Search

Guidelines are presented that summarise the legal position regarding the audio/visual recording of doctors and others in hospitals. In general, there are few, if any, legal grounds for refusing a request by patients to record procedures and/or discussions with clinicians, although some staff may feel uncomfortable being recorded. Trusts and others are advised to draw up local policies and ensure staff and patients are adequately informed. [ABSTRACT FROM AUTHOR]

Serious neurological lesions such as vertebral canal haematoma are rare after obstetric regional analgesia/ anaesthesia, but early detection may be crucial to avoid permanent damage. This may be hampered by the variable and sometimes prolonged recovery following 'normal' neuraxial block, such that an underlying lesion may easily be missed. These guidelines make recommendations for the monitoring of recovery from obstetric neuraxial block, and escalation should recovery be delayed or new symptoms develop, with the aim of preventing serious neurological morbidity. [ABSTRACT FROM AUTHOR]

Which journals cite work published in anaesthetic journals is of potential interest to authors, editors and publishers. We analysed citations made in 2017-2018 for articles, reviews, editorials and letters published by 12 anaesthetic journals in 2016, using the Web of Science™ citation index platform. We analysed 12,544 citations made for 3518 items. Citations were most often made by specialist anaesthesia journals and critical care journals, and occurred most commonly in articles, followed by reviews, editorials and letters. The median (IQR [range]) number of citations made per item was 3.3 (2.6-4.1 [1.6-5.1]). The median (IQR [range]) number of journals that cited the 12 source journals was 302 (236-449 [139-671]). The median (IQR [range]) proportion of citations made by the same journal that published the items (i.e. 'self-citations') was 15% (11-17% [5-32%]). There were 1305/1932 (68%) citations made by North American journals for items published in North American journals and 1712/2063 (83%) citations made by European journals for items published in European journals, p < 0.0001. Our analysis may inform authors, editors and publishers where to submit work, what editorial policy to pursue and what journal strategy to follow, respectively. [ABSTRACT FROM AUTHOR]

Anaesthetists are thought to be at increased risk of suicide amongst the medical profession. The aims of the following guidelines are: increase awareness of suicide and associated vulnerabilities, risk factors and precipitants; to emphasise safe ways to respond to individuals in distress, both for them and for colleagues working alongside them; and to support individuals, departments and organisations in coping with a suicide. [ABSTRACT FROM AUTHOR]

Summary: Following a 2–3‐month period of publicity, anaesthetists were invited to participate in an online survey that was administered by a third party company on behalf of the Association of Anaesthetists and ran between 3 September and 31 October 2018. Anaesthetists working in the UK or Ireland were asked about the presence or absence of welfare/support structures or resources in their workplace in the case of mental illness, addiction and/or suicide. Anaesthetists working anywhere in the world were also asked for their experiences of a colleague's suicide, defined as a colleague's taking his or her own life – whether intentional or not – while practising as an anaesthetist in the UK or Ireland, in the same department and at the same time as the respondent. Respondents were also asked about experiences of other suicides not meeting this definition. A total of 3638 responses were received. Most respondents were unaware of the existence of policies/guidance on mental illness, addiction or suicide, or of welfare leads, within their Trust or department. A total of 1916 cases of suicide meeting the survey's definition were reported by 1397 respondents, although the actual number of discrete cases is unknown because of likely multiple reporting of the same cases. A third of respondents who reported a suicide had experience of more than one case. Most reports were of suicide in the last 10 years, and most reported cases involved anaesthetic drugs. Deficiencies were noted in the support available and in the way the deaths were handled, although examples of good support were also described. A further 1715 respondents reported suicides that did not meet the primary definition. Overall, 92% of respondents reporting suicide experienced it through work, and 41% outside of work (total > 100% as some reported both). Although unable to provide estimates of suicide rates, or numerical associations between the features of the deaths, this survey highlights the considerable emotional and mental burden of suicide on anaesthetists. [ABSTRACT FROM AUTHOR]

Audio recording consent discussions, and giving a copy of the recording to the patient to keep, might improve the consent process and reduce the risk of misunderstandings, complaints or medicolegal claims. However, there may be concerns over confidentiality and how being recorded could affect the consent discussion. We ascertained the views of 50 postnatal women and 100 maternity staff (25 anaesthetists, 25 obstetricians and 50 midwives) on making audio recordings of consent discussions. There was a wide range of opinions, with women and staff similarly supportive of audio recording overall, but the women were more supportive of recording than the staff when asked if they were against it, or whether they would support recording the discussion if the patient requested it; and less concerned than the staff regarding the potential disadvantages of audio recording. There were no significant differences in the views between anaesthetists, obstetricians and midwives. [ABSTRACT FROM AUTHOR]

Keywords: central neuraxial block; complications; history; regional anaesthesia EN central neuraxial block complications history regional anaesthesia 414 416 3 02/08/21 20210301 NES 210301 Epidurals are standard practice nowadays but have not always been so; all innovations require enthusiasts and pioneers. Evolving use of epidural and caudal blocks Dawkins's list of cases in which he used epidural blocks included upper and lower abdominal, perineal, breast, diagnostic and therapeutic, and miscellaneous. [Extracted from the article]

