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Healthcare's environmental sustainability is increasingly an area of research and advocacy focus. The Australian and New Zealand College of Anaesthetists (ANZCA) has produced a professional document, PS64, Statement on Environmental Sustainability in Anaesthesia and Pain Medicine Practice, and a background paper, PS64 BP. The purpose of the statement is to affirm ANZCA's commitment to environmental sustainability and support anaesthetists in promoting environmentally sustainable work practices. This article presents the main features of PS64 and its background paper, and the associated supporting evidence. The healthcare sector is highly interconnected with activities that emit pollution to air, water and soils, considerably adding to humanity's collective ecological footprint. As anaesthetists, we are uniquely high-carbon doctors due to our work anaesthetising with greenhouse gases (particularly desflurane and nitrous oxide) and our exposure and contribution to large amounts of resource and energy use and waste generation in operating theatres. Discussion is made of the improving research base of anaesthetic life-cycle assessments--that is, cradle-tograve studies of how much energy, water and so on a product or process requires throughout its entire life. Thereafter, reducing, reusing and recycling as well as water use are examined. Ongoing research efforts within environmentally sustainable anaesthesia are highlighted. Environmentally sustainable anaesthesia requires scholarship, health advocacy, leadership, communication and collaboration. The focus is placed on practical initiatives within PS64 and the background paper that can be achieved by all anaesthetists striving towards more sustainable healthcare practices that reduce waste, reap financial benefits and improve health. [ABSTRACT FROM AUTHOR]

John Davies Thomas (1844-1893) described a two-ounce drop-bottle for chloroform in 1872 while he was a resident medical officer at University College Hospital, London. After working as a ship's surgeon, he settled in Australia. In May 1875, Thomas presented a paper on the mortality from ether and chloroform at a meeting of the Medical Society of Victoria in Melbourne, Victoria. Surveys conducted in Europe and North America had established that the mortality from chloroform was eight to ten times higher than that from ether. At that time, chloroform was the most widely administered anaesthetic in Australia. Thomas' paper was published in The Australian Medical Journal and reprinted by the Medical Society of Victoria for distribution to hospitals in the Colony of Victoria. Later that year, Thomas moved to Adelaide, South Australia, where he may have been influential at the Adelaide Hospital in ensuring that ether was administered more often than chloroform. It does not appear that Thomas' papers on anaesthesia had a significant effect on the conduct of anaesthesia in Victoria or New South Wales. [ABSTRACT FROM AUTHOR]

The Australian and New Zealand College of Anaesthetists (ANZCA) recently reviewed and updated the guideline on equipment to manage a difficult airway. An ANZCA-established document development group, which included representatives from the Australasian College for Emergency Medicine and the College of Intensive Care Medicine of Australia and New Zealand, performed the review, which is based on expert consensus, an extensive literature review, and bi-nationwide consultation. The guideline (PG56(A) 2021, https://www.anzca.edu.au/getattachment/02fe1a4c-14f0-4ad1-8337-c281d26bfa17/PS56-Guideline-on-equipment-to-manage-difficult-airways) is accompanied by a detailed background paper (PG56(A)BP 2021, https://www.anzca.edu.au/getattachment/9ef4cd97-2f02-47fe-a63a-9f74fa7c68ac/PG56(A)BP-Guideline-on-equipment-to-manage-difficult-airways-Background-Paper), from which the current recommendations are reproduced on behalf of, and with the permission of, ANZCA. The updated 2021 guideline replaces the 2012 version and aims to provide an updated, objective, informed, transparent, and evidence-based review of equipment to manage difficult airways. [ABSTRACT FROM AUTHOR]

The psychological impact (second victim effect) of in-theatre critical incidents is increasingly recognised. Different styles of psychological support programme have recently been published, including some utilising 'near in time' peer support. Most of these programmes either target their support to individuals, or focus on one vocational group rather than the multidisciplinary team. However, the in-theatre team consists of different craft groups who nonetheless function as a single team and are therefore 'peers'. This paper sets out the design and implementation of a critical incident peer response programme at Waikato Hospital, New Zealand, which provides peer-led group psychological first aid to full theatre teams. The programme is administered by trained representatives from multiple in-theatre craft groups including nurses, midwives, anaesthetic technicians, recovery room nurses, surgeons and anaesthetists. It emphasises team education and peer support, and has a wholly welfare focus. The programme has voluntary participation but mandatory activation triggers so that individuals do not need to seek support actively at a time when they may not recognise the need to do so. The programme is becoming embedded in the Waikato Hospital theatre culture so that participating in psychological support is normalised following a critical event. This framework is shared in the hope that it will assist other hospitals to develop welfare interventions to support full theatre teams. [ABSTRACT FROM AUTHOR]

Sub-Saharan Africa faces high rates of maternal mortality and there is an urgent need to reduce this. Shortfalls in access to safe surgery and anaesthetic care result in avoidable maternal death. Providing quality training to anaesthesia providers is of key importance to reduce mortality. This mixed-methods prospective study incorporated workplace observations of anaesthesia for Caesarean section, a paper-based questionnaire and semi-structured, face-to-face interviews in Felege Hiwot Referral Hospital in Ethiopia. A total of 67 Caesarean section cases under spinal anaesthesia provided by 12 non-physician anaesthetists were observed and a 92% (n = 11) response rate to questionnaires obtained. Deficiencies were observed in communication, pre-operative assessment, spinal height evaluation and application of lateral tilt, while interviews revealed anaesthesia provider perceptions of hierarchy within the surgical team and deficiency in anticipation of potential complications. This study suggests that focusing on communication and anticipation of complications could aid providers in preventing and preparing for complications. [ABSTRACT FROM AUTHOR]

The article describes a study which compared the financial and environmental costs of reusable and single-use/disposable plastic anaesthetic drug trays using a life cycle assessment (LCA) model. LCA modeling revealed that single-use plastic trays are more expensive, produced more carbon dioxide, and consumed more water as compared to the reusable trays.

