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The 7th National Audit Project of the Royal College of Anaesthetists studied peri-operative cardiac arrest in the UK. We report the results of the vascular surgery cohort from the 12-month case registry, from 16 June 2021 to 15 June 2022. Anaesthesia for vascular surgery accounted for 2% of UK anaesthetic caseload and included 69 (8%) reported peri-operative cardiac arrests, giving an estimated incidence of 1 in 670 vascular anaesthetics (95%CI 1 in 520-830). The high-risk nature of the vascular population is reflected by the proportion of patients who were ASA physical status 4 (30, 43%) or 5 (19, 28%); the age of patients (80% aged > 65 y); and that most cardiac arrests (57, 83%) occurred during non-elective surgery. The most common vascular surgical procedures among patients who had a cardiac arrest were: aortic surgery (38, 55%); lower-limb revascularisation (13, 19%); and lower-limb amputation (8, 12%). Among patients having vascular surgery and who had a cardiac arrest, 28 (41%) presented with a ruptured abdominal aortic aneurysm. There were 48 (70%) patients who had died at the time of reporting to NAP7 and 11 (16%) were still in hospital, signifying poorer outcomes compared with the non-vascular surgical cohort. The most common cause of cardiac arrest was major haemorrhage (39, 57%), but multiple other causes reflected the critical illness of the patients and the complexity of surgery. This is the first analysis of the incidence, management and outcomes of peri-operative cardiac arrest during vascular anaesthesia in the UK., (© 2024 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

The 7th National Audit Project (NAP7) of the Royal College of Anaesthetists studied complications of the airway and respiratory system during anaesthesia care including peri-operative cardiac arrest. Among 24,721 surveyed cases, airway and respiratory complications occurred commonly (n = 421 and n = 264, respectively). The most common airway complications were: laryngospasm (157, 37%); airway failure (125, 30%); and aspiration (27, 6%). Emergency front of neck airway was rare (1 in 8370, 95%CI 1 in 2296-30,519). The most common respiratory complications were: severe ventilation difficulty (97, 37%); hyper/hypocapnia (63, 24%); and hypoxaemia (62, 23%). Among 881 reports to NAP7 and 358 deaths, airway and respiratory complications accounted for 113 (13%) peri-operative cardiac arrests and 32 (9%) deaths, with hypoxaemia as the most common primary cause. Airway and respiratory cases had higher and lower survival rates than other causes of cardiac arrest, respectively. Patients with obesity, young children (particularly infants) and out-of-hours care were overrepresented in reports. There were six cases of unrecognised oesophageal intubation with three resulting in cardiac arrest. Of these cases, failure to correctly interpret capnography was a recurrent theme. Cases of emergency front of neck airway (6, approximately 1 in 450,000) and pulmonary aspiration (11, approximately 1 in 25,000) leading to cardiac arrest were rare. Overall, these data, while distinct from the 4th National Audit Project, suggest that airway management is likely to have become safer in the last decade, despite the surgical population having become more challenging for anaesthetists., (© 2023 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

Complications and critical incidents arising during anaesthesia due to patient, surgical or anaesthetic factors, may cause harm themselves or progress to more severe events, including cardiac arrest or death. As part of the 7th National Audit Project of the Royal College of Anaesthetists, we studied a prospective national cohort of unselected patients. Anaesthetists recorded anonymous details of all cases undertaken over 4 days at their site through an online survey. Of 416 hospital sites invited to participate, 352 (85%) completed the survey. Among 24,172 cases, 1922 discrete potentially serious complications were reported during 1337 (6%) cases. Obstetric cases had a high reported major haemorrhage rate and were excluded from further analysis. Of 20,996 non-obstetric cases, 1705 complications were reported during 1150 (5%) cases. Circulatory events accounted for most complications (616, 36%), followed by airway (418, 25%), metabolic (264, 15%), breathing (259, 15%), and neurological (41, 2%) events. A single complication was reported in 851 (4%) cases, two complications in 166 (1%) cases and three or more complications in 133 (1%) cases. In non-obstetric elective surgery, all complications were 'uncommon' (10-100 per 10,000 cases). Emergency (urgent and immediate priority) surgery accounted for 3454 (16%) of non-obstetric cases but 714 (42%) of complications with severe hypotension, major haemorrhage, severe arrhythmias, septic shock, significant acidosis and electrolyte disturbances all being 'common' (100-1000 per 10,000 cases). Based on univariate analysis, complications were associated with: younger age; higher ASA physical status; male sex; increased frailty; urgency and extent of surgery; day of the week; and time of day. These data represent the rates of potentially serious complications during routine anaesthesia care and may be valuable for risk assessment and patient consent., (© 2023 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

