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Miguel Cotto
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The Newsletter
of the
of Anaesthetists
of Great Britain
and Ireland
Postcode lottery in
anaesthetic training
The history of the specialty
of Anaesthesia in the UK
[email protected]
ISSN 0959-2962
No. 317
Editorial Contents
03 Editorial
04 President’s Report
05 Trainees… what can the NIAA
do for you?
06 FRCA viva revision – the Skype
is the limit
08 8th IHSA, Sydney, 2013
09 The Great Anaesthesia Bake
10 AAGBI: A year in review
Scan and learn...
18 Postcode lottery in anaesthetic 10
20 The history of the specialty of Anaesthesia in the UK
22 Annual Congress review
24 [email protected]
27 The development of a block room
29 Your Letters
31 Anaesthesia Digested
32 Particles
Retrospective: Goodbye and thanks
for all the flowers
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Think these are great? Wait till you see all of X-Porte’s features!
Experience X-Porte first hand at ICS 2013, London,16-18 December.
In this edition we publish our annual review, and some editor’s
highlights from Annual Congress in Dublin. Looking further
back, the history boys (and girls) have been busy, and the
reproduction of a paper describing the birth of our College and
Association makes interesting reading.
The phrase ‘..of necessity, large numbers of routine aneasthesia
and most of the emergency anaesthesia in hospitals must be
administered by interns’ reflects the reality of the NHS that
I joined in 1981, and we still have some way to go before
consultant-delivered care is anything but a pipe-dream. Indeed,
some of you may still regard it as a nightmare.
Like Iain Wilson, who wrote last month’s editorial, I am looking
back on my career in anaesthesia and at the AAGBI - I will
be leaving the specialty soon and left the AAGBI at Annual
Congress in September. I would second Iain’s feelings about
the AAGBI having been a great organisation to work with, as
has the wider NHS. Despite all the negative press, the care we
give to patients undergoing surgery today is so much better
than it was thirty years ago, at the start of my career. Having
said that, I suspect that there may be some giant leaps in
our understanding in the fairly near future that will help us to
improve outcomes to an extent that we have hardly dreamt of to
date. That was certainly the message I heard listening to Daniel
Sessler at Annual Congress in September - read more on that
subject in the report from Dublin.
Pending 510(k) clearance. X-Porte is not available for sale in the United States.
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London W1B 1PY
Telephone: 020 7631 1650
Fax: 020 7631 4352
Email: [email protected]
Anaesthesia News
Chair Editorial Board: Nancy Redfern
Editors: Kate O’Connor, Nicholas Love and Caroline Wilson (GAT),
Nancy Redfern, Val Bythell, Richard Griffiths, Sean Tighe, Tom Woodcock,
Mike Nathanson, Rachel Collis and Upma Misra
Address for all correspondence, advertising or submissions:
Email: [email protected]
Design: Christopher Steer
AAGBI Website & Publications Officer
Telephone: 020 7631 8803
Email: [email protected]
Printing: Portland Print
Copyright 2013 The Association of Anaesthetists of Great Britain and Ireland
The Association cannot be responsible for the statements or views of the contributors.
No part of this newsletter may be reproduced without prior permission.
Advertisements are accepted in good faith. Readers are reminded that Anaesthesia
News cannot be held responsible in any way for the quality or correctness of products
or services offered in advertisements.
FUJIFILM SonoSite, Inc. the SonoSite logo and other trademarks not owned by third parties are registered and unregistered trademarks
of FUJIFILM SonoSite, Inc. in various jurisdictions. All other trademarks are the property of their respective owners.
©2013 FUJIFILM SonoSite, Inc. All rights reserved.
MKT02533 10/13
34 If you’re going to San Francisco...
Anaesthesia News December 2013 • Issue 317
A younger colleague recently asked me to pass on a few tips. He felt
I must have learned something that would be helpful to him over the
years. I was initially flummoxed, but have returned to the question
from time to time. Looking at a couple of nascent ‘glossies’ (Fatigue
and Occupational Health – both strongly recommended reads – they
should be published early in the New Year), and reflecting on my own
career, I have three ‘top tips’; not things that I think I have done well,
but that I ought to have done better:
‘Have lunch’ is pretty much my No 1 tip. Really, I skipped an awful
lot of meals and ate an awful lot of KitKats, and I am not sure I really
did anyone any favours in doing so. We need to stay healthy to be
able to do a good job.
At the risk of sounding corny, and in the light of my recent experiences
as a patient, I would have to say that my No 2 tip is ‘listen to patients’.
I mean this in a slightly broader sense than just listening to their
responses to your questions – go a bit further and cultivate empathy.
Last, but not least, make an effort to understand yourself better at
an early stage of your career. I did some of this work in the course
of learning to mentor others, but I could have done with some of the
self-knowledge I gained in that way earlier. There are other ways
of doing this, and different kinds of knowledge. ANTS training will
give some insight into areas that we all find challenging clinically – I
think it is still the case that most of us learn that we too can err (for
example by making a drug error) the hard way, in the clinical forum.
It doesn’t need to be that way - simulation can help us to learn these
lessons about our behavior.
My husband (also an anaesthetist – Phil Bayly) has two tips: Say
‘yes’ to opportunities - you’ll be surprised what you can do; and put
as much money as you can into an equity (not cash) ISA every year
so that you can retire when you want to. This latter advice comes
with the warning that Phil is an anaesthetist not a financial adviser….
Last but not least, my newly-retired outstanding colleague Ian
Warnell offers this: ‘Take a sabbatical. You won’t miss anything’.
I feel these tips are enough from me – you are extraordinary people
and you do extraordinary things every day. Keep up the good work
and look after yourselves as well as your patients! Have an excellent
Christmas and a safe, happy and productive 2014.
Val Bythell
PS; we haven’t included a Christmas quiz, but you could pursue the
historical theme and tackle the History of Anaesthesia Society’s online
quiz at
Elective Funding
Up to £750
Medical students in the UK and Ireland are eligible
to apply to the Association of Anaesthetists of
Great Britain and Ireland for funding towards a
medical student elective period.
Elective Funding
Up to £750
Preference will be given to those applicants who
can show the relevance of their intended elective
to anaesthesia, intensive care or pain relief.
For further information and an application form please
visit our website:
or email [email protected]
or telephone 020 7631 8807
Dear Santa,
Having been an exceptionally good boy in the last year, I think it only reasonable to send you a list of Christmas wishes that is a little
more challenging than usual. I would therefore be most grateful if you would consider placing the following in my stocking, which you
will find nailed to the desk in the President’s Office at 21 Portland Place on 25th December 2013:
Closing date: 06 January 2014
The Wylie Medal will be awarded to the most
meritorious essay on this year’s topic related to
anaesthesia Something old, something new,
something borrowed, something blue written by
an undergraduate medical student at a university in
Great Britain or Ireland.
PRIZE 2014
A new NHS Consultant Contract that recognises that there
are some hospital specialties that provide a lot of complex
and acute care out-of-hours, and that the best way to reward
consultants in these specialties, and to make sure that highquality medical graduates continue to embark on careers
in these key medical specialties, is to pay them properly for
working at unsocial and non-family-friendly times, even if
this means paying anaesthetists, intensivists, obstetricians,
surgeons and A&E doctors quite a lot more than doctors
who are almost exclusively clinic-based during weekdays.
A totally new reward system to replace the current Clinical
Excellence Award scheme that is fair to all specialties and
does not lead to the inequitable situation in which the
self-same, clinic-based doctors who stay in their beds all
night, every night end up with four times as many local and
national awards than genuinely clinical excellent specialties
such anaesthesia and A&E medicine.
A system of training in hospital specialties that does not keep
changing every other year in response to political pressures,
that appreciates that trainees are hard-working and
dedicated professionals, that “generalists” in anaesthesia
are in reality highly specialised, and that an ever-shorter
training period means even less clinical experience.
A pension scheme for doctors that is not downgraded at
every politically convenient opportunity.
Prizes of £500, £250 and £150 will be awarded to
the best three submissions.
Hospital managers who are motivated to put patient safety
well ahead of “cost improvement” in any list of priorities.
The overall winner will receive the Wylie Medal in
memory of the late Dr W Derek Wylie, President of
the Association 1980-82.
Senior NHS leaders with unbesmirched reputations who
value the work of healthcare professionals and put patient
safety first.
A Government that does not view doctors as soft political
targets for repeated financial attacks but values them as
being at the very heart of healthcare, and worthy of just
reward for a lifetime of commitment.
For further information and an application form please
visit our website:
or email [email protected]
or telephone 020 7631 8807
Closing date: 06 January 2014
teamwork in the operating theatre rather than adding layer
upon layer of top-down, mandatory dictats that only serve
to overcomplicate patient care and foster a blame culture.
Surgeons who respect and value the theatre team rather than
interpreting a “team-based approach” as an opportunity to
shout at the whole team rather than at individuals.
A non-Luer spinal and epidural needle connector design
that is based on ISO standards, has been appropriately
bench-tested and then clinically trialled, and is introduced in
a logical and systematic way.
An effective solution to the workforce problems in the
Republic of Ireland that means that all those completing
their training in anaesthesia will wish to stay in Ireland
rather than leave for countries in which they view consultant
anaesthetists as being more valued, better rewarded and
less overworked.
Massive donations to the Lifebox Foundation that will allow it
to put a pulse oximeter in every one of the 75,000 operating
theatres in the world in which patients are treated without
this literally vital form of physiological monitoring.
A Ducati Multistrada 1200 S Granturismo.
I do realise that giving me all of the above for Christmas will be
a bit of a tall order so, if you can only grant one of these wishes,
I think I will opt for the Ducati Multistrada. Meanwhile, the AAGBI
is working on its New Year’s Resolution, which is likely to bear
a strong resemblance to last year’s: to continue to advance
safety, education and research in anaesthesia and its related
Happy Christmas!
William Harrop-Griffiths
AAGBI President
A healthcare system that understands that the safety of
surgical patients is best served by promoting and supporting
Anaesthesia News December 2013 • Issue 317
Anaesthesia News December 2013 • Issue 317
55 Trainees…
what can the NIAA do for you?
What is the NIAA?
The National Institute of Academic Anaesthesia
(NIAA) was established in March 2008 as a response
to the crisis in academic anaesthesia identified by
the 2005 Pandit report1. Its aims include improving
patient care by promoting the translation of research
findings into clinical practice, facilitating high profile,
influential research, and supporting training and
continuing professional education in academia2.
FRCA viva revision
– the Skype is the limit
with ‘big cases’. Enthusiastic consultants who are cognizant of the
current SOE formats are an extremely valuable but surprisingly scarce
resource. Even if your hospital possesses such consultants, onthe-job viva practice is often far from ideal with interruptions, delays
and cancellations inevitable as you compete for your consultant’s
attention with normal service provision.
voice for trainees in the organisation. The NIAA also intends to support
high quality trainee research networks, such as the South West
Anaesthetic Research Matrix (SWARM) and is holding its first National
Trainee Research Federation meeting later this year.
Provision of funding information
The NIAA coordinates grants, awards and fellowships offered by
its founding and other funding partners. Full information regarding
current opportunities, eligibility criteria and application processes are
available via the NIAA website. Trainees are eligible to apply for many
of these grants and should check the funding pages regularly if they
are looking to fund a research project.
The NIAA trainee strategy
Supporting the training and development of trainee anaesthetists has
been a core value of the NIAA since its inception and is emphasised
in the 2012-2017 strategic plan3. There is a lack of formal academic
posts in anaesthesia, with only seven of the advertised 268 academic
clinical fellow (ACF) posts for 2013 being in the specialty4. However,
many anaesthesia trainees in standard clinical training programmes
are engaged in research and the NIAA activities aim to support the
development of all trainees (Figure 1). The NIAA Academic Trainee
Coordinator is Dr Ramani Moonesinghe assisted by two trainee
representatives, Dr Robert Saunders and Dr Eleanor Carter.
A core value of the NIAA is to support the training and development
of the next generation of academic anaesthetists. Current activities
include provision of written and online resources, organisation of
training courses and trainee representation. The future aims are to
expand and develop these activities resulting in high quality research
exposure for all trainees ensuring a bright future for academic
Figure 1
Summary of the NIAA trainee activities
The NIAA holds a database of research-active individuals, both senior
anaesthetists and trainees, that is accessible via its website. Trainees
can join the database and search for other individuals working in
their area of interest for networking opportunities and to identify
potential research supervisors. The NIAA has also asked researchactive trainees to log their details with the Institute and provide a
brief summary of their current research. This information will be used
to build a complete picture of the level of research participation by
trainees and to publish a report on their activities.
