes will better prepare them for the roles
and responsibilities of a modern NHS Consultant.
There are three main aspects to our project:1.
Trainee produced goals and delivery plan:
We have split the non-clincal aspects of training into four perspectives –
Knowledge & Education, Audit, Research and Corporate & Management. At
the start of each training block trainees will develop goals within each
perspective. The goals will be described as having a tiered level of success –
Bronze, Silver and Gold.
Bronze represents the minimum requirements for that block, whilst Silver and
Gold describe success beyond the basic curriculum requirements.
Trainees then produce a delivery plan for the achievement of those goals,
each step.
2.
Trainer Facilitation:
To support and supervise trainees as they achieve their goals Educational
Supervisors will have a more regular role in overseeing their trainees. The
Trainee will update their goals and delivery plan onto a ‘cloud’ based
document. The Trainee and Educational Supervisor will interact remotely on
a weekly basis via this document, the Trainee updating progress and the
Educational Supervisor providing advice, support and direction. If the trainee
appears to be failing to meet their agreed goals, either party can initiate a
face-to-face meeting to re-evaluate the Trainee’s progress. For Educational
Supervisors the tool provides evidence of the fulfillment of their
responsibilities for appraisal and revalidation.
3.
Trainee Resource and Time Ownership:
The tool developed allows trainees to demonstrate success in their
professional development and effective use of time allocated such that they
should be given greater control over their non-clinical teaching time. The
Trainee will effectively be given the equivalent of Consultant SPA time on the
agreement that they meet their goals.
Progress
The Phase I pilot is underway with a cohort of senior Anaesthesia trainees and their
educational supervisors at King’s College and once validated is planned to roll out to
all trainees in the department as well as recruiting other departments
Page 32 of 49
regionally/nationally. With backing from the HEE we are keen to spread awareness
and recruit other Trusts as the scope of the project is widened.
Validation
Qualitative: Likely survey of trainer and trainee before implementation and at 3 and 6
months
Quantitative: Blind assessment of trainee performance before implementation and at
6 months
Summary
We believe teaching time should be of measurable benefit to trainees and that there
should be high quality demonstrable weekly interactions with supervisees. Training
professionals can deliver this.
Once Training Professionals produces evidence that both Trainees and Educational
Supervisors find it of benefit and that it demonstrates real improvements to Trainee’s
career progression we hope that it will be incorporated into training program curricula
and either work alongside or within Trainee’s e-portfolios.
Page 33 of 49
MYXOEDEMA MADNESS: TO HALLUCINATE OR TO INTUBATE?
ABSTRACT
Dr Omar Siddique (ACCS Anaesthetics CT1: Darent Valley Hospital) May 2013
CJ a 55 year old male was admitted to a psychiatric unit due to increased agitation,
confusion and odd behaviour. He had no past medical history of note. CJ was under
stress after being made redundant and low in mood prior to admission. A set of blood
tests were taken and revealed T4 – 6.3 with TSH 162.27 therefore was referred for
medical admission with Hypothyroidism.
On admission his condition rapidly deteriorated becoming increasingly aggressive
and agitated despite sedation with Olanzapine, Haloperidol and Diazepam. CJ
developed auditory and visual hallucinations and was non compliant with medication
and aggressive towards staff. He was subsequently intubated and ventilated in order
to facilitate treatment and taken to ITU for further management. CT head was
performed, which detected no abnormality. He was commenced on 25mcg
Levothyroxine via NG tube and given 48 hours of IV Liothyronine 10mcg BD. The
patient unfortunately self-extubated however his condition improved and psychosis
had resolved therefore was transferred to the ward. One week later the patient was
discharged home on long term Levothyroxine.