Healthcare relies on high levels of human performance, as described by the 'human as the hero' concept. However, human performance varies and is recognised to fall in high-pressure situations, meaning that it is not a reliable method of ensuring safety. Other safety-critical industries embed human factors principles into all aspects of their organisations to improve safety and reduce reliance on exceptional human performance; there is potential to do the same in anaesthesia. Human factors is a broad-based scientific discipline which aims to make it as easy as possible for workers to do things correctly. The human factors strategies most likely to be effective are those which 'design out' the chance of an error or adverse event occurring. When errors or adverse events do happen, barriers are in place to trap them and reduce the risk of progression to patient and/or worker harm. If errors or adverse events are not trapped by these barriers, mitigations are in place to minimise the consequences. Non-technical skills form an important part of human factors barriers and mitigation strategies and include: situation awareness; decision-making; task management; and team working. Human factors principles are not a substitute for proper investment and appropriate staffing levels. Although applying human factors science has the potential to save money in the long term, its proper implementation may require investment before reward can be reaped. This narrative review describes what is known about human factors in anaesthesia to date., (© 2023 Association of Anaesthetists.)

Human factors is an evidence-based scientific discipline used in safety critical industries to improve safety and worker well-being. The implementation of human factors strategies in anaesthesia has the potential to reduce the reliance on exceptional personal and team performance to provide safe and high-quality patient care. To encourage the adoption of human factors science in anaesthesia, the Difficult Airway Society and the Association of Anaesthetists established a Working Party, including anaesthetists and operating theatre team members with human factors expertise and/or interest, plus a human factors scientist, an industrial psychologist and an experimental psychologist/implementation scientist. A three-stage Delphi process was used to formulate a set of 12 recommendations: these are described using a 'hierarchy of controls' model and classified into design, barriers, mitigations and education and training strategies. Although most anaesthetic knowledge of human factors concerns non-technical skills, such as teamwork and communication, human factors is a broad-based scientific discipline with many other additional aspects that are just as important. Indeed, the human factors strategies most likely to have the greatest impact are those related to the design of safe working environments, equipment and systems. While our recommendations are primarily provided for anaesthetists and the teams they work with, there are likely to be lessons for others working in healthcare beyond the speciality of anaesthesia., (© 2023 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

Between October 2020 and January 2021, we conducted three national surveys to track anaesthetic, surgical and critical care activity during the second COVID-19 pandemic wave in the UK. We surveyed all NHS hospitals where surgery is undertaken. Response rates, by round, were 64%, 56% and 51%. Despite important regional variations, the surveys showed increasing systemic pressure on anaesthetic and peri-operative services due to the need to support critical care pandemic demands. During Rounds 1 and 2, approximately one in eight anaesthetic staff were not available for anaesthetic work. Approximately one in five operating theatres were closed and activity fell in those that were open. Some mitigation was achieved by relocation of surgical activity to other locations. Approximately one-quarter of all surgical activity was lost, with paediatric and non-cancer surgery most impacted. During January 2021, the system was largely overwhelmed. Almost one-third of anaesthesia staff were unavailable, 42% of operating theatres were closed, national surgical activity reduced to less than half, including reduced cancer and emergency surgery. Redeployed anaesthesia staff increased the critical care workforce by 125%. Three-quarters of critical care units were so expanded that planned surgery could not be safely resumed. At all times, the greatest resource limitation was staff. Due to lower response rates from the most pressed regions and hospitals, these results may underestimate the true impact. These findings have important implications for understanding what has happened during the COVID-19 pandemic, planning recovery and building a system that will better respond to future waves or new epidemics., (© 2021 Association of Anaesthetists.)

