GAT Issue: The Olympics and Anaesthesia - aagbi

Anaesthesia
The Newsletter
of the
Association
of Anaesthetists
of Great Britain
and Ireland
News
ISSN 0959-2962
No. 300 July 2012
GAT Issue:
The Olympics
and Anaesthesia

1384_AN March 2012 Half Page Ads Split v3.indd 1 25/01/2012 15:22
2012 ULTRASOUND TRAINING COURSES
2012 Course Dates:
Introductory Ultrasound Guided
Regional Anaesthesia
19 – 20 November
Ultrasound Guided Venous Access
11 October
8 November
Ultrasound Guided Chronic Pain Management
26 November
Paediatric Ultrasound Guided Venous Access
26 July
Venue: SonoSite Education Centre – Hitchin
Ultrasound Guided Critical Care
courses also available
For the full listing of SonoSite training
and education courses, dates and to
register go to:
www.sonositeeducation.co.uk
© 2012 SonoSite, Inc. All rights reserved. 03/12
These courses are organised by Regional Anaesthesia UK (RA-UK) in conjunction with SonoSite Ltd for training in ultrasound guided
regional anaesthetic techniques. Previous experience in regional anaesthesia is essential.
Course Dates Location Organisers
9 –10 July Brighton (A) Dr Susanne Krone
20 – 21 September Liverpool Dr Steve Roberts
30 November – 1 December Nottingham (A) Dr Nigel Bedforth
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.
Programme
Day 1
• Ultrasound a ppearance 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)
SonoSite, the world leader and specialist in hand-carried ultrasound, has teamed up with some of
the leading specialists in the medical industry to design a series of courses, for both novice and
experienced users, focusing on point-of-care ultrasound.
Introductory Ultrasound Guided Regional Anaesthesia
The two-day introductory course is designed to teach those who have little or no experience in the
use of ultrasound in their normal daily practice. The course comprises of didactic lectures on the physics
of ultrasound, ultrasound anatomy and regional anaesthesia techniques. The lectures and hands-on
sessions will concentrate on the brachial plexus, upper and lower limb blocks.
Ultrasound Guided Venous Access
This one-day course is aimed at physicians and nurses involved with line placement and comprises
didactic lectures, ultrasound of the neck, hands-on training with live models, in-vitro training in
ultrasound guided puncture and demonstration of ultrasound guided central venous access.
The emphasis is on jugular venous access, but femoral, subclavian and arm vein access will also
be discussed.
Ultrasound Guided Chronic Pain Management
The course is aimed at chronic pain specialists, or other interested parties practising in chronic pain
medicine who have little or no experience of musculoskeletal ultrasound and who wish to obtain an
introduction to ultrasound in chronic pain medicine skills.
Fees: £375 (two-day courses) includes VAT, lunch, refreshments and course materials.
£260 (one-day courses) includes VAT, lunch, refreshments and course materials.
If you have any questions or should need further information please contact:
Dee Banks, SonoSite Ltd, Alexander House, 40A Wilbury Way, Hitchin Herts, SG40
AP
Tel: +44 (0) 1462 444800 Fax: +44 (0) 1462 444801 E-mail: education@sonosite.com
2012 ULTRASOUND GUIDED REGIONAL
ANAESTHESIA – BEYOND INTROD UCTORY
Day 2
• 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
Guest
Editorial
This year’s trainee issue of Anaesthesia News has been
compiled by the Group of Anaesthetists in Training, and
is unashamedly a celebration of all things Olympic as
this momentous sporting event gets underway in towns
and cities around our land.
In 1948, the same year that London last played host to the Olympic
games, a major change to the provision of healthcare in the United
Kingdom was initiated with the founding of the National Health
Service. Despite its infancy, the NHS exerted an influence on the
games that year with Stoke Mandeville Hospital in Oxfordshire
hosting what would become the Paralympics’ Games. 2012 will
see in changes which impact on the National Health Service too:
the passing of the Health and Social Care Bill in parliament, the
start of single-CCT Intensive Care training, and the BMA holding a
ballot of its membership on industrial action.
Whilst doing some background research, we discovered that the
Olympic motto “citius, altius, fortius - which translates as “faster,
higher, stronger”- was introduced at the Paris games of 1924. It is
a motto that could easily describe the performance demanded of
our modern NHS. The idea “the important thing is not winning but
taking part”- although frequently mistaken for the Olympic motto
- is actually a misquote of the Olympic Creed which states: “The
most important thing in the Olympic Games is not to win but to take
part, just as the most important thing in life is not the triumph but the
struggle. The essential thing is not to have conquered but to have
fought well.” We feel this is applicable to all anaesthesia trainees in
2012, when clearing the many hurdles to successfully gain a CCT
seems impossibly daunting at times. In recent years, host cities
have taken to adopting a motto to capture the spirit of the particular
games and its legacy. The London 2012 Games’ motto is “Inspire
a generation” and along with “Light the fire within” (Salt Lake City) is
what we as trainees are looking for from out trainers and mentors.
Contents
03 Editorial
08
16
38
12
31
The Association of Anaesthetists of Great Britain and Ireland
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Anaesthesia News
Editor: Val Bythell
Assistant Editors: Kate O’Connor (GAT), Nancy Redfern and Felicity Plaat
Address for all correspondence, advertising or submissions:
Email: anaenews@aagbi.org
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Telephone: 020 7631 8803
Email: chris@aagbi.org
Printing: Portland Print
04 The Olympic Timeline
05 How do we think of ‘function’;
disability sport and competition
08 A ‘how to’ guide:
Anaesthetising the elite athlete
10 A Pool of Opportunity
12 A quick jog through
the history of running
16 Performance Enhancement
- Citius, Altius, Fortius* At All Cost
20 Consent in 2012
22 International Relations Committee
Latest Report
22 Anaesthesia Digested
25 Mass gatherings
and infectious disease
27 Going for Gold!
29 Exertional heat illness in half
marathon runners – Experiences
of the Great North Run
31 Cardiopulmonary Exercise Testing:
Thresholds of Success
36 Particles
38 Diabetes and sport: more than just
good glucose control
Copyright 2012 The Association of Anaesthetists of Great Britain and Ireland
For further information and to register logon to
www.sonositeeducation.co.uk
© 2012 SonoSite, Inc. All rights reserved. 03/12
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.
Anaesthesia News July 2012 • Issue 300 3
3

Editorial continued
Some of the others are just as relevant in our anaesthetic
world: “Share the spirit” (Sydney), “One World, One Dream”
(Beijing), “Passion lives here” (Torino). Others sum up
our multi-disciplinary work environment: “Harmony and
progress” (Seoul), “With glowing hearts” (Vancouver). The
Paralympics’ motto of “Spirit in motion” may be what some
of our surgical colleagues perceive a good anaesthetist to
be, but we all know better!
Olympic Flame for the London 2012
Games is lit in Ancient Olympia
© LOCOG, www.london2012.com
In this issue we bring to you a medical perspective on
“London 2012” with a selection of articles on such wideranging
topics as exercise physiology and infectious disease,
medical Olympians and performance enhancement! You
will undoubtedly agree that this is an eclectic mix, but we
hope these articles will provide you with an illuminating and
enjoyable read as the games unfold.
Nicholas Love
GAT Committee Chair
Kate O’Connor
Editor (GAT) Anaesthesia News
The AAGBI is
now connecting
with members
through online
social networks
Facebook and
Twitter.
@AAGBI
AAGBI1
THE OLYMPIC TIMELINE
1896 Athens The 1st Modern Olympic Games, 14 countries compete.
1900 Paris
1904 St Louis
1906 Athens Intercalated Games (medals not considered official by IOC)
1908 London Mt Vesuvius eruption in 1906 forces games to move from
Rome to London
1912 Stockholm Women compete in swimming for the 1st time
1916 Cancelled due to WWI
1920 Antwerp Olympic Flag introduced
1924 Paris Originally planned for Amsterdam
1928 Amsterdam Women compete in Track&Field for first time but so
many collapse after the 800m race that this event is
banned until 1960. Olympic Flame introduced.
1932 Los Angeles
1936 Berlin Jesse Owens wins 4 gold medals; Politically and
culturally one of the most crucial events in Olympic
history, laying question to the “superiority” of the Aryan
race. First Olympic Torch Relay & first televised Games.
1940 & 1944 Cancelled due to WWII
1948 London Previously right-handed Hungarian Karoly Takcaz,
having lost his dominant hand to a grenade attack in 1938,
wins gold in the rapid fire pistol event with his left hand.
1952 Helsinki Czech Emil Zatopek sets Olympic Record in 5000m, 10000m
and then the marathon – having never run one before!
1956 Melbourne Numerous countries boycott games in protest of Soviet
invasion of Hungary and for the first time all nations march
in closing ceremony together rather than as separate teams.
1960 Rome 18yr old Cassius Clay wins gold in boxing…later to
become world famous for his fancy footwork and
showmanship! Use of amphetamine in a Danish cyclist, Knuth
Jensen, leads to his collapse mid-race and subsequent fatal
skull fracture
1964 Tokyo Japan spends $3million on revitalising an earthquake and
WWII – torn city to produce Games where 25 Olympic & World
Records are broken.