Primary hypothyroidism with myxoedema psychosis is a dangerous yet reversible
condition. Patients with low thyroid hormone can often present with psychosis and
delirium alone. Diagnosis is usually made by lab testing, and treatment is thyroid
replacement. If untreated can lead to coma, and irreversible damage due to chronic
metabolic changes to the brain. CJ was intubated to facilitate early treatment and
prevention of coma and deterioration. Patients often require heavy sedation and can
exhibit severe psychiatric symptoms. There are a wide variety of subtle
manifestations of hypothyroidism making it an easily missed diagnosis. Thyroid
hormone dysfunction should be considered in all patients with new psychiatric
symptoms. If identified early, rapid treatment can be effective and life-saving.
References: 1. Asher R. Myxoedematous madness. Br Med J 1949;2:555-62, 2. Gupta SP, Gupta PC, Kumar V, et
al. Electroencephalographic changes in hypothyroidism. Inidan J Med Res 1972;60: 1101-6, 3. Vanderpump MP,
Tunbridge WM. Epidemiology and prevention of clinical and subclinical hypothyroidism. Thyroid. 2002;12:839–847.,
4. Benvenga S, Lapa D, Trimarchi F. Don't forget the thyroid in the etiology of psychoses. Am J Med. 2003;115:159–
160
Page 34 of 49
NOT JUST A UTI; EMPHYSEMATOUS PYELONEPHRITIS
Dr Preeya Chakraborty MB BS FRCA, Dr Wessam Nabeih MB BCh FCAI
Emphysematous pyelonephritis is a rare life-threatening condition where there is an
infection, commonly an ascending urinary tract infection, resulting in a suppurative,
gas forming disease of the renal paranchyma. The commonest causative organism,
by far is E.Coli.
Unsurprisingly, the disease is more common in women (who are more prone to
urinary tract infection) and in poorly controlled diabetics. In the latter group, a triad of
high glucose levels in the tissue, gas-forming bacteria and impaired tissue perfusion,
facilitate the production of carbon dioxide and hydrogen via fermentation of glucose
and lactate.
There is much debate within the specialty of Urology regarding optimal treatment of
these patients. Due to the relative rarity of this disorder, no clinical institution
worldwide has been able to define guidelines regarding important prognostic factors
or optimal management strategy for the treatment of the disease. Nephrectomy was
traditionally the gold standard of treatment, but in recent years, antibiotic treatment,
paired with percutaneous drainage, has gained popularity. Review of the literature
seems to favour aggressive medical management and insertion of percutaneous
nephrostomy, but with early consideration of nephrectomy. Renal preservation,
particularly in bilateral disease, is also key to decision making in this regard.
We present a case of E.coli emphysematous Pyelonephritis in a 78-year old poorly
controlled female diabetic, who was medically managed, with a successful outcome.
References:
LearningRadiology.com – Emphysematous Pyelonephritis: USA: Einstein Medical
Center in Philadelphia , Pennsylvania; 2002
Available from
http://www.learningradiology.com/notes/gunotes/emphysemapyelopage.htm
Goichot B, Andres E. Emphysematous Pyelonephritis. New England Journal of
Medicine. 2000: 342:60-61
Huang J, Tseng C. Emphysematous Pyelonephritis, Clinicoradiological
Classification, Management, Prognosis and Pathogenesis. Arch Internal
Medicine.2000 March; (Vol 160):797-805
Available from
http://archinte.jamanetwork.com
Shokeir AA, El-Azab M, Mohsen T, El-Diasty T. Emphysematous Pyelonephritis: a
15-yr experience with 20 cases.Urology. 1997; (49):343-346
Page 35 of 49
DIAGNOSING TETANUS
Dr Preeya Chakraborty MB BS FRCA, Dr Harpreet Gill MbChB
Tetanus is a disease, which is relatively rare in the UK; there were 198 reported
cases of tetanus in England and Wales, within a twenty-year period (1984-2004).
The causative organism is Clostridium tetani, a neurotoxin producing bacteria.
Tetanus immunization was first introduced in the UK armed forces in 1938, and
became part of the National Immunisation Programme for infants in 1961. High risk
groups for contracting the disease (due to poor immunization status) are neonates,
the elderly and intravenous drug users.