Background: Anaphylaxis during anaesthesia is a serious complication for patients and anaesthetists., Methods: The 6th National Audit Project (NAP6) on perioperative anaphylaxis collected and reviewed 266 reports of Grades 3-5 anaphylaxis over 1 yr from all NHS hospitals in the UK., Results: The estimated incidence was ≈1:10 000 anaesthetics. Case exclusion because of reporting delays or incomplete data means true incidence might be ≈70% higher. The distribution of 199 identified culprit agents included antibiotics (94), neuromuscular blocking agents (65), chlorhexidine (18), and Patent Blue dye (9). Teicoplanin comprised 12% of antibiotic exposures, but caused 38% of antibiotic-induced anaphylaxis. Eighteen patients reacted to an antibiotic test dose. Succinylcholine-induced anaphylaxis, mainly presenting with bronchospasm, was two-fold more likely than other neuromuscular blocking agents. Atracurium-induced anaphylaxis mainly presented with hypotension. Non-depolarising neuromuscular blocking agents had similar incidences to each other. There were no reports of local anaesthetic or latex-induced anaphylaxis. The commonest presenting features were hypotension (46%), bronchospasm (18%), tachycardia (9.8%), oxygen desaturation (4.7%), bradycardia (3%), and reduced/absent capnography trace (2.3%). All patients were hypotensive during the episode. Onset was rapid for neuromuscular blocking agents and antibiotics, but delayed with chlorhexidine and Patent Blue dye. There were 10 deaths and 40 cardiac arrests. Pulseless electrical activity was the usual type of cardiac arrest, often with bradycardia. Poor outcomes were associated with increased ASA, obesity, beta blocker, and angiotensin-converting enzyme inhibitor medication. Seventy per cent of cases were reported to the hospital incident reporting system, and only 24% to Medicines and Healthcare products Regulatory Agency via the Yellow Card Scheme., Conclusions: The overall incidence of perioperative anaphylaxis was estimated to be 1 in 10 000 anaesthetics., (Copyright © 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: Anaphylaxis during anaesthesia is a serious complication for patients and anaesthetists., Methods: The Sixth National Audit Project (NAP6) of the Royal College of Anaesthetists examined the incidence, predisposing factors, management, and impact of life-threatening perioperative anaphylaxis in the UK. NAP6 included: a national survey of anaesthetists' experiences and perceptions; a national survey of allergy clinics; a registry collecting detailed reports of all Grade 3-5 perioperative anaphylaxis cases for 1 yr; and a national survey of anaesthetic workload and perioperative allergen exposure. NHS and independent sector (IS) hospitals were approached to participate. Cases were reviewed by a multi-disciplinary expert panel (anaesthetists, intensivists, allergists, immunologists, patient representatives, and stakeholders) using a structured process designed to minimise bias. Clinical management and investigation were compared with published guidelines. This paper describes detailed study methods and reports on project engagement by NHS and IS hospitals. The methodology includes a new classification of perioperative anaphylaxis and a new structured method for classifying suspected anaphylactic events including the degree of certainty with which a causal trigger agent can be attributed., Results: NHS engagement was complete (100% of hospitals). Independent sector engagement was limited (13% of approached hospitals). We received >500 reports of Grade 3-5 perioperative anaphylaxis, with 266 suitable for analysis. We identified 199 definite or probable culprit agents in 192 cases., Conclusions: The methods of NAP6 were robust in identifying causative agents of anaphylaxis, and support the accompanying analytical papers., (Copyright © 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: Anaphylaxis during anaesthesia is a serious complication for patients and anaesthetists. There is little published information on management and outcomes of perioperative anaphylaxis in the UK., Methods: The 6th National Audit Project of the Royal College of Anaesthetists (NAP6) collected and reviewed 266 reports of Grade 3-5 anaphylaxis from all UK NHS hospitals over 1 yr. Quality of management was assessed against published guidelines., Results: Appropriately senior anaesthetists resuscitated all patients. Immediate management was 'good' in 46% and 'poor' in 15%. Recognition and treatment of anaphylaxis were prompt in 97% and 83% of cases, respectively. Epinephrine was administered i.v. in 76%, i.m. in 14%, both in 6%, and not at all in 11% of cases. A catecholamine infusion was administered in half of cases. Cardiac arrests (40 cases; 15%) were promptly treated but cardiac compressions were omitted in half of patients with unrecordable BP. The surgical procedure was abandoned in most cases, including 10% where surgery was urgent. Of 54% admitted to critical care, 70% were level 3, with most requiring catecholamine infusions. Ten (3.8%) patents (mostly elderly with cardiovascular disease) died from anaphylaxis. Corticosteroids and antihistamines were generally administered early. We found no clear evidence of harm or benefit from chlorphenamine. Two patients received vasopressin and one glucagon. Fluid administration was inadequate in 19% of cases. Treatment included sugammadex in 19 cases, including one when rocuronium had not been administered. Adverse sequelae (psychological, cognitive, or physical) were reported in one-third of cases., Conclusions: Management of perioperative anaphylaxis could be improved, especially with respect to administration of epinephrine, cardiac compressions, and i.v. fluid. Sequelae were common., (Copyright © 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

We analysed data from 14,000 patients in the 2013 United Kingdom Anaesthesia Activity Survey of the Fifth National Audit Project of the Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Ireland to examine anaesthetic, organisational and clinical practice for patients with obesity. We compared practice then with current guidance on management of this patient group. Obesity was reported in 22%, mainly Black, Afro-Caribbean and White Caucasian patients. There was minimal variation in surgical timing, anaesthetic seniority, induction location or day-case procedure rates. As BMI increased above 25kgm -2 ASA grade rose and there were modest changes in practice towards that recommended for this patient group. Some practice changes were counter-intuitive. When BMI exceeded 35kgm -2 safety based practice changed markedly. For patients receiving GA there was an increase in immediate (operative) mortality as BMI rose. UK anaesthetic practice in 2013 appears to underestimate patient levels of obesity, does not reflect recent published guidelines for the management of patients with obesity undergoing anaesthesia and, taken with the mortality findings, raises concerns over the reliability of safe management of such patients., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