The use of high flow nasal oxygen in the care of COVID-19-positive adult patients remains an area of contention. Early guidelines have discouraged the use of high flow nasal oxygen therapy in this setting due to the risk of viral spread to healthcare workers. However, there is the need to balance the relative risks of increased aerosol generation and virus transmission to healthcare workers against the role high flow nasal oxygen has in reducing hypoxaemia when managing the airway in high-risk patients during intubation or sedation procedures. The authors of this article undertook a narrative review to present results from several recent papers. Surrogate outcome studies suggest that the risk of high flow nasal oxygen in dispersing aerosol-sized particles is probably not as great as first perceived. Smoke laser-visualisation experiments and particle counter studies suggest that the generation and dispersion of bio-aerosols via high flow nasal oxygen with flow rates up to 60 l/min is similar to standard oxygen therapies. The risk appears to be similar to oxygen supplementation via a Hudson mask at 15 l/min and significantly less than low flow nasal prong oxygen 1-5 l/min, nasal continuous positive airway pressure with ill-fitting masks, bilevel positive airway pressure, or from a coughing patient. However, given the limited safety data, we recommend a cautious approach. For intubation in the COVID-positive or suspected COVID-positive patient we support the use of high flow nasal oxygen to extend time to desaturation in the at-risk groups, which include the morbidly obese, those with predicted difficult airways and patients with significant hypoxaemia, ensuring well-fitted high flow nasal oxygen prongs with staff wearing full personal protective equipment. For sedation cases, we support the use of high flow nasal oxygen when there is an elevated risk of hypoxaemia (e.g. bariatric endoscopy or prone-positioned procedures), but recommend securing the airway with a cuffed endotracheal tube for the longer duration procedures when theatre staff remain in close proximity to the upper airway, or considering the use of a surgical mask to reduce the risk of exhaled particle dispersion. [ABSTRACT FROM AUTHOR]

In April 2018, a statue commemorating J Marion Sims was removed from Central Park, New York, and relocated to Green-Wood Cemetery in Brooklyn, where he is buried. In 1849, Sims developed a repeatable surgical solution for obstetric fistula, a debilitating condition caused by prolonged, obstructed labour, which damages the vaginal wall, resulting in permanent leakage via the vagina from either the bowel or bladder and sometimes both. Initially, Sims appears worthy of widespread adulation. There are several commemorative statues of him, he has been afforded the title of the 'father of modern gynaecology', and for 37 years, the American Urogynecological Society held an annual eponymous lecture, among other honours. Obstetric fistula rendered women social pariahs, unable to engage fully in either domestic or public life. Sims was able to create a reliably repeatable surgical solution but did so through ongoing experimentation on enslaved women. One of these women, Anarcha, was operated on at least 30 times without the use of anaesthesia over a four-year period, despite the availability of anaesthesia for the majority of the experimentation period. Over 170 years later, Sims' story retains its relevance because it represents a clear point at which race, gender and class intersect with medicine. This paper will use Sims' own account to drive the narrative, then examine matters of agency, ethics and consent that come from it, to show that his work, and subsequent renown, were only possible because of the inherent violence of chattel slavery and other systemic forms of oppression. [ABSTRACT FROM AUTHOR]

In spite of a growing corpus of studies concerned with the body and its relationships to organizing and organization, there is a distinct lack of empirical work to take seriously the nature of `embodiment' in the workplace. This paper presents a video-based study of teamwork in preoperative anaesthesia in order to propose an approach to analysing the body that focuses on organizational members' practical orientations to the body, and in particular dynamic bodies, in the workplace. To demonstrate the value of this approach, the paper considers coordination work among anaesthetic teams and highlights the importance of intercorporeal knowing in the real-time coordination of a team's work. The analytic orientation is drawn from ethnomethodology and conversation analysis. [ABSTRACT FROM AUTHOR]

The London surgeon and anaesthetist, Joseph Thomas Clover (1825–1882), and the Birmingham surgeon, Joseph Sampson Gamgee (1828–1886), are well known figures in the history of medicine. Draft letters among the surviving papers of Joseph Clover have been transcribed and reveal new information about their friendship, their financial affairs and Clover's motivation to become a full-time anaesthetist. They have also led to the discovery that Gamgee was briefly imprisoned in Warwick County Goal for debt in 1859. [ABSTRACT FROM AUTHOR]

Over the past 30 years, there has been much research into the health benefits of humour and laughter. Although often viewed very positively, rigorous evaluation of the therapeutic effect of clowning is complex. Clowning is a multi-modal intervention, which may have an impact on medical conditions, procedures, family functioning and health care teams. Clowns help children to adapt to their hospital surroundings and can distract from, and demystify, painful or frightening procedures through ‘doses of fun’ to complement traditional clinical interventions. This paper provides a review of the paediatric literature and reveals studies looking at the effect of clown interventions on various practical procedures and individual medical conditions, and the effects of clowning within clinical teams. [ABSTRACT FROM PUBLISHER]