Upper limb disorders (affecting the hand, arm and neck) are common. The nature of anaesthetists' work poses a potential extra risk from poor posture that may contribute to the development of upper limb disorders in this professional group. However, to date, the problem has received scant attention in the literature. Following a 2 to 3-month period of publicity via newsletter, email and social media, all 10,231 electronically accessible members of the Association of Anaesthetists were invited by email to complete an online survey that was administered by a third-party company. A total of 3884 usable responses were received (38%). Analysis of possible risk factors found a significant association between upper limb disorders and years since starting anaesthetic training, having children (irrespective of respondents' sex or the number of children) and right-handedness. Years of practice and having children are less modifiable identified risk factors. However, right-handedness may be linked to the ergonomic design of the environment/equipment used within this specialty and may thus be a potentially modifiable risk factor worthy of further investigation. [ABSTRACT FROM AUTHOR]

We analysed how long it has taken for papers authored by Scott Reuben, Joachim Boldt and Yoshitaka Fujii to be retracted: investigations into these three anaesthetists have shown much of their research to be unethical or fraudulent. To date, 94% of their combined papers requiring retraction have been retracted; however, only 85% of the retraction notices were compliant with guidelines produced by the Committee on Publication Ethics. We contacted the Editors-in-Chief and/or publishers of all the journals containing articles that had been identified as requiring retraction but had not yet been retracted. In response to our enquiries, 16 articles have since been retracted; we have documented the journals' responses regarding the remaining papers and await further retractions in the future. There is room for improvement in the way that unethical or fraudulent papers are handled by journals and publishers, beyond the identification of the authors' misconduct. [ABSTRACT FROM AUTHOR]

We examined the prevalence of novel acronyms in the titles of anaesthetic and related studies and the response of anaesthetists to them. We separately analysed trainee-led research projects in the UK supported by the Research and Audit Federation of Trainees (RAFT), and a 10-year cohort of papers identified using the PubMed literature search tool. We also conducted a survey of 20 anaesthetists within our institution regarding the utility and impact of titles containing acronyms, and their recall of the associated topics. Finally, we developed a scoring system for acronym accuracy and complexity, the ORigin of AcroNym letterinG Used Term AppropriateNess (ORANGUTAN) score, and measured the progression of acronym usage over the 10-year period studied. Our results show that while acronyms themselves are sometimes considered memorable, they do not aid recall of topics and are, in general, not considered helpful. There has been an increase in the prevalence of acronymic titles over 10 years, and in the complexity of acronyms used, suggesting that there is currently a selective pressure favouring the use of acronyms even if they are of limited benefit. [ABSTRACT FROM AUTHOR]

We analysed data from the electronic rota system CLWRota, covering 2,689,962 anaesthetic sessions between 01/01/2014 and 31/12/2015, in 91 UK Trusts, in order to investigate trainees' supervision. There were 8209 trainee attachments analysed, during which 618,695 sessions were undertaken by trainees. The number of supervised sessions per week that trainees worked varied considerably (median (IQR [range]) 2.6 (1.6-3.6 [0-10]) for all grades combined), with senior trainees more likely than junior trainees to be supervised for fewer than the three sessions per week mandated by the Royal College of Anaesthetists. The number of supervised sessions was unrelated to Trusts' size, suggesting that trainees in smaller hospitals receive the same level of supervision as in larger teaching hospitals. Analysis of a dataset of this size should be a good reflection of the delivery of anaesthesia training in the UK. [ABSTRACT FROM AUTHOR]

We investigated the strength of commonly used spinal needles in relation to the amount of deformation, and registered forces during standardised testing. We investigated differences between manufacturers for the same length and gauge of Luer and non-Luer needles, and examined the effect of the internal stylet in terms of needle strength. A specialised rig was designed to perform the testing in both the horizontal and axial plane, reflecting common industrial tests and clinical use. Needles from four commonly used manufacturers were used (Vygon, Becton Dickinson, B Braun, and Pajunk). Needles of 25 G and 27 G were tested in 90-mm and 120-mm lengths. We found significant differences in terms of the size of final deformation and 'toughness'/resistance to deformation between needles of different brands. There were also significant differences between horizontal tests conducted as an industry standard and our own axial test. This may have bearing on clinical use in terms of the incidence of bending and breakage. The presence of the internal stylet resulted in significantly greater toughness in many needles, but had little effect on the degree of deformation. Comparison of Luer and non-Luer needles of the same brand and size showed few significant differences in strength. This result is reassuring, given the imminent change from Luer to non-Luer needles that is to occur in the UK. [ABSTRACT FROM AUTHOR]