Resources available to assist candidates revising for the FRCA
examinations traditionally take the form of large and comprehensive
textbooks supplemented by smaller revision-style texts, continuing
education articles, and written question banks specific to particular
examination sub-sections. In the past ten years these resources
are increasingly complemented by use of online question banks,
smart-phone applications and revision courses of significant cost but
variable quality.
Trainee resources
The NIAA website has a section specifically for trainees with useful
information for those considering a career in academic anaesthesia.
In addition, there are links to articles on routes into research and
other online resources such as e-learning for health research training
modules. NIAA Board members have also contributed information
on research training to the GAT Handbook. The aim is to expand the
online resources to further assist with research training.
Training courses
The NIAA research week earlier this year brought together research
courses from the BJA, Anaesthetic Research Society and NIAA
Health Services Research Centre. The aim was to facilitate access
to research training for anaesthetists and allow participants to attend
multiple research events if desired. The NIAA also recently hosted
an Introduction to Research course for trainees in association with
the London Deanery. The intention is to introduce similar courses
throughout the UK, to enable anaesthesia trainees to access research
training early in their careers.
Trainee representation
The NIAA has an academic trainee coordinator and two trainee
representatives who attend and contribute to NIAA Board, providing a
There are many barriers to organising regular, structured, face-toface revision for the structured oral examination (SOE) components
of the FRCA examination, and anyone who has sat the examination
will remember the intense frustration of spending valuable revision
time arranging viva practice only for it to be cut short by extraneous
factors. Candidates must contend with colliding EWTD shift-patterns,
geographical dispersion across large deaneries and placement in
departments with no other trainees sitting the examination.
We observed many of these obstacles during revision for the Primary
FRCA and decided to use new technology to maximise opportunities
for viva practice for the Final SOE by using Skype, a free online video
conferencing tool, to connect to each other for practice.
Researcher and trainee databases
For the SOE sub-part to the Primary and Final examination candidates
typically revise in small groups in their spare time and with local
consultants during working hours, squeezed into lunch breaks or lists
Although based at different hospitals, and deaneries, we used Skype
to viva in pairs or small groups from our own homes. Skype video
calls gave us face-to-face practice that replicated the ‘across the
desk’ atmosphere of a real viva, and we experienced no problems with
connectivity or bandwidth on our domestic broadband connections.
Group work was done without video, as this is a feature requiring paid
subscription. The virtual nature of our viva’ing saved hours of time
traveling to work or each other’s houses and the history log kept us
informed of how many hours work we put in. By working in an informal
network of five candidates there always seemed to be another person
available to practice, and we each performed approximately 70 hours
of viva’ing on Skype in the weeks before the examination. There is
also a great convenience viva’ing from home, with textbooks, the
internet and most importantly the kettle all at your fingertips.
For a small monthly subscription Skype users can upgrade to use
multi-video conference calls and though we did not use this feature
the benefits for group work are obvious. This subscription upgrade
also allows a ‘shared desktop’ function, with evident advantage for
Primary candidates who need to reproduce appropriate diagrams as
part of their basic science explanations.
Skype viva’ing formed a significant part of our revision strategies
alongside more conventional revision tools like consultant viva’ing,
courses, and of course lots and lots of reading. We would heartily
recommend its use to prospective candidates at either SOE
Drs David Hewson, Nikhail Balani and James Wight,
ST4, Guy’s and St Thomas’ NHS Foundation Trust
Dr Alexa Curtis,
ST4, Brighton and Sussex University Hospitals NHS Trust
Editor’s note:
This is clearly an idea whose time has come; a number of you have submitted similar
stories. There are several other similar technologies that would achieve the same ends.
Eleanor Carter
Specialty Trainee in Anaesthesia
East of England
Pandit JJ. A National Strategy for Academic Anaesthesia. The Royal College of
Anaesthetists; 2005 [accessed 23 Feb 2013]. Available from:
Mahajan RP. National Institute of Academic Anaesthesia Strategic Plan 20122017; 2012 [accessed 2 Aug 2013]. Available from:
Carter E. Academic anaesthesia for trainees. Anaesthesia News 2013; 310: 20-2.
Anaesthesia News December 2013 • Issue 317
How long do you delay cardiac surgery
if your patient is on Clopidogrel?
Anaesthesia News December 2013 • Issue 317
Since 1982 an International
Symposium on the History of
Anaesthesia has been held
approximately every four years.
The venues for the first seven were
successively Rotterdam, London,
Atlanta, Hamburg, Santiago de
Compostela, Cambridge and Crete.
These Symposia have generated
a huge archival record on the
development of anaesthesia,
analgesia and intensive care
worldwide. The eighth ISHA was
held in Sydney, Australia from 22
to 26 January 2013 – providing
an opportunity for expansion of
previous research, new topics and
exchange of ideas.
8th IHSA,
Sydney, 2013
The Great Anaesthesia Bake
Monday 10th June was the day when the covert bakers of Wythenshawe Hospital Anaesthetic Department
came out of the cake baking closet and answered the call to arms (or aprons), from the Association –
the day of the ‘Great Anaesthesia Bake’ in aid of ‘Lifebox’ was upon them and it was time to step up to
the plate and show what they were made of: and step up they did, with admirable results!
Fig. 2: Sydney Harbour Cruise: (L to R) Dr J Wilkinson (UK), Dr W Stratling (UK) and Dr M van Wijhe (The Netherlands).
Welcome reception: organizer Dr Michael Cooper
(extreme left) is thanked by 3 delegates who attended the
first ISHA in 1982: (L to R) Prof J Severinghaus (USA),
Dr Jean Horton (UK) and Dr J Rupreht (The Netherlands).
Presentation of Gwen Wilson Prize: (L to R) Dr W
Stratling, Dr G Kantianis, Dr Christine Ball (Organizer),
Dr M Cooper, Dr M Graves, Prof J Severinghaus.
Closing ceremony: Dr David Wilkinson thanks Co-Chair
Prof Ross Holland.
The delegates from the northern hemisphere
had to adjust to a temperature of 40 degrees
Celsius, but this was soon accomplished with
the aid of local cold beverages, which came
in strange measures: ‘schooner’, ‘middy’ and
There were over 150 delegates from at least
12 countries. The History of Anaesthesia
Society (UK) was well represented with 14
delegates (delivering a total of 14 lectures),
including the President, Dr Anne Florence.
More than 90 presentations were delivered;
a particularly memorable presentation was
the first French educational video on muscle
relaxants, which was quite shocking. It
demonstrated not only the rabbit head drop
test, but administration of muscle relaxant to a
human volunteer without general anaesthesia!
Notable events were the Young Historians’
essay competition (12 presentations) and
an anaesthetic history book-signing/ sale
from international authors. Alistair McKenzie
represented the AAGBI in this regard. There
was also a workshop on the value of reinstating
the history of anaesthesia into the anaesthesia
training curriculum – with a resolution to set
up a website on this topic. The highlight of the
non-academic program was a dinner cruise
round Sydney Harbour. During this, the winner
of the Young Historians’ essay competition, Dr
Martin Graves was awarded the Gwen Wilson
Prize for his paper on the role of the Australian
anaesthetist in World War I.
At the closing ceremony the organising
committee (for the Australian Society of
Anaesthetists, the Australian & New Zealand
College of Anaesthetists and the New Zealand
Society of Anaesthetists) were congratulated
for a tremendous meeting. They had
convinced the delegates of the theme of the
symposium “History matters!” Finally the
successful bid for hosting the next (9th) ISHA
2017 was announced, so make a diary note
now: 9th IHSA meeting, Boston, 2017
When faced with organising any event like
this, the first impulse for most is to mentally
envisage the hurdles that would have to
be jumped in order to make it happen:
the next impulse is to yawn, turn the page
and move onto the next article. Thankfully
Sarah Wheatly, an Anaesthetic Consultant
at Wythenshawe Hospital, resisted those
impulses and made it happen.
Boston of course was where the first public
demonstration of general anaesthesia (with
ether) took place on 16 October 1846.
Once the Trust Mandarins had been sweet
talked into agreeing to the enterprise (which
was no small feat in itself), there came the
small matter of whipping up the enthusiasm
of colleagues to whip up some eggs in aid
of an admirable cause. Despite numerous
assurances of good intentions and promises
of support, there was always the worry
that none of the produce would actually
materialise and the whole thing would flop
like a sagging soufflé.
Alistair McKenzie
Consultant Anaesthetist, Edinburgh
Hon Archivist, AAGBI
In the event, these concerns were
unfounded. By 8am on the allotted morning,
Cake Mission Control was established in the
Not all patients
respond to Clopidogrel
in the same way…
Education Centre where projected ‘footfall’
would be optimum (thanks for specialist
insight from Alan Sugar et al). By 9am the
several Anaesthetic volunteers (including the
vice-President of the RCOA) who had offered
their services for the day were inundated
with cakes of every variety and nationality,
ranging from Polish Yeast Cake to Anzac
Cookies. We even had a ‘Pulse Oximeter’
Cake, complete with wave-form and
saturation reading that was put up for raffle
to great effect. Contributions and support
came from every grade of Anaesthetist in the
department, from the most junior through to
the immediate Ex-President of the RCOA (or
possibly his wife!).
commandeered for the day and converted
into cake dispensing trolleys, groaning with
delicious fayre: these were then dispatched
to every corner of the Hospital – nowhere
was safe: even a Trust Board meeting was
interrupted for a Charity Cake Bake Break
(with excellent feedback from all concerned)!
The whole day was a tremendous success on
many levels: morale boosting, team building,
bridge building with other departments,
positive PR for the department and, above
all, great fun!
…and the final and most important result?
Over £1000 raised for LifeBox to provide
not just Pulse Oximeters where the need
is greatest, but also an essential training
package in how to use an Oximeter safely
and effectively:
I would hope that The Great Anaesthetic Bake
will become a regular event, and that any
Departments that have considered getting
involved just get on and do it! It’s a sure
recipe for a guaranteed great experience in
aid of a truly worthwhile cause!!
Adam Dobson,
Consultant Anaesthetist, UHSM
Approximately 32% of Patients do not
respond to Clopidogrel1.
With the Multiplate® Analyser you can quickly and easily establish a patient’s current
level of platelet function and use this to:
• Make a decision about surgical delay2,3 • Guide platelet use in surgery4
For more information visit: or call 01444 256 782
1. Di Dedda et al. Eur J Cardiothorac Sur 2013. 2. Ann Thorac Surg. 2012 Nov;94(5):1761-81 3. Ann Thorac Surg 2011;91:123–30 4. Anesthesiology 2012; 117:531– 47
er success
hare a
as an
The year 2
value to
at all stages
members fessional career
their pro
At the Annual Members’ Meeting in Bournemouth in
September 2012, we were pleased to welcome three newly
elected council members:
• Dr Rachel Collis, Consultant Anaesthetist, University
Hospital of Wales
• Dr Matthew Checketts, Consultant Anaesthetist, Ninewells
• Dr Roshan Fernando, Consultant Anaesthetist, University
College London Hospitals
At the AMM in Dublin, in September 2013, we were again
pleased to welcome:
• Dr Upma Misra
Full details are at
• Dr Paul Barker
• Dr Mike Nathanson
Cases from 1 October 2013.
Anaesthesia Cases
can no longer be
From 1st October 2013 case reports
The Anaesthesia
submitted directly to Anaesthesia.
AAGBI and may be
Cases website is hosted by the Case
reached here www.anaesthesia
on online at
reports will be considered for publicati
and a proportion will
the Anaesthesia Cases website,
10 The AAGBI continues to make progress in its drive to become
more environmentally friendly, for example using more energy
efficient lighting and encouraging recycling where possible.
Clinical guidelines and other publications are available for
download from the website and limited print runs to reduce the
environmental impact
The GAT Committee was joined by four new elected members
at the Annual General Meeting in Glasgow in June 2012:
• Dr Ben Fox, Addenbrookes Hospital,
Membership Categories
• Dr Claire Gillan, Lothian University Hospitals NHS Trust
• Dr Jonathan Price, Royal Free Hospital
Snapshot of March 2013
• Dr Elaine Yip, Forth Valley Royal Hospital
of Anaesthesia
Following the successful launch
ate will
AGM in
Oxford esiacases.or
2013: g
Overseas Retired
Cases earlier
is the new way to submit your
sion of case
become the sole route for submis
case report to Anaesthesia
Emily Robson,
ST6, London
reports to either Anaesthesia or
Total members
We are pleased to report a healthy 93% retention rate
and a total of nearly 10,600 members including 723
new members joining during the year.