A shift in practice by anaesthetists away from anaesthetic gases with high global warming potential towards lower emission techniques (e.g. total intravenous anaesthesia) could result in significant carbon savings for the health system. The purpose of this qualitative interview study was to understand anaesthetists' perspectives on the carbon footprint of anaesthesia, and views on shifting practice towards more environmentally sustainable options. Anaesthetists were recruited from four hospitals in Western Sydney, Australia. Data were organised according to the capability–opportunity–motivation model of behaviour change. Twenty-eight anaesthetists were interviewed (July−September 2021). Participants' age ranged from 29 to 62 years (mean 43 years), 39% were female, and half had completed their anaesthesia training between 2010 and 2019. Challenges to the wider use of greener anaesthetic agents were identified across all components of the capability–opportunity–motivation model: capability (gaps in clinician skills and experience, uncertainty regarding research evidence); opportunity (norms, time, and resource pressures); and motivation (beliefs, habits, responsibility and guilt). Suggestions for encouraging a shift to more environmentally friendly anaesthesia included access to education and training, implementing guidelines and audit/feedback models, environmental restructuring, improving resource availability, reducing low value care, and building the research evidence base on the safety of alternative agents and their impacts on patient outcomes. We identified opportunities and challenges to reducing the carbon footprint of anaesthesia in Australian hospitals by way of system-level and individual behavioural change. Our findings will be used to inform the development of communication and behavioural interventions aiming to mitigate carbon emissions of healthcare. [ABSTRACT FROM AUTHOR]

In 2023, a Diploma of Rural Generalist Anaesthesia (DipRGA) was implemented across Australia. Developed collaboratively by the Australian and New Zealand College of Anaesthetists (ANZCA), the Australian College of Rural and Remote Medicine (ACRRM) and the Royal Australian College of General Practitioners (RACGP), the 12-month qualification is completed during or following ACRRM or RACGP Rural Generalist Fellowship training. Focused on the needs of rural and remote communities for elective and emergency surgery, maternity care, resuscitative care for medical illness or injury, and stabilisation for retrieval, the DipRGA supports rural generalist anaesthetists working within collaborative teams in geographically isolated settings. The goal is a graduate who can anaesthetise American Society of Anesthesiologists physical status class 1, 2 and stable 3 patients for elective surgery, provide obstetric anaesthesia and analgesia, anaesthetise paediatric patients and undertake advanced crisis care within their scope of practice. Crucially, they also recognise both limitations of their skills and local resources available when considering whether to provide care, defer, refer or transfer patients. DipRGA curriculum design commenced by adapting the ANZCA specialist training curriculum with consideration of the training approach of both the ACRRM and the RACGP, particularly the rural and remote context. Curriculum content is addressed in seven entrustable professional activities supported by workplace-based assessments and multisource feedback. Trainees are supervised by rural generalist anaesthetists and specialist anaesthetists, and complete flexible learning activities to accommodate geographical dispersion. Standardised summative assessments include an early test of knowledge and an examination, adapted from the ACRRM structured assessment using multiple patient scenarios. [ABSTRACT FROM AUTHOR]

Two published versions of a letter in which Oliver Wendell Holmes, MD, recommended the name anaesthesia were identified from publications supportive of the claims of W. T. G. Morton. The earliest known publication of Holmes' letter is in a pamphlet published by Edward Warren in May-June 1847. Another version of the letter was published 12 years later in Nathan P. Rice's biography of Morton. Holmes' letter to Morton was probably lost when a substantial part of a collection of Morton's papers was damaged during storage. There are no reported copies of Holmes's letter. The currently available information does not provide any assistance in determining the correct form of Holmes's letter. [ABSTRACT FROM AUTHOR]

This paper describes the implementation of the 'Stop Before You Block' (SB4YB) initiative in an Australian teaching hospital. This process, which began in the UK in 2010, is a pre-procedure pause to confirm the correct side of a regional anaesthetic block. A change in practice was implemented with the formal roll out of a SB4YB educational program. Use of the initiative was then audited over a subsequent three-month period. It was hoped that after implementing the initiative, at least 80% of blocks would have a site check performed. However, despite apparent support for the initiative, uptake was less than expected with only about 57% of blocks having a site check performed. A site check was less frequent if the block was done as an emergency procedure, outside of an operating theatre or by a locum or visiting anaesthetist. Our conclusion from the audit was that education is insufficient to promote a change in this practice. We propose that Stop Before You Block or a block time-out should be performed prior to all unilateral nerve blocks. Success of this initiative requires education, and both cultural and systems changes to occur. We propose that a formal block time-out should become part of the surgical safety checklist and this activity should be endorsed and promoted by anaesthetic professional bodies. [ABSTRACT FROM AUTHOR]

A teaching portfolio (TP) is a document containing a factual description of a teacher's teaching strengths and accomplishments, allowing clinicians to display them for examination by others. The primary aim of a TP is to improve quality of teaching by providing a structure for self-reflection, which in turn aids professional development in medical education. Contents typically include a personal statement on teaching, an overview of teaching accomplishments and activities, feedback from colleagues and learners, a reflective component and some examples of teaching material. Electronic portfolios are more portable and flexible compared to paper portfolios. Clinicians gain the most benefit from a TP when it is used as a tool for self-reflection of their teaching practice and not merely as a list of activities and achievements. This article explains why and how anaesthetists might use a TP as a tool for professional development in medical education. [ABSTRACT FROM AUTHOR]

In her valuable history of the arrival of the news of etherisation in Australia and its implementation by many doctors and dentists, titled One Grand Chain, the late Dr Gwen Wilson asserted that the dentist and the doctor who pioneered etherisation in Australia, "Belisario and Pugh... were charged by the authorities with possession of an illicit still". This paper examines the evidence for the truth or otherwise of this assertion, in relation to Dr Pugh. [ABSTRACT FROM AUTHOR]