We present a case of tetanus, which had a relatively insidious onset. It responded to
empirical treatment, although the patient needed mechanical ventilation. It is
imperative to treat the patient in view of their clinical symptoms, since a plasma
diagnosis may be belated, taking weeks to return from the highly specialised
laboratories, that run this assay.
Given the rare incidence of tetanus, clinicians in the UK tend to be relatively
inexperienced at diagnosing and treating this potentially fatal disease. We aim to
raise awareness of the clinical presentation, and encourage a differential diagnosis
of tetanus to be at the forefront of the clinicians’ mind.
References:
Hawker J, Begg N, Weinberg J, Blair I, Reintjes K. Communicable Disease Control
Handbook. Blackwell Science; 2001
HPA.org.uk. Public Health England: Epidemiology; 2010 (updated 8 August 2013)
Available from:
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Tetanus/Epidemiologi
calData/tet01TetanusCasesAge.
Page 36 of 49
RECOGNITION & MANAGEMENT OF ACCIDENTAL DURAL PUNCTURE &
PDPH AT LEWISHAM MATERNITY UNIT: A RETROSPECTIVE AUDIT
R Mistry and M. Agarwal
Lewisham Healthcare NHS Trust, London, UK
ravin.mistry@nhs.net
Dural puncture (DP) whilst performing epidural or spinal analgesia/anaesthesia can
be deliberate (“mini spinal” or spinal anaesthesia) or inadvertent. Post-dural puncture
headache (PDPH) is a rare but significant complication1. Practice may vary amongst
trainees and consultants in managing accidental DP whilst siting epidural catheters,
be it re-siting at an alternative level or siting an intrathecal catheter. Our current local
guideline suggests the former approach.
Methods
A retrospective 12-month report was generated from our local obstetric database
auditing 1.The incidence of accidental DP, 2. The management of accidental DP and
the incidence/management of subsequent PDPH and, 3. The incidence and
management of all PDPHs.
Results
2600 central neuraxial procedures were undertaken in the 12- month study period.
The overall incidence of PDPH was 1%. Of the 26 cases of PDPH, 21 were after
epidural analgesia, 3 following spinal anaesthesia for Caesarean section and 2
following combined spinal-epidural anaesthesia. 10 of 26 cases of PDPH required an
epidural blood patch.
Of the 21 cases of PDPH following epidural analgesia, 11 cases were recognised at
the time - 6 had obvious CSF flow from the Tuohy needle and 5 had CSF aspirated
from the catheter. Of these 11 cases, 9 were re-sited in an alternative space and 2
were managed as intrathecal catheters. 3 of the 9 re-sited epidural catheters
required a blood patch. Both cases of intrathecal catheter required a blood patch.
Conclusions
The use of intrathecal catheters is rare in our unit. There were no adverse outcomes
reported with the 2 intrathecal catheters placed.
Our PDPH rate remains unchanged at approximately 1%. The majority of PDPHs
were managed conservatively.
Our local policy remains to not advocate the use of intrathecal catheters in the vent
of inadvertent DP. If an intrathecal catheter is sited, we suggest a local2 or national
guideline should be in place to provide analgesia and anaesthesia via this route to
minimise maternal and fetal morbidity and mortality.
1. Epidural Information Card. OAA. http://www.oaaanaes.ac.uk/assets/_managed/editor/File/Info%20for%20Mothers/EIC/2008_eic_
english.pdf.
2. http://www.rcht.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/Clinical/A
naesthetics/GuidelineForTheManagementOfAccidentalDuralPuncture.pdf.