The enhancement of membership services is a key
focus. New services launched this year were: AAGBI
Core Topics in Anaesthesia 2012 and the online case
reports site Anaesthesia Cases launched in 2013.
Additionally, we now offer an exclusive discount for
members wishing to purchase the FRACQ online
exam resource from Cambridge University Press.
publication in
be passed to Anaesthesia for possible
by Anaesthesia will
the Journal. Those not published
for publication
be passed back to Anaesthesia Cases
in the Journal for
there. Once published online (or
be submitted
those accepted there), reports cannot
for publication elsewhere.
Anaesthesia News December 2013 • Issue 317
Our Grade II listed building in London has attacted around 300
visitors a week and hosted numerous meetings, events and
seminars during the year.
We continue to offer office space to the World Federation
of Societies of Anaethesiology (WFSA) and Lifebox, the
international charity of which AAGBI is a founder member.
The AAGBI staff provide secretariat and event services for 20
specialist societies, the largest being DAS, APA and OAA. Eight
one-day conferences and five study days were organised for
specialist societies, together with upgrades to IT systems to
enhance the service provided.
In the last year we
a total of 9,
g of
making a CO2 savin
to 126 trees saved!
Social Media
Our Facebook and Twitter accounts have been extremely popular and we
are now connecting with our members and new audiences through these
interactive means. We have over 1600 followers on Twitter.
Join us on Twitter
@aagbi or Facebook
Anaesthesia News December 2013 • Issue 317
One of the AAGBI’s
principal activities is the
advancement of patient
care and safety in the field
of anaesthesia. Over the
last year the AAGBI’s Safety
and Standards Committees
have worked with likeminded organisations,
industry and governments
to advise and act on
safety matters that affect
anaesthetists and their
The AAGBI Foundation maintains
an active programme of support for
anaesthesia worldwide, including
grants towards educational projects
in lower resource countries, book
donations and funding of educational
resources. This year 37 grants were
awarded towards work in 17 countries.
esia Fund
The Overseas Anaesthesia Fund (OAF) enables individuals and
organisations to donate directly to AAGBI programmes that
support training and promote safer anaesthesia in developing
Nearly 100 regular donors generated a total
of £50,000 last year.
hip Scheme
Now in its seventh year,
23 doctors are currently being
supported in training.
Joint funding support is
provided by RCoA, OAA, DAS
and WAS.
Neuraxial connectors
In February 2013, AAGBI, RCoA, OAA, RA-UK, APA, and RCoA Faculty of Pain
Medicine and Patient Liaison Group released an updated statement to advise
hospitals and support clinicians in the NHS in the process of introducing non-Luer
connectors for neuraxial and regional anaesthesia. The AAGBI is represented on
the External Reference Group established to support the safe implementation of
new devices. We would like to hear of your experiences with the new non-Luer
needles. Please e-mail us at [email protected]
AAGBI and the Safe Anaesthesia Liaison Group (SALG)
“These young men an
d women
are the new face of an
in Uganda. The more
we can
improve our numbers
, the more
we can develop our sp
We are noticing bette
outcomes all the tim
The AAGBI works with SALG to promote learning from incident reporting. It has two
networks (with a total of 800 individuals) that disseminate information and provide
valuable feedback. It publishes quarterly Patient Safety Updates to highlight reported
safety incidents, the latest one relates to fire safety on intensive care and in theatre.
National Audit Project 5 (NAP5)
NAP5 was launched by the AAGBI and RCoA in June 2012 to investigate accidental
awareness during general anaesthesia in the UK and Ireland. All four Chief Medical
Officers endorsed the work. Cases continue to be sent in and the results will be
published in Anaesthesia and the BJA. Several follow-up projects are planned.
Dr Stephen Ttendo, He
ad of Department
at Mbarara University
Hospital, Uganda
Assistance for the Anaesthetist statement
The AAGBI released a supporting statement on assistance for the anaesthetists in
September 2012 to supplement the existing Anaesthesia Team 3 guideline.
National Essential Anaesthetic Drug List (NEADL)
The WHO defines national essential medicines as ‘those that satisfy the priority
healthcare needs of the population’. The AAGBI canvassed the views of delegates
attending the WSM 2013 meeting on essential anaesthetic drugs and produced the
first version of NEADL. At this year’s Annual Congress we will conduct another
consultation with members.
AAGBI is proud to be a founder member of the
international charity, Lifebox. Lifebox is a not-forprofit organisation saving lives by improving the
safety and quality of surgical care in low-resource
countries by ensuring that every operating room in
the world has a pulse oximeter.
Checking Anaesthetic Equipment (checklist)
The machine checklist published in June 2012 to complement the Checking
Anaesthetic Equipment safety guideline will be tailored to suit the machines of a
variety of manufacturers.
12 Anaesthesia News December 2013 • Issue 317
Anaesthesia News December 2013 • Issue 317
Lifebox UK-registered charity (No. 1143018)
Education: face to face and
The AAGBI is committed to providing opportunities for
anaesthesia professionals to keep up to date with their
professional development and continues to develop new
resources for its members.
AAGBI Publications
Conferences and seminars
Anaesthesia is the official journal of the AAGBI, published by
Wiley Blackwell, and is international in scope and comprehensive
in coverage. The journal has a very high impact factor of 2.958
demonstrating the relevance of articles to the anaesthesia community.
Greater numbers of educational events were provided for the
profession in the form of three national conferences: GAT, AC
2012 and WSM London 2013.
Attracting 1,800 delegates, significantly more than previous
years. WSM London in January 2013 was the largest ever
attendance at 848 delegates. 2251 delegates attended our
seminar programme throughout the year and our regional core
topics programmes attracted almost 1200 delegates.
AAGBI online
Video Platform and e-education
Anaesthesia News
E resource
“An excellent CM the
allowing memb
atch up on
opportunity to c
etings from
Association me
f home!”
the comfort o
tant Anaesthetist
Dr Chris Gornall,
Heritage Centre
The Arts Council accredited
AAGBI Heritage Centre hosted
nearly 750 visitors in London and
at events around the country.
Development of e education and online learning for CPD is
a key priority. Our online video platform now offers over
200 lectures and CPD content from our conference and
seminars. It attracts, on average, over 900 views a month
The AAGBI is working to incorporate the video platform
into a CPD zone which will allow users to record CPD for
appraisal and revalidation purposes.
@AAGBI and
The bi-weekly enewsletter, @AAGBI, provides members
with quick, effective and convenient communication with the
latest information about the AAGBI and current issues within
the profession.
The average opening rate continues to be 30 - 40%. In
addition, we sent out 40 individual e-flyers which had an
opening rate of 42%.
14 E
The exhibition A Blessing in
Disguise proved to be extremely
popular and was extended for
an additional six months. Our
dedicated team of hardworking
volunteers were joined by two
new volunteers and we have
developed a new internship
programme this year.
Anaesthesia News reaches over 10,500 anaesthetists every month
and submitting content is a great way of sharing your experiences
and information with fellow members.
98% of our members read Anaesthesia News regularly with the
favourite content being feature articles and letters to the editor.
Our guidelines cover a wide range of clinical and non-clinical issues.
In the last year we have produced these new titles:
Checking Anaesthetic Equipment 2012 published June 2012.
Checklist for Anaesthetic Equipment 2012 A4 sheet published
June 2012.
Management of Proximal Femoral Fractures 2011 published
June 2012.
Immediate Post-anaesthesia Recovery 2013
Web-Published March 2013. Hard copy published August 2013
Obstetric Anaesthetic Services 2013 published August 2013
GAT - Who is the Anaesthetist 2013 published July 2013
Regional Anaesthesia and Patients with Abnormalities of
Coagulation. Web-published August 2013 (http://onlinelibrary.
Best practice in pre-operative hypertension for elective
surgery, avoiding cancellation on the day of operation –
joint with the British Hypertension society
Care of the Older Surgical Patient
Out of Hours Operating
Peri-operative Management of the Morbidly Obese Patient
– joint with SOBA
Preventing iatrogenic hypoglycaemic brain injury caused
by sample contamination of blood drawn from arterial lines
Preventing iatrogenic hypoglycaemic brain injury caused
by sample contamination of blood drawn from arterial lines
The AAGBI Foundation is
one of the UK’s largest single
grant providers for anaesthetic
tour group visito
Feedback from a
ive, one of the best
“It was all very posit
many places! The
and we have visited
relevant, the timing
was interesting and
all, your speakers
just right and above
ga g
knowledgeable, en
superb. They were
ht amount of humo
and with just the rig
They were happy to
l very welcome.”
you all made us fee
Anaesthesia News December 2013 • Issue 317
New working parties were established on
In the past year we allocated nearly
£130,000 in for research funding
through the National Institute for
Academic Anaesthesia (NIAA)
and in addition provided funding
towards the fifth National Audit
Project (NAP5) on awareness
during surgery.
Through the NIAA, the AAGBI
now has a portfolio of 34 funded
research projects
Promoting innovation
The AAGBI launched its annual award for
innovation in anaesthesia, critical care
and pain in 2011. The award is open to
all British and Irish based anaesthetists,
intensivists and pain specialists, with
the emphasis being on new ideas
contributing to patient safety, high quality
clinical care and improvements in the
working environment. The judges are
a distinguished panel of experts in their
field. The prize is awarded at the Winter
Scientific Meeting in January.
Association of Anaesthetists of Great Britain
and Ireland - Finance Overview 2012-2013
School of Medicine
School of Medicine
AAGBI – Where our income came from
& FRIDAY 17th th & FRIDAY 17th THURSDAY 1
JANUARY 2014 2014 VENUE: JANUARY Clinical Education Centre, Leicester Royal VENUE: Clinical Education Centre, Leicester Royal Infirmary FEE: Infirmary FEE: Thursday OSCE £140.00 Friday S O
OE/VIVA Thursday SCE ££140.00 140.00 Thursday Friday: ££140.00 260.00 Friday S&OE/VIVA 25th Anaesthesia,
Critical Care & Pain
Val d’Isere
Centre de Congrés
27-30 January, 2014
Thursday & Friday: £260.00 AAGBI – How we used our income
Lunch/refreshments and car parking (if required) included and car parking (if Lunch/refreshments Please Note: Accommodation is NOT included required) included Please Note: Accommodation is NOT included This is a 1 or 2 day course devoted to intensive VIVA & OSCE preparation, individual appraisal, and small Total AAGBI expenditure for 2012-2013 = £2,712,000
AAGBI Foundation - Summary of financial
statement - Finance Overview 2012-2013
As a professional association, the AAGBI
is constantly active in representing the
interests of anaesthetists and acting as
a voice for the profession.
We would like to say a huge
thank you to all our members
for their continued support!
AAGBI Foundation - Where our income came from
Total AAGBI Foundation income for 2012-2013 = £2,760,000
24–25 February 2014
RCoA, London
(code: C84)
Session 1: Welcome and course
Session 2: Learning and teaching
Session 3: Feedback: the fuel to drive
Session 4: Workplace teaching: planning
Registration fee:
AAGBI Foundation – How we used our income
£425 (£320 for RCoA
registered trainees
and affiliates)
Event organisers:
Dr S Williamson
Session 5: Workplace teaching:
skills teaching
Session 6: Workplace assessment
Session 7: Practice teaching
Session 8: Wrap up
Association of Anaesthetists of Great Britain & Ireland,
21 Portland Place, London, W1B 1PY
Fax: +44 (0) 20 7631 4352
airman of the AA
Dr Sean Tighe, Ch
16 a
Date and venue:
Follow @rcoa_events
Tel: +44 (0) 20 7631 1650
Email: [email protected]
Over the year, the Association has supported members with the Revalidation
process and has published a position statement on CPD, actively liaising
with the General Medical Council (GMC).
The AAGBI has also responded to the Office of Fair Trading and Competition
Commission investigations of private healthcare and contributed to the
Department of Health consultations on training, manpower planning and
the future consultant role.