Ethiopian Abebe Bikila wins his 2nd Olympic Marathon
just 6 weeks after an appendicectomy.
1968 Mexico City Highest Olympic Games at an altitude of 7349ft (2240m).
200m medallists Tommie Smith & John Carlos raise hands
in the Black Power salute on the podium and subsequently
receive a ban and deportation. First drug disqualification….for
excessive alcohol imbibement.
1972 Munich Eleven Israeli athletes tragically die during the Black
September Terrorist group kidnaps and failed rescue. The
Games holds a period of mourning but remains
overshadowed by this event.
1976 Montreal
1980 Moscow First Olympics held in communist country but US boycott
in protest of Soviet invasions
1984 Los Angeles Carl Lewis follows in the footsteps of Jesse Owens, winning 4
gold medals in the same events
1988 Seoul Ben Johnson sets a new 100m world record of 9.79secs but
tests positive for anabolic steroid and is stripped of the medal.
‘Flo-Jo’ (and those famous finger nails!) wins 3 gold medals.
Officially the first Olympics to allow ‘professional’ athletes to
compete.
1992 Barcelona Every nation with an Olympic Committee attends for the first
time in decades
1996 Atlanta Bomb in centennial Olympic park kills 1 and injures 111
2000 Sydney North and South Korea enter the stadium under one flag
Cathy Freeman wins gold in 400m and Steve Redgrave wins
gold medals in his 5th consecutive Olympic Games
2004 Athens
2008 Bejing Air pollution 2-3 times greater than considered safe by WHO;
China enforces a 30% emission reduction by local plants in
Bejing. Olympic Torch carried to the summit of Mt Everest in
May by female Tibetan climbers
2012 London
2016 Rio
HOW DO WE THINK OF ‘FUNCTION’;
DISABILITY SPORT
AND COMPETITION
As peri-operative, critical care and pain physicians, we are
acutely aware of the importance of an individual’s function
in the context of their normal daily lives as it offers a means of
assessing their fitness for any surgical procedure. Number-based
values (walk tests, stress investigations and CPX) can certainly
offer a great deal of information but teasing out the details gives
a far broader picture for us to use in assessment. How much
a patient can physically do every day, and what exactly limits
them, gives huge insight into their overall functional capacity
and what further investigations are warranted pre-operatively. It
also provides information such as how they might cope with the
practical consequences of major surgery, whether they can use
a PCA button and the likelihood of post-operative confusion or
psychological difficulty. All too familiar is the patient scheduled
for a hip replacement whose exercise is currently so limited by
pain that coronary disease, if present, would not be symptomatic.
This article looks briefly at an internationally approved approach
to ‘function’ and gives a very simplistic overview of disability sport
in competition. These concepts provide an interesting perspective
on the limitations with which our own patients present.
Classifying Disability and Function
London 2012:
Brands Hatch Paralympic
Road Cycling Venue
© Photograph by Dave Poultney,
LOCOG, www.london2012.com
Function and disability are multi-dimensional concepts relating to
body function and experiences within an individual’s life context
and cultural population.
The International Classification of Functioning, Disability and
Health (ICF) (endorsed by the World Health Assembly May 2001
and adopted as WHO taxonomy in 2002) aimed to develop a
systematic and translatable coding system for chronic health
states and, driven mainly by physiotherapy and rehabilitation
specialties, provided a scientific basis for their classification.
It utilises an outcome measurement tool called the WHO
Disability Assessment Schedule II (WHODAS II), which provides
an assessment framework across six domains of activity and
function. This facilitates the identification of specific needs,
areas of potential modification and treatment benefit and allows
monitoring of these over time. Its first phase referred to common
chronic health states (12 core diseases including COPD, chronic
pain and depression) and phase 2 was expanded to include
acute health states.
Anaesthesia News July 2012 • Issue 300 5

WHODAS II: The Six Domains of Assessment
Domain 1. Understanding and Communication
Domain 2. Getting Around
Domain 3. Self Care
Domain 4. Getting along with People
Domain 5. Life Activities
Domain 6. Participation in Society
The degree of limitation experienced in specific aspects of each
domain are assessed by the patient, the limitation is graded as
none=1, mild=2, moderate=3, severe=4, extreme limitation/cannot
do=5. These scores are then used in the overall assessment of
functional limitation and apply to the state of chronic health in the
previous 30 days only.
Classifications in Disability Sport
There are 5 major impairment classes within the Paralympic Games:
• Spinal Cord (Congenital & Acquired)
• Limb (Congenital & Acquired)
• Cerebral Palsy
• Visual Impairment
• Les Autres (Now includes Intellect groups again)
Essentially, to be eligible an athlete must have a primary and
permanent impairment of one of the following types: hypertonia,
athetosis, ataxia, loss of muscle strength, loss of range of movement,
loss of limb, limb deficiency, short stature, low vision or intellectual
impairment. Classification is a two-step process and specific subclassifications
exist within each sport.
400m race faster than the first 200m, and he has in ablebodied
races. After a ruling by the IAAF, which banned him from
competition in 2008, categorising his cheetahs as ‘aids’ an appeal
resulted in an overturn of this ban in 2009.
Cycling, both track and road, is a relatively new sport to the
Paralympics first appearing in Seoul 1988 for the visually impaired.
Hand cycling was introduced in Bejing in 2008 bringing the total of
classes to four: CP, locomotor, visually impaired and hand cycles.
.
Hand cyclists naturally produce lower VO2 peak values but have
been recorded at up to 53.7ml/kg/min.
Adaptive rowing was introduced to the Paralympics in Bejing after
its origins in the 1970s. It encompasses a range of disciplines for
limb, neurological and visual impairment groups.
In 2007 the Paralympic movement approved the International
Paralympic Committee (IPC) Classification Code as an overarching
structure of categorisation. The IPC Classification Code was
developed using the ICF system and, as such, clinical disability and
chronic health development form an intrinsic part of this broad field
of sports medicine.
The History of UK Disability Sport
As the 2nd World War progressed, the UK experienced an influx
of injured and paralysed servicemen returning from combat. In
response to this, in September 1943, the government asked a
German-born and Polish-trained doctor, Ludwig Guttman, if he would
take charge of a dedicated spinal ward for casualties. Ward X was
opened thereafter in Stoke Mandeville Hospital, Buckinghamshire
on 1st February 1944. Guttman set out to care medically for these
patients, but also to challenge the commonly held view of the time
that the future of a paraplegic was ‘hopeless’. His approach to care
involved drives to increase activity, both physically and mentally.
Guttman had recognised early on in his career that activity and skill
development offered huge benefits to the sick and infirm. On July
28th 1948, Stoke Mandeville hosted an archery event on its lawn
for 16 former servicemen. Four years later the event had grown,
and atheletes were invited from Holland. From then on, the Stoke
Mandeville Games were seen as the (annual) Olympic event for
disabled sportsmen. The first Paralympics (‘Para’- along side the
Olympics) Games were held on 18th September 1960 in Rome with
400 athletes competing in 9 events. Athelets with visual impairment
and amputees were added as classes in 1976; followed by athletes
with cerebral palsy (1980), ‘Les Autres’ (1984) and athelets with
learning disabilities (1996). This last (6th) category was short-lived,
and was abolished following controversy at the Sydney Olympics in
2000, but has been re-instated for London 2012. Over 4000 athletes
will compete in 20 sports in the London 2012 Paralympic Games.
Summer Paralympic Sports
Athletics Rowing
Archery
Sailing
Boccia
Shooting
Cycling
Swimming
Equestrian Table Tennis
Football (5 a-side) Volleyball (sitting)
Football (7 a-side) Wheelchair Basketball
Goalball
Wheelchair Fencing
Judo
Wheelchair Rugby
Powerlifting Wheelchair Tennis
Specifics of Disability Sports
The evolution of specific sports has helped to define how their
competitions are conducted and how disability sub-classifications
are defined. Each sport is governed by its own regulatory body.
Judo for the visually impaired developed in Asia and first appeared
in Seoul in 1988. It remains specific to this impairment class and
encourages proprioception development, upper body strength and
teaches important life skills such as protective techniques in falling.
In contrast, archery - the founding sport for disability competition -
is held as a mixed ability event and is a highly technical discipline.
Swimming is broadly divided into physical disability groups and
visual impairment groups. Athletes in the physical impairment group
undergo a two-stage assessment: firstly a bench test and secondly
a test in water to allow functionality to be assessed. This results
in a more mixed ability competition with athletes in higher classes
(ie less impairment) demonstrating similar lactate profiles to that of
able-bodied competitors. Classification within athletics is complex
but includes track, road, jumping, throwing and combined events for
all 5 impairment classes which, in contrast to swimming, compete
separately. Elite wheelchair athletes demonstrate formidable
endurance and physiology with the world record marathon time
currently standing at 1:20:14 for men. Paraplegic athletes can
.
produce 100-150W average power output, peak VO2 of greater
than 3L/min and are often competitive internationally across a much
broader range of distances compared with able-bodied runners.