We investigated the flow rates of 25-G and 27-G spinal needles, of 90-mm and 120-mm lengths, from Vygon, BD, B. Braun and Pajunk; the needles had either a Luer connector, or a Surety® or UniVia® non-Luer connector. We used a bench-top model of entering the spinal space, pressurised to 35 cmH2 O to simulate cerebrospinal fluid pressure in the sitting position. We examined the time to first appearance of simulated cerebrospinal fluid in the needle hub, as well as the amount of fluid collected over 120 s after the needle was introduced. The mean (SD) times to first appearance of fluid in the needle hub of Luer spinal needles varied from 0.36 (0.22) s for the 25-G 90-mm BD to 3.14 (0.72) s for the 27-G 120-mm B. Braun, and in the non-Luer spinal needles from 0.22 (0.17) s for the 25-G 90-mm B. Braun to 2.99 (0.71) s for the 27-G 120-mm Pajunk. There was a significant difference in the time to first appearance of fluid in the needle hub between Luer and non-Luer needles of the same type for seven of 14 comparisons made, of which four showed slower appearance of fluid in the non-Luer version. In some of these cases, the time to appearance of fluid was nearly twice as long with the non-Luer counterpart. The mean (SD) weight of fluid collected in 120 s using the Luer spinal needles varied from 0.21 (0.05) g for the 27-G 120-mm Pajunk to 1.21 (0.18) g for the 25-G 90-mm Vygon, and using the non-Luer spinal needles from 0.25 (0.05) g for the 27-G 120-mm Pajunk to 1.55 (0.05) g for the 25-G 90-mm B. Braun. All of the needle types showed a greater weight of fluid collected using the non-Luer compared with the Luer version, with six of the 14 needle types showing a significant difference. Significant variations in flow were also seen between the same needle type from different manufacturers. We conclude that changing from Luer to non-Luer versions of spinal needles does not merely change the hub design and connection, but may introduce important differences in function. [ABSTRACT FROM AUTHOR]

Neuraxial anaesthesia is widely used in obstetrics and neurological complications are rare. However, when they occur, subsequent investigation and management are time-critical and correlate with the extent of neurological recovery. The Third National Audit Project recommended the implementation of guidelines in obstetric epidural management, including advice on monitoring for early signs of problems and acting upon concerns. However, no national guideline exists for postoperative management in the obstetric population. We conducted a national survey of monitoring after obstetric neuraxial blockade and the management of an abnormally prolonged block. We received responses from 112/189 (59.3%) obstetric anaesthetic leads invited to participate. We determined that post-neuraxial blockade monitoring in the UK is highly variable: only 63/112 (56.3%) respondents' units had a monitoring policy in place, although most of these did not undertake formal neurological monitoring, and a range of different monitoring methods and schedules were employed. In 12/63 (19%) local policies, the first review of neurology was performed at the standard postoperative visit the following day, and 66/112 (58.9%) units had no protocol in place to address emergency management of abnormally prolonged neuraxial blockade. Where a policy was in place, the initial recommended action and the type of imaging used were variable. [ABSTRACT FROM AUTHOR]

Previous guidelines on consent for anaesthesia were issued by the Association of Anaesthetists of Great Britain and Ireland in 1999 and revised in 2006. The following guidelines have been produced in response to the changing ethical and legal background against which anaesthetists, and also intensivists and pain specialists, currently work, while retaining the key principles of respect for patients' autonomy and the need to provide adequate information. The main points of difference between the relevant legal frameworks in England and Wales and Scotland, Northern Ireland and the Republic of Ireland are also highlighted. [ABSTRACT FROM AUTHOR]

The author offers his view regarding the inaugural Featherstone Oration, Research not research – a rant in four acts, and Ireland's Winter Scientific Meeting that was held at the Association of Anaesthetists of Great Britain and in London, January 2016, respectively. He mentions that the his four area of concern about research such as precision in communications, absurd situation, and training programs in managing research.

The article discusses national obstetric-specific difficult airway guidelines developed by the Obstetric Anaesthetists' Association in Great Britain to provide a framework for safe obstetric general anaesthesia and management of difficult or failed tracheal intubation. Topics include challenges of anaesthetists in making decisions in case of clinical emergencies in the obstetric setting; and a hypothetical case of a nulliparous woman in labour requiring caesarean section for fetal bradycardia.

In a previous paper, one of the authors (JBC) used a chi-squared method to analyse the means (SD) of baseline variables, such as height or weight, from randomised controlled trials by Fujii et al., concluding that the probabilities that the reported distributions arose by chance were infinitesimally small. Subsequent testing of that chi-squared method, using simulation, suggested that the method was incorrect. This paper corrects the chi-squared method and tests its performance and the performance of Monte Carlo simulations and ANOVA to analyse the probability of random sampling. The corrected chi-squared method and ANOVA method became inaccurate when applied to means that were reported imprecisely. Monte Carlo simulations confirmed that baseline data from 158 randomised controlled trials by Fujii et al. were different to those from 329 trials published by other authors and that the distribution of Fujii et al.'s data were different to the expected distribution, both p < 10(-16) . The number of Fujii randomised controlled trials with unlikely distributions was less with Monte Carlo simulation than with the 2012 chi-squared method: 102 vs 117 trials with p < 0.05; 60 vs 86 for p < 0.01; 30 vs 56 for p < 0.001; and 12 vs 24 for p < 0.00001, respectively. The Monte Carlo analysis nevertheless confirmed the original conclusion that the distribution of the data presented by Fujii et al. was extremely unlikely to have arisen from observed data. The Monte Carlo analysis may be an appropriate screening tool to check for non-random (i.e. unreliable) data in randomised controlled trials submitted to journals. [ABSTRACT FROM AUTHOR]

The authors discuss the impact of the reports on anesthesia by the 5th National Audit Project (NAP5) and by the Mothers and Babies: Reducing Risk Through Audit and Confidential Enquiries Across the UK (MBRRACE-UK) on obstetric general anesthesia. Topics discussed include cases of awareness in obstetric anesthesia, recommendations of the reports for anaesthetists, and a forecast for general anaesthesia.