Enlisting an author on a published paper, whose input was insufficient, is called honorary authorship. The aim of this study is to assess the proportion of honorary authorship in the field of pain medicine. Data were collected from seven high-impact journals. Corresponding authors were sent a survey regarding their awareness on authorship guidelines, the decision-making in authorship and specific contributions made to the surveyed article. We identified two types of honorary authorship: (1) self-perceived honorary authorship, which is measured by asking the corresponding author if honorary authorship was present according to their opinion and (2) International Committee of Medical Journal Editors (ICMJE)-defined honorary authorship, which is honorary authorship based on the guidelines. In total, 1051 mails were sent and 231 responded, leading to a response rate of 22.0%. 81.3% of the respondents were familiar with the ICMJE authorship guidelines, while 59.6% were aware of the issue of honorary authorship. 13.3% of the respondents were employed at a department in which the senior member is automatically included on all manuscripts. The ICMJE-defined honorary authorship was 40%, while self-perceived honorary authorship was 13.5%. There seems to be a high awareness of the ICMJE guidelines among corresponding authors in the field of Pain Medicine. Despite this high awareness, a high proportion of journal articles had honorary authorship, suggesting that authorship guidelines fail to be applied in a significant proportion of the literature. [ABSTRACT FROM AUTHOR]

Background: Thermal ablation, usually performed with tumescent local anaesthesia (TLA), is the preferred method for varicose veins treatment. Tumescent local anaesthesia is always cited; however, little detail of the procedure is presented in publications. This retrospective audit of clinical tumescent local anaesthesia practice aims to provide detailed information on an important aspect of endovenous practice. Methods: Patients who underwent three types of endothermal treatment (Venefit, Radiofrequency Induce Thermal Therapy and Endovenous Laser Ablation) to a single saphenous trunk using tumescent local anaesthesia were assessed. Differences in tumescent local anaesthesia volume per unit length of treated vein were assessed for the followings: type of saphenous trunk, length of vein treated, effect of additional phlebectomy and bilateral versus interval unilateral treatment for bilateral veins. Descriptive data are reported as mean and standard deviation, and groups were compared using the one-way ANOVA test. Results: Between 2008 and 2014, single-saphenous-trunk ambulatory TLA thermal ablation was performed in 979 patients, mean age was 54 years. A total of 1229 limbs had truncal ablations and synchronous phlebectomy was performed in 470 limbs. No tumescent local anaesthesia-related complications occurred. There was no significant difference in standardised tumescent local anaesthesia volume per centimetre (ml) used for the three devices. Tumescent local anaesthesia volume per centimetre (ml) differed significantly between saphenous trunks. On average, a standard 10–12 ml/cm of tumescent local anaesthesia was used for saphenous trunks. Mean total tumescent local anaesthesia volume per patient, when treating the great saphenous vein alone, was 931 ml for bilateral and 425 ml for unilateral treatment. Conclusion: This report of over 1000 endovenous procedures demonstrates safe performance of laser and radiofrequency treatments using tumescent local anaesthesia. Although no attempt was made to determine minimum volume requirements, a mean tumescent local anaesthesia volume of 10–12 ml/cm administered to the perivenous space provides adequate anaesthesia for truncal saphenous ablation. [ABSTRACT FROM AUTHOR]

Follow-up for ongoing management and monitoring of patients is important in clinical practice and research. While common, telephone follow-up is resource intensive and, in our experience, yields low success rates. Electronic communication using mobile devices including smartphones and tablets can provide efficient alternatives - including SMS (text), online forms and mobile apps. To assess attitudes towards electronic follow-up, we surveyed 642 parents and carers at Perth Children's Hospital, targeting demographics, device ownership and attitudes towards electronic follow-up. Mobile phone ownership was effectively universal. Almost all respondents were happy to communicate electronically with the hospital. Promisingly, 93.2% of respondents were happy to receive follow-up SMSs from the hospital and 80.3% were happy to reply to SMS questions. There was less enthusiasm regarding other modalities, with 59.9% happy to use a website and 69.0% happy to use a mobile app. The results support the introduction of electronic communication for follow-up in our paediatric population. [ABSTRACT FROM AUTHOR]

The aim of this paper is to link the history of the Multicentre Australian Study of Epidural Anaesthesia in high risk surgery, the MASTER Trial, the first National Health and Medical Research Council (NHMRC) funded multicentre randomised clinical trial in Australia led by anaesthetist researchers, and the decision of The Australian and New Zealand College of Anaesthetists (ANZCA) to establish a clinical trials network, in 2003, to the success of contemporary researchers in Australia and New Zealand in anaesthesia and perioperative medicine. [ABSTRACT FROM AUTHOR]

Modern anaesthetists rely on the intravenous route for administration of drugs and fluids. This paper traces the development of intravenous equipment from the first, tentative experiments with the intravenous route through to the first intravenous cannulas. [ABSTRACT FROM AUTHOR]

This paper reviews the clinical situation in anaesthesia before the introduction of halothane into clinical practice in 1956, emphasising the limitations of agents available at the time. The background to the development of halogenated hydrocarbon compounds as anaesthesia agents is presented, including the involvement of Imperial Chemical Industries in England. The Nuffield Department of Anaesthetics was involved in the clinical trials and the designing and execution of these. The results of their work and the problems encountered are presented. [ABSTRACT FROM AUTHOR]