Background: Understanding the patient perspective on healthcare is central to the evaluation of quality. This study measured selected patient-reported outcomes after anaesthesia in order to identify targets for research and quality improvement., Methods: This cross-sectional observational study in UK National Health Service hospitals, recruited adults undergoing non-obstetric surgery requiring anaesthesia care over a 48 h period. Within 24 h of surgery, patients completed the Bauer questionnaire (measuring postoperative discomfort and satisfaction with anaesthesia care), and a modified Brice questionnaire to elicit symptoms suggestive of accidental awareness during general anaesthesia (AAGA). Patient, procedural and pharmacological data were recorded to enable exploration of risk factors for these poor outcomes., Results: 257 hospitals in 171 NHS Trusts participated (97% of eligible organisations). Baseline characteristics were collected on 16,222 patients; 15,040 (93%) completed postoperative questionnaires. Anxiety was most frequently cited as the worst aspect of the perioperative experience. Thirty-five per cent of patients reported severe discomfort in at least one domain: thirst (18.5%; 95% CI 17.8-19.1), surgical pain (11.0%; 10.5-11.5) and drowsiness (10.1%; 9.6-10.5) were most common. Despite this, only 5% reported dissatisfaction with any aspect of anaesthesia-related care. Regional anaesthesia was associated with a reduced burden of side-effects. The incidence of reported AAGA was one in 800 general anaesthetics (0.12%), Conclusions: Anxiety and discomfort after surgery are common; despite this, satisfaction with anaesthesia care in the UK is high. The inconsistent relationship between patient-reported outcome, patient experience and patient satisfaction supports using all three of these domains to provide a comprehensive assessment of the quality of anaesthesia care., (© The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Details of current UK anaesthetic practice are unknown and were needed for interpretation of reports of accidental awareness during general anaesthesia (GA) within the 5th National Audit Project., Methods: We surveyed NHS anaesthetic activity to determine numbers of patients managed by anaesthetists and details of 'who, when, what, and where': activity included GA, local anaesthesia, sedation, or patients managed awake. Anaesthetists in NHS hospitals collected data on all patients for 2 days. Scaling enabled estimation of annual activity., Results: Hospital response rate was 100% with 20,400 returns. The median return rate within departments was 98% (inter-quartile range 0.95-1). Annual numbers (% of total) of general anaesthetics, sedation, and awake cases were 2,766,600 (76.9%), 308,800 (8.6%), and 523,100 (14.5%), respectively. A consultant or career grade anaesthetist was present in more than 87% of cases. Emergency cases accounted for 23.1% of workload, 75% of which were undertaken out of hours. Specialties with the largest workload were orthopaedics/trauma (22.1%), general surgery (16.1%), and gynaecology (9.6%): 6.2% of cases were non-surgical. The survey data describe: who anaesthetized patients according to time of day, urgency, and ASA grade; when anaesthesia took place by day and by weekday; the distribution of patient types, techniques, and monitoring; where patients were anaesthetized. Nine patients out of 15 460 receiving GA died intraoperatively., Conclusions: Anaesthesia in the UK is currently predominantly a consultant-delivered service. The low mortality rate supports the safety of UK anaesthetic care. The survey data should be valuable for planning and monitoring anaesthesia services., (© The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Hypotensive anesthesia is routinely used during craniosynostosis corrections to reduce blood loss. Noting that cerebral oxygenation levels often fell below recommended levels, the authors sought to measure the effects of hypotensive versus standard anesthesia on blood transfusion rates., Methods: One hundred children undergoing craniosynostosis corrections were randomized prospectively into two groups: a target mean arterial pressure of either 50 mm Hg or 60 mm Hg. Aside from anesthesiologists, caregivers were blinded and strict transfusion criteria were followed. Multiple variables were analyzed, and appropriate statistical testing was performed., Results: The hypotensive and standard groups appeared similar, with no statistically significant differences in mean age (46.5 months versus 46.5 months), weight (19.25 kg versus 19.49 kg), procedure [anterior remodeling (34 versus 31) versus posterior (19 versus 16)], or preoperative hemoglobin level (13 g/dl versus 12.9 g/dl). Intraoperative mean arterial pressures differed significantly (56 mm Hg versus 66 mm Hg; p < 0.001). The captured cell saver amount was lower in the hypotensive group (163 cc versus 204 cc; p = 0.02), yet no significant differences were noted in postoperative hemoglobin levels (8.8 g/dl versus 9.3 g/dl). Fifteen of 100 patients (15 percent) received allogenic transfusions, but no statistically significant differences were noted in transfusion rates between the hypotensive [nine of 53 (17.0 percent)] and standard anesthesia [six of 47 (13 percent)] group (p = 0.056)., Conclusions: No significant difference in transfusion requirements was found between hypotensive and standard anesthesia during craniosynostosis corrections. Considering potential benefits of improved cerebral blood flow and total body perfusion, surgeons might consider performing craniosynostosis corrections without hypotension., Clinical Question/level of Evidence: Therapeutic, II.