There are multiple methods of assessing the height of block before caesarean section under regional anaesthesia, and surveys of practice suggest considerable variation in practice. So far, little emphasis has been placed on the guidance to be gained from published research literature or textbooks. We therefore set out to investigate the methods of block assessment documented in published articles and textbooks over the past 30 years. We performed two searches of PubMed for randomised clinical trials with caesarean section and either spinal anaesthesia or epidural anaesthesia as major Medical Subject Headings. A total of 284 papers, from 1984 to 2013, were analysed for methods of assessment of sensory and motor block, and the height of block deemed adequate for surgery. We also examined 45 editions of seven anaesthetic textbooks spanning 1950-2014 for recommended methods of assessment and height of block required for caesarean section. Analysis of published papers demonstrated a wide variation in techniques, though there has been a trend towards the increased use of touch, and an increased use of a block height of T5 over the study period. Only 115/284 (40.5%) papers described the method of assessing motor block, with most of those that did (102/115; 88.7%) describing it as the 'Bromage scale', although only five of these (4.9%) matched the original description by Bromage. The required height of block recommended by textbooks has risen over the last 30 years to T4, although only four textbooks made any recommendation about the preferred sensory modality. The variation in methods suggested by surveys of practice is reflected in variation in published trials, and there is little consensus or guidance in anaesthetic textbooks. [ABSTRACT FROM AUTHOR]

During central neuraxial blockade, identifying the midline in parturients can be difficult, particularly if they are obese. We assessed the ability of women in late pregnancy, both obese and non-obese, to identify the midline of their own back by pointing and by pinprick discrimination with reference to the true midline identified by ultrasound. Thirteen out of 25 (52%) obese women were accurate to within 5 mm in identifying the midline of their back by pointing with their fingertip, compared with 21/25 (84%) non-obese women (p = 0.03). The median (IQR [range]) fingertip-midline distance was greater in obese women (5 (5-10 [0-10]) mm compared with non-obese women (2 (0-5 [0-12]) mm; p = 0.007). Identification of the midline using pinprick was poorer by obese women (median (IQR [range]) 33 (25-45 [3-85]) mm) than by non-obese women (18 (13-25 [8-40]) mm; p < 0.0001). However, women in both groups were correct > 99% of the time in identifying that a stimulus was either to the left or to the right side. [ABSTRACT FROM AUTHOR]

Prevention of aortocaval compression is essential for effective cardiopulmonary resuscitation in late pregnancy. This can be achieved by either lateral maternal tilt or lateral uterine displacement. Results from a previous manikin study show that a firm foam-rubber wedge allowed successful chest compressions whilst providing stable and reliable lateral tilt. However, it did not investigate resuscitation in the supine position with manual uterine displacement. The aim of this study was to compare the effectiveness of chest compressions in a manikin in the supine position vs lateral tilt using a foam-rubber wedge, both on the floor and on a typical patient bed. Overall, we found that compressions were easier to perform in the supine position (p = 0.007 (bed) and 0.048 (floor)), and with greater stability in the supine position on the floor (p = 0.011). The effectiveness of chest compressions was similar in both the supine/uterine displacement and the lateral tilt positions, suggesting that either method may be suitable for CPR. [ABSTRACT FROM AUTHOR]

Haemorrhage remains an important cause of maternal mortality worldwide. Cell salvage carries a theoretical risk of amniotic fluid embolus syndrome and is too expensive for use in many parts of the world. To explore cheaper options, we investigated whether a leucocyte depletion filter alone removes components of pure amniotic fluid. Amniotic fluid was collected from 10 women during elective caesarean section and passed through a LeukoGuard® RS filter. Pre- and post-filtration samples were compared in the laboratory. Lamellar bodies and fetal squames were almost completely removed (filtration efficacy 96.6% and 99.9%, respectively; p < 0.0001 and <0.0004), and hair was completely removed (p = 0.002). Filtration had no effect on concentrations of α-fetoprotein, tissue factor or endothelin-1, or on the presence of meconium or vernix. Additional work is required to evaluate whether cell salvage using filtration alone may be useful in maternal haemorrhage in the developing world. [ABSTRACT FROM AUTHOR]

There has been little published work defining 'normal' thromboelastography (TEG®) values in healthy parturients, and few large studies defining reference ranges for traditional coagulation tests in this patient group. Our aim was to establish peri-operative reference ranges for TEG and for standard laboratory coagulation tests in our pregnant population. Fifty healthy term parturients presenting for elective caesarean section under spinal anaesthesia had blood samples taken pre-operatively, on arrival in the recovery room and, in a subset of 33 women, 4 h after routine thromboprophylaxis with enoxaparin 40 mg. All three samples had TEG analysis, the first and second having standard laboratory coagulation tests in addition. Reference ranges for our pregnant population were established, demonstrating a hypercoagulable state in term parturients and a significant effect of enoxaparin. The standard coagulation reference ranges were within 98% of the local non-pregnant ranges. These reference ranges provide a useful comparator for peri-operative TEG and routine coagulation analysis in term parturients. [ABSTRACT FROM AUTHOR]