Obstetric surgical suites differ from most inpatient surgical suites, serving one specialty, and often small. We evaluated long-term capacity planning for these operating rooms. The retrospective cohort study included all caesarean births in three operating rooms over 28 years, 1994 through 2021, plus all other obstetric procedures over the latter 19 years. We calculated the obstetric anaesthesia activity index, 0.5 × neuraxial labour analgesia placement + 1.0 × caesarean births. Annual caesarean births from one year to the next had a Pearson linear correlation coefficient of 0.993. Therefore, linear regression can be used for long-term capacity planning. However, the difference between 0.9 and 0.1 quantiles in weekly caseloads was greater than tenfold larger than the annual rate of growth in births per week. Therefore, clinicians likely would be unable to distinguish, by experience, between growth versus being busy due to variability, suggesting value of the modelling. Over 19 years, the fraction of the obstetric workload from caesarean births was unchanging, Pearson correlation coefficient of 0.04. Therefore, use of the obstetric anaesthesia activity index to judge changes in workload was appropriate. The annual total for the index increased linearly, Pearson correlation coefficient of 0.98, supporting validity of the finding that long-term capacity can be planned with linear regression. The difference between 0.9 and 0.1 quantiles in weekly totals of the index exceeded annual rate of growth, supporting validity of the finding that variability week to week is very large relative to growth. These results help decision-makers ensure that operating rooms and staff meet referring hospitals' needs. [ABSTRACT FROM AUTHOR]

Professor Tess Cramond joined the Queensland anaesthesia workforce in 1958, and contributed to high standards of clinical practice, pain management, training, scholarship and research. Evidence of her excellence, within the clinical, political and community spheres was recognised by multiple awards. Though deceased in 2015, she remains a role model for all physicians, using her expert knowledge, technical skills, clinical reasoning, emotions and values for the benefit of the individuals and community which she served. [ABSTRACT FROM AUTHOR]

Corneal abrasions are an uncommon complication of anaesthesia. The aim of this study was to identify potential risk factors, treatment and outcomes associated with corneal abrasions reported to the web-based anaesthesia incident reporting system (webAIRS), a voluntary de-identified anaesthesia incident reporting system in Australia and New Zealand, from 2009 to 2021. There were 43 such cases of corneal abrasions reported to webAIRS over this period. The most common postoperative finding was a painful eye. Common features included older patients, individuals with pre-existing eye conditions, general anaesthesia and procedures longer than 60 minutes. Most cases were treated with a combination of lubricating eye drops or aqueous antibiotic eye drops. The findings indicate that patients who sustain a perioperative corneal abrasion can be reassured that in many cases it will heal within 48 hours, but they should seek earlier review if symptoms persist or deteriorate. None of the cases in this series resulted in permanent harm. Well established eye protective measures are important to utilise throughout the perioperative period, including the time until the patient has recovered in the post-anaesthesia care unit. [ABSTRACT FROM AUTHOR]

An anonymous poem and a cartoon about etherisation were published in Bell's Life in Sydney on 26 June 1847, less than 3 weeks after ether was first administered in Sydney, New South Wales. Almost a year later, an Adelaide newspaper, The South Australian Register, reproduced a poem about chloroform from the British satirical magazine Punch. This poem, 'The Blessings of Chloroform', has been attributed to Percival Leigh, a British medical practitioner who became a comic writer. [ABSTRACT FROM AUTHOR]

Introduction: Shear wave elastography (SWE) presents nerves in colour, but the dimensions of its colour maps have not been validated with paired B-Mode nerve images. Our primary objective was to define the bias and limits of agreement of SWE with B-Mode nerve diameter. Our secondary objectives were to compare nerve area and shape, and provide a clinical standard for future application of new colour imaging technologies such as artificial intelligence. Materials and Methods: Eleven combined ultrasound-guided regional nerve blocks were conducted using a dual-mode transducer. Two raters outlined nerve margins on 110 paired B-Mode and SWE images every second for 20 s before and during injection. Bias and limits of agreement were plotted on Bland-Altman plots. We hypothesized that the bias of nerve diameter would be <2.5% and that the percent limits of agreement would lie ±0.67% (2 SD) of the bias. Results: There was no difference in the bias (95% confidence interval (CI) limits of agreement) of nerve diameter measurement, 0.01 (−0.14 to 0.16) cm, P = 0.85, equivalent to a 1.4% (−56.6% to 59.5) % difference. The bias and limits of agreement were 0.03 (−0.08 to 0.15) cm2, P = 0.54 for cross-sectional nerve area; and 0.02 (−0.03 to 0.07), P = 0.45 for shape. Reliability (ICC) between raters was 0.96 (0.94–0.98) for B-Mode nerve area and 0.91 (0.83–0.95) for SWE nerve area. Conclusions: Nerve diameter measurement from B-Mode and SWE images fell within a priori measures of bias and limits of agreement. [ABSTRACT FROM AUTHOR]

Despite the self-evident importance of hospital funding, many anaesthetists remain unsure of exactly how their daily work relates to hospital reimbursement. A lack of awareness of the nuances of the Australian hospital activity-based funding system has the potential to affect anaesthetic department reimbursement and thus resourcing. Activity-based funding relies on clinical coders reviewing clinical documentation and quantifying the care given to a patient during an admission. Errors in funding allocation may arise when there is a disconnect between the work performed and the information coded. In anaesthesia, there are several factors impeding this process, including clinical understanding of coding, system setup and coders' understanding of anaesthesia. This article explores these factors from the clinical anaesthetist's point of view and suggests solutions, such as awareness and education, clinician-coder cooperation and redesign of documentation systems at a systems level that anaesthetic departments can incorporate. [ABSTRACT FROM AUTHOR]

Medication error is a well-recognised cause of harm to patients undergoing anaesthesia. From the first 4000 reports in the webAIRS anaesthetic incident reporting system, we identified 462 reports of medication errors. These reports were reviewed iteratively by several reviewers paying particular attention to their narratives. The commonest error category was incorrect dose (29.4%), followed by substitution (28.1%), incorrect route (7.6%), omission (6.5%), inappropriate choice (5.8%), repetition (5.4%), insertion (4.1%), wrong timing (3.5%), wrong patient (1.5%), wrong side (1.5%) and others (6.5%). Most (58.9%) of the errors resulted in at least some harm (20.8% mild, 31.0% moderate and 7.1% severe). Contributing factors to the medication errors included the presence of look-alike medications, storage of medications in the incorrect compartment, inadequate labelling of medications, pressure of time, anaesthetist fatigue, unfamiliarity with the medication, distraction, involvement of multiple people and poor communication. These data add to current evidence suggesting a persistent and concerning failure effectively to address medication safety in anaesthesia. The wide variation in the nature of the errors and contributing factors underline the need for increased systematic and multifaceted efforts underpinned by a strengthening of the current focus on safety culture to improve medication safety in anaesthesia. This will require the concerted and committed engagement of all concerned, from practitioners at the clinical workface, to those who fund and manage healthcare. [ABSTRACT FROM AUTHOR]