This is a 1 or 2 day course devoted to intensive VIVA group tutorials directed by experienced teachers and & examiners. Candidates can register for 1 day or both OSCE preparation, individual appraisal, and small group doirected by experienced teachers and days dtutorials epending n requirements. examiners. Candidates can register for 1 day or both TO REGISTER PLEASE EMAIL YOUR DETAILS TO days [email protected] depending on requirements. OR CONTACT FRCA COURSE TO REGISTER PLEASE EMAIL OUR DETAILS TO ADMINISTRATOR SAN TYHORPE ON OR C2ONTACT [email protected] 0116 58 5735. FRCA COURSE ADMINISTRATOR SAN THORPE ON 0116 258 5735. /royalcollegeof
CPD Matrix Codes: 1H01, 1H02, 2H01 and 2H02
Total AAGBI Foundation expenditure for 2012-2013 = £2,453,000
View the full financial statements
and annual reports online:
Anaesthesia News December 2013 • Issue 317
Contact: 020 7092 1673
[email protected]
Postcode lottery
in anaesthetic training
The first two years of anaesthetic training lay the foundations on which future practice is based. The “Basis
of Anaesthetic Practice”1, provides a comprehensive introduction to the principles and practices involved in
anaesthetic care, with the achievement of the Initial Assessment of Competency (IAC) the endpoint. The next 21
months (“Basic Anaesthetic Training”1) provides exposure to different subspecialties, with expected competencies
documented in the curriculum.1 Whilst there is no prescriptive order in which training should be delivered, the
Intensive Care Medicine unit of training (ICM) should be delivered in a dedicated three-month block.1
Following trainee feedback and evidence obtained at the ARCP, we
undertook a survey of core trainees that highlighted inconsistencies
in the delivery of training and experience within Wessex Deanery. We
focused on ICM training, the IAC, out-of-hours (OOH) anaesthesia and
Following permission from the Associate Dean for Quality
Management, all CT1 and 2’s were invited to participate in the survey
via email. 58 trainees were invited; 33 replied.
Intensive Care Medicine
As part of “Basic Anaesthetic Training” , ICM should occur after
gaining of the IAC. The curriculum defines learning outcomes to be
achieved during this module, including those associated with airway
management.1 The importance of adequate airway training in relation
to ICM was highlighted in NAP4, with a lack of training a contributory
factor in 58% of reported events.2
Trainees had cited issues with ICM timing, and the impact they felt this
had on training. We enquired about the timing of their ICM module.
Figure 1
Trainees that started their ICM module immediately after their
IAC (month 4, all smaller DGH) felt they had inadequate time to
consolidate their anaesthetic and airway skills.
Inadequate training was noted by NAP4 to be a contributory factor
in many incidents2. Without their IAC, trainees are not expected to
perform airway management on ICU patients unsupervised. ICM
is more suited for trainees to consolidate their airway skills. The
authors feel this would best be achieved following a period practising
anaesthesia. The next ICM module will be in ST3, and trainees will
perform airway management on critically ill patients under distant
supervision. If they are inexperienced, is this adequate both for training
and more importantly, patient safety?
The authors feel the curriculum should be more prescriptive as to
the timing of the ICM module, and that it should follow six months
of anaesthetic training. Whilst evidence for this recommendation is
lacking, it is prudent to allow a period of consolidation of newly acquired
skills. However, rota obligations often means in smaller DGH’s trainees
rotate to ICM before this time (10 of 20 prior to month 6).
Training location therefore has an impact in the amount of OOH
anaesthesia trainees will be exposed to. Most, though not all, trainees
in Wessex will rotate to the larger DGHs/university hospital, and will
have the opportunity to perform OOH anaesthesia. For some of the
CT2s, most of this experience is in obstetrics. Is a lack of previous
experience in OOH anaesthesia acceptable for these trainees when
starting on the obstetric rota?
Obstetric Anaesthesia
Concerns have been highlighted both nationally 5 and locally (by
trainers and trainees) as to whether CT2s are achieving an adequate
caseload prior to appointment to both the obstetric on call rota and to
ST3 posts.
The main aims of basic obstetric training are to become competent in
essential obstetric anaesthetic skills, and obtain the IAC in obstetric
anaesthesia (IACOA). The curriculum does not stipulate how obstetric
training is delivered, but suggests an obstetric block is beneficial1. We
surveyed trainees with, or undertaking, the IACOA (n=26) regarding
how their obstetric training was delivered.
All trainees at larger hospitals had a dedicated obstetric block and
practised OOH obstetric anaesthesia. Only one of four smaller
hospitals provided a dedicated obstetric block, and of 9 respondents
in smaller DGH’s, 6 had other commitments that prevented them from
gaining experience in OOH obstetric anaesthesia.
To see if trainees were accruing enough obstetric experience, a
predetermined caseload (100 cases, 50 epidurals, extrapolated from
the college audit standard for airway experience during the IAC6) was
stipulated. Trainees were asked whether they felt they would achieve
this by the end of CT2.
Figure 2
Initial Assessment of Competency
18 5 of the 6 trainees undertaking ICM in month one felt this was
detrimental to their training. Potentially they may not accrue
adequate experience in the complexities of airway management
in the critically ill, with the frequent combination of airway
abnormalities, hypoxaemia and cardiovascular instability.
ICM forms part of “Basic Anaesthetic Training” in the curriculum,
therefore is undertaking ICM in month one against the curriculum
We have highlighted potential solutions to the issues we have identified:
• undertaking ICM after month 6 of training,
• CT1s providing OOH cover for emergency theatres with local
• a dedicated group of consultants for continuity of supervision
during the IAC,
• a dedicated obstetric training block for CT2 trainees.
We recognise this is the ideal training programme and realistically would
be difficult to achieve in most hospitals. Undesirable consequences
Dr Patrick Tapley
Anaesthetic Registrar, North Shore Hospital, New Zealand
Dr Kathy Torlot
Anaesthetic Consultant, Portsmouth Hospitals NHS Trust
In Wessex, training during the IAC varies. We questioned how
supervision was organised. 17 of 31 trainees had a core group of
supervising consultants; all found this useful. 10 of the 14 trainees who
didn’t have a core group felt this would have been beneficial.
From these results trainees find a core group of mentoring consultants
beneficial. Benefits include monitoring of progress, provision of
consistent feedback and identification of the trainee in trouble. Those
trainees not attaining skills, as highlighted in a recent audit3, such as
endotracheal intubation and facemask anaesthesia, will be identified
early. It is well established that inadequate supervision can contribute
to stress and has a negative impact on learning in doctors4.
OOH anaesthesia offers many training opportunities, with trainees
often providing anaesthesia with distant supervision. Anecdotally
trainees experience in OOH anaesthesia varies widely.
The opportunity to perform OOH anaesthesia varied with training
location. 31 of 32 respondents had performed OOH anaesthesia. In
three of seven hospitals trainees were allocated to cover ICU OOH
(one dependent on the year of training), thus limiting the opportunity
to conduct OOH anaesthesia. Worryingly one CT2 had not performed
any OOH anaesthesia.
Anaesthesia News December 2013 • Issue 317
rota gaps, and difficulty providing daytime list cover, especially if
resident OOH consultant cover is introduced
a further shift in balance between in hours versus out of hours
caseload by higher trainees (previously noted following the
implementation of the European Working Time Regulation7).
Concerns with regards to the adequacies of training are not unique
to our region, and have been previously highlighted in the 2012 and
2013 GMC National Training Survey. 8% of CT1s and 15% of CT2s
were neutral or not very confident that their current post will help
them acquire the competencies they need at that particular stage of
The IAC is a requirement prior to trainees anaesthetising without direct
supervision. It is prescriptive for learning outcomes and assessments.
Out of Hours Anaesthesia
A postcode lottery does exist in basic anaesthetic training, and we have
shown areas of training in our Deanery that may need improvement.
Trainers also benefit4. Consistent observations by regular supervisors
enable fair and reliable assessments over a period of time.
Figure 1 shows the ICM start date month relative to the size of
hospital, and highlights some issues:
Royal College of Anaesthetists. Curriculum for a CCT in Anaesthetics. http://www.
The Royal College of Anaesthetists and The Difficult Airway Society. 4thNational
Audit Project: Major Complications of Airway Management in the UK. March
Blandford C. Do novice anaesthetic trainees receive enough training in airway
management skills? A five-year data collection from a district general hospital.
Anaesthesia News June 2012; 299: 20-21
Greaves JD et al. Watching anaesthetists work: using the professional judgement
of consultants to assess the developing clinical competence of trainees. Br J
Anaesth 2000; 84: 525-33
Paul RG et al. The effect of the European Working Time Directive on anaesthetic
working patterns and training. Anaesthesia 2012, 67, 951-956
Whymark C. Airway management training for novice anaesthetists. Raising the
standard: a compendium of audit recipes, 2012.
McIndoe AK. Modern anaesthesia training: is it good enough? Br J Anaesth
National Training Survey. General Medical Council.
Figure two breaks this down dependent on whether a dedicated
obstetric block was provided. From our limited numbers, the
provision of a dedicated obstetric training block (including OOH)
would be beneficial for accrual of experience.
One solution to the problem encountered by trainees at smaller DGH’s
would be to provide obstetric training as a dedicated block in the larger
hospitals. However this would lead to inevitable manpower issues at
the smaller DGH’s for both daytime theatre lists and out of hours shifts.
Anaesthesia News December 2013 • Issue 317
19 The history of the specialty
of Anaesthesia in the UK
Since the RCoA’s launch of a new video made to celebrate the 65th anniversary of the NHS in July this
year, the AAGBI has received a number of queries about the history of the specialty of Anaesthesia. In the
video1, Dr Peter Venn says that: “the specialty of Anaesthesia is widely regarded as being the same age” (as
the NHS itself), implying that the creation of the Faculty of Anaesthetists of the Royal College of Surgeons,
later to become the College of Anaesthetists (in 1988) and later still the Royal College of Anaesthetists,
marked the start of the specialty of Anaesthesia in the UK. As some of the historical experts we consulted
seemed not fully to agree with this assertion, we sought some more objective evidence about the origins of
our specialty. We believe that we have found a good and accurate contemporary description in an article
published in Anesthesia & Analgesia in 1949. The article is based on a talk given by Dr Henry Featherstone,
founder of the AAGBI, to a meeting of the International Anesthesia Research Society in October 1948, a
very short time after the creation of both the NHS and the Faculty of Anaesthetists. It seems to tell a rather
different story in which the Section of Anaesthesia of the Royal Society of Medicine and the AAGBI worked
with the then President of the Royal College of Surgeons, Sir Alfred (later Lord) Webb-Johnson to promote
the creation of the Faculty. The first Dean of the Faculty was Dr Archibald Marston (Dean 1948 – 1952) who
had shortly before this demitted office as President of the AAGBI (1944 – 1947). We reproduce this article in
full with the permission of Anesthesia & Analgesia. We hope you will enjoy it.
Dr Henry Featherstone
“History Boy”
Royal College of Surgeons England - Featherstone
The Faculty of Anesthetists of the Royal College
of Surgeons of England.*
(A Note on Its Origin and Purpose)
H. W. Featherstone, O.B.E., M.A., M.D., LL.D., F.F.A.
R.C.S. Eng., D.A., F.I.C.A., J.P., Birmingham, England
University Lecturer in Anesthetics, Birmingham University,
Senior Anesthetist, United Birmingham Hospitals
HERE ARE TWO ASPECTS of anesthesia which I
should like to discuss: first, the organization and status
of the specialty of anesthesia, with special reference
to the chain of events which has led to the formation
of the Faculty of Anaesthesia and second, in a later
paper, the teaching of anesthetics. Although these two
problems have of course affected anesthetists on this side of the Atlantic
very closely, and indeed have received most important attention from the
International Anesthesia Research Society and other bodies of anesthetists
in this continent, nevertheless I hope you will find it instructive to receive
an exposition from the point of view of British anesthetists.
In the course of the development of the specialty of anesthesia in the
United Kingdom, we have evolved the Section of Anaesthetics of the
Royal Society of Mediche-which was inaugurated about forty years ago,
when the Royal Society of Medicine absorbed the former Society of
Anaesthetists-then the Association of Anaesthetists of Great Britain and
Ireland, and, during the past few months, the Faculty of Anaesthetists of
the Royal College of Surgeons of England. In addition, since the War,
the British Medical Association has established the anesthetists’ group,
membership of w’hich is limited to doctors w’ho are interested primarily
in anesthesia. Its function is to represent anesthetists within the British
Medical Association.