Background Informed consent should be sought when performing anaesthesia on pregnant patients. There is no standard for consent for general anaesthesia on the delivery suite. This study was designed to assess post-partum women's awareness of the complications of general anaesthesia and the level of risk at which they felt these risks should be discussed. Methods One hundred and fifty parturients from two London hospitals who had undergone uncomplicated vaginal deliveries were asked on the first post-partum day about their knowledge of the potential complications of general anaesthesia for obstetrics. They were also asked about the level of risk at which they would wish to be informed before consenting to a general anaesthetic procedure. Results The knowledge of the risks of general anaesthesia among the parturients was poor, with awareness, allergy, nausea and vomiting being known by over 50%. Knowledge of difficult intubation and its consequences, dental damage, malignant hyperpyrexia and suxamethonium apnoea was known by less than 30% of the respondents. The level of risk at which mothers felt they should be informed was variable, with 50% wishing to know all risks up to 1 : 1000, and 19% wishing to know risks of greater than 1 : 1,000,000. All known risks were wished by nearly 30% of those questioned. Conclusions Anaesthetists must be flexible when providing information to mothers about general anaesthesia and should provide more information to mothers if they wish it. [ABSTRACT FROM AUTHOR]

Chlorohexidine/ethanol is commonly used for skin disinfection before neuraxial procedures. Two applications of this solution have been advocated but no evidence exists to support this. Our aim was to ascertain whether two applications of chlorohexidine/ethanol solution are more effective than one for skin disinfection before neuraxial anaesthesia. A 4-cm diameter soya agar contact plate was applied to the skin of the lumbar region of 309 healthy volunteers, followed by a single spray application of chlorhexidine gluconate 0.5% w/v in 70% v/v denatured ethanol. This was allowed to dry and a second contact plate applied. The disinfectant was re-applied and after drying, a third contact plate applied. Agar plates were incubated at 37 °C for 24 h. No growth occurred in any plates after the first or second spray (p < 0.0001). We feel reassured that the current practice of using a single application of chlorhexidine/ethanol solution is sufficient to disinfect the skin before regional anaesthesia, particularly in the emergency situation when waiting for a second application to dry may add needless delay and risk translocation of excess chlorhexidine into the subarachnoid space. [ABSTRACT FROM AUTHOR]

In a randomised controlled study, we compared the ease of railroading a GlideRite nasal tracheal tube over a fibrescope with that of a pre-rotated RAE™ nasal tracheal tube. We studied 110 anaesthetised patients with no known airway difficulties undergoing elective dental or maxillofacial surgery. Impingement was more common with the GlideRite tubes (11/55 (20%)) compared with the pre-rotated RAE tubes (3/55 (5%); p = 0.02). The median (IQR [range]) time to intubation (GlideRite 7.6 (4.7-10.8 [3.0-46.2]) s; RAE 8.0 (6.2-10.7 [2.4-30.0]) s) and postoperative sore throat numerical ratings (GlideRite 2 (0-3 [0-10]); RAE 2 (0-5 [0-8])) were similar. A 90° anticlockwise pre-rotation of a standard nasal RAE tube has a higher initial rate of successful railroading at first attempt and is therefore superior to a GlideRite nasotracheal tube during nasal fibreoptic intubation. [ABSTRACT FROM AUTHOR]

We assessed the ability of palpating the radial arterial pulse and observing the oximeter trace to estimate the automated non-invasive systolic pressure reading in 20 healthy female volunteers and 20 parturients undergoing spinal anaesthesia for elective caesarean section. Using real-time values of cuff pressure during inflation/deflation, the pressure was recorded when the manually palpated radial arterial pulse or pulse oximeter waveform disappeared and reappeared. The actual measured systolic pressure was noted and the results compared using Bland-Altman analysis. In the volunteers, the bias/precision for radial arterial palpation was −12.9/22.1 mmHg (inflation) and −9.7/16.7 mmHg (deflation), and for oximetry 29.5/18.8 mmHg (inflation) and −20.7/21.7 mmHg (deflation). In the parturients, the bias/precision was −19.0/47.6 mmHg (inflation) and −15.5/51.0 mmHg (deflation) for arterial palpation, and 22.6/16.1 mmHg (inflation) and −14.2/19.9 mmHg (deflation) for oximetry. Our results suggest that neither method is accurate at estimating the non-invasive systolic pressure, with all except oximetry (inflation) underestimating it by approximately 10-20 mmHg and with poor precision. [ABSTRACT FROM AUTHOR]

The author reflects on the issues of retraction and corrections published in the journal "Anaesthesia." He stresses on the subject of ethics in research and its correlation to publication ethics which follow guidelines provided by the Committee on Publication Ethics (COPE) in Great Britain so that publication errors could be avoided. The author suggests the use of the iThenticate software CrossCheck scan to determine the authentication and authorship of editorials before publishing.