Background: Measuring outcomes and quality in anaesthesia is challenging. In the UK, there is increased focus on these as a result of changes in Department of Health strategy and the imminent introduction of mandatory revalidation for all doctors. A definition of quality may differ according to the observer's standpoint and numerous performance measures may contribute to overall quality. Patients, surgeons, anaesthetic assistants, recovery nurses, managers, and anaesthetic peers are each likely to have their own perspective on 'anaesthetic quality' and would perhaps suggest different metrics to measure it. Speed, efficiency, cost, interpersonal skills, complication rates, patient recorded outcome measures, and satisfaction are all valid as quality measures, but none alone captures anaesthetic quality. Performance data are frequently presented as single-dimension measurements (e.g. pain, postoperative nausea and vomiting, patient satisfaction), but this does not address the fact that two or more domains may be closely related (e.g. use of regional anaesthesia and quality of analgesia) or in opposition (e.g. use of regional anaesthesia and speed)., Methods: We introduce the concept of a 'performance polygon' as a tool to represent multidimensional performance assessment. This method of data presentation encourages balanced appraisal of anaesthetic quality., Results: Performance polygons may be used to compare individual performance with peers, published outcome norms, trends in performance over time, to explore aspects of team performance and potentially capture data that are required for medical revalidation., Conclusions: Performance polygons enable easy comparison with any relevant data set and are a visual tool that potentially has wider applications in healthcare quality improvement.

We studied the i-gel™ in 120 anaesthetised children (92 boys, 28 girls; median (IQR [range]) age (3 -7 [0.4 -13]) years and weight 19 (15-26 [7-35]) kg) to assess efficacy and usability. Insertion was successful on the first/second/third attempt in 110/8/1 children and failed in one child. Median (IQR [range]) insertion time was 14 (9-16 [6-200]) s. Manual ventilation was possible in all cases, although excess leak precluded a tidal volume above 7 ml.kg(-1) in three children. Fibreoptic inspection through the i-gel revealed a clear view of the vocal cords in 40 out of 46 cases (87%). Median (IQR [range]) leak pressure was 20 (16-26 [8-30]) cmH(2) O. During maintenance of anaesthesia, 16 manipulations were required in 11 children to improve the airway. One child regurgitated without aspirating. Other complications and side effects were infrequent. The i-gel was inserted without complications, establishing a clear airway and enabling spontaneous and controlled ventilation, in 113 (94%) children., (© 2011 The Authors. Anaesthesia © 2011 The Association of Anaesthetists of Great Britain and Ireland.)

Many anaesthetists have found the size 1.5 classic Laryngeal Mask Airway unsuitable for use in children under 10 kg, whereas recent studies evaluating the ProSeal Laryngeal Mask Airway (PLMA) show high success rates, even during laparoscopic surgery. Our routine practice has been to use tracheal intubation for inguinal herniotomy in children weighing less than 10 kg. Following the introduction of the PLMA to our hospital, we decided to audit our use of the PLMA 1.5 in this group of patients. We included 20 consecutive infants, aged less than six months and weighing 5 to 10 kg. We recorded patient, anaesthetic and insertion details, device performance data and complications. No aspect of anaesthetic practice was changed by involvement in this audit. The PLMA was inserted successfully at the first attempt in 85% (17/20) of infants. Overall successful insertion occurred in 90% (18/20) and satisfactory airway maintenance was provided for the duration of anaesthesia in 90% (18/20). The mean leak pressure was 24 cmH2O (range 15 to 30 cmH2O). We found the 1.5 PLMA provided a satisfactory airway in 90% of infants. This report adds to the evidence that the PLMA 1.5 can provide a satisfactory alternative to intubation in selected infants.

Inadequate anaesthesia may cause distress to the patient and lead to medical litigation. All claims made to the NHS Litigation Authority 1995-2007 were obtained and the data was examined independently by all authors and classified. In a dataset of 1067 claims there were 161 cases of inadequate anaesthesia and data were suitable for analysis in 159: intra-operative awareness (79), brief awake paralysis (20) and inadequate regional anaesthesia (60). The total cost of closed claims was pound 3.2 m. Cost was incurred in 100% of claims of brief awake paralysis, 87% of claims of awareness and 80% of claims of inadequate regional blockade. Mean cost of closed claims was pound 32,680 for anaesthetic awareness, pound 29,345 for inadequate regional blockade and pound 24,364 for brief awake paralysis. Inadequate anaesthesia accounts for 19% of anaesthesia-related claims in the NHS in England. Strategies that reduce anaesthetic awareness, drug errors and inadequate regional blockade are known and their improved implementation is likely to reduce such claims.