There are also several more or less local societies or associations of
anesthetists in different parts of the British Isles. The three principal
bodies, however, which deal with the specialty of anesthesia in the United
Kingdom are those which I mentioned first: the Section of Anaesthetics,
the Association of Anaesthetists, and the Faculty of Anaesthetists. These
three are in close cooperation, and members of each are on the Coun.cils
of the other two. It should be clearly understood that each organization
deals with a different aspect of anesthesia, and a description of the origin
and function of each will show how the three bodies are able to strengthen
the position of the specialty in a remarkable manner, and that the newly
formed Faculty of Anaesthetists is a body which offers the possbbilities
of a brilliant future.
The Section of Anaesthesia of the Royal Society of Medicine is concerned
entirely with the point of view of science and research in anesthetics.
The Section provides the forum where British anesthetists describe their
work and their views. Moreover, during the War, many anesthetists from
Carada, the United States and other allied countries took a much valued
part in discussions of the Section at the House of the Royal Society of
Medicine in Wimpole Street. Dr. Ronald Jarman is now President of the
Eighteen years ago, in 1930, when I was President of the Section, the
Section was the only “central” organization of anesthetists which they
could join, but we found that the strict limitation of its powers, solely to
study and research, rendered the Secticn unable to perform other functions
which were becoming more and more urgent.
In the sixteen years after the beginning of War I, surgery and anesthesia
had undergone important advances. The operations of routine surgery
had become standardized, many more elaborate procedures were being
carried out, and surgical team work had become everyday practice.
A skilled anesthetist was regarded as an essential member of the team.
*Presented before the Twenty-Third Annual Congress of Anesthetists, Joint Session of the Internatonal Anesthesia Research Society and the International Collcge
of Anesthetists, Montreal, Canada, Octoher 18~21, 1948.
20 Anaesthesia News December 2013 • Issue 317
Drugs and technique provided better and safer anesthesia, but they
demanded the ripe experience and sound training of specialists. In order
to provide this large and increasing service of anesthetists, it was evident
that considerable numbers of practitioners would be required. But
although the demand was obvious, the conditions for the workers had
been shown by the experiences of many senior and skilled anesthetists
to be financially unreliable, and the status of those who had undertaken
the special study and practice of anesthesiology often depended far
more upon their personality, and on the success in private practice of
the surgeons with whom they worked, than upon their skill and industry.
The large voluntary hospitals, where at that time most of the operative
surgery was performed, offered no salaries for visiting anesthetists (and
indeed for the most part, at that time, they preferred to attend on an
honorary basis), but the pool of remunerative work in private practice
was not large enough to meet the needs of all the workers whom the
anesthesia service required.
It was clear that the status of specialists in anesthesia urgently needed
a hallmark or test to indicate that they had attained a proper standard
of training and skill; they also required an autonomous body of their
own through which their views could be collected and represented in
negrtiations with outside bodies, such as departments of the Government,
universities, examining bodies and hospital authorities.
I discussed the problem with the senior anesthetists of the British
teaching hospitals, with the result that in 1932 we founded the
Associalion of Anaesthetists of Great Britain and Ireland Thanks to the
enthusiastic cooperation of most of those who have specialized in the
subject, the Association has achieved remarkable success. The Diploma
in Anaesthetics soon came into being through the ready response of
the Royal College of Surgeons of England to our suggestions, and the
diploma has proved to be of the greatest value in establishing the specialty.
During the War, not only did the enhanced position of anesthetists receive
confirmation in the Services through the appointment of specialists and
graded specialists on conditions similar to those of other departments
of medicine, but the diploma was of particular value in assessing the
capabilities of candidates for these posts.
From another angle the diploma was very useful. Of necessity large
numbers of routine anesthesia and most of the emergency anesthesia
in hospitals must be administered by interns. Formerly, the interns who
administered these anesthesias knew little of the subject. But in recent
years a candidate for the diploma should have held a post as resident
anesthetist at an approved hospital, and in consequence more of these
posts have been created, with resulting improvement in the standard of
anesthesia in routine and emergency surgery.
Our specialty naturally follows the changes, not only of the technique
of surgery, but also of the type and organization of the hospitals in
which it is practiced. In England until twenty years ago, most operative
surgery was performed in the main voluntary hospitals, either attached to
medical schools or situated in the larger cities and towns. The Poor Law
Infirmaries with many beds were used almost entirely for the chronic
sick, but in 1928, by Act of Parliament, the Infirmaries came under the
Minister of Health and they were then gradually improved both in medical
staffs and in equipment, so that just before the War many were already
offering a standard of surgical work of a high order. This process has been
expedited during the past ten years with the result that many more posts
for skilled anesthetists have been provided. Accordingly the Association
has altered its rules of membership. Formerly nearly all specialists in
anesthesia were on the staff of teaching hospitals and membership was
limited to these; but in order to meet the new developments membership
is now on a broader basis and the more senior members are eligible for
election as Fellows.
Since the War, we have been preparing for a National Health Service
Anaesthesia News December 2013 • Issue 317
which is to provide, among many other things, a complete hospital
service available for every individual in England, Scotland and Wales.
As a corollary of this vast change nearly all hospital consultants and
specialists are tecoming part-time or whole-time salaried officers of the
Service. The grading of salaries is a problem of lively interest to all of
them. But it was pointed out that if all the specialists were to be treated on
a similar grading of salary, they should offer similar skill and should have
undergone training and examination tests of equally high order. Although
perhaps each specialty is different - some are more interesting, some
more strenuous, some more difficult, and some more sought after than
others - nevertheless, this principle carries much weight. Accordingly,
it was decided that not only should the standard of the Diploma in
Anaesthesia be raised, but that the examination should be taken in two
parts instead of at one sitting. In addition to anesthesia and analgesia
the syllabus was extended to include physiology, pharmacology, clinical
pathology, anatomy, clinical medicine and surgery in so far as they have
application to anesthesia.
This step brought the problems connected with training, particu-larly in
its theoretical aspects, into serious prominence. It became evident that
since the Royal College of Surgeons of England granted the Diploma, it
was most desirable that anesthetists should be able to collaborate as far
as possible with that body in arranging the lines of instruction. Already,
Brigadier Ashley Daly (the Consulting Anesthetist to the Army) when
he was President of the Association, had secured their interest and help
and they had provided accommodation and secretarial assistance in the
College buildings. I feel I must mention in parenthesis that, until this
arrangement was made, most of the office work had been provided free
of charge by Dr. Mennell, who was treasurer for ten jears. preaitlent for
rhree years and my own most helpful comrade in the early adventures.
An important further move was now possible, because under the farseeing guidance of its distinguished President, Lord Webb-Johnson
of Stoke-on-Trent, the College was proceeding forward from the
granting of diplomas in many departments of medicine and surgery to
the establishment of faculties in those branches of surgical science and
practice for which they were desired.
The Faculty of Dental Surgery had already been formed when, less than
twelve months ago, Dr. Marston, who had already performed splendid
services for anesthetists while he was secretary and afterwards president
of the Association. took the lead in arranging for the institution of the
Faculty of Anaesthetists. In this project he had the keen and unanimous
support of the other officers, fellows and members of the Association.
The Faculty of Anaesthetists is controlled by a Board of Faculty of which
Dr. Marston is the Dean. The Faculty is part of the organization of the
Royal College of Surgeons, but it is given as free a hand as possible. The
Board comprises, in addition to ex-officio representatives of the Council
of the College, twenty-one diplomate in anesthesia who have been
selected from among the leading anesthetists of the country. All who
hold the Diploma in Anesthetics are eligible for election to membership,
and by special selection from among the members, Fellows of the
Faculty are elected.
The Faculty has now entered upon its principal duties and for
postgraduate students has arranged a comprehensive course of
three months’ duration which will include lectures, demonstrations
and tutorials. A (library committee looks after the special needs of
anesthetists. The Section of Anaesthetics fosters scientific discussion and
research in anesthesia ; the Association is the independent deliberative
body which represents anesthetists, and the new Faculty will provide for
the training of anesthetists.
It appears to be a source of strength that anesthetists should possess
vigorous sections in the Royal Society of Medicine, in the British
Medical Association and in the Royal College of Surgeons.
21 John Snow Lecture
The Road to Perdition
Dr Rhona Mahony, Dublin, Ireland
Annual Congress really was an excellent affair this year. I found myself relatively free to attend the talks and
workshops that I was really interested in, and to browse the posters without having to judge, speak or undertake
other duties. Then there was the social side – particularly splendid. I really enjoyed seeing so many old friends
from far-flung places (There was even the odd kilted highlander…). You really can’t do all that online.
With some difficulty, Nancy and I have selected one ‘top talk’ each for
special mention. You will be able to see these (and many other) talks
on the AAGBI’s video platform soon (via [email protected]).
I have chosen Dan Sessler’s talk for special mention, because it
seems to me that he has done more work that has directly changed
my clinical practice than any other single figure during my clinical
career, and that the breadth and simplicity of his insights are totally
Long term perioperative outcomes
Prof Dan Sessler, Cleveland, USA
Raised (above the level of undetectable) fourth generation troponin
plasma levels (TnT) during the first three post-op days predict 30 day
mortality (the greater the peak level, the greater the mortality). He
emphasised that the current clinical guidelines (Thygeson, Circulation
2012) about diagnosing MI use specific, arbitrarily determined cut-off
points for biochemical markers of MI (90% of the population) which
are unrelated to patient outcomes. He argued that this is the wrong
way round, and that ‘prognosis defines diagnosis’ works better as a
There is no information yet (trials in progress) about options for
reducing the incidence. He opined that MAP matters (vide infra) and
that there is a threshold effect at a MAP of 55mmHg – he felt it was
likely that the aetiology of perioperative MIs lay in the myocardial
supply-demand equation, in contrast to non-perioperative, where the
aetiology is different. Nevertheless, he said (low dose) aspirin is very
effective for primary prevention and initial management of MI, and that
we should give this if in doubt.
What should we do now?
Avoid/treat MAPs less than 55, measure TnT postoperatively more
frequently especially in high risk patients, give aspirin if in doubt.
Keep our eyes open for more trials reporting data.
Perioperative blood transfusion
More harmful than we thought. A RCT is in progress, but the
immunosuppressive effects may be particularly harmful, extending
beyond cancer recurrence. We should limit transfusions and keep an
eye on the literature. I didn’t catch his references…
The ‘triple low’.
Sessler’s own research addresses this (Sessler, Anesthesiology, 2012)
I have made a précis of the top points as I understood them:
In his opening spiel (which was protracted due to technical issues with
his slides, perhaps fortunately, as he made some excellent off-the-cuff
observations) Sessler observed that we are beginning to understand
that the interventions and choices we make as anaesthetists can
influence patient outcomes (such as survival) years down the line. The
days of lamely complaining that it is hard to make our contribution
seem important when all we have to measure in terms of outcomes
are PONV, sore throat and so on are emphatically over.
22 Perioperative Myocardial Infarction (MI): ‘Prognosis defines
This is back on the table. Referring to the VISION study (JAMA 2012),
which is a preliminary publication of results relating to the first 15,000
patients in this massive study, he informed us that in all patients
over 45y of age, undergoing any non-cardiac inpatient surgery, the
incidence of perioperative MI is 9%, of which 80% are silent. Mortality is
the same for silent vs symptomatic MIs, and mortality of perioperative
MIs remains about double that of MIs presenting as such to A&E.
Low MAC (less than 0.8)
Low MAP (less than 75)
Low BIS (less than 45)
Any one, sustained for more than 15 mins in total during an anaesthetic
predicts increased length of stay.
‘Triple low’ predicts 4 x mortality, ‘double low’ (any combo) predicts 2
x mortality.
Cause/effect relationship is unknown; a big trial is in progress to
see whether interventions directed at correcting low values improve
I have chosen the John snow lecture, given by Dr Rhona Mahony.
For me, this provided a fascinating insight into events and beliefs that
surround the very different attitudes the UK and Ireland has had to
women’s health and childbirth. Dr Rhona Mahony is an obstetrician,
Master at the National Maternity Hospital, Dublin, the first woman
appointed to this role since its foundation in 1894. With 9,000 deliveries
per year, one-in-eight of all Irish children are delivered in the hospital.