Prosthesis technology for amputees has rapidly evolved, and further
development is expected with the promise of future biotechnology.
The world record 100m sprint for a bilateral amputee stands at
10.91secs and high jump for single leg amputee at 2m 10cm. The
prosthetic ‘cheetahs’ that Oscar Pistorious has come to characterise
remain controversial. Debate continues as to whether they confer
biomechanical advantage as he can complete the latter half of a
Football exists in two forms in disability sport; a 7 a-side adaptation
for cerebral palsy and 5 a-side for visually impaired competitors.
Team sports, on the whole, use a cumulative scoring system
that is calculated from the ‘ability score’ of each team member.
Wheelchair rugby was started in the 1970s after more severely
disabled basketball competitors found this sport increasingly
inaccessible to them as it grew in speed and skill. Wheelchair
basketball, started in the 1940s for injured US soldiers, has
become one of the most popular spectator disability sports and is
one of the fastest and most endurance-demanding. Wheelchairs
are designed specifically with a cambered axel for stability and
.
to avoid hand injuries from collisions. Peak VO2 measurements
recorded range from 2.07L/min (in 1 point players) to 3.66L/min
(in 4.5 point players)
Although most sports involve adaptations from their original formats,
some sports have developed specifically for disability groups such
as goalball and boccia. Goalball uses a bell-containing ball for the
visually impaired and boccia is a form of boules for athletes with
severe neurological disability.
The specific medical management of disability athletes relates
both to their sport and to the physiological and biomechanical
characteristics of the individual. Competing athletes abide by
specific antidoping rules governed by WADA. Management of any
medical problem requires common sense, lateral thinking and an
understanding of that individual’s functionality.
Single leg amputees have a leg length discrepancy to allow the
prosthetic limb to swing through unimpaired; this is important
for efficiency but also for safety in everyday life (e.g. falls). This,
in turn, can give rise to lower back and supporting limb injuries.
There may be compounding factors such as the residual effects of
a traumatic injury or contracture. At different points in the athlete’s
‘on’ or ‘off’ season, changes in training practices and intensity
give rise to RSI (that’s repetitive strain injury in most other walks of
life!) and for amputees, potential pressure damage where the limb
meets the prosthesis. Spinal injury patients may have difficulties
with autonomic function; this can lead (amongst other things) to
CVS instability, heat injury and altered responses to the metabolic
demands. Patients with severe CP or neuromuscular disability
affecting the trunk may have developed kyphoscoliosis leading to
reduced lung capacities.
Positioning and posture can still form a crucial aspect of their
respiratory capacity. Lactate profiles in athletes with increased
.
muscle tone (spasticity in CP) generally show lower VO2 at
.
© British Paralympic Association
Psychological issues are integral to performance in all elite
sport, but offer fascinating perspectives in disability athletes. For
amputees and wheelchair users it is crucial to consider that any
supportive ‘equipment’ used by such sportsmen and women is not
just a ‘piece of kit’ but often forms an essential and integrated part
of their body in everyday life and is often adapted and tailored for
their personal requirements. Guttman’s conviction that activity and
skill development are integral to rehabilitation physiology, strength,
esteem and confidence is nowhere more evident than in this arena.
Athletes have arrived at the discicplines in which they now
compete via many different routes in life; some are born with
an impairment and some acquire them. Most anaesthetists will
have accompanied young patients to the CT after sustaining
significant traumatic brain injury and most will not know where
those patients who survived their ITU stay are now. A number of
our 2012 Paralympic Team GB are such individuals, making up a
team of over 100 athletes, competing at an international level and
proving that ‘function’ and ‘fitness’ are far more than just tests on
a treadmill.
Dr Alex Beckingsale
ST6, Northern School of Anaesthesia
Royal Victoria Infirmary, Newcastle-upon-Tyne
Acknowledgement
Dr Nick Webborn MB BS FFSEM FACSM MSc,
Chief Medical Officer to Paralympics GB London 2012
British Paralympic Association
References
Webborn, N. Special Considerations- Disability Sport. In Sports Injuries,
section 4.4, edited by Hutson, M and Speed, C. Oxford University
Press 2011
World Federation for Physical Therapy, Keynotes; Health Classifications
2: Using the ICF in Clinical Practice, 2007
Introduction to the International Classification of Functioning, Disability
and Health (ICF), World Health Organization 2001. International
Classification of Functioning, Disability and Health. Geneva: WHO.
Buckley, Exercise Physiology in Special Populations, Elsevier
Winter Paralympic Sports
anaerobic threshold and increased fatigability, even after significant
Alpine Skiing
conditioning and training. Protective equipment becomes very
Biathlon
important in certain sports such as hard helmets in wheelchair
Cross country skiing
use above distances of 400m and eye protection for goalball and
Ice Sledge Hockey
adaptive rowing in the visually impaired.
Wheelchair Curling
Website: www.paralympic.org
6 Anaesthesia News July 2012 • Issue 300 Anaesthesia News July 2012 • Issue 300 7

This summer’s Olympic and
Paralympic games will see over
17 000 athletes competing in 26
different sports across the UK.
These individuals have trained
to extraordinary limits in their
individual fields and can display
extremes of physiology and
anatomy, which in themselves
would challenge their anaesthetic
management. In addition, the
occupational impact that any
medical intervention may have
would be highly significant for
individuals in whom the slightest
physical change could be career
limiting or ending.
A ‘how to’ guide:
Anaesthetising the elite athlete
Some of the potential challenges of anaesthetising Olympians
and other professional sports persons are discussed here.
Anaesthetic Technique
Planning the mode of anaesthesia for a world-class athlete should
involve the same processes as for any other patient including
thorough preoperative assessment.
Regional anaesthesia may be appropriate and neuraxial anaesthesia
is generally considered safe. The risk of nerve damage with peripheral
blocks is small; but even minor, temporary neuropraxias could be
devastating to an athlete’s career. Accurate informed consent is
always core to patient choice. General anaesthesia however, also
carries the risk of nerve damage thus meticulous positioning and
extremity protection is essential.
There is little evidence to inform the decision between TIVA and
volatile for maintenance of anaesthesia. Both have good clinical
recovery profiles to allow for a prompt return to activity. There is only
one reported case of propofol infusion syndrome in an athlete and
this case had many complicating issues 15 that make it difficult to
assign causality. In those who are post-exercise and dehydrated there
may be increased risk of hypotension with TIVA. Sevoflurane can
cause QT prolongation and may be best avoided where conduction
abnormalities (often associated with athletic hearts).
Size and shape
While many athletes display the ideal physique, certain sports are
associated with a habitus that could make laryngoscopy difficult, The
thick-muscled neck seen in weight-lifters and boxers could prove a
challenge. In addition many athletes are at the extremes of size and
muscle mass and correct calculation of drug doses as well as correct
sizing of equipment is especially important.
Drugs in Athletes
The list of substances that are prohibited from use in sports men
and women is extensive and complicated. Testing can occur at any
time and substances permitted during competition differ from those
allowed out of competition, and according to the sport involved. For
this summer’s games the ‘in competition’ time begins 30 minutes
prior to the beginning of the opening ceremony for all competitors
and continues until the end of the closing ceremony. Table 1 shows
the status of widely used anaesthetic drugs in athletics. Some
substances (such as diuretics) are banned because, although they
are not in themselves performance-enhancing, they can be used to
aid weight loss to achieve entry criteria for defined divisions within
some sports. For this reason colloid fluids are banned when given as
an infusion but permitted in and out of competition when administered
as an intravenous injection. All drugs can be checked quickly and
easily on the global drug reference online website (www.globaldro.
com) or by contacting the UK anti-doping agency.
If surgery is planned, or any other medical therapy for that matter,
athletes need to apply for a therapeutic use exemption (TUE), which
permits the use of these banned substances for medical indications.
The official advice is that all athletes should be treated according to
clinical need in the event of an emergency. Accurate record keeping
is crucial as a TUE will often be sought retrospectively in these
circumstances, though there is no guarantee that such an exemption
will be granted. Apart from the hazards of working around anti-doping
regulations, medical practitioners need to be alert to the possibility that
athletes may be using illicit substances for performance enhancement
purposes, which can both interact with other medications and mask
normal physiological responses under anaesthetic. Lastly it is important
to consider the side effects of any medication administered- however
minor. b - agonists may be legally and legitimately administered for
asthma but even a minor resulting tremor could be disastrous in
sports requiring fine motor control.
8 Anaesthesia News July 2012 • Issue 300 Anaesthesia News July 2012 • Issue 300 9
Physiology
While anaesthesia in fit individuals is usually straightforward an
awareness of the possible consequences of extreme training is vital.
Medical management of sportsmen particularly following endurance
events may be complicated by critical fluid and electrolyte imbalance,
arrhythmias and rhabdomyolysis. Exertional rhabdomyolysis is
more likely in hot humid conditions and is the most common cause
of exercise related myoglobinuric acute renal injury in athletes.