The distribution of medico-legal claims in English anaesthetic practice is unreported. We studied National Health Service Litigation Authority claims related to anaesthesia since 1995. All claims were reviewed by three clinicians and variously categorised, including by type of incident, claimed outcome and cost. Anaesthesia-related claims account for 2.5% of all claims and 2.4% of the value of all claims. Of 841 relevant claims 366 (44%) were related to regional anaesthesia, 245 (29%) obstetric anaesthesia, 164 (20%) inadequate anaesthesia, 95 (11%) dental damage, 71 (8%) airway (excluding dental damage), 63 (7%) drug related (excluding allergy), 31 (4%) drug allergy related, 31 (4%) positioning, 29 (3%) respiratory, 26 (3%) consent, 21 (2%) central venous cannulation and 18 (2%) peripheral venous cannulation. Defining which cases are, from a medico-legal viewpoint, 'high risk' is uncertain, but the clinical categories with the largest number of claims were regional anaesthesia, obstetric anaesthesia, inadequate anaesthesia, dental damage and airway, those with the highest overall cost were regional anaesthesia, obstetric anaesthesia, and airway and those with the highest mean cost per closed claim were respiratory, central venous cannulation and drug error excluding allergy. The data currently available have limitations but offer useful information. A closed claims analysis similar to that in the USA would improve the clinical usefulness of analysis.

Background: The Laryngeal Tube Sonda (LTS) is a supraglottic airway which, like the ProSeal Laryngeal Mask Airway (PLMA), incorporates a drain tube. We compared the performances of LTS and PLMA during controlled ventilation anaesthesia., Methods: The devices were studied in 32 ventilated patients by randomized crossover trial. Primary outcome was airway seal pressure. Secondary outcomes included insertion success and time, manipulations required, ventilation quality, peak and plateau airway pressures, ability to pass a gastric tube and fibreoptic laryngeal view., Results: The PLMA produced a higher seal pressure (median values, PLMA 26 cm H(2)O and LTS 24 cm H(2)O, P<0.01). First-attempt insertion succeeded with PLMA 28 times and LTS 22 times (P>0.05). The PLMA required fewer manipulations (P<0.05) in fewer patients (P<0.05) and took less time to insert (P<0.01). All PLMA patients and 22 LTS patients achieved optimal ventilation (P<0.01). Peak airway pressure was lower with the PLMA than with the LTS (P<0.01). The vocal cords were visible through the PLMA in 32 patients and through the LTS in nine patients (P<0.001). The laryngeal view was superior through the PLMA (P<0.001)., Conclusion: The difference in seal pressure between devices was clinically unimportant. However, the LTS had an unexpectedly high failure rate. PLMA performance exceeded LTS performance in many clinically useful measures. The PLMA has greater clinical utility than the LTS during controlled ventilation.

We report the anaesthetic management of an adult with Rubenstein-Taybi syndrome. This rare congenital syndrome is characterized by severe learning difficulties, cardiac abnormalities, gastrooesophageal reflux, and cranio-facial abnormalities with the likelihood of difficult intubation. A ProSeal laryngeal mask airway was used to ventilate the patient for eye surgery.

Summary: We collected blank non‐specialist anaesthetic records from 71 National Health Service Trusts in England. A data set was established by collating all data items found in an initial tranche of 28 records. All 71 records were subsequently analysed for each data item in this data set. We found significant variation: the most populated record included 216 data items and the least included 38 data items: a greater than five‐fold variation. There was significant variation in the inclusion of data items commonly considered important to patient safety; 42% of records omitted documentation of fasting status, 72% omitted documentation of a discussion around the risk of accidental awareness during general anaesthesia, 92% omitted documentation of quantitative neuromuscular blockade monitoring and 63% omitted documentation for 'Stop Before You Block' when performing regional anaesthesia. The study highlights significant variability in the composition of anaesthetic records across England which may impact on its value as a data repository, an action trigger, a medicolegal account, and a tool to facilitate safe handover. Standardisation of the anaesthetic record or the establishment of standards of recording would help to allay potential risks to patient safety and assist in guiding future procurement of electronic solutions for anaesthetic records. [ABSTRACT FROM AUTHOR]

Summary: We reviewed all 1230 claims against anaesthesia notified to NHS Resolution (formerly the NHS Litigation Authority, 1995–2017) in England between 2008 and 2018. Claims were categorised by incident type, severity (whether physical or psychological), and cost, and comparisons were made against a similar published analysis of data from 1995 to 2007. While the annual number of claims against anaesthesia increased by 62% from the earlier period, anaesthesia now accounts for smaller proportions of all claims submitted to NHS Resolution (1.5% vs. 2.5%) and of the total cost of all claims (0.7% vs. 2.4%). The absolute costs related to anaesthesia claims rose over 300%, totalling £145 million between 2008 and 2018, but the mean cost per closed claim (retail price index adjusted) fell by 6% to £74,883. The most common clinical categories were regional anaesthesia (24%), inadequate anaesthesia (20%) and drug administration (20%). Claims related to airway management, central venous catheterisation and cardiac arrest remained infrequent but severe and costly. The proportion of claims relating to regional anaesthesia and obstetric anaesthesia fell significantly, but claims relating to peripheral nerve blockade doubled. Our analysis includes categories relating to organisational and human factors which are present in a substantial proportion of claims; categories with the highest mean cost per claim included delayed care, planning, monitoring and consent. Overall, the specialty of anaesthesia is at low risk of litigation. Our analysis provides important insights into current and changing patterns in claim distributions that may help improve the quality of patient care and reduce future litigation. We recommend the establishment of a structure for national review and learning from all cases of litigation. [ABSTRACT FROM AUTHOR]