She chose as her title ‘The Road to Perdition’ and gave a well
researched and moving account of the role of women in Ireland over the
last 100 years and of attitudes to childbirth and the rights of the mother
and fetus. The description of Dublin’s abject poverty, overcrowding,
maternal mortality from pre-eclampsia, haemorrhage and infection,
coupled with high perinatal mortality, would have been true of many
Edwardian cities. The effect the 1914-18 war had on women, liberating
them to work outside the home as nurses and in other roles, was not
unique to Ireland. But the next 50 years were remarkably different on
the two sides of the Irish Sea. There were no roaring twenties. Women
were compulsorily retired as soon as they married, they couldn’t take
the civil service exams or serve on juries. Many of those who found
themselves pregnant out of wedlock were incarcerated in the now
infamous Magdalene laundries. For some, the only option seemed
to be infanticide; until 1952 there were no arrangements for formal
Underpinning what now seems an archaic attitude was Ireland’s desire
to be a pure society. In pursuit of this aim, seemingly useful innovations
such as a free antenatal care package and free healthcare for children
were opposed, lest Catholic women went to protestant doctors who
might discuss contraception and sex education. Termination of
pregnancy was illegal and in 1935 use or distribution of contraception
was made a criminal offence. It has only been since the 1990s that
people spoke openly about sexual abuse in Catholic institutions,
repression and its impact on peoples’ lives.
What should we do now? Hard to know. My personal view is that it is
unlikely to be harmful to try and avoid a triple low – though one could
argue that there might be an increased risk of awareness. Watch out
for more trials reporting on the effects of interventions.
History shapes our culture. Dr Mahony gave a straightforward and
dispassionate explanation of events and the beliefs that underpinned
them. For me this was both captivating and disturbing. Hearing this
account has made me look at people like Mary Robinson and our own
Ellen O’Sullivan, President of the College of Anaesthesia of Ireland in a
new light. See what you think.
Val Bythell
Nancy Redfern
Anaesthesia News December 2013 • Issue 317
Anaesthesia News December 2013 • Issue 317
23 !
[email protected]
[email protected] was launched at Annual Congress in Dublin in
September this year, and already many of you have used this site to
record your many and varied CPD activities.
[email protected] is the equivalent of your ‘bottom drawer”, a place
to store your reflective notes on a variety of activites, and a vehicle
to access our video platform. This platform has over 250 videos,
and once you have watched a video, the system will produce a CPD
certificate for you, which automatically populates your CPD area.
Step 3: Click on [email protected], in all its pink glory!
Here you will find written instructions on what to do, a video of me
reminding you what to do (!), 6 topical talks and most importantly the
log in area at the top right hand corner. That’s the easy part!
As WSM is round the corner and we are expecting >1000 attendees,
I thought I would give those of you who haven’t used [email protected]
before a few top tips:
This is your entry point for for your own CPD area and for the AAGBI
video platform.
Once you have submitted this form, you will be provided with a CPD
This is an ever growing resource of videos from our conferences,
seminars and interviews. You search videos by:
• List of Categories (e.g. Airway Management, Burns)
• AAGBI Conference (e.g. AC 2013) or Seminar
• One of the 4 GMC Domains ((Knowledge, skills and performance/
Safety and quality/Communication, partnership and teamwork/
Maintaining trust
• Primary/Final/Pre Consultant interviews content
When you choose a video, you will see which GMC domain and CPD
code is covered. I have chosen to watch the video ‘Detecting research
fraud’ by John Carlisle.
Step 1: Go to
If you click onto the ‘my CPD area’, you can see how your CPD is
Step 4: Click on ‘log in’
You will now have to remember where you put your AAGBI membership
card, or look on the front of your unopened Anaesthesia journal for your
membership number on the address label. If you have forgotten your
password, just click the appropriate buttons and your password will
be sent to you within seconds. This ONLY works if you have registered
your correct email address with us. If in doubt email [email protected] or call 0207 631 8801/8866. When using the system for the
first time, you will be asked to enter your name and surname.
Step 2: Click on Education and Meetings
Once logged in, this is the first thing that you see:
You will be provided with information about the author and a short
summary of the video and the length of the video. When you have seen
the video, click on the words at the bottom of the page which state
‘Finish video to access the reflective learning form’ and start filling in
your reflective form. The feedback form will automatically contain the title
of the video and the meeting at which it was presented. You can reflect
and save the form as a draft which you can modify later or submit the
form which cannot be modified further.
24 Anaesthesia News December 2013 • Issue 317
Anaesthesia News December 2013 • Issue 317
You can view all your CPD content from any time length on the
screen or hide it to show current activity
You can download all selected reflection and CPD certificates
You can click on ‘Register a reflective activity at the top of the
page. This is really useful as it allows you to reflect on any meeting,
journal club, departmental meeting, M and M, critical incident,
quality improvement activity etc. and store it in your CPD area. You
can register this activity anytime, but it is particularly good if, like
me, you like to reflect whilst or as soon after an event as possible,
25 The Development of a Block Room
in order not to add it to the growing list of ‘things I need to
do’! The key is to put as much information about the activity
you are recording in the title area, as this is what flags up on
your CPD page e.g. Lecture on Rotem, by Dr Tim Hooper,
Frenchay 18.07.13.
Block rooms are increasingly being used and developed in the UK having been successfully used in North America and Scandinavia.
In this article we review our experience of setting up and working in a block room at the Sunderland Royal Hospital.
My [email protected] logo is now bookmarked on my iPad and
iphone ready for me to reflect at a moments notice.
The patient centered benefits of regional anaesthesia are well known. Indeed regional anaesthesia is advocated by the department of health
document Delivering Enhanced Recovery1, by the PROSPECT group for total knee replacements2 and by the UK Hand Surgery Report3):
Scottish Airway Group
Annual Meeting 2014
Speakers include:
Anil Patel, London
Mark Stacey, Cardiff
David Ray, Edinburgh
Suzie Thomson, EMRS
All of my educational activities and learning relevant to all 4 of
the GMC domains can be recorded, reflected on, and will then
automatically populate my CPD area.
All that leaves me to do is to just download it all into my Trust
appraisal e-portfolio whenever I want to. Easy peasy…. and this
is just Phase 1, wait till you see what we have planned for Phase
2 in 2014!
When: Friday 7th March 2014, 09:00-17:00
Where: Royal College of Physicians of Edinburgh,
9, Queen Street, Edinburgh.
Fee: £120 (£100 if booked before 8th January)
£60 reduced rate for trainees
Limited places for non-medical staff - £30
Abstracts encouraged: see online.
Closing date 31st January
Best abstract and best oral presentation £150 prize
Apply: Online at
Feedback from 2013…very enjoyable meeting, with thought provoking speakers…came away feeling
inspired...excellent meeting…best meeting I have been to in ages...excellent value for money...excellent
meeting clarifying a few controversial issues and generating new ones...thought-provoking and relevant.
Patients, in most hospitals, move through the operating suite in a linear fashion, starting at reception and ending in the recovery room in a series
of sequential steps. One case is competed before the next can begin and periods of time that could be used for operating are left unused.
5 CPD points applied for
Photograph used under a Creative Commons licence
are seeking funding to work, or to deliver
educational training courses or conferences,
in low resource countries.
Please note that the grant application forms were revised in
April 2013 and only these updated forms will be accepted.
Grants will not normally be considered for attendance at
congresses or meetings of learned societies. Exceptionally,
they may be granted for extension of travel in association
with such a post or meeting. Applicants should indicate their
level of experience and expected benefits to be gained from
their visits, over and above the educational value to the
applicants themselves.
For further information and an application form
please visit our website:
or email [email protected]
or telephone 020 7631 8807
March 2013
A major advantage of using a block room to administer regional anaesthesia, is that the block can be performed, and established whilst a case
is currently on going: so called ‘parallel processing’. Regional anaesthesia is commenced, in a dedicated block area, within the theatre suite,
while the previous case is still taking place. The patient is monitored, in a dedicated ‘cooking area’, until the operating theatre is vacated. Then
they are moved into the prepared theatre with very minimal downtime and surgery commenced seamlessly. Time can be built in for any change
of anaesthesia plan e.g. rescue blocks, and importantly teaching time can be accommodated whilst operating continues. Procedures such as
tourniquet application, patient positioning and the timely administration of antibiotics may also be performed.
Parallel processing removes the large variability of time needed for anaesthesia. This changes the rate-limiting step of patient throughput to that
of theatre preparation. This is shorter and less variable than that of anaesthesia, the result being a gain of operative time within a theatre session
available for additional cases.
Figure 2
[email protected]
Delegate rate fixed
since 2011!
When you next have an opportunity, try
[email protected] (, it will
make appraisal, revalidation, reflecting and learning
more interesting, fun and make you think you are ents Manager TRAVEL GRANTS/IRC FUNDING
an incredibly organised person…… at least that’s +44 (0) 20 7631 8805
my New Years’ resolution, hopefully it should last
The International Relations Committee
until 15th January for the beginning of WSMortland
Place, London W1B(IRC)
offers travel grants to individuals who
Dr Samantha Shinde
Honorary Secretary Elect
A commonly quoted disadvantage of regional anaesthesia is its perceived effect on patient throughput. Regional anaesthetic techniques require
a significant time for administration and onset of effective anaesthesia, with a high degree of skill and expertise required to use modern ultrasound
guided techniques. The use of a block room takes away some of the time pressure for the anaesthetist, and provides as relaxed environment
where the patient can await surgery.
Figure 1
Programme includes:
Challenging airways
The airway in ICU & the Emergency Department
Airway management in remote & rural locations
Training in airway management
Front of neck access
“3.15 Anaesthetic support should include facilities for regional anaesthesia by brachial plexus block, which is the optimum mode of anaesthesia
for many hand trauma cases. It provides excellent postoperative analgesia and avoids the risk of disruption of repairs during a restless recovery
from general anaesthesia.”
One of the criticisms of parallel processing is the cost of employing extra staff to run a block room system. A major advantage of this system of
working, however, is its ability to increase efficiency and generate additional income. This potential for additional income generation outweighs
the modest increase in staffing costs. This is especially the case if, as in Sunderland, the anaesthetic cover can be removed from upper-limb
orthopaedic lists, with patients on these lists receiving regaional anaesthesia in the newly created block room.
As can be seen in figure 2, in theory it may be possible to perform additional cases without overrunning a theatre list. But does this work in
practice? We ran a pilot over a 5-day period in early 2010, servicing two primary lists and an effort was made to service other lists as required. This
Anaesthesia News December 2013 • Issue 317
27 Constructing a business plan
A business case was constructed based on this time saving of 123
minutes per day. Trust data indicated that our average income per
orthopaedic case was £2207 (once prosthetic and staffing costs had
been taken into account). Initially the block room was to run 3 days a
week. With this information we formulated three levels of productivity
outcomes, dependent upon the amount of extra cases performed. The
worst-case scenario was one extra case per week, the intermediate
case was one extra case per day and our best-case scenario was one
extra case per list (3 lists) per day. These would give the projected
additional annual incomes outlined in table 1.
Table 1
Projected increase in annual income (£)
Test run to wider practice
A typical block room day now involves servicing both standard
orthopaedic lists and hand lists. In the morning the block room team
consisting of a consultant anaesthetist, a trainee anaesthetist (often
the regional anaesthesia fellow) and the block room ODP gather all
the lists for the operating suite. They identify cases that may potentially
require blocks and will then discuss these cases with the anaesthetist
responsible for that list. It is not unusual in a single day for the block
room team to perform well over 15 blocks for a variety of procedures,
encompassing neuroaxial blockade, popliteal sciatic nerve blocks,
femoral nerve blocks, axillary, interscalene and ankle blocks.
The block room team has to co-ordinate with the various theatres
as to when they are likely to require their next patient blocking and,
as with so many aspects of anaesthesia, for this to work effective
communication is key.
Have we achieved what we set out to?
In 2010 the average number of cases performed per session was
2.08. By 2011 it had risen to 3.10 cases per session rising still further
to 3.58 per session by the end of 2012. This equates to 3 extra cases
per day being performed since the block room was introduced. But
does this just mean we’re working longer and harder rather than
We looked at start and finish times for our theatre lists, with a late
finish being a finish > 30minutes from the scheduled finish time, we
found that since the introduction of the block room, and in spite of not
starting earlier (and increasing number of cases performed as above),
we are finishing lists earlier. The number of early finishes rose from
26.4% to 38.9% over the period, giving extra for further improvements
in productivity.