Erythropoetin is difficult to detect in athletes and has been used to
enhance performance by increasing the body’s maximum oxygen
consumption capacity. Physiological consequences of this abuse
include hyperviscosity, increased risk of thrombosis and renal failure.
There is evidence that competitive athletes performing exercise at high
work rates can induce chronic epithelial injury resulting in bronchial
hyper-responsiveness. The occurrence and extent of injury is related
to hyperpnoea and environmental factors and varies between sports.
This phenomenon may also account for the reports suggesting an
increased risk of upper respiratory tract infections following long
distance events.
Another recent study has shown aerobic fitness to be related to the
delayed onset of cerebral autoregulation meaning that athletes may
be more prone to instances of symptomatic cerebral hypoperfusion.
Pain tolerance in athletes may also be altered compared to controls.
A recent study looked at the response to pain of marathon runners
and found them to have a reduced experience of pain compared to a
control group of non-runners 13 .
Cardiovascular Disease
The resting ECG of an elite athlete may display a spectrum of
variations that would be considered abnormal in non-athletic persons.
The degree of abnormality is related to the type, intensity and duration
of training. Sinus bradycardia is the commonest benign abnormality
and is attributed to increased vagal tone and an altered intrinsic
heart rate. Resting heart rates of 33 bpm has been recommended
and prophylactic administration of 1-2 mg atropine during anesthesia
recommended 6 . Vagotonia also causes more frequent and longer
sinus pauses in athletes compared with controls. Supraventricular
ectopic beats as well as conduction abnormalities such as a
prolonged PR interval; Wenckebach AV block and right bundle branch
block are common in these individuals. ST segment elevation due to
early repolarisation and U waves are also recognised benign findings.
Unlike in the diseased heart, the ECG changes related to the athletic
heart are not usually symptomatic and do not progress with exercise.
Distinguishing between changes that are a physiological adaptation
to prolonged exercise and pathological disease is difficult. Sudden
cardiac death is the leading cause of death in young athletes with an
incidence of 1-2 per 100 000. Hypertrophic obstructive cardiomyopathy
and prolonged QT syndrome have been most commonly implicated.
Co-morbidities
In addition to physiological changes which occur as a result of intense
and prolonged training athletes are subject to the same spectrum
of disease that occurs within the general population. Sickle cell trait
may be benign in most carriers but conditions such as hyperthermia,
dehydration and acidosis can trigger crises and organ infarction. In fact
there are multiple reports of deaths in athletes related to this condition 9 .
Marfan’s syndrome which occurs with an incidence of 1:5000 in the
general population is thought to be more prevalent in sports such as
volleyball and basketball where tall stature and increased span are
advantageous, and is associated with a 40 fold increase in mortality
in young men. Diabetes requires careful control to avoid the well
documented complications of poor management. The management
of diabetes in sports persons has in recent years been complicated
by insulin being placed on the list of banned substances by the World
Anti-Doping Agency; it may now only be used with a therapeutic
exemption order within the context of treating diabetes. The potential
for misuse of insulin for its anabolic properties remains, and as testing
for other banned substances becomes more sophisticated there may
be heightened scrutiny on diabetics to gauge whether unnecessary
administration is taking place under a TUE. It is unlikely that many of
us will be charged with anaesthetising an Olympian, but awareness
of the physiological changes which accompany extreme training as
well as the implications of each aspect of anaesthetic management
for future competition will help achieve an optimal outcome for this
extraordinary group of individuals.
Rachel Alexander
Specialist Registrar, Bristol School of Anaesthesia
Table 1. Classification of widely used agents in anaesthesia.
SAFE BANNED IN COMPETITION BANNED AT ALL TIMES
Propofol Fentanyl Corticosteroids
Thiopentone Remifentanil Colloid fluids (infusion)
Ketamine Alfentanil Dextran (IV)
Midazolam Morphine Albumin
Lignocaine Pethidine Mannitol (IV)
Bupivicaine Ephedrine Diuretics
Muscle Relaxants Adrenaline (inhaled/IV/IM) Insulin
Tramadol
Salbutamol (IM/IV/SC/PO)
Codeine
Paracetamol
Antibiotics
Local anaesthetic agents
Editor’s note: The AAGBI has established that medical defence organisations offer assistance
and indemnity in the usual way for members undertaking the treatment of athletes as medical
volunteers, in Good Samaritan acts or when anaesthetising them. Specific to private practice,
it should be clear that the athlete is the patient and that no contractual relationship exists with
the club/employer of the individual. Some insurers impose a liability limit of £10 million. If in
doubt, please discuss this with your defence organisation before undertaking any such work.
For further information: www.medicalprotection.org/uk/casebook-may-2012/olympic-dilemmas
References
1. UK antidoping agency. www.ukad.org.uk
2. Robertson S. Anaesthesia for the athlete: volatile or TIVA South African J Anaesthesia and
Analgesia 2011 17 (1) pp 20-21.
3. Welch E. Anaesthesia and analgesia drugs contraindicated in competitive athletes. South African
J anaesthesia and Analgesia 2011 17 (1) pp 22-24.
4. Abdulatif M et al. Multiple electrocardiographic anomolies during anaesthesia in an athlete. Can J
Anaesthesia 1987/34:3 pp 284-7
5. Ferst J A, Chaitman BR. The electrocardiogram and the athlete. Sports Medicine 1 390-403 (1984)
6. Dominci L et al. Anaesthesia in high level athletes. Ann Fr Anaesthesie Reanim 8:667-669 1989
7. Kippelen P, Anderson SD. Airway injury during high level exercise. British J Sports Medicine 2012
Jan 12.
8. Holly RG, Shaffrath JD, Amsterdam EA. Electrocardiographic alterations associated with the
hearts of athletes. Sports Med. 1998 Mar;25(3):139-48.
9. Eichner ER. Sickle cell trait in Sports Current sports medicine reports. Vol 9 No 6 pp 347-351 2010
10. Domenico Corrado, M.D., Cristina Basso, M.D., Maurizio Schiavon, M.D., and Gaetano Thiene,
M.D. Screening for Hypertrophic Cardiomyopathy in Young Athletes N Engl J Med 1998; 339:364-
369
11. Patel DR, Gyamfi R, Torres A Exertional rhabdomyolysis and acute kidney injury Phys Sportsmed.
2009 Apr;37(1):71-9.
12. Lind-Holst M, Cotter JD, Helge JW, Boushel R, Augustesen H, Van Lieshout JJ, Pott FC. Cerebral
autoregulation dynamics in endurance-trained individuals J Appl Physiol. 2011 May;110(5):1327-
33. Epub 2011 Mar 3.
13. Johnson MH, Stewart J, Humphries SA, Chamove AS. Marathon runners’ reaction to potassium
iontophoretic experimental pain: Pain tolerance, pain threshold, coping and self-efficacy. Eur J
Pain. 2012 May;16(5):767-74. doi: 10.1002/j.1532-2149.2011.00059.x. Epub 2011 Dec 19.
14. Nieman DC. Is infection risk linked to exercise workload Med Sci Sports Exerc 2000;32:S406–
15. Felleiter P.Propofol infusion syndrome – A Fatal Case at a Low Infusion Rate Anesthesia and
Analgesia. October 2006 Vol 103 No 4 1050.

A Pool
of Opportunity
Aquatics Centre
Photograph by Steve Bates@ODA
© www.london2012.com
Aged 9 and starting out life as a very young competitive swimmer, I had
hopes and dreams (like all aspiring athletes) of taking part in the Olympic
games. Twenty years on, I will be taking my place amongst a select few in
the world when the Olympics come to London, sadly not as a competitor,
but I will be part of the games nonetheless. I have been appointed by FINA
– the world governing body for swimming - as one of the two starters for the
swimming events, selected from a worldwide panel!
“Tell me where it all began.”
My local swimming club hosted many competitions. Although I
was a fast swimmer, the field was occasionally faster than me and
I didn’t always qualify for each gala. My parents were involved
in the swimming club too, and would run a tombola stall to raise
funds for the club at these home meets. Even if I was not swimming
I would go along to the competitions, and while shouting on my
teammates I would make myself useful with administration tasks
for the organisers. I managed to complete the tasks efficiently- this
skill stood me in good stead as a prospective medical student- and
I was spotted by other clubs and asked to attend their competitions
to administrate there. From there the county association asked me
to attend and help run the county championships.
“Give me an example of leadership.”
Clubs frequently organise their own competitions as a source
of club funds. In 2001, at short notice, our club’s competition
manager was relocated to a different part of the country leaving
nobody to organise our competition. Over time we’d built up a
loyal club base who returned year on year to compete at our
competition, and to cancel would have left our club short of the
vital funds relied upon to run development camps. I was about
to sit my A-levels, I was only 17 and I suddenly found I’d signed
up to be the youngest ever meet manager in the country! I was
the only person in the club who had the experience to carry it off,
experience gleaned from working with clubs around my county.
Despite cutting my training sessions down to four a week, I’d
almost bitten off more than I could chew.