Page 37 of 49
ANAESTHETIC ASSESSMENT AND MANAGEMENT OF THE AIRWAY IN
OVERWEIGHT AND OBESE PEOPLE AT DVH DARTFORD
Dr M Pemmaraju1, Dr K Reid2, Dr M Satisha3 Dr R Madan4
1,2
Specialist Registrars, 3,4Consultant Anaesthetists, Darent Valley Hospital,
Dartford
1
pemmarajum@gmail.com,
BACKGROUND:
Obesity is becoming an increasing problem in the U.K. Anaesthesia for the Obese is
a recognised risk issue. Managing and Securing the Airway in obese patients is often
challenging and there is a definite risk issue attached to managing airways and
providing anaesthesia for the obese.
INTRODUCTION:
Obesity is defined as a BMI greater than 30kg/m2. The concept of bariatric
anaesthesia is relatively new in the UK. This audit is a local initiative to help
improving the standards and provide essence of care in keeping with the
recommendations and guidelines laid by existing societies.
AIMS AND OBJECTIVES:
•
To assess existing practice.
•
To improve standards of care.
•
To create local protocols.
•
To re-audit and look for any improvement.
METHODOLOGY:
Patient’s records were reviewed prospectively over a period of four weeks during the
year 2011 and the results were compared with those of re-audit done in 2012.
RESULTS:
Results: Less than 10% of the obese patients were referred to Anaesthetist for
preoperative assessment. While majority of obese patients were anesthetised by
Consultants, about 40% were anaesthetised by other junior grades. Documentation
of airway assessment was better in the re-audit but still could be much better.
CONCLUSIONS:
Only small proportion of obese patients were referred to Anaesthetist. There is
increased use of regional anaesthesia during the recent audit compared to the earlier
audit. There is a need to improve documentation of airway assessment in this patient
population. Anaesthetic charts need to be redesigned to incorporate these changes.
REFERENCES:
1.
Peri-operative management of morbidly obese patient-AAGBI-2007
2.
Anaesthesia for obese patients-The Society for Obesity and Bariatric Anaesthesia guidelines.
Page 38 of 49
SAFE USE OF OXYGEN CYLINDERS: AN UNANSWERED SAFETY ALERT
Dr Andrew McKechnie and Dr Beccy Campbell
Background
Following the tragic fire at Royal United Hospital Bath, a national patient safety alert
(NPSA) was issued regarding the use of oxygen cylinders during patient transfer.
Therefore we decided to audit practice within our district general hospital (DVH)
when transferring patients to and from theatre, from theatre to the recovery area and
within ITU.
Methods
A survey was distributed to members of the multidisciplinary theatre team regarding
their knowledge and experience of working with oxygen cylinders. Subsequently
oxygen cylinder use was observed within main theatres, obstetric theatres and the
ITU. Data was collated and analysed in Microsoft excel.
Results
Survey
Question
Are you aware of any guidelines governing safe use of oxygen
cylinders?
Are you aware of any guidelines governing use and transport of
O2 when transferring patients?
Have you experienced patient safety issues using portable O2
cylinders?
Have you had any formal training in safe use of oxygen cylinders?
Observation
Transfer Observed
Ward to Theatre
Theatre to Recovery
Delivery Suite
ITU
Overall
Cylinder
Safe %
0
53
0
20
38
YES
%
33
NO %
67
47
53
47
53
13
87
Cylinder
unsafe %
100
47
100
80
62
Conclusions
Our audit clearly shows that further education regarding the safe use of oxygen
cylinders is required. We plan to issue guidelines regarding cylinder use and will reaudit.
References
Page 39 of 49
Kelly, F. E., Hardy, R., Hall, E. A., McDonald, J., Turner, M., Rivers, J., Jones, H.,
Nolan, J. P., Cook, T. M. and Henrys, P. (2013), Fire on an intensive care unit
caused by an oxygen cylinder. Anaesthesia, 68: 102–104. doi:
10.1111/anae.12089
K. Edmonds, M. John, R. John, Closing the door on fire, Anaesthesia, 2013, 68,
8
http://www.bathchronicle.co.uk/Staff-relive-wall-RUH-intensive-care-unitinquest/story-19501214-detail/story.html
AUDIT OF PREVENTATIVE MEASURES FOR DEEP VENOUS THROMBOSIS IN
NEUROSURGICAL PATIENTS
NM Canchi, E. Lillie, R. Santhirapala, G Dezylva. King’s College Hospital
London
Background:
Incidence of thromboembolic complications in neurosurgical patients is a significantly
high. Deep Vein Thrombosis (DVT) is 25% and Pulmonary Embolus (PE) ranges
between 9 to 50%. Heparin prophylaxis in this group of patients is to be balanced
against risk of bleeding complication (RR 1 – 3.9%).