We analysed 366 claims related to regional anaesthesia and analgesia from the 841 anaesthesia-related claims handled by the National Health Service Litigation Authority between 1995 and 2007. The majority of claims (281/366, 77%) were closed at the time of analysis. The total cost of closed claims was £12 724 017 (34% of the cost of the anaesthesia dataset) with a median (IQR [range]) of £4772 (£0–28 907 [£0–2 070 092]). Approximately half of the claims (186/366; 51%) were related to obstetric anaesthesia and analgesia and of the non-obstetric claims, the majority (148/180; 82%) were related to neuraxial block. The total cost for obstetric closed claims was £5 433 920 (median (IQR [range]) £5678 (£0–27 690 [£0–1 597 565]) while that for non-obstetric closed claims was £7 290 097 (£3337 (£0–31 405 [£0–2 070 062]). Non-obstetric claims were more likely to relate to severe outcomes than obstetric ones. The maximum values of claims were higher for claims related to neuraxial blocks and eye blocks than for peripheral nerve blocks. Despite many limitations, including lack of clinical detail for each case, the dataset provides a useful overview of the extent, patterns and cost associated with the claims. [ABSTRACT FROM AUTHOR]

We have evaluated the TEG® thromboelastograph and the ROTEM® thromboelastometer, two point-of-care devices that measure blood coagulation. During a one-week period, seven consultant anaesthetists, one consultant haematologist, one associate specialist anaesthetist and two senior trainee anaesthetists were trained by the manufacturers and set up, calibrated and used both systems, after which their views were obtained and specific technical/support information was sought from the manufacturers using a questionnaire. Although the devices shared common features, they differed in complexity and aspects of ease of use, and in their purchase and running costs. [ABSTRACT FROM AUTHOR]

We contacted the duty obstetric anaesthetist in 219 of the 220 consultant-led maternity units in the UK (99.5%) and asked about departmental and individual practice regarding temperature management during Caesarean section. Warming during elective Caesarean section was routine in 35 units (16%). Intravenous fluid warmers were available in 213 units (97%), forced air warmers were available in 211 (96%) and warming mattresses were available in 42 (19%). Only 18 (8%) departments had specific guidelines for temperature management during Caesarean section. Personal intra-operative practice was variable, although all of those contacted would initiate some form of active temperature management after a mean (SD) volume of blood loss of 1282 (404) ml, length of surgery of 78 (24) min, or core body temperature (if measured) of median (IQR [range]), 36 (35.5–36 [34–37.2]) °C. [ABSTRACT FROM AUTHOR]

The performance of the occlusion and Pethick tests in detecting faulty inner tubes in co-axial circle and Bain systems was compared. Twelve co-axial circle and 12 Bain anaesthetic breathing systems were tested using the occlusion and the Pethick tests. For each system, three tubes were intact, and the remaining nine had a defect deliberately created in the inner tube (three proximal, three middle and three distal). The investigators were blinded to which of the tubes were defective, and to each other’s results. The results showed 100% specificity for both tests. The sensitivity of the occlusion test for detecting faulty breathing systems was found to be good (98%). Our results suggest that the occlusion test should be performed in preference to the Pethick test when testing co-axial circle and Bain systems. [ABSTRACT FROM AUTHOR]

Epidural mixtures containing lidocaine with or without additives are commonly used to convert epidural analgesia in labour to anaesthesia for emergency Caesarean section, but direct comparisons with alternative, single agents in this situation are few. In a prospective double-blinded trial, we compared a freshly prepared lidocaine-bicarbonate-adrenaline mixture (final concentrations 1.8%, 0.76% and 1 : 200,000, respectively) with our standard agent, levobupivacaine 0.5%, for extending epidural blockade for emergency Caesarean section. Using a sequential analysis technique, with data analysed in blocks of 40, women receiving epidural analgesia in labour who required top-up for Caesarean section were randomly assigned to receive 20 ml of epidural solution over 3 min. The first analysis ( n = 40) indicated that the study should be stopped, as significant differences were found in our primary outcome data. Median (IQR [range]) times to reach a block to touch to T5 and cold to T4 were, respectively, 7 (6–9 [5–17]) min and 7 (5–8 [4–17]) min for lidocaine-bicarbonate-adrenaline, and 14 (10 −17 [9–31]) min and 11 (9–14 [6–30]) min for levobupivacaine (p = 0.00004 and 0.001, respectively). Pre- and intra-operative supplementation/pain, maternal side-effects and neonatal outcomes (excluding five women who underwent instrumental delivery) were similar between the groups. Intra-operative maternal sedation (scored by the mother on a 10-point scale) was greater with lidocaine-bicarbonate-adrenaline (4.5 (3–8 [1–9])) than with levobupivacaine (3 (1–4 [1–7])), but not significantly so (p = 0.07). We conclude that epidural lidocaine-bicarbonate-adrenaline halves the onset time when extending epidural analgesia for Caesarean section although there is a possibility of increased maternal sedation. [ABSTRACT FROM AUTHOR]

This study compared the efficacy of an anterior jaw lift manoeuvre with that of the Berman airway in clearing the upper airway during oral fibreoptic tracheal intubation in anaesthetised, paralysed patients. Fifty patients were randomly assigned to undergo fibreoptic-assisted intubation with one method, followed by crossover to the alternative method. The time taken to view the vocal cords was the primary endpoint, and we also noted the rate of failure to view the cords, i.e. cords not seen after 120 s of endoscopy. Anterior jaw lift yielded significantly shorter times to view the vocal cords (median [interquartile range; range]: 22 [17–46; 7–120] s vs 40 [29–67; 21–120] s, p = 0.001) and a higher success rate (49/50 vs 42/50, p = 0.014). We conclude that the anterior jaw lift is more effective than the Berman device for achieving airway clearance in this setting. [ABSTRACT FROM AUTHOR]