I had anticipated some of the extra administration that would
come with the role but I didn’t anticipate having to negotiate with
pool operators on a £1500 bill for pool hire. The hardest task was
trying to negotiate and shape the views of a panel of well meaning
volunteers! In the end I organised two successful meets and
raised £10000 for my club.
“How did your career take shape from there”
I had a year out, eventually got my medical school place and
commenced my undergraduate medical training. I was asked to
go along to the BUSA Swimming championships in my first year
of uni, I’d actually been to two championships before – in 1994
and 2000 when they were held at my local pool. I showed off my
organisational skills and by the end of the weekend I was asked
to be part of the sport management group. I also organised a
Fresher’s week and many other college events during my years
as a student. Throughout university I maintained my commitment
to swimming, attending many county, regional and subsequently
national events.
“What makes you different from everyone else in here”
I sat my technical exams and became eligible to work as a
technical official, and began being appointed to regional and local
competitions volunteering as judge and starter. On the national
stage I was mainly doing competition management duties, with
the odd appointment as a judge.
In Athens in 2004 there was a major embarrassment for FINA. The
winner of the 100m Backstroke was disqualified for a technical
infringement at the turn, after a protest from the American team
was upheld. The scrutiny of this incident resulted in a change
in the way FINA appointed technical officials for its international
competitions. A new directive was created which stipulated that
no technical official aged 60 or over would be appointed onto
the lists of internationally approved technical officials. British
Swimming was required to rethink its own strategy for the officials
they appointed. Traditionally the international appointments were
reserved for those who had served for a number of years at the
top of the game. Overnight, their positions were in jeopardy. They
began to identify a pool of talent already working at national
standard that would be eligible for international appointment with
the right mentorship.
As luck would have it I was invited to start the events at the 2006
British Swimming Championships. I was assessed on my ability to
correctly start races fairly there; and over the next 4 years I continued
to be invited to national events as a starter. I was assessed on each
occasion, and out of the individuals on the development programme
I was identified as one of the starters to be nominated onto the FINA
list of accredited international technical officials. My international
appointment started in 2011 and runs for four years, during which time
I am eligible for appointment to European and World Championships,
along with the Olympic Games.
“Have you anything to show for your achievements”
There are only two starters appointed for the swimming events at the
Olympic games – for consistency one does all of the male races,
the other all the female races. I’m absolutely thrilled to be able to
represent my country at the top of my game. It may be a somewhat
untraditional “national representation” in the sense of the Olympics,
but I’m still incredibly proud that I’ve been selected because of my
talent and ability.
“Seems like it takes up a lot of time – is it worth it”
Volunteering is tough. Officials don’t get paid for any of the work they
do for swimming, and sometimes it is really hard. Officials take a lot
of flak from coaches and parents too. We organise the competitions
and make a lot of unpopular decisions. At times I’m away for long
periods, which means I don’t have much of a social life and seldom
see my friends. Between my on-call rota and swimming on sometimes
alternate weekends there isn’t much time left for exam revision.
I wouldn’t change it though. I find the work incredibly rewarding
despite the many challenges. Hearing the shouting and cheers
makes the hairs on the back of my neck stand on end – especially
at the university championships. I have a look around and take stock
occasionally, and I realise I’d do it just for those experiences, and I
feel satisfied to have created this rewarding part of my life .
Swimming appears to attract anaesthetists for some reason –
Alistair Fale is Training Programme Director and Regional Advisor
for anaesthesia in West Yorkshire and a swimming referee. Retired
consultant anaesthetist Susan Coe will be going to the Paralympics
to officiate at the swimming. Ian Whitehead, consultant anaesthetist
and ARCP panel chair in the Northern School of Anaesthesia, will also
be going to the Olympics to work as a deck official. Ian also works
as the Technical Director for the British Universities Championships
and has taken the lead on one of the modules in mentorship and
development of future technical officials for Great Britain.
Luckily for me the Northern School of Anaesthesia have continued to
encourage me through this busy period by supporting my application
for an out of programme experience. I will be out of sync for ST3
applications but it’s a sacrifice I’m willing to make.
“What has swimming taught you”
My extra-curricular work with swimming has greatly supported my
professional development. I’ve learned important leadership skills
and to be diplomatic when required, I’ve also developed important
time management tactics. I’ve learned how to manage the most
difficult team member of them all – the volunteer! I find it so rewarding
to give back to the sport, and stressful as it may be at times, I enjoy
that my hobby is so different to my day job.
Sport England estimate that around two million people volunteer for
at least an hour a week. A population study in Germany concluded,
“Helping others increases people’s individual wellbeing” . People
who volunteer frequently are likely to report higher life satisfaction
than non-volunteers. In Europe, on average, 32% of the population
do voluntary work – this constitutes an equivalent of 4.5 million full
time jobs . Volunteers are less prone to depression and elderly
volunteers have a lower risk of mortality .
Regardless of the stimulus for volunteering – either intrinsic or
extrinsic I’d encourage anyone and everyone to volunteer. We’re
medics – I’m certain a massive proportion of those reading this
article will volunteer in some way or another – if you don’t – give it
a go, it is likely to improve your status in society, make you more
employable to interview panels and provide you with an excellent
avenue to look down when work gets stressful. It also gives you that
warm fuzzy glow. Volunteering in swimming could take the form of
teaching or coaching swimming, or doing technical duties like I do.
In particular, medics are required in the classification process of
disability swimmers, in addition to staffing high profile events.
To get further information about volunteering in swimming or disability
swimming contact the swimming administrator, Jane Davies at jane.
davies@swimming.org or check out the website: www.swimming.org.
And don’t forget to look out for me poolside!
Dr Robin Butterfield
CT2 Anaesthetics, Northern Deanery
Dr Ian Whitehead
Consultant Anaesthetist, Northern Deanery
10 Anaesthesia News July 2012 • Issue 300
Anaesthesia News July 2012 • Issue 300 11

1. Apollo and Daphne; Antakya Museum, Turkey
Humans are the world’s best runners in the heat,
able to outpace other animals over distance. Other
mammals may be able to sprint away from us,
but they will eventually overheat and have to rest.
By having an upright stance, and having a neck
that rotates and enables us to keep our prey in
sight as our shoulders sway, we can keep jogging
after our prey, and eventually simply walk up and
spear them when they are obliged to stop through
exhaustion. Long distance running, and hence
our ability to perform this persistence hunting has
played a key role in the evolution of our species. 1
A quick jog through
the history of running
With its premier position as the last event of the Olympics, and its
perceived link with ancient Greece, the (men’s) marathon will be one
of the leading events in the forthcoming London 2012 games. The 80
entrants will follow a telegenic route of 42.195km in central London.
While not limiting the discussion exclusively to marathons, this article
will discuss how this distance arose and several other aspects of
the development of distance running. This may be of background
interest to the considerable number of anaesthetists who assist with
the medical services at distance running events.
It is often thought that athletics started in Greece some two and
a half thousand years ago. This is not entirely true, as in ancient
Mesopotamia and Egypt the royal courts were entertained by
athletes and gymnasts. Even well before then competitive sports
such as boxing and running took place. However, athletics as both
a participatory and spectator activity at large scale events for the
general public probably started in Greece. ‘Of all the cultural legacies
left by the ancient Greeks, the three which have had the most obvious
impact on modern Western life are athletics, democracy and drama’. 2
The first Greek games were probably held sometime in the 8th
century BC at Olympia (not Mount Olympus). Games were held at
Olympia every four years (an Olympiad). Later, games were held at
Delphi (586BC), Isthmia near Corinth (580BC) and Nemea (573BC).
At Nemea one of the earliest known locker rooms was found. The
ancient Greeks spread their games as their influence extended,
perhaps in much the same way as cricket spread through the
expanding British Empire, centuries later. It’s well known that the
first prize was usually a wreath made from a laurel tree. Was that
all the winners received, and why laurel The various myths are
somewhat contradictory, but, in brief, Apollo the son of Zeus was hit
by a golden love-arrow shot by Eros; following this he fell in love with
Daphne, a gorgeous wood nymph, the daughter of a river god. When
Apollo chased her she ran away, calling for help despite Apollo’s
protestations that he loved her and meant no harm. Eros interfered
again, slowing Daphne down so that Apollo could catch her up.
Hearing her cries, her father rescued Daphne by the rather peculiar
tactic of changing her into a laurel tree. So, when Apollo grabbed her
he only grasped handfuls of laurel rather than a fair maiden. Despite
what must have been a rather frustrating moment for him, the laurel
tree became Apollo’s favourite and he made it evergreen (Figure 1).
The Delphic (or Pythian) games were held in honour of Apollo, and
hence the laurel became a symbol of victory. Medicine and healing
are also associated with Apollo through his son Asclepius, whose
rod, a snake-entwined staff, remains a medical symbol today.
Apollo was a god of many assorted things including poetry and
music, and prize-winners in these fields were given laurel wreaths as
well as athletes. However the wreath was not the only prize; winners
brought status and prestige to their city-states (Greece was not then
a unified country). A successful male athlete became a celebrity and
could expect to be given a home, a tax-free income and have a high
standard of living- not unlike today’s top sportsmen.