This year marks the centenary of the start of World War I and, with the coming centenary of the involvement of the Australian and New Zealand Army Corps in the Gallipoli campaign in April 2015, we look at the careers of four doctors who served at Gallipoli and their various contributions to anaesthesia. Drs Eric W. B. Woods, John W. B. Bean, Piero F. B. Fiaschi and Bernard T . Zwar all served as part of the Australian Army Medical Corps. All survived the war. [ABSTRACT FROM AUTHOR]

Upper airway compression is one of the clinical manifestations of thoracic aortic aneurysm, which is associated with poor prognosis and high mortality. A 44-year-old patient with ascending aortic and arch aneurysm who was scheduled for Bentall surgery and total arch replacement under cardiopulmonary bypass suffered difficult ventilation after endotracheal intubation. The patient did not exhibit any positional dyspnoea or orthopnoea, did not show any difficulties in the supine position, and had no noteworthy medical history. However, we encountered unexpected hypoventilation after intubation. Isoprenaline infusion was effective while emergency cardiopulmonary bypass was established to deal with this crisis. Fibreoptic bronchoscopy revealed complete obstruction of the carina and confirmed the supracarinal position of the tube. Complete airway obstruction may occur even if there are no symptoms before surgery in patients with thoracic aortic aneurysm. Comprehensive preoperative assessment, a well-developed airway management plan, and responses to possible emergencies are essential to reduce unnecessary events or complications. [ABSTRACT FROM AUTHOR]

Opioid misuse is common, as is opioid agonist treatment of opioid dependence. Almost 3% of Australians and over 3.5% of those living in New Zealand report misuse of analgesics. Over 50,000 Australians receive opioid agonist treatment with methadone or buprenorphine for management of severe opioid use disorder. The perioperative period is an opportunity to identify pre-existing opioid misuse, and to introduce interventions to reduce the risk of development of opioid use disorder. Challenges of acute perioperative pain management or intensive care management of patients receiving opioid agonist treatment include opioid tolerance and ongoing prescribing of methadone or buprenorphine. There has been some ambiguity about the optimal perioperative management of buprenorphine, a partial agonist at the mu receptor. In this article, a framework to identify emerging opioid misuse problems, identify risk of overdose and to manage the opioid-dependent patient on opioid agonist treatment perioperatively or in the intensive care unit is provided. Diagnostic criteria and risk stratification criteria are presented. Management strategies include trauma-informed care, care planning and care coordination with community practitioners and opioid agonist treatment providers. Continuing methadone or buprenorphine perioperatively with additional opioid and non-opioid analgesia is generally recommended. Increased opioid agonist treatment doses may be required on discharge. An algorithm for decisions about opioid agonist treatment management in the intensive care unit based on the risks of opioid withdrawal and toxicity is considered. Strategies for managing the opioid-dependent patient who is not in treatment are also discussed. [ABSTRACT FROM AUTHOR]

The article presents an overview of the progression of various techniques in neuromuscular monitoring used in clinical anaesthesia and reviews them chronologically. The period covering the introduction of neuromuscular monitoring is divided into 5 sections that included early assessment of neuromuscular block, commencement of electrical nerve stimulation under anaesthesia and post-tetanic count. It refers to double burst stimulation (DBS) technique that show residual neuromuscular blockade.

Local perivenous anaesthesia has evolved from tumescent anaesthesia which has had a huge impact on liposuction procedures. Perivenous anaesthesia has had a similar effect on peripheral venous surgery. Safety during its application is further enhanced when combined with skilled ultrasound guidance and astute operator awareness. [ABSTRACT FROM AUTHOR]

The article discusses a study that tested the hypotheses that a small proportion of total operating suite waste are produced by anaesthetists, that a significant amount of anaesthesia waste is recyclable, and that there is minimal cross-contamination of infectious with non-infectious waste. Included in the operating suite waste was cardboard waste. Infectious items were included in the general waste, which were potentially recyclable. A barrier to recycling is the failure to eliminate infectious waste from general waste.

This paper was presented at the World Conference on Surgical Patient Care, Barcelona, Spain, 25-29 September 2005. [ABSTRACT FROM AUTHOR]

The first news to reach New Zealand about the beneficial effects of inhalation of ether during surgical operations arrived in Wellington on Sunday July 4 1847. This was 283 days after the first successful demonstration in Boston. The mail services that brought this news and the original source of this news are described. After this news had reached Wellington, it then took another 84 days before the first successful trial of the agent took place in the recently opened Wellington Colonial Hospital. This period of eighty-four days compares unfavourably with those for Sydney and Cape Town. The reasons for this delay are discussed and using information available in the local Sydney and Wellington newspapers, the delay is shown to have been due to the unavailability of supplies of the necessary chemical reagents. [ABSTRACT FROM AUTHOR]