Traditional medical decision making is unstructured and incorporates evidence haphazardly. I present a more structured approach based on decision analysis, a model that considers all relevant options and outcomes informed by evidence where appropriate. This method is useful both for planning clinical management and for analysing decisions already taken. [ABSTRACT FROM AUTHOR]

The handover of patient information between shifts enables continuity of care and increases patient safety. We surveyed UK practice during handovers in obstetric anaesthesia. A questionnaire was sent to 239 lead consultant obstetric anaesthetists to record routine practice in their unit and individual opinion about handover procedures. Responses were received from 168 anaesthetists, a 70% response rate. Handover policies were available in 10% of units. Most (76%) responding units had an allocated time for handover. In most units (76%), the duration of handover was reported as being < 15 min but the actual duration and depth of any discussion involved were not specified. Handovers were rarely documented in writing (7%). Consultant anaesthetists were most likely to be present at the morning handover and few handovers were multidisciplinary. Four percent of units reported critical incidents following inadequate handovers in the past 12 months. We identify features in handover procedures that could be improved. [ABSTRACT FROM AUTHOR]

One hundred women were randomly allocated to the left lateral, Oxford or sitting position for induction of combined spinal-epidural anaesthesia for Caesarean section using 2.5 ml hyperbaric bupivacaine 0.5% and 10 μg fentanyl. Women in the left lateral were then turned to the right lateral position; women in the Oxford position were turned to the same position on their opposite side; and women in the sitting group were turned to the supine left tilt position. Women remained in these positions until ready for surgery, which was conducted in the supine position with a wedge placed under the right hip. Ephedrine requirements before re-positioning for surgery were less in the sitting position than in the other two positions: median (IQR[range]) doses for the lateral, Oxford and sitting groups were 21 (12–30[6–48]), 18 (7.5–24[6–48]) and 12 (6–21[6–42]) mg, respectively; p = 0.04. Sensory block to touch sensation at the T5 dermatomal level was most quickly achieved in the lateral position with median (IQR[range]) block onset times for the lateral, Oxford and sitting groups of 9 (6–13[4–30]), 15.5 (9–22[4–34]) and 14 (9–18[6–36]) min, respectively; p = 0.004. In the Oxford position, more epidural catheters required dosing to achieve a sensory block of T5 before surgery: the number of patients (proportion) bolused in the lateral, Oxford and sitting groups was 1 (3%), 7 (22%) and 1 (3%), respectively; p = 0.01. We did not demonstrate any advantage in using the Oxford position for combined spinal-epidural anaesthesia for elective Caesarean section. [ABSTRACT FROM AUTHOR]

The article discusses the lack of skills in doctors needed for evaluating and interpreting scientific papers. The purpose of a scientific publication, of which there are numerous types, is to communicate information. Editorials are summary or personal views, perhaps commenting on a specific paper. Reviews are longer, in-depth analyses of the literature. There are generally two aspects to excellence in an experimental study -- first, the study's conduct and second, its presentation. Particular attention should be given to the avoidance of surrogate measures, appropriate measurement tools, appropriate use of control groups, and appropriate application and interpretation of statistics.

We describe a simple, homemade model for teaching cricothyrotomy. It can easily be constructed from materials found in every anaesthetic room and is cheap, portable and usable several times before requiring replacement. We also describe evaluation of the model in a two-part study. First, 20 anaesthetic trainees, both with and without prior experience of percutaneous cricothyrotomy/tracheotomy, cannulated the‘trachea’ using two percutaneous airway sets (Ravussin jet ventilation catheter®[VBM] and Mini-Trach II Seldinger®[Portex]), then scored the model for realism and usefulness for training. Next, 20 further trainees used the Mini-Trach II Seldinger on both the homemade model and a commercially available cricothyrotomy/tracheotomy trainer (Pharmabotics), scoring both models as before. In the first part of the study, trainees found the homemade model a useful substitute for practice of percutaneous techniques and teaching. In the second part, both models were rated well, with similar scores. The homemade model is an easily assembled alternative to more expensive models. Both experienced and inexperienced trainees find practising on such models useful. [ABSTRACT FROM AUTHOR]

We compared ropivacaine 0.75% and bupivacaine 0.5% for extending low-dose epidural analgesia for emergency Caesarean section, using a prospective double-blind randomised controlled trial design. The trial was halted after 45 patients were studied (23 ropivacaine; 22 bupivacaine) because bupivacaine was replaced by levobupivacaine in our unit. Time to reach T4 for loss of cold sensation was similar in both groups, although analgesic supplementation was required less often in the ropivacaine group than in the bupivacaine group (2/23 vs. 9/21; p = 0.01). [ABSTRACT FROM AUTHOR]

We conducted a prospective, randomised, double-blind trial to study the effect of Synacthen Depot in 18 parturients with postdural puncture headache following deliberate or accidental dural puncture. Women were randomly allocated to receive either Synacthen Depot 1 mg (1 ml) or 0.9% saline 1 ml intramuscularly. Using a 10-cm visual analogue scale, severity of headache was measured before and at intervals until 48 h after injection. There was no difference in the severity of headache or requirement for epidural blood patch. We conclude that there is no advantage to the use of Synacthen Depot 1 mg for the treatment of postdural puncture headache. [ABSTRACT FROM AUTHOR]