Further to this, it allows for a greater utilization of the skill mix available
along the theatre corridor. Previously it may have been difficult to
provide all patients who may have benefited from regional anaesthesia
with the specific technique they required. In the block room system of
working an anaesthetist with a specific interest in regional anaesthesia
is available to all patients and provides an easy point of contact for
colleagues requiring assistance.
97% of our patients report no pain in recovery, and we have high
patient satisfaction levels with 100% of patients recently surveyed
following axillary brachial plexus blocks being either satisfied or very
satisfied with the block (as measured on a 5 point likert scale).
Review of our processes for awake hand surgery has lead to new
protocols allowing these patients to bypass recovery and go straight
back to our day-case unit, freeing up space and staff within the
recovery room.
But is it all positive?
What about the anaesthetists looking after the patients who receive
anaesthesia from th eblock room staff? There certainly is the
possibility of deskilling the non-block room anaesthetists. However,
the presence of a block room has increased the profile of regional
anaesthesia within the department and increased the total number of
regional blocks performed. Colleagues with a regional interest have
the opportunity to cover block room sessions and also continue to
perform their own blocks, especially at busy times and when use of
the block room will not lead directly to increased efficiency. There are
obvious advantages in the system for the occasional orthopaedic
Future developments
Currently the block room works out of an anaesthetic room for a
decommissioned theatre. The block room has been so successful
that a purpose built block room is being created in a more suitable
location that will further enhance the flow of patients through theatres.
Dear Editor,
your Letters
We refer to the AABGI patient safety alert1 issued in November
2012, and your article in the April edition of Anaesthesia News2
regarding a fire on an intensive care unit which was caused by
an oxygen cylinder.
We would like to report an incident regarding an oxygen cylinder
which occurred in our hospital, whilst transporting a ventilated
intensive care patient to the CT scanner. The oxygen cylinder
had been laid on the bottom of the patient’s bed, and whilst the
bed was being turned around a corner, the end of the bed was
accidentally hit against the frame of a door. During this, the top
of the oxygen cylinder was also knocked, causing damage to
the cylinder neck and valve. The oxygen cylinder began to leak
very noticeably and loudly and the Oxylog portable ventilator
stopped ventilating. The patient was ventilated via self-inflating
bag on room air, the oxygen cylinder turned off and the patient
returned quickly to the intensive care unit. The patient did not
come to any harm.
We strongly support the AAGBI suggested practice regarding
the use of appropriately designed oxygen cylinder holders, and
keeping the cylinder upright rather than lying the cylinder on the
bed or trolley next to the patient, to avoid potential damage to
the oxygen cylinder during transfers, as occurred in our case;
and in the case of an ignition2,3 to minimise its impact.
Shilpa Patel & Edward Todman,
Anaesthetic Specialty Trainees 7, National Hospital for
Neurology and Neurosurgery, London
Safe handling of oxygen cylinders. AAGBI safety committee.
November 2012
Kelly F, McDonald J. Fire on intensive care caused by an oxygen
cylinder. Anaesthesia News 2013; 309: 8-9
Kelly FE, Hardy R, Hall EA, McDonald J, Turner M, Rivers J, Jones
H, Nolan JP, Cook TM, Henrys P. Fire on an intensive care unit
caused by an oxygen cylinder. Anaesthesia 2013; 68:102-104
The Editor, Anaesthesia News at [email protected]
Please see instructions for authors on the AAGBI website
Dear Editor,
A reinforced message
We would like to report an incident involving a reinforced endotracheal tube that was used
for a rapid sequence induction for an emergency category one neurosurgical craniotomy.
A reinforced tube was chosen as per the norm in our establishment for neurosurgical
cases for their resistance to kinking. All equipment was checked prior to induction
including checking the inflation of the endotracheal tube’s cuff.
Anaesthesia was induced and a grade IIb view was gained on direct laryngoscopy.
A bougie was placed uneventfully into the trachea and whilst trying to railroad the reinforced
ET tube over the bougie it became evident that the tube would not advance even before
entering the mouth. Closer inspection showed that the reinforced tube was irreversibly
compressed just above the cuff not allowing the passage of the small diameter Frova
bougie. The tube was quickly discarded and replaced by another reinforced endotracheal
tube, anaesthesia was maintained and the case proceeded without any ill effects.
On further detailed inspection of the discarded tube there was no obvious external damage
to it or packaging and it wasn’t immediately evident unless a ‘dent’ was specifically
looked for (Fig 1). We postulate that at some time the tube had been clamped or crushed
somehow – which is surprising as the metallic inner is meant to protect from kinking.
The Sunderland block room experience has been a positive one, for
patients, consultants, trainees and the trust. It has improved the quality
of service provided to patients and leaves them with high levels of
satisfaction. It has improved the quality of regional anaesthesia training
and we have been able to demonstrate a significant improvement in
theatre productivity and efficiency. We hope to continue to develop
the block room service and believe that the block room system of
working may be a useful model for other NHS trusts.
Ian Baxter, Nathaniel Haslam and Andrew Morrison
Consultant anaesthetists, Sunderland
Delivering Enhanced Recovery: Helping patients get better sooner after
surgery. Department of Health, product 200977, pg 20.
PROSPECT (Procedure Specific Postoperative Pain Management)
Recommendations for Total Knee Arthroplasty (2007).Available from (last accessed 16/5/13)
Hand Surgery in the UK Manpower, resources, standards and training.
The British Society for Surgery of the Hand. Pg 14.
Other benefits
Are there any benefits other than the increased productivity of theatres?
From an educational point of view the trainees who are allocated to
the block room get to see a wide range of blocks performed on a
regular basis, enabling a more rapid attainment and better retention of
both knowledge and skills in ultrasound guided regional anaesthesia.
Anaesthesia News
pilot demonstrated a reduction in ‘down time’ from 410 to 300 minutes
(a reduction of 27%) whilst the time in theatre remained constant
(1127 vs. 1134 minutes). We repeated this for three weeks, servicing
additional theatres and we were able to demonstrate time savings, on
average, of 123 minutes per day. Potentially this time could be used
to undertake an extra case.
Anaesthesia News now reaches
over 10,500 anaesthetists
every month and is a great way
of advertising your course,
meeting, seminar or product.
Anaesthesia News
is the official newsletter
of the Association of
Anaesthetists of Great
Britain & Ireland.
There have been previous case reports highlighting that even reinforced tubes are prone to
damage especially by biting during emergence, however we would like to raise awareness
of this as a pre-induction problem and also underline how important it is to check the
endotracheal tube fully and not just the inflation of the cuff. Revisiting the AAGBI equipment
check it is clear that a part of the guideline is pre-operative airway equipment check (which
was done). However the guideline does specifically state that airway equipment should be
available in all appropriate sizes and ‘have been checked for patency”3. This was clearly
not done here and had a bougie not been required, the ETT would have been placed
unknowingly and could have given rise to a potentially problematic ventilation intra-op and
increased ventilation pressures with no evident cause.
This has certainly reinforced that looking down the endotracheal tube or checking its
patency via the ventilation tubing (as we commonly do with the HME filters) is something to
do pre-operatively alongside the other checks. We do acknowledge that had we opted to
insert a stylet to stiffen the tube, we may have identified the problem earlier – pre insertion.
However the use of a stylet isn’t always warranted and shouldn’t replace the full checking
of endotracheal tubes.
now for
a media
L. Bowen,
ST6 Anaesthetics, University Hospital Wales, Cardiff
S. Rees,
Consultant Anaesthetist. University Hospital Wales, Cardiff
For further information on advertising
Tel: 020 7631 8803
or email Chris Steer:
[email protected]
Malhotra D., Rafiq M., Qazi S., Gupta S.D. (2007). Ventilatory Obstruction with Spiral Embedded
Tube – Are they as safe? Indian Journal of Anaesthesia. 51 (5):432-33
Brusco L, Weissman C. (1993). Pharyngeal obstruction of a reinforced orotracheal tube. Anesth
Analg. 76:653-4.
Hartle A., Anderson E., Bythell V., Gemmell L., Jones H., McIvor D., Pattinson A., Sim P. and
Walker I. (2012) AAGBI Safety Guideline. Checking Anaesthetic Equipment. Page 12.
Dr Les Gemmell
Immediate Past Honorary Secretary
28 Anaesthesia News December 2013 • Issue 317
21 Portland Place, London W1B 1PY
Anaesthesia News December 2013 • Issue T:317
+44 (0)20 7631 1650
F: +44 (0)20 7631 4352
E: [email protected]
These courses are organised by Regional Anaesthesia UK (RA-UK) in conjunction with FUJIFILM SonoSite Ltd for training in
ultrasound guided regional anaesthetic techniques. Previous experience in regional anaesthesia is essential.
2014 Course Dates
10–11 January
11–12 April
14–15 July
25–26 September
28–29 November
Newcastle (A)
Bristol (A)
Brighton (A)
Nottingham (A)
Dr Ian Harper / Dr Nat Haslam
Dr Tony Allan / Dr Barry Nicholls
Dr Susanne Krone / Dr Ali Diba
Dr Steve Roberts / Dr Raj Naveen
Dr Nigel Bedforth / Dr James French
December 2013
T. Heidegger, D. Saal and M. Nüblin
Faculty will vary depending on location
10% Discount for ESRA members – 15% Discount for RA-UK (FULL) members. Cost: £400 / £500 (A) including a CD with presentations and course notes.
Pre-course material can be downloaded once registered on the course – including US physics, anatomy of the brachial / lumbar plexus, current articles of interest
and MCQ’s. A pre course questionnaire will be sent 30 days before each course.
Day 1
Day 2
Ultrasound appearance of the nerves
Machine characteristics and set-up
Imaging and needling techniques
Common approaches to the brachial plexus / upper / lower limb
Workshops – using phantoms / models / cadaveric prosections (A)
Patient satisfaction with anaesthesia – Part 1: Satisfaction as part of outcome
– and what satisfies patients
Consent / training and image storage
Upper / lower limb techniques
Abdominal / thoracic techniques
Cervical plexus / spinal / epidural / pain procedures
Workshops – using phantoms / models / cadaveric prosections (A)
(A) – Anatomy based courses / with cadaveric prosections
M. Nübling, D. Saal and T. Heidegger
Patient satisfaction with anaesthesia – Part 2: Construction and quality
assessment of questionnaires
E. McGrady
For further information and to register logon to
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e he
Du n t ear
ti Y
ou ew
‘Anaesthesia for the Elderly’ – advance notice.
Articles on: Multidisciplinary peri-operative care; Pre-operative
assessment/risk stratification; Frailty; Legal/ethical aspects of care;
Analgesia; National research strategies; Emergency surgery; and
General management of elderly patients.
Patient feedback and anaesthetists: what are patients assessing and why?
One of the elements now required for revalidation is
patient feedback. At best, the additional workload required
is often regarded as a nuisance, especially if the tools are
not validated. At worst, the outcomes of any feedback can
be misleading. One of the pertinent questions is: “what is
the patient feeding back on, in the case of anaesthesia?”
There are clear dangers that, in cases where the primary
dissatisfaction is with surgical outcomes, the anaesthetist
who has delivered a high-quality, pain- and nausea-free
experience will nonetheless be tarred with the same
negative brush as surgical or other colleagues. Equally
giving a ‘terrible’ (to our own high standards) anaesthetic
(with apparently traumatic airway management, multiple
attempts at venous access, poor blood pressure control,
abandoned epidural replaced with IV opiates, etc) can
still leave the patient (unaware of any difficulties) entirely
contented, with a pain free and excellent outcome and
positive feedback.
In the November issue of the journal, two articles
by Heidegger’s group analysed ‘patient satisfaction’
in relation to anaesthesia in some detail and the work
provides resource material for anyone wishing to study
and develop this important topic. Further, McGrady’s
accompanying editorial offered some very helpful
and pragmatic advice for those colleagues facing the
perhaps daunting task of collecting patient feedback.
She makes the helpful point that the emphasis really is
on communication, and outlines how forms might be
distributed and collected. There is one small aspect which,
in my ignorance, I did not previously know; namely that
the distribution of forms to patients should be ‘random’.
This is surprising because nobody really knows what
‘random’ means, or how to achieve it (e.g. even the proper
‘randomness’ of a randomised controlled trial is often
hotly debated). Pragmatic alternatives might be ‘universal’
(especially where response rates are low), or ‘consecutive’
or ‘representative’. What will almost inevitably be near to
random is whether or not the patient actually completes
the form.