Aim:
Our aim was to evaluate whether current DVT prophylaxis in our neurosurgical unit is
in accordance with local protocol.
Methods:
The audit was conducted as a retrospective, case-note review of adult patients
undergoing neurosurgical procedures in our centre.
We excluded patients undergoing interventional procedures, patients directly
transferred to intensive care unit post operatively and Paediatric patients.
Data was collected regarding the type of surgery, duration, and risk assessment as
per local guideline, pre-operative anticoagulant use, any intraoperative VTE
preventative measures and postoperative administration of thromboprophylaxis.
We also noted any subsequent complications or delayed heparin administration in
the postoperative phase.
Outcomes noted during the audit phase were DVT, PE or any bleeding sequelae in
this group of patients.
Results:
A total of 45 patient case notes were followed during the phase of the audit. Nearly
2/3rd of the patients underwent intracranial surgery and the remaining had extra
cranial surgery.
20/45 patients had a risk score of 3 and 16/40 had a VTE risk score of 2. While a
small proportion 5/45 of the patients scored > 3 on the VTE scores.
We noticed non-adherence to the protocol (i.e. delayed start of prophylaxis) with 7/45
patients during the audit. 6/7 had intracranial surgery. 1/7 patient among the group
went on to develop DVT on day 40 and subsequently was commenced on
enoxaparin.
100% of the patients undergoing surgery had suitable intra-operative preventative
measures and 100% of patients who were on anticoagulants pre-operatively were recommenced on those medications in the immediate postoperative phase.
Page 40 of 49
We found no cases of post-operative bleeding in patients started on prophylactic
therapy.
Conclusions:
We had a low incidence of complications, with a single case of DVT. Audit showed
no particular problems with respect to bleeding post-operative due to
thromboprophylaxis.
KEEPING NICE AND WARM
Dr Pemmaraju1, Dr Madhusudhan Puchakayala2
1
Specialist Registrar, 2Consultant Anaesthetist Guys and St Thomas’s Hospital
1
pemmarajum@gmail.com, 2Madhusudan.Puchakayala@gstt.nhs.uk
BACKGROUND:
NICE published Inadvertent perioperative hypothermia (NICE clinical guideline 65) in
April 2008, which recommends that each patient undergoing anaesthesia should be
assessed for risk of inadvertent perioperative hypothermia and forced air warming
used where indicated to keep patients warm. The purpose of this audit is to assess
the prevalence of periop. Hypothermia in our trust and see whether or not they are in
concordance with NICE guidelines.
INTRODUCTION:
Inadvertent perioperative hypothermia is a recognised and common occurrence
during surgery. There are a number of reviews of the adverse effects of inadvertent
peri-operative hypothermia (IPH) in the literature. Research has shown that IPH can
lead to morbidity including prolonged recovery and hospital stay.
AIMS AND OBJECTIVES:
 Re-audit of an audit done in 2009 and 2010 on Perioperative Hypothermia at
GSTT.
 Assess prevalence of perioperative hypothermia in our trust.
 compare concordance with NICE recommendations
METHODOLOGY:
This is a prospective re-audit covering both Guys and St Thomas sites. Each theatre
was provided with a three part questionnaire based on NICE guidelines to be
completed by ODP, Anaesthetist and Recovery staff. The data obtained was
analysed and comparisons drawn against proposed targets suggested in NICE
guidelines and against the audit done in 2009-10.