This cross-sectional overview of the second 4000 incidents reported to webAIRS has findings that are very similar to the previous overview of the first 4000 incidents. The distribution of patient age, body mass index and American Society of Anesthesiologists physical status was similar, as was anaesthetist gender, grade, location and time of day of incidents. About 35% of incidents occurred during non-elective procedures (vs. 33% in the first 4000 incidents). The proportion of incidents in the various main categories was also similar, with respiratory/airway being most common, followed by cardiovascular, medication-related and medical device or equipment-related incidents. Together these categories made up about 78% of all incidents in both overviews. The immediate outcome was comparable with reports of harm in about a quarter of incidents and a similar rate of deaths (4.7% vs. 4.2%). However, the proportion of patients who had received total intravenous anaesthesia was higher (17.6% vs. 7.7%) and the proportion of patients who received combined intravenous and inhalational anaesthesia was lower (52.3% vs. 58.4%), as was the proportion receiving local anaesthesia alone (1.6% vs. 6.7%). There was a small increase in the number of incidents resulting in unplanned admission to a high dependency or intensive care unit (18.1% vs. 13.5%). It is not clear whether these differences represent trends or random observations. About 48% of incidents were considered preventable by the reporters (vs. 52% in the first 4000). These findings support continued emphasis on human and system factors to promote and improve patient safety in anaesthesia care. [ABSTRACT FROM AUTHOR]

The most recent estimates, published in 2016, have indicated that around 70% of anaesthesia providers in Papua New Guinea are non-physician anaesthetic providers and that they administer over 90% of anaesthetics, with a significant number unsupervised by a physician anaesthetist. Papua New Guinea has a physician anaesthetist ratio estimated to be 0.25 per 100,000 population, while Australia and New Zealand have a ratio of 19 physician anaesthetists per 100,000, which is 75 times that of Papua New Guinea. To reach a ratio of seven per 100,000, recommended as the minimum acceptable by the Lancet Commission in 2016, there will need to be over 35 practitioners trained per annum until 2030, at a time when the average annual numbers of recent years are less than three physicians and less than five non-physician anaesthetic providers. We review the development of anaesthesia administered by non-physician indigenous staff and the stages of development from heil tultuls, dokta bois, liklik doktas, native medical assistants, aid post orderlies, and Anaesthetic Technical Officers up to the current Anaesthetic Scientific Officers having attained the Diploma in Anaesthetic Science from the University of Papua New Guinea. [ABSTRACT FROM AUTHOR]

Airway Management is the key for anaesthetists dealing with patients undergoing diagnostic procedures and surgical interventions. The present coronavirus pandemic underpins even more how important safe airway management is. It also highlights the need to apply stringent precautions to avoid infection and ongoing transmission to patients, anaesthetists and other healthcare workers (HCWs). In light of this extraordinary global situation the aim of this article is to update the reader on the varied aspects of the ever-changing tasks anaesthetists are involved in and highlight the equipment, devices and techniques that have evolved in response to changing technology and unique patient and surgical requirements. [ABSTRACT FROM AUTHOR]

The article introduces papers presented at a meeting of the Royal Society of Medicine's Section of Anaesthesia on April 7, 1995, including a paper by J. Alderson entitled "Anaesthesia for Paraplegics."

The infectious pandemics and epidemics of the past 200 years have caused millions of deaths. However, these devastating events have also led to creative thinking, imaginative experimentation and the evolution of medical care. As a result, the history of critical care medicine is entwined with the story of these global disasters. This article will take case studies from recent pandemics and epidemics and examine their impact on the development of anaesthesia and intensive care medicine. [ABSTRACT FROM AUTHOR]

The primary aim of this study was to evaluate the perceptions of Australian anaesthetists in relation to smartphone use within anaesthetic practice. In particular, we aimed to assess the frequency of smartphone use, the types and number of smartphone applications used, how reliant anaesthetists perceive themselves to be on smartphones and whether they perceive them to be a factor that aids or distracts from their practice. Secondly, we assessed whether there is an association between the type, frequency, reliance and perceptions of smartphone use and the years of experience as an anaesthetist. A 24-item questionnaire addressing these questions was created and distributed to an email list of credentialled anaesthetists in Melbourne, Australia. A total of 113 consultant anaesthetists who practise at 55 hospitals in Melbourne completed the questionnaire. Our results suggest that the majority of anaesthetists are using smartphones regularly in their practice. About 74% of respondents agreed that they rely on their smartphone for their work. We found that respondents were more likely to rely on smartphones and consider them to aid patient safety than to consider them a distraction. This phenomenon was particularly apparent in those who had been a consultant anaesthetist for less than three years. Furthermore, those who had been a consultant anaesthetist for less than three years were more likely to have more smartphone apps relating to anaesthetics, use them more often and rely on them to a greater degree. Our results highlight the ubiquitous and perceived useful nature of smartphones in anaesthetic practice. [ABSTRACT FROM AUTHOR]

Early excision of deep burn eschar and the expeditious closure of the resultant wounds have become established as gold standard burn care. However, early burn excision has been accepted as up to four days post injury based on a series of misconceptions, not least that the patient is too unwell to undergo surgery and tolerate anaesthesia too soon after injury. There are several reasons why immediate burn excision yields superior survival outcomes, and these are expounded in this article. The systemic pathophysiology following major burn injury, especially when complicated by the respiratory pathophysiology accompanying smoke inhalation, evolves. The hours immediately after burn injury offer several windows of surgical opportunity, windows closed by the pathophysiological events that peak 24 hours later and make surgery and anaesthesia at that time both dangerous and ill-advised. [ABSTRACT FROM AUTHOR]