J J Pandit,
Editor, Anaesthesia
N.B. the articles referred to can be found either in a print issue or on Early View (ePub ahead of print)
Anaesthesia News December 2013 • Issue 317
31 Particles
Adelson PD, Wisniewski SR, Beca J et. al. for the Paediatric Traumatic Brain
Injury Consortium.
Comparison of Hypothermia and
Normothermia after Severe Traumatic Brain
Injury in Children (Cool Kids): A Phase 3
Randomised Control Trial
The Lancet 2013; 12: 546-53
Severe traumatic brain injury (TBI) remains a leading cause of paediatric
death and permanent disability around the world. Evidence from previous
trials investigating the role of therapeutic hypothermia in TBI in children has
been conflicting1,2,3. Following a phase 2 trial showing reduced mortality using
hypothermia in children after severe TBI2, the authors aimed to assess whether
therapeutic hypothermia (32–33°C) with slow rewarming over 48-72 hours
improved mortality at 3 months.
This randomised controlled, multi centred, multinational trial was conducted in
the USA, Australia and New Zealand. Children, aged 0-17, were enrolled within
6 hours of injury and were included if they had sustained a non-penetrating head
injury, a GCS of 3-8 and a motor score of less than 6 following resuscitation.
Randomisation was via a web-based assignment algorithm and investigators
who assessed outcome were masked to treatment allocation. Patients
were managed in conjunction with a standardised, two-tiered head injury
management protocol.
The primary outcome measure was mortality at three months post-injury.
Secondary outcome measures were global function at 3 months post-injury
(using the Glasgow Outcome Score - Extended Paediatrics) and occurrence of
adverse events. Based on a previous randomised controlled study2, the authors
planned to recruit 340 children. This would allow detection of a 10% difference
in mortality with 80% power.
77 patients (39 in the hypothermia group, 38 in the normothermia group) were
recruited into the study between November 2007 and Feb 2011. An interim
data analysis on these patients led the authors to terminate the study early on
the grounds of futility. The mortality rates at 3 months were 6/39 (15%) in the
hypothermia group vs. 2/38 (5%) in the normothermia group. Poor outcomes
did not differ between groups and there was no between group difference in the
occurrence of adverse events.
The authors conclude that hypothermia for 48hrs with slow rewarming does
not reduce mortality or improve global functional outcome after paediatric
severe TBI. However, the study only recruited 77 of the projected 340 patients
required to show a statistical difference. The study was terminated at this point
as an interim futility analysis showed that there was less than 20% chance of
confirming the primary hypothesis. This futility analysis was performed due to
slow accrual of patients into the study and due to safety concerns from another
randomised controlled trial, which showed that hypothermia in children with TBI
might be associated with worse outcome1. The authors highlight several of the
difficulties of performing studies in this field and the need for further studies to
define the role of hypothermia in TBI in children.
Fiona Yau
ST6, London Deanery
Tajinere Fregene
Research Fellow, London Deanery
Hutchison JS, Ward RE, Lacroix J, et al. Hypothermia therapy after
traumatic brain injury in children. New England Journal of Medicine 2008;
358: 2447-56
Adelson PD, Ragheb J, Kanev P, et al. Phase 2 clinical trial of moderate
hypothermia after severe traumatic brain injury in children. Neurosurgery
2005; 56: 740-54
Biswas AK, Bruce DA, Sklar FH, Bokovoy JL, Sommerauer JF. Treatment
of acute traumatic brain injury in children with moderate hypothermia
improves intracranial hypertension. Critical Care Medicine 2002; 30:
32 Anaesthesia News December 2013 • Issue 317
Futier et al, for the IMPROVE study group
Ashton-Cleary DT
A Trial of Intraoperative Low-Tidal-Volume
Ventilation in Abdominal Surgery
Is thoracic ultrasound a viable alternative
to conventional imaging in the critical care
NEJM 2013; 369: 428-437
Lung protection ventilation utilising low tidal volumes and positive end expiratory
pressure (PEEP) is considered best practice in critically ill patients1. Its role in
general anaesthesia for major surgery is unknown. This patient group includes
230 million patients worldwide2. Large cohort studies have shown that 20-30% of
this group is intermediate to high risk for postoperative pulmonary complications.
This was a multicentred, double blinded, parallel-group trial. Patients were
randomised to either lung protective ventilation (LPV) or non- protective
ventilation (NPV)3,4. Inclusion criteria were age >40 years old, elective major
abdominal surgery, duration >2 hours, preoperative risk index for pulmonary
complications of >2. Exclusions included emergencies, recently unwell and
obese subjects.
Protective ventilation included tidal volumes of 6-8ml/kg (predicted), PEEP
of 6-8cmH2O, recruitment (30cmH2O for 30s every 30 minutes), and plateau
pressures of <30cmH2O. Non-protective ventilation included tidal volumes of
10-12ml/kg (predicted) with no PEEP or recruitment.
Primary outcome was a composite of major pulmonary and extra-pulmonary
complications at 7 days post surgery. Secondary outcomes were followed up
to 30 days.
Over 18 months 400 patients were randomised. There were no differences
in groups in type and duration of surgery, epidural use or fluid use. Primary
outcomes occurred in 10.5% in the LPV group versus 27.5% in the NPV group
(RR: 0.40; 95% CI, 0.24-0.68, P=0.001). Within 7 post-operative days 5.0% of
the LPV group required non-invasive ventilation or intubation for respiratory
failure compared to 17% assigned to NPV (RR, 0.29; CI, 0.14-0.61; P=0.001).
Length of hospital stay was shorter among patients receiving LPV compared to
NPV (mean difference -2.45 days; 95% CI, -4.17 to -0.72; P=0.006).
According to this study LPV resulted in a 69% reduction in the number of
patients requiring ventilator support within 7 days of surgery. The observed rate
of postoperative complications was higher than predicted. This may have been
due to exclusion of patients with a low risk of complications. They suggest that
this improvement is due to reduction in ventilator-associated lung injury. The
tidal volumes in the NPV group were 10-12 ml/kg, which was felt to be standard
practice. Important study limitations include the failure to standardise fluid
administration; although administration was similar in the two groups.
James Day
ST6 Oxford Deanery
The Acute Respiratory Distress Syndrome Network. Ventilation with lower
tidal volumes as compared with traditional tidal volumes for acute lung
injury and the acute respiratory distress syndrome. New England Journal
of Medicine 2000; 342: 1301-8
Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the
global volume of surgery: a modelling strategy based on available data.
Lancet 2008; 372: 139-44
Bendixen HH, Hedley-Whyte J, Laver MB. Impaired oxygenation in
surgical patients during general anesthesia with con- trolled ventilation:
a concept of atelectasis. New England Journal of Medicine 1963; 269:
Jaber S, Coisel Y, Chanques G, et al. A multicentre observational study of
intraoperative ventilatory management during general anaesthesia: tidal
volumes and relation to body weight. Anaesthesia 2012; 67: 999-1008
Anaesthesia News December 2013 • Issue 317
British Journal of Anaesthesia 2013 111 (2): 152-60.
Thoracic ultrasound in the past has been dismissed as a useful investigation,
but with renewed enthusiasm in its uses, opinion is changing. This review
examined relevant studies between 1995 and 2012, focusing on four common
conditions that require repeated imaging to diagnose and monitor treatment.
Pleural effusion: Using computed tomography (CT) as the reference standard,
several studies demonstrate the superior ability and reliability of critical care
ultrasonography (CCUS) to detect pleural effusions over chest x-ray (CXR).1 Of
more clinical relevance is the identification of effusion characteristics. Evidence
is heterogenous but suggestive that useful estimations of effusion volume may
be derived.2 Further work is required to identify one single, simple method of
volume estimation that would validate current evidence.
Consolidation & atelectasis: Distinguishing between alveolar oedema, interstitial
oedema and consolidation on CXR is difficult. From alveolar consolidation
studies, Lichtenstein and colleagues show that CCUS can provide an accurate
lung assessment by combining four ultrasound features. This was with
comparable diagnostic performance to CT.3 However many subsequent studies
by other groups failed to reproduce such findings.
Extravascular lung water: There may be an emerging role for ultrasound here,
however evidence is conflicting. CCUS may enable differentiation between
pneumonia and pulmonary oedema through specific ultrasound features. It
performs well at identifying cardiogenic pulmonary oedema, compared to
echocardiography and functional cardiac testing.3 More research is required to
support the role of ultrasound in this area.
Pneumothorax: CCUS is considered valuable in detecting pneumothorax.
Diagnosis is defined by an absence of B-lines, lung sliding and the presence
of A-lines. If lung movement is likely to be absent, A-lines themselves can be
used to differentiate between diagnoses. The largest study of critical care
pneumothoraces excluded ventilated patients due to reduced ultrasound
sensitivity – an anomaly not mentioned in other studies.4 In general, CCUS
outperformed CXR in diagnosis and monitoring, with CT used as the reference
The four reviewed conditions have a varying evidence base to support the role
of thoracic ultrasound. Overall CCUS appears to approach the quality of CT
and surpasses that of CXR. CCUS can potentially save time and provide cost
savings, however the difficulty for implementation is that of training. Guidance is
available regarding necessary core competencies, however the accreditation of
CCUS is still largely undecided.
Emma McLaughlin
ST3 Anaesthesia and Intensive Care Medicine
South-East Scotland Deanery
Lichtenstein D, Goldstein I, Mourgeon E, et al. Comparative diagnostic
performance of auscultation, chest radiography, and lung ultrasonography
in acute respiratory distress syndrome. Anaesthesiology 2004; 100: 9-15.
Roch A, Bojan M, Michelet P, et al. Usefulness of ultrasonography in
predicting pleural effusions > 500ml in patients receiving mechanical
ventilation. Chest 2005; 127: 224-32.
Lichtenstein DA, Meziere GA. Relevance of lung ultrasound in the
diagnosis of acute respiratory failure: the BLUE protocol. Chest 2008;
134: 117-25.
Galbois A, Ait-Oufella H, Baudel JL, et al. Pleural ultrasound compared
with chest radiographic detection of pneumothorax resolution after
drainage. Chest 2010; 138: 648-55.
33 If you’re going to
San Francisco...
Photography © Sarah Kessler, Lifebox
As the 1967 song by Scott McKenzie goes, be sure to wear some flowers in your hair. And, although there are
still many flower children and hippies to be seen in the city, this was not actually the dress code for the American
Society of Anesthesiologists (ASA) annual meeting in San Francisco where the AAGBI was represented by our
President William Harrop Griffiths, Vice President Isabeau Walker and Executive Director Karin Pappenheim. There
were also around 130 UK delegates amongst the 15,000 anaesthetists, industry reps and others attending this
major five day event in October.
AAGBI Vice President and Lifebox
member, Dr Isabeau Walker pres
ents an oximeter
to Elizabeth Ogboli Nwasor from
With a packed multi stream programme starting at 7.30 am on many days, finding your
way to the right session at the right time was often challenging. Highlights included:
Dr Jane Fitch taking up her role as new ASA president, only the second woman
to hold this office in the organisation’s history. Dr Fitch is professor and chair of
the Department of Anesthesiology at the University of Oklahoma Health Sciences
Centre in Oklahoma City.
The launch of ASA’s public affairs campaign ‘When seconds count’ promoting the
role of anaesthetists.
A debate on the death penalty linked to ASA action to persuade policy makers not
to use anaesthetics for executions. ASA successfully lobbied the State Governor of
Missouri to stop possible use of Propofol for this purpose, so averting the threat to
anaesthetic treatment from this move.
Lifebox fundraising and workshop.
Patient Safety as the theme of the conference with Hollywood actor Dennis Quaid
taking part by video in a plenary session on the Chasing Zero Project promoting
safety and quality.
An important discussion on drug shortages took place at a World Federation of
Societies of Anaesthesiologists (WFSA) session – where the ongoing work by AAGBI
on the national essential anaesthetics drug list (NEADL) was a focus and joint action by
the Association, WFSA and European Society of Anaesthesiologists was agreed as a
follow up.
As always at such events, there are many opportunities for networking with colleagues
and a meeting was held between CEO’s of national societies for information sharing as
well as a lunch for Presidents of member organisations from around the world.
34 34
Karin Pappenheim
Executive Director, AAGBI
Delegates at the
Lifebox worksho
Anaesthesia News
News December
December 2013
2013 •• Issue
Issue 317

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