In ancient Greece the competitive running
distance was a stade, thus the derivation of
our modern word stadium. It’s often taken
as about 192m, but in fact was somewhat
variable. The dolichos was the long race 3 ,
typically 7-24 stadia. The race at Olympia was
one of the longest at 24 stadia; Acanthus of
Sparta won the first one held in 720BC. Much of
our knowledge comes from illustrations on vases
such as the one seen in Figure 2, along with
ancient texts and archaeological excavations.
Greek 10€ coin showing
dolichos runners in the
background, relay runners
in the foreground
At that time there were no long races, nothing remotely approaching
a modern half or full marathon. Long distance running was not for
athletes, but for the professional messengers such as Pheidippides.
The story of Pheidippides is much clouded by the mists of time.
However he or another messenger probably did run to Sparta,
about 250km from Athens, arriving the day after leaving, to ask for
help when the Persians invaded and immediately running back to
Athens with the negative reply. (Modern day spartathlons, 246km,
2. Greek Vase ca 530 BC
are based on this feat, with the modern-day record time for the run on
the original route standing at 20:25. 35yr old Emily Gelder of Dulwich
won the women’s spartathlon in 2010. Its fair to say that Spartathlons
have not really caught the wider public’s imagination and are hardly
mass participation events. Once the Persians had been decisively
defeated at the battle of Marathon, Pheidippides had to run from the
plain of Marathon back to Athens to announce victory, a distance of
about 40km, in the summer heat. 4 On arrival in Athens he is said to
have shouted “Nike!” – not an advertising slogan for running shoes,
but “Victory!” This story is probably mythical but marathon runs
have indeed caught on in recent years, despite the fatal ending of
Pheidippides’ run - at least according to the Robert Browning poem.
“Unforeseeing one! Yes, he fought on the
Marathon day: So, when Persia was dust, all cried
‘To Akropolis! Run, Pheidippides, one race more!
the meed is thy due! “Athens is saved, thank Pan,”
go shout!’ He flung down his shield, Ran like fire
once more: and the space ‘twixt the Fennel-field
And Athens was stubble again, a field which a
fire runs through, Till in he broke: ‘Rejoice, we
conquer!’ Like wine thro’ clay, Joy in his blood
bursting his heart, he died – the bliss!”
Robert Browning “Pheidippides”, 1879 (penultimate verse)
The Greek games were an integral part of their society, and nothing
was allowed to interfere, not even war – rival cities’ armies would lay
down their arms in a sacred truce while the games were on. Even
when the Persians were attempting their 480BC invasion of Athens,
the games at Olympia went ahead.
Women had their own games; the Hera games, which started in the
6th century BC. They were not allowed to even watch the
male games, possibly because the Spartan tradition of
male competition in the nude had been adopted. The
official penalty for a woman found spectating male
athletics was to be thrown off a cliff. Women competitors
in the Hera games were not naked, but wore a short
tunic, often with one breast bared to confirm their
gender – male athletes attempting to compete, as
females were not unknown. Other activities that
we may consider cheating included taking herbs
containing performance-enhancing drugs. Like
modern athletes, they were not above switching allegiance – Astylus
of Crotona won three Olympic victories but switched nationality from
Crotona to Syracuse, presumably for financial reasons.
The early Greek stadia were long and narrow in the shape of
a horseshoe (Figure 3), often cut into the side of a hill to give
spectators good visibility in tiered seating. The ancient Greeks also
built hippodromes, wide enough for four-horse chariot races. Later
the Romans also built two types of stadia: the circus was long and
narrow and designed for chariots, whilst the amphitheatre was round
or oval and completely enclosed, the forerunner of a modern stadium.
Amphitheatres were variable in dimension, which did not really matter
as they were designed for gladiatorial combat- the Colosseum in
Rome being the best known. It was here that Marcus Aurelius, the
‘philosopher emperor’ who according to the historian Herodian had
a ‘blameless character and temperate way of life’, made history by
appointing a sporting event medical director around the year 200AD.
Claudius Galen (figure 4) was a Greek physician who became Marcus
Aurelius’ personal doctor. He thought that disease was caused by an
imbalance of black bile, yellow bile, blood and phlegm. While that
theory may not impress modern-day FRCA examiners, he did at least
attempt to study medicine systematically, and showed for example that
arteries carried blood, not air. Medical students studied his writings
for well over a thousand years. Galen was put in charge of medical
facilities in the Colosseum mainly treating wounded gladiators. Galen
also studied sports, observing, for example, that a horse could run a
dolichos better than a man - a dolichos not being sufficient distance
for man’s endurance running superiority to show.
3. Panathinaikon Stadium
Following the Roman invasion of Greece the Greek games declined,
and running as a sporting activity declined. Activities based on war
became predominant, such as archery or chariot racing. In other
cultures, while festivals involving physical activity are certainly
recorded, for example the 2000-year history of Dragon Boat festivals
in China, running as such is not widely recorded for many hundreds
of years. In England, John Dover’s Cotswold Games started in the
very early 1600s, and continued for two and a half centuries, and
the Kentish Games started in 1638 with prizes recorded for men
and women runners. In the 18th century in Britain many towns and
villages would have had an annual fair with short races, competed
for by both men and women, often with more women competitors
than men 5 . However distance races were far more commonly a male
preserve. Many of these were run for wagers, mostly solo, or with
just two competitors. The runner would take wagers that he could
run from one spot (e.g. a church steeple in a town centre) to another
similar spot, often in another town. This gives rise to three difficulties to
us in assessing these runs. Firstly in knowing the precise route taken,
meaning the exact distance is not known. Secondly, towns would
12 Anaesthesia News July 2012 • Issue 300 Anaesthesia News July 2012 • Issue 300 13

4. Claudius Galen
The first named sporting
event medical director
often each have their own time – midday in one was not the same as
midday in the other. It was not until the coming of the railways that it
was necessary for towns to keep the same time. Finally, records of
the exact times of the runs were often not kept; all that was necessary
was to record whether the runner beat the challenge, or not.
Running was an activity undertaken by all social classes from the
poorest up to the Duke of York. There were no supervisory athletics
bodies to impose rules, and of course no health and safety
bureaucracy. Deaths did occur, but the sensible view was that of a
chapter author who stated that there was nothing better than exercise
“if appropriately used, for the preservation of the body: nothing so
bad if it be unreasonable, violent, or overmuch”. 6 Any rules were laid
down simply as part of the wager. Some were sensible, so that if a
younger runner challenged an older person, the younger might have
to carry a weight as handicap. Some were silly, for example in the
1760’s one man won a wager by running seven miles in 45 minutes
carrying half a hundredweight (25.4kg) of fish on his head.
Due to the limitations of timing described earlier, some of the run
times should be taken with a pinch of salt. However there is no doubt
that some runners were very good. Just as Timex or Omega may
keep time in today’s runs, so specialist watchmakers like Brambles of
London would have kept time with especially accurate watches then,
so it is possible to know that a runner called Pinwire ran 12 miles in a
time of 64”5’ in 1739, a respectable time.
It is often thought that large events watched by sizeable crowds are a
recent phenomenon in this country. Not so. Starting in the early 19th
century, crowds watching events grew larger and larger. For the first
time doctors and physicians were regularly in attendance. Sudden
deaths were recorded, sometimes in young runners, quite possibly
due to long QT syndrome or HCM. Newspapers regularly warned
against the risks of over-exertion. For some, the financial rewards
were enormous. Captain Barclay ran one mile every hour for 1000
hours in 1809, watched by many thousands of people. He gained
£16,000, a vast fortune, 320 times the national average income of the
time, and would be the equivalent of over £50 million today 7 . This is
quite possibly the greatest running prize ever.
However, by the mid-19th century, distance running declined as an
activity undertaken by all social classes. Sport became more of a
middle and upper class activity, undertaken by public school boys,
and those educated on the playing fields of Eton certainly did not
participate in sport alongside millworkers and miners. For distance
runners, like other sportsmen, professionalism was abhorred, just as
amateurism was praised, and those who might have to earn a living
by their distance running were excluded from the sport. In a sense
this was a return to the Greek ways when Pheidippides and his like
were professional runners, not sportsmen, and were not eligible to
take part in Greek games. In the late 1800s Baron Pierre de Coubertin
and a group of colleagues set about establishing a modern version
of the ancient Greek games. Based on the Greek timescale of one
every Olympiad (4 years), the Olympic games were held in 1896 in
Athens. Michel Breal, one of de Coubertin’s colleagues suggested
that a long distance race be held to commemorate Pheidippides’ run,
commemorated in the then recently published poem by Browning.
The race was supposed to be the same distance as Pheidippides had
run. It was won by Spiridon Louis, a Greek farm boy, in 2:58:50. He
won a silver medal as there were no gold medals awarded at the early
Olympics. The annual Boston marathon started the year afterwards in
1897, and is often regarded as the world’s premier marathon.