Background: Research has demonstrated that anaesthesia providers are susceptible to substance abuse. Several preventive measures are being implemented in certified registered nurse anaesthetist programmes to educate future providers about substance abuse. Given the continued prevalence and impact of the problem, more research is needed about the prevalence of substance abuse among student registered nurse anaesthetists and the implementation of preventive strategies in the educational setting. Aims: The purpose of this narrative literature review was to examine the state of the science related to substance abuse among US certified anaesthesia providers. This literature review covered abuse of alcohol, tobacco, recreational drugs, opioids and anaesthetic agents. Methods: This narrative review was conducted using the following search terms: anaesthesia, student, wellness, stress, substance abuse, satisfaction, personality, depression, nurse, nurse anaesthetist, propofol, isoflurane and fentanyl. References were identified using PubMed, CINAHL, Google Scholar, and the American Society of Anesthesiologists and American Association of Nurse Anesthetists websites. A total of 36 articles were identified as relevant to this literature review based on content and country of publication. This literature review was limited to articles published in the past 15 years. With one exception, our search was limited to manuscripts from the US. Results: The literature underscored that various risk factors contribute to substance abuse. Board-certified anaesthesia providers fall prey to substance abuse due to ease of access, the high stress associated with administering anaesthesia, and the propensity to become addicted to opioids and other anaesthetics. A gap in the science exists about the prevalence of substance abuse among student registered nurse anaesthetists and the effectiveness of preventive strategies in the educational setting. Conclusions: Anaesthesia providers are at high risk of abusing substances. To create a safer environment, future research should explore the prevalence of substance abuse among student registered nurse anaesthetists and emphasise the integration of effective preventive strategies in the educational setting. [ABSTRACT FROM AUTHOR]

The purpose of this study was to identify surface anatomy of digital nerves in relation to the pigmented border of digits. Three-hundred and sixty digital nerves in 36 preserved adult cadaveric hands were dissected under magnification. The digital nerves were constantly located anterior to the pigmented border. The median curvilinear distance along the skin from the pigmented border to the digital nerves of the index, middle, ring and little fingers was 1.4 mm. In the thumb, this distance was 2.4 and 3.7 mm on the radial and ulnar sides, respectively. The digital nerve was located 2.4 mm deep to the skin in all fingers. The median angle to the nerve from the skin at the pigmented border was 30°. These dimensions differed in the thumb compared with the rest of the fingers. We conclude that the pigmented border of digits is a reliable anatomical landmark to locate digital nerves. [ABSTRACT FROM AUTHOR]

Transfusion, as we know it today, developed into a very sophisticated treatment modality as a result of centuries of experimentation. Intraoperative cell salvage is a transfusion technique where autologous blood lost during surgery is reinfused. The success of this process relies on specialised equipment and techniques to collect, process, anticoagulate filter and reinfuse blood. Through a literature review, we collected information about the early origins of specific techniques relevant to intraoperative cell salvage: the ability to collect lost blood, to prevent collected blood from clotting, to remove debris through processing and other harmful aspects through filtering, the benefits of autologous blood transfusion, reinfusion and traditional concerns and contraindications. A culmination of knowledge specific to each of these techniques over centuries provides the background to the safe intraoperative cell salvage technique used today. In addition, we aimed to identify the reasons why specific equipment and techniques developed, why practice changed and what is still unknown. This article reviews relevant allogeneic transfusion and autotransfusion history, starting in Roman times, and includes landmark events through the centuries. [ABSTRACT FROM AUTHOR]

The first 4000 reports to the webAIRS anaesthesia incident reporting database were used to evaluate pulmonary aspiration in patients undergoing procedures under general anaesthesia or sedation. Demographic data, predisposing factors, outcome and potential preventative measures were evaluated. In these reports, 121 cases of aspiration were identified. Aspirated substances included gastric contents, bile type fluids, blood and solids; 60 (49.6%) patients were admitted to the intensive care unit/high dependency unit, and 43 (35.5%) required mechanical ventilation. Aspiration was associated with significant harm in >50% of reports, and eight (6.6%) patients died. Factors associated with a risk ratio of aspiration >1.5 and outside the 95% confidence interval for no event included: age >80 years, emergency procedure, procedure undertaken in freestanding day unit or gastroenterology department, procedure undertaken between 1800 and 2200 hours and endoscopy procedures. Only 11 (9%) cases appeared to be inadequately fasted, and 77 (64%) were definitely fasted. In the remaining 33 (27%), fasting was not mentioned. In 18 (14.9%) cases, aspiration occurred in the presence of cricoid pressure. Potential measures to prevent aspiration included using a cuffed endotracheal tube rather than a laryngeal mask airway in cases at high risk of aspiration and being made more aware of potential risk factors by improvements in team communication. Aspiration continues to be an important complication of anaesthesia, and one that can be difficult to predict and to prevent. [ABSTRACT FROM AUTHOR]

There is a recognition of the contribution to global warming from emissions of anaesthetic gases into the atmosphere. We audited sevoflurane use to help guide future initiatives to reduce consumption. We observed sevoflurane use during paediatric anaesthesia in a single operating theatre over eight weeks. We recorded demographics, timing of induction and maintenance of anaesthesia, type of circuit used and amount of liquid sevoflurane used (in mL). Ninety-four cases were available for analysis. Of these, 65 had gas inductions and 29 had intravenous (IV) inductions. The median sevoflurane use was 19 mL (interquartile range, IQR 13–24 mL). The median duration of cases was 50.5 min (IQR 35–78 min). The median sevoflurane consumption for cases with a gas induction was 22 mL (IQR 16–26 mL) and for those with an IV induction was 11 mL (IQR 7–17 mL; P < 0.00001). The duration of cases for the gas and IV induction cohorts were similar. During maintenance of anaesthesia, there was no difference between the IV and gas induction cohorts. There was little difference in sevoflurane use between the T-piece and circle system groups. Cases performed with gas inductions consumed twice the sevoflurane as those with IV inductions. Future interventions to reduce sevoflurane consumption should focus on this period. [ABSTRACT FROM AUTHOR]