Summary: This guideline updates and replaces the 5th edition of the Standards of Monitoring published in 2015. The aim of this document is to provide guidance on the minimum standards for monitoring of any patient undergoing anaesthesia or sedation under the care of an anaesthetist. The recommendations are primarily aimed at anaesthetists practising in the UK and Ireland, but it is recognised that these guidelines may also be of use in other areas of the world. Minimum standards for monitoring patients during anaesthesia and in the recovery phase are included. There is also guidance on monitoring patients undergoing sedation and during transfer. There are new sections specifically discussing capnography, sedation and regional anaesthesia. In addition, the indications for processed electroencephalogram and neuromuscular monitoring have been updated. [ABSTRACT FROM AUTHOR]

Background: Videolaryngoscopy (VL) is increasingly used, but not yet routine practice, for tracheal intubation. Few departments formally trial equipment before adopting it into practice. We describe the decision-making and implementation processes that our department used when introducing universal VL, with the C-MAC© (Karl Storz, Germany), throughout our anaesthesia and intensive care departments.Methods: We used a structured process to assess the feasibility of a change to universal VL. After departmental training, we undertook a 2 month trial period of mandating VL for all adult in-theatre intubations. Thereafter, VL remained widely available, but not mandated. We regularly surveyed anaesthetists and anaesthetic assistants to evaluate departmental opinion regarding the introduction of universal VL.Results: Before the trial period, one-third of anaesthetists judged that universal VL would be of overall benefit to patient safety, team dynamics, and quality of care. Reservations from both junior and senior anaesthetists focused on training concerns. Support for a changeover to VL, amongst both anaesthetists and anaesthetic assistants, increased throughout the trial period. Six months after the 2 month trial, support had grown further and was almost unanimous. Anaesthetists reported significant benefits in clinical performance, teaching, and human factors, especially teamwork and situation awareness.Conclusions: Performing a formal and prolonged trial of mandatory VL in theatre led to changes in perceptions and departmental consensus. As a result of the trial, the department agreed to the use of C-MAC© videolaryngoscopy as the default intubation technique throughout theatres and intensive care, with removal of standard Macintosh laryngoscopes from routine use. [ABSTRACT FROM AUTHOR]

The author reflects on Consensus on Airway Research Ethics (CARE) guidelines. Topics discussed include problem in the intensive care unit (ICU) and emergency department (ED), where rates of failed intubation and airway-related mortality dwarf those in routine anaesthesia, issues such as the use of videolaryngoscopy and optimal oxygenation techniques and important questions around patient safety.

The article examines the literature around litigation and complaints that take place in day-case anesthesia and discusses themes especially pertinent to the area of practice. Topics covered include risk factors associated with patient complaints in day-case anesthesia, the ASA Closed Claims Project database that reported liability and day-case anesthesia in 2000, and specific surgical procedures associated with anesthesia claims.

Background.: There are increasing numbers of videolaryngoscopes marketed and increasing interest in the technology. The Difficult Airway Society's 2015 guidelines recommend that videolaryngoscopes should be immediately available at all times and that all anaesthetists should be trained and skilled in their use.Methods.: An electronic survey was sent to all UK National Health Service hospitals to examine availability, use, and attitudes to videolaryngoscopy, and closed in January 2014.Results.: The return rate was 67%. Videolaryngoscopy was available in 91% of operating theatres, ∼50% of intensive care units (ICUs) and obstetric theatres, with lower availability in emergency departments (EDs), paediatric anaesthesia, and independent sector hospitals. The most widely available devices were the Airtraq, the GlideScope, and C-MAC. Approximately one in seven respondents reported availability of videolaryngoscopy in all clinical areas. Most departments imposed restrictions on videolaryngoscopy use, especially the ICU and ED. Device selection was only infrequently based on published literature or formal trial. Structured introduction of videolaryngoscopy into practice was uncommon. Penetration of videolaryngoscopy was highly variable; fewer than a third reported widespread use or enthusiasm, although this increased where the C-MAC and GlideScope were widely available.Conclusions.: Videolaryngoscopy is available in most hospitals' main operating departments, but in fewer than half of other locations. There is marked variation in device, methods of introduction, usage, and clinical adoption. Most hospitals need to change practice to comply with current guidelines. Selection and implementation vary widely. [ABSTRACT FROM AUTHOR]