RESULTS:
86 complete forms were collected and data in those forms were at varying levels of
completion. Pre op temperature measurement in the ward has improved to 85%
compared to 80% in 2010, and 29 % in 2009. 81% of patients had temperature
monitoring (34% in 2010 and 37% in 2009). 90% of the patients had active warming
measures (94% in the high risk group & 83% in the low risk group) - Similar to 2010
data. 90% of the patients entering recovery are normothermic (irrespective of risk).
Temperature at discharge >= 36.
CONCLUSIONS:
Awareness has increased among nursing staff, ODAs and may be doctors. The
availability of forced air warming devices was approx. 60% excluding day surgery in
2009 compared to 100% in 2010. Fluid warmers are available more freely.
Page 41 of 49
REFERENCES:
1.
2.
3.
4.
5.
Inadvertent perioperative hypothermia (NICE clinical guideline 65) - April 2008
Recommendations for Standards of Monitoring during Anaesthesia and Recovery (4th
Edition).
Frank SM et al. Perioperative maintenance of normothermia reduces the incidence of morbid
cardiac events. A randomized clinical trial. J Am Med Assoc. 1997;277:1127–1134.
Scott EM et al. Effects of warming therapy on pressure ulcers – a randomized trial. AORN
J
2001;73:921–927, 9–33, 36–38.
Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of
surgical-wound infection and shorten hospitalization. Study of Wound Infection and
Temperature Group. New Engl J Med 1996;334:1209–1215
AAGBI, London 2007
Page 42 of 49
SEPSIS IN PREGNANCY
Dr Francoise Iossifidis MD, FRCA
Consultant Anaesthetist, Lead Obstetric Anaesthetist, Darent Valley Hospital
The eighth report of the United Kingdom Enquiries into Maternal Deaths “Saving
Mothers’ Lives”, was published in March 2011.
For international comparison, the UK Maternal Mortality Ratio for 2006–8 is 6.69 per
100 000 live births.
The true UK maternal mortality rate, calculated from all maternal mortality directly or
indirectly due to pregnancy identified by this Enquiry, for 2006–8, was 11.39.
The 2006-08 report showed a small decline in overall maternal death for the first time
in many years, and a large reduction in the number of Direct death due to pregnancy.
However, deaths from infection of the genital tract i.e. sepsis, mainly from
community-acquired Group A Streptococcal disease, have increased. The overall
rate has increased to 1.13 deaths per 100 000 maternities compared with 0.85 for
2003-05. This is on a background of an increased death rate from Group A
Streptococcal infection in the general population but also prior to the H1N1
pandemic.
In this report sepsis was the top cause of death and the following recommendation
was made as part of the top ten recommendations.
“There is an urgent need for a national clinical guideline to cover the identification
and management of sepsis in pregnancy, labour, and the post-natal period. Until
such time as a national guideline is developed, the guidelines for the management of
acute sepsis developed and updated by the Surviving Sepsis Campaign should be
used.”
As a result the Royal College of Obstetricians and Gynaecologists produced the
Green Top Guideline no64a “Bacterial Sepsis in Pregnancy” which emphasizes the
back to basics approach recommended by the CMACE report.
It highlights the ten red flags described in the report for the diagnosis of sepsis and
takes a lot of the recommendations from the “Surviving Sepsis Campaign”.
The ten red flags are:







Pyrexia 38C. A normal temperature does not exclude sepsis. Paracetamol
and other analgesics may mask pyrexia, and this should be taken into
account when assessing women who are unwell;
sustained tachycardia .100 beats/ min;
breathlessness
abdominal or chest pain;
diarrhoea, vomiting, or both;
reduced or absent fetal movements, or absent fetal heart;
spontaneous rupture of membranes or significant vaginal discharge;
Page 43 of 49


uterine or renal angle pain and tenderness;
The woman is generally unwell or seems unduly anxious.