Pregnant women were randomly assigned to receive, at booking, the usual written information pack either with or without the Obstetric Anaesthetists' Association's (OAA's) leaflet 'Pain Relief in Labour'. At 36 weeks' gestation, a structured interview was conducted at which we assessed the sources of information the women had used and their knowledge of specific aspects of obstetric analgesia and anaesthesia described in the OAA leaflet. The most useful sources of information overall were friends, family, midwives, books and information leaflets (no significant difference between the groups); 72% of all women felt they had received adequate information although 70% said they would have liked to have discussed methods of analgesia with an anaesthetist before delivery. Parturients allocated to receive the leaflet (n = 37) were more knowledgeable than those who received only standard booking information (n = 39) about all analgesic and anaesthetic techniques except for systemic pethidine, although this difference in knowledge only reached statistical significance for extending epidural analgesia for emergency Caesarean section. We conclude that the OAA leaflet improves women's knowledge of analgesic techniques and suggest that all information of this type be formally assessed in this manner; furthermore given the practical difficulties in conducting studies of this type, the latter should be adequately resourced, perhaps by the bodies that issue such leaflets. [ABSTRACT FROM AUTHOR]

We studied the success rates for tracheal intubation in 32 healthy, anaesthetised patients during simulated grade IIIa laryngoscopy, randomised to either the multiple-use or the single-use bougie. Success rates (primary end-point) and times taken (secondary end-point) to achieve tracheal intubation were recorded. The multiple-use bougie was more successful than the single-use one (15/16 successful intubations vs. 9/16; p = 0.03). With either device, median [range] total tracheal intubation times for successful attempts were < 54 [24-84] s and there were no clinically important differences between these times. We conclude that the multiple-use bougie is a more reliable aid to tracheal intubation than the single-use introducer in grade IIIa laryngoscopy. [ABSTRACT FROM AUTHOR]

We studied the success rates for tracheal intubation in 64 healthy patients during simulated grade III laryngoscopy after induction of anaesthesia, using either the single-use bougie or oral flexible intubating fibrescope, both in conjunction with conventional Macintosh laryngoscopy. Patients were randomly allocated to either simulated grade IIIa or grade IIIb laryngoscopy, and also to one of the two study devices. Success rates for tracheal intubation (primary outcome measure) and times taken to achieve intubation (secondary outcome measure) were recorded. For the simulated grade IIIa laryngoscopy group, the fibreoptic scope was more successful than the bougie (16/16 successful intubations vs. 8/16; p = 0.02). For the simulated grade IIIb laryngoscopy group, the fibreoptic scope was also more successful than the bougie (8/16 successful intubations vs. 1/16; p = 0.02), but clearly use of the fibreoptic scope was not as successful as it had been in simulated grade IIIa laryngoscopy (p = 0.04). With either device, median (range) total tracheal intubation times for successful attempts with either grade of laryngoscopy were less than 60 s (19-109) and there were no clinically important differences. We conclude that the fibrescope used in conjunction with Macintosh laryngoscopy is a more reliable method of tracheal intubation than the single-use bougie in both types of grade III laryngoscopy. This finding has implications for the management of patients in whom grade III laryngoscopy is encountered unexpectedly after induction of anaesthesia, and also for the management of patients previously known to have grade III view at laryngoscopy. [ABSTRACT FROM AUTHOR]

We conducted a two-part study to assess the practice of withholding neuromuscular blockade until the ability to ventilate the lungs using a bag and face mask (mask ventilation) has been established following induction of anaesthesia. The first part of the study consisted of a postal survey (71% response rate) of 188 anaesthetists in the Oxford region to assess their current practice. Thirty per cent of respondents always checked mask ventilation before administering a neuromuscular blocking drug, whereas 39% of respondents (all them consultants) never did this. A further 31% only did so in the case of known or anticipated difficulty with the airway. In the second part of the study, we measured inspired (V(TI)) and expired (V(TE)) tidal volumes before and after neuromuscular blockade in 30 patients undergoing general anaesthesia. The ratio V(TE)/V(TI) was used as a measure of the efficiency of ventilation. There was no difference in V(TE)/V(TI) before [mean (SD) 0.47 (0.13)] and after [0.45 (0.13)] neuromuscular blockade. We conclude that neuromuscular blockade does not affect the efficiency of mask ventilation in patients with normal airways. [ABSTRACT FROM AUTHOR]

We investigated the attitudes of 96 patients and 163 anaesthetists to the need for obtaining informed consent before specialist airway techniques. Participants were asked to score six questions using a numerical scale, as to whether they thought consent was necessary before specific procedures, particularly in relation to fibreoptic intubation used for teaching or maintaining skills. Significant differences in opinion were found between patients and anaesthetists despite a wide range of views. Overall, patients felt that specific consent was required for non-routine techniques, whilst anaesthetic respondents felt this was unnecessary, even if teaching. We conclude that guidance in obtaining consent is needed to support anaesthetists wishing to practice or teach fibreoptic intubation. [ABSTRACT FROM AUTHOR]