Background: The 4th National Audit Project of the Royal College of Anaesthetists' and Difficult Airway Society (NAP4) made recommendations to improve reliability and safety of airway management in hospitals. This survey examines its impact.Methods: A survey was sent to all UK National Health Service hospitals to examine changes in practice in response to NAP4. We performed a 'gap analysis' to determine whether NAP4 had reduced the 'safety gap' between actual and ideal practice.Results: The response rate was 62% (192 of 307 hospitals), and 78% answered all questions. Most (97%) respondents reported changes in practice in response to NAP4 but these differed by specialty: 95% in anaesthesia; 80% in intensive care (ICU) and 59% in the emergency department (ED). Approximately 25% reported changes in organizational aspects of airway and human factors teaching. Practice changes led to a median closure of the 'safety gap' in anaesthesia of 39% (IQR 14-66%, range 11-83%), 59% in ICU (IQR 54-73%, range 31-81%) and 48% in ED (IQR 39-53%, range 35-53%).Conclusions: Publication of NAP4 was followed by changes in practice in the majority of responding departments within two yr. Improvements included improved provision of difficult airway equipment and more widespread routine use of capnography. The biggest change occurred in ICU; the impact on training nursing and junior staff was modest and here, significant safety gaps remain. [ABSTRACT FROM AUTHOR]

We present the main findings of the 5th National Audit Project on accidental awareness during general anaesthesia. Incidences were estimated using reports of accidental awareness as the numerator, and a parallel national anaesthetic activity survey to provide denominator data. The incidence of certain/probable and possible accidental awareness cases was ~1:19 600 anaesthetics (95% CI 1:16 700-23 450). However, there was considerable variation across subtypes of techniques or subspecialties. The incidence with neuromuscular blockade was ~1:8200 (1:7030-9700), and without it was ~1:135 900 (1:78 600-299 000). The cases of accidental awareness during general anaesthesia reported to 5th National Audit Project were overwhelmingly cases of unintended awareness during neuromuscular blockade. The incidence of accidental awareness during caesarean section was ~1:670 (1:380-1300). Two thirds (82, 66%) of cases of accidental awareness experiences arose in the dynamic phases of anaesthesia, namely induction of and emergence from anaesthesia. During induction of anaesthesia, contributory factors included: use of thiopental; rapid sequence induction; obesity; difficult airway management; neuromuscular blockade; and interruptions of anaesthetic delivery during movement from anaesthetic room to theatre. During emergence from anaesthesia, residual paralysis was perceived by patients as accidental awareness, and commonly related to a failure to ensure full return of motor capacity. One third (43, 33%) of accidental awareness events arose during the maintenance phase of anaesthesia, most due to problems at induction or towards the end of anaesthesia. Factors increasing the risk of accidental awareness included: female sex; age (younger adults, but not children); obesity; anaesthetist seniority (junior trainees); previous awareness; out-of-hours operating; emergencies; type of surgery (obstetric, cardiac, thoracic); and use of neuromuscular blockade. The following factors were not risk factors for accidental awareness: ASA physical status; race; and use or omission of nitrous oxide. We recommend that an anaesthetic checklist, to be an integral part of the World Health Organization Safer Surgery checklist, is introduced as an aid to preventing accidental awareness. This paper is a shortened version describing the main findings from 5th National Audit Project - the full report can be found at . [ABSTRACT FROM AUTHOR]

The 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society ( NAP4) analysed reports of serious events arising from airway management during anaesthesia, intensive care and the emergency department. We conducted supplementary telephone interviews with 12 anaesthetists who had reported to NAP4, aiming to identify causal factors using a method based on the Human Factors Investigation Tool (HFIT). We identified contributing human factors in all cases (median [range] 4.5 [1-10] per case). The most frequent related to: situation awareness (failures to anticipate, wrong decision) (nine cases); job factors (e.g. task difficulty; staffing, time pressure) (eight cases); and person factors (e.g. tiredness, hunger, stress) (six cases). Protective factors, such as teamwork and communication, were also revealed. The post-report HFIT interview method identified relevant human factors and this approach merits further testing as part of the investigation of anaesthetic incidents. [ABSTRACT FROM AUTHOR]

Background As part of the 5th National Audit Project of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland concerning accidental awareness during general anaesthesia, we issued a questionnaire to every consultant and staff and associate specialist anaesthetist in the UK. Methods The survey was designed to ascertain the number of new cases of accidental awareness that became known to them, for patients under their direct or supervised care, for a calendar year, and also to estimate how many cases they had experienced during their careers. The survey also asked about use of monitoring designed to measure the depth of anaesthesia. Results All local co-ordinators responsible for each of 329 hospitals (organised into 265 ‘centres') in the UK responded, as did 7125 anaesthetists (82%). There were 153 new cases of accidental awareness notified to respondents in 2011, an estimated incidence of 1:15 414, lower than the 1-2:1000 previously reported in prospective clinical trials. Almost half the cases (72, 47%) occurred at or after induction of anaesthesia but before surgery, with 46 (30%) occurring during surgery and 35 (23%) after surgery before full recovery. Awareness during surgery appeared to lead more frequently to pain or distress than at induction and emergence (62% vs 28% and 23%, respectively). Depth of anaesthesia monitors were available in 164 centres (62%), but routinely used by only 132 (1.8%) of anaesthetists. Conclusion The disparity between the incidence of awareness as notified to anaesthetists and that reported in trials warrants further examination and explanation. [ABSTRACT FROM PUBLISHER]