The early Olympic marathons were not without their trials and
tribulations. Up to three Greeks had died in the trials for the original
1896 marathon. Spiridon Belokas came in third in the 1896 marathon,
but was subsequently found to have covered part of the course in
a carriage. At the St Louis Olympics in 1904 Thomas Hicks won the
title. Hicks however had tired in the race, but had been given 1/60
grain (about 1mg) of the alkaloid strychnine by his trainer, along with
brandy and egg white. He continued, but later lay down on the course
as he was again tired. He was given more strychnine, brandy and
eggs, and was able to resume running. Despite his valiant efforts,
Hicks was then passed by Fred Lorz who went on to cross the finish
line first. Lorz had also become exhausted after about 14km. Rather
than strychnine, his trainer gave him a lift in his car for the next 17km,
getting out- refreshed and in time- to pass Hicks. However Lorz had
been seen by spectators, and was stripped of his title, and banned
for life. The lifetime ban did not last long, even less than modern
“lifetime” bans, and he was reinstated after apologising and went on
to win the 1905 Boston Marathon the following year.
The early Olympic marathons were simply that, a marathon, or long
race, with no fixed distance. At the London Olympics in 1908 the
organisers fixed the distance at 26miles, from Windsor Castle to
the entrance of the White City Stadium. However Queen Alexandra
wanted the finish by the royal box, so a partial circuit inside the stadium
was added, making the distance 26miles 385 yards (42.195km). The
race distance varied in subsequent Olympics, until 1921 when it was
decided to standardise to that of the 1904 event – why 42.195km was
picked rather than a simple distance is not clear.
That women were “quite unsuitable” to run in distance races was
obvious to everyone, particularly de Coubertin. Indeed women were
barred from all track and field events until 1928. It is not clear whether
de Coubertin thought that athletics was dangerous to women, or
whether their presence would be dangerously distracting to male
competitors. However a Greek woman who called herself Melpomene
after a muse, had run unofficially in the original 1894 marathon, simply
joining in and trailing the men, passing several who had dropped
out with exhaustion. She finished about 90mins after Spiridon Louis,
but was barred from the now empty stadium, running her final lap
around the outside of the building. Another woman, Stamata Revithi,
(actually thought by some to be the same person as Melpomene),
ran the course the day after. In 1967 Kathrine Switzer entered the
Boston Marathon under an assumed name. When this deceit was
discovered 2 miles into the run, the race director and another official
tried to block her and tear off her number but, after a fracas, was
prevented from doing so by other runners. 8 It was not until 1980 that
the American College of Sports Medicine announced “there exists
no conclusive medical evidence that long distance running is contraindicated
for the healthy trained female athlete”. The first Olympic
Marathon for women was held at the 1984 Los Angeles games.
In the 1980’s, jogging as an activity slowly gained in popularity, though
Brendan Foster recalls it was still common for runners to be jeered
at in the street, certainly in North-eastern England. Foster saw mass
participation runs In New Zealand while training for the 1976 Montreal
Olympics, where he won bronze in the 10,000m - the sole British track
and field medal winner in the whole competition. He and a group of
friends decided to hold a small road race based in Newcastle and so
the Great North Run, a half marathon, was born in 1981 - incidentally
the same year the London Marathon was born. The number of runners
in the GNR has gone on to expand year on year, with the exception
of the run following the events of 11 September 2009. The entry is
capped at 55,500 by the medical committee, mainly due to worries
about ambulance transport capacity and ease of movement on the
crowded course. Like all major sporting events, the run’s timing is
determined by television. The run depends on commercial sponsorship
for its financial viability, and sponsors want their posters etc shown
on the television. In addition, except perhaps to keen runners, simply
watching a distance run on the TV could be somewhat boring at times.
Thus the race is split into what are in effect four separate races, the
wheelchair, the elite women, the elite men, and finally the main pack,
along with assorted celebrities, allowing the TV to switch between the
various races. The Great North Run and the London Marathon remain
the UK’s two largest participatory distance runs.
What does the future hold for distance running
Will human runners continue to get faster and faster This is difficult
to predict. Horses can be bred specifically for running, yet the winning
times for both the UK Epsom Derby and the US Kentucky Derby have
remained static for decades, so it does seem as if a plateau has been
reached. Whether humans have reached a plateau remains to be
seen. In the last 30 years women have made greater improvements in
their GNR times than men, possibly reflecting a poorer standard at the
race’s inception.
Despite the popularity of mass participation events, the population
as a whole grows progressively more obese, with the UK being the
European leader in fatness. The least fat European countries are
Austria, Italy, Norway and Switzerland, none of which have large,
famous mass participation events. The world’s fattest country, the
USA is also home to two of the most prestigious marathons, Boston
and New York. It seems that the presence of big running events on
their own do little for obesity at large, and encouragement of daily
exercise by investment in public transport, cycle paths etc along with
a more general change of attitude is needed. Although the winning
times in the GNR continue to improve, the times of the ‘average runner’
are relatively unchanged, or worsening in the case of male runners.
The population as a whole does not appear to be getting fitter, with
other factors outweighing any beneficial effects of increasing public
participation in distance running.
1896 Olympic marathon
What about medical aspects
The last decade or so has seen the increasing appreciation of overhydration
and concomitant hyponatraemia as a medical problem. Our
early ancestors in the heat of the African savannah could hunt down
antelope without a drinks station every mile, so early drinking advice
for runners has been toned down. There is also occasional pressure
for medical check ups to become compulsory before any event for
runners. This would require a long and detailed discussion, but I am
not convinced of the benefit, and feel that any barriers put in the way
of entry may deter unfit individuals from embarking on training that
could be of enormous benefit to them. School age ECG checks, as
advocated by the charity CRY are more persuasive to me.
The recent press and public reaction to the sad death of a female
competitor in London is a reminder that the spotlight will always be
on major public running events, and medical cover has to be of the
highest standard. It’s not good enough just to do our best; we must
be as good as the best. Certainly in the GNR I have been fortunate
that the presence of many anaesthetists at the event has helped us to
keep it that way.
Chris Vallis
Consultant Anaesthetist, Royal Victoria Infirmary, Newcastle upon Tyne
Medical Director, Great North Run.
References
1. Lieberman DE, Bramble DM, Raichlen Da, Shea JJ (2009) Brains, brawn and the
evolution of human endurance running capabilities. In The First Humans: Origin
and Early Evolution of the Genus Homo. Grine FE, Fleagle JG, Leakey RE (eds)
New York: Springer
2. Hall, Edith (2002) in the Cambridge Illustrated History of Ancient Greece,
Cartledge, P (ed), Cambridge University Press
3. Miller, SG (2004) Ancient Greek Athletics: the events at Olympia, Delphi, Nemea
and Isthmia. Yale University Press
4. Grogan, r (1981) Run, Pheidippides, Run! The Story of the Battle of Marathon.
Brit.J.Sports.Med 15, No 3, 186-189
5. Radford, P (2000) Endurance runners in Britain before the 20th century. In
Marathon Medicine (ed Tunstall Pedoe, D) London: Royal Society of Medicine
6. Burton, Robert (1638) Oxford: Henry Cripps, quoted in Radford.
7. www.measuringworth.com/ukcompare (accessed 03/05/12)
8. Switzer, K (2009) Marathon Woman, Running the race to Revolutionize Women’s
Sports. Da Capo Press.
14 Anaesthesia News July 2012 • Issue 300 Anaesthesia News July 2012 • Issue 300 15

PERFORMANCE
ENHANCEMENT
- CITIUS, ALTIUS, FORTIUS* AT ALL COST
In any competitive setting, human beings will attempt to gain an advantage over
their opponents in order to win. This is particularly true in the sporting arena, and
once an athlete has achieved their peak performance through dedication, training
and perseverance, the lure provided by illegitimate methods of performance
enhancement proves too great for some. The Olympic motto - “faster, higher,
stronger”* - has been too keenly observed by these athletes and in the process
the essence of sportsmanship, “playing true”, has been lost. With this summer’s
Olympic games already underway, this article provides an overview of how the
international community has banded together to preserve the true “spirit of sport”
and “Olympism” as a celebration of the human spirit, body and mind.
The History of Doping
Despite the perception that doping is a modern phenomenon, there are
many examples of substance use dating back to ancient times. Roman
gladiators were known to imbibe unspecified stimulants derived from
plants to combat fatigue and injury, for example fly agaric (Amanita
muscaria), Cola nitida and cocoa leaves. Diet was recognised as a
factor too and it is well documented that dried figs were used to
invigorate the performance of Charmis, the Spartan winner of the stade
race (about 183m) at the Olympic games of 668BC.
As modern pharmacology and medicine developed in the latter half
of the 19th century, the number and type of performance enhancing
agents escalated. Stimulants were used to improve muscular work
capacity and the anabolic effects of substances later classified as
hormones began to be recognised. As there were no rules prohibiting
this, athletes did not try to conceal their use of these compounds and
as such good records of doping exist for this time. Trainers had their
preferred doping cocktails: mixtures of brandy and stimulants such as
cocaine, strychnine and caffeine. In 1886, during the 600km cycle race
between Paris and Bordeaux, these cocktails were first seen to have
lethal consequences with the death of a competitor.