Due to the changes in physiology associated with pregnancy and the fact that it is a
normal state the diagnosis of sepsis can be difficult. The increase use of MEOWS
charts should help but its use is still not widespread.
Early and prompt referral to hospital and treatment by intensivists is recommended.
These patients should be treated by senior clinicians.
The guideline follows the SSC recommendation with antibiotics within an hour of
diagnosis, fluid resuscitation, invasive monitoring and inotropes.
The main issue is that these women are first seen by midwives who are used to
seeing normal deliveries and junior doctors not exposed to seriously ill patients. A big
effort has been placed on training all team members in recognising sepsis.
MMBRACE should produce the next report in the near future. The issue to look at is
not only mortality but the morbidity associated with sepsis.
1. Saving mother’s lives Reviewing maternal deaths 2006-2008 The Eighth
Report of the Confidential Enquiry into Maternal Deaths in the UK.
2. RCOG Green Top Guideline No 64a, Bacterial Sepsis in Pregnancy.
Page 44 of 49
Dr. M. Javaid Consultant Nephrologist
Darent Valley Hospital, Dartford
Acute kidney injury is a frequent occurrence on ITU. The condition is often
associated with high mortality, morbidity and prolonged hospital stay. In majority of
cases the underlying cause is related to sepsis, drugs or volume problems, however
in some patients the pathology can be multifactorial. Such patient can present with
atypical features making the diagnosis difficult and tricky. One needs to be mindful of
such conditions and high index of suspicion is needed for proper diagnosis and
management’’.
Dr Armando Gonzalez Consultant Microbiologist
Darent Valley Hospital, Dartford & Gravesham NHS Trust
Invasive candidiasis is a severe fungal infection which is not uncommon in ITU
patients.
Predisposing factors include prolonged ITU stay, total parenteral nutrition,
complex/multiple abdominal surgery, steroids and antibiotic treatment.
A high index of suspicion required for timely diagnosis as candidaemia is not always
present.
Management guidelines have been recently updated following the development of
equinocandins, a new class of efficacious and safe antifungal drugs.
As most cases of candidaemia are secondary to IV line infection, withdrawal/change
of central lines is mandatory, together with daily clinical examination and fundoscopy
to rule out invasive candidiasis to define length of treatment.
ANAESTHETIST IN CARDIAC CENTRE
Dr M Satisha
Consultant Anaesthetist, Darent Valley Hospital
Dartford & Gravesham NHS Trust
Anaesthetists are asked to be present/assist/sedate number of patients outside
operating theatre.
Numbers of interventions in cardiology are ever increasing. It is not uncommon in
small district hospitals to have a dedicated anaesthetist doing sessions outside
operating theatre. Anaesthetising a patient in remote locations is not without
complications. In addition to patient related problems with anaesthesia, there are lots
of organisational factors to be taken into account. My presentation will try to focus on
some of these issues.
Page 45 of 49
ULTRASOUND FOR THE ANAESTHETIST
Dr Richard Beese Consultant Radiologist
Darent Valley Hospital, Dartford & Gravesham NHS Trust
The talk is on:
The point of care ultrasound
The history:
The current status and the future with relevance to anaesthetists
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OUR SPONSORS
Sponsor
Representative
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B Braun
Sally Jones
LIDCO
Phillip Ellis
Wesleyan
Dawn Mitchell
Brian Smith
Mediplus
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Fresenius Kabi
Julia Donovan
Page 47 of 49
VOTE OF THANKS
I am extremely grateful to all those who have helped out
and supported the meeting.
I would like to thank my colleagues who went the extra
mile to help me to organise the event.
I also want to thank Jackie Shone and Trish Bannister for
their help.
A special note of thanks and appreciation goes out to
Helen Langman without whom it would have been difficult
to put everything together.
Finally, I feel that I must thank my wife and daughters for
their patience in the last few days and letting me get on
with the ‘preparation’ for the Meeting.
Dr Raman Madan FRCA
Consultant Anaesthetist
Darent Valley Hospital, Dartford
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