Around the same time, Charles Édouard Brown-Sequard reported
to the Society of Biology in Paris in 1891 that he had experienced
significant restoration of strength following a 3 week programme of
self-injection of “first the blood of testicular veins; secondly the semen;
and thirdly juice from a testicle...of a dog or guinea pig.” The effects
were temporary and one month after the last injection he “experienced
almost a complete return of the state of weakness”. These findings
were most likely the result of a placebo effect, but the idea of hormone
replacement was duly conceived. The potential of this research was
unsurprisingly considered for athletic performance, and it is alleged that
as early as 1936 the German Olympic team at the Berlin games was
taking testicular extracts. Twentieth century doping was characterised
by scientist’s new understanding of the pharmacology of specific
compounds and their ability to synthesise them. There are early reports
of testosterone being trialled in racehorses, and the observation of a
markedly positive effect on performance and muscle bulk led to its first
use in sport by bodybuilders. This was followed in the late 1930s by
increasing use of amphetamines, first among servicemen fighting in
World War II then among college students and athletes. The use of
stimulants became particularly prevalent in cycling in the 1960s and
70s. The first televised doping fatality occurred during the 1967 Tour de
France, when the English cyclist Tom Simpson died with high circulating
levels of methamphetamine. Around this time doping practices
moved up a gear, and suspicions abounded of state sponsored
doping in athletes from several countries. Confirmation of this came
with the collapse of the Berlin wall, when reports emerged from the
former German Democratic Republic that PhD programmes had been
established to develop the ideal regimens for the enhancement of
athletic performance.
The Anti-Doping Movement: The World Anti-Doping Agency (WADA)
Prior to the end of World War I, the use of performance enhancing
substances was neither prohibited nor discouraged, as it was not
considered to be cheating. The International Amateur Athletics
Federation (IAAF) was the first international sports body to ban the use
of stimulants formally in 1928, but the anti-doping cause was hampered
by a lack of effective tests with which to police the substance bans.
The controversy surrounding the death of Danish cyclist Knud Enemark
Jensen at the Rome Olympic Games in 1960, following amphetamine
consumption, provided further impetus to sporting authorities of the
time. In 1967 the International Olympic Committee (IOC) established
its Medical Commission and voted to adopt a drug-testing policy for
banned substances; these tests were first introduced at the Olympic
games held the following year. Despite the leadership shown by the
IOC in this area, other organisations were slow to follow; for example
the US National Football League only introduced anti-doping testing
as recently as 1982. The major breakthrough came in 1974 with the
development of a reliable urinary test for anabolic steroids; a marked
increase in drug disqualifications followed, particularly in strength
related sports like throwing and weightlifting. When combined with outof-competition
testing, this surveillance provided a major disincentive
for athletes to use banned substances. It was recognised at the World
Conference on Doping held in Lausanne in 1999, following the high
profile Tour de France doping scandal of 1998, that an independent
international agency was required with powers to set in place unified antidoping
standards and to coordinate the support needed from sporting
organisations and public authorities to administrate the process. Out
of this was born the World Anti-Doping Agency; the development of
the WADA Code and their list of Prohibited Substances and Methods
are credited as the most important achievements in the fight to ensure
athletes play true.
Athlete regulation
The World Anti-Doping Agency Code is a document that provides
the framework of anti-doping rules, regulations and policies for all
stakeholders. It works in conjunction with five International Standards
to bring harmonisation across the anti-doping community with respect
to testing, laboratories, Therapeutic Use Exemptions (TUEs), the list
of Prohibited Substances and Methods, and the protection of privacy
and personal information. Since its adoption in 2004, the Code has
proved a powerful and effective tool for the anti-doping movement
and has received overwhelming support from governments and sports
institutions worldwide. Doping is defined as the occurrence of one or
more violation/s across the 8 categories specified by the code. The
Code has also brought about the concept of “non-analytical violations”
meaning that a sanction can be applied where there is evidence of an
anti-doping violation but where there is no positive doping control test.
Athlete testing takes place both “in-competition” and “out-ofcompetition”.
Blood and urine specimens are collected using a strict
protocol to prevent mis-identification, tampering or contamination. “Incompetition”
refers to the period beginning 12-hours prior to the official
start of an event and ends with the event or on completion of the sample
collection processes associated with the event.
“Out-of-competition” testing facilitates athletes being screened at
almost any time and in any place. In this regard, the registered testing
pool of athletes (usually the top international and national competitors
in each sport) are required to provide “whereabouts” information to
their country’s anti-doping organisation via ADAMS (the Anti-Doping
Administration and Management System). This involves the specification
of their exact location during a 1-hour time slot each day. Any 3 occasions
of failure to provide “whereabouts” details or missed tests entail a
violation sanctionable with a 1-2 year ban- as occurred to Rio Ferdinand
in 2003 and for which he received an 8 month sanction. Experience has
shown that out-of-competition testing is a crucial element in the fight
against doping as a number of prohibited substances and methods are
detectable only for a limited period of time in an athlete’s body despite
providing a longer-term performance enhancing effect. “The only way to
perform such testing is by knowing where athletes are, and the only way
to make it efficient is to be able to test athletes at times at which cheaters
may be most likely to use prohibited substances and methods” 4 .
The Athletes Biological Passport is a recent development, first
implemented in 2009 in response to blood doping concerns at the
Winter Olympics of 2006. It is now recognised that the monitoring of
selected biological variables may indirectly reveal the effects of doping
as opposed to the traditional one-off direct, essentially toxicology, tests.
At present, biological monitoring is focused on blood counts and red
cell indices but the next phase will include the introduction of hormonal
profiling. Biological monitoring throughout an athlete’s sporting career
should make any prohibited preparation far harder to administer and
act as an added deterrent. In May this year a landmark event in WADA’s
crusade against performance enhancement took place with the 4-year
sanction of Portuguese long distance runner Helder Ornelas on evidence
obtained solely from his Athlete’s Biological Passport.
Prohibited substances
The WADA List of Prohibited Substances is updated annually with
the 2012 version being a 9-page document. The main categories of
performance enhancing drugs and methods are given in the table, but for
an exhaustive list readers are referred to the WADA website. WADA has
recently established a Monitoring Programme of substances which are
not on the Prohibited List at present, but which WADA wishes to monitor
in order to detect patterns of misuse in sport. Nicotine, B2 adrenergic
receptor agonists and the out-of-competition use of glucocorticoids
are all examples of substances included in the Monitoring Programme
this year. Samples for testing are collected in the same way as for
prohibited substances and the anonymised aggregate analysis is made
publicly available by sport. Caffeine has recently been removed from the
Prohibited List too. “Expert consensus holds that caffeine is ubiquitous
in beverages and food and that reducing the threshold might therefore
create the risk of sanctioning athletes for social or diet consumption of
caffeine. In addition, caffeine is metabolised at very different rates in
individuals” 5 . The 2010 and 2011 Monitoring Programs did not reveal
global specific patterns of misuse of caffeine in sport, though a significant
increase in consumption in the athletic population was observed.
Therapeutic Use Exemptions (TUEs)
“Athletes, like all others, may have illnesses or conditions that require
them to take particular medications. If the medication an athlete is
required to take to treat an illness or condition happens to fall under the
Prohibited List, a TUE may give that athlete the authorisation to take the
needed medicine” 6 . The criteria for granting a TUE are:
• The athlete would experience significant health problems without
taking the prohibited substance or method
• The therapeutic use of the substance would not produce significant
enhancement of performance, and
• There is no reasonable therapeutic alternative to the use of the
otherwise prohibited substance or method.
International level athletes are required to submit TUE applications to
the International Federation of their specific sport whilst national level
athletes make applications to their National Anti-Doping Organisation. If
the TUE is denied a process of appeal through WADA can be initiated.
TUEs are granted for a specific medication with a defined dose and for
a specific period of time, and may contain conditions that should be
adhered to. Athletes legitimately using drugs on the Prohibited List by
means of a TUE must declare the drug and the TUE when undergoing
routine doping control procedures. If the TUE is valid at the time of a
“positive” test and the drug levels are consistent with therapeutic use, a
negative test result will be recorded.
16 Anaesthesia News July 2012 • Issue 300 Anaesthesia News July 2012 • Issue 300 17

The winning distance in the women’s Olympic shot put - since the introduction of effective testing in the 1980’s the winning
distance has fallen such that the winner in Beijing (2008) would not have made the final in Moscow (1980). 3
Penalties for Doping
The WADA code discusses in detail the types of doping violations
and their associated penalties, but the responsible body for the
administration and enforcement of this is the individual National Anti-
Doping Organisation’s. Ineligibility sanctions range from 1 year to lifetime
bans and the penalties handed down by doping authorities depend on
many factors, for example, first versus second time offences and missed
tests versus trafficking activities. This remains an area of controversy
in the international anti-doping community as the lack of hard and fast
rules introduces a degree of inconsistency; the penalties handed down
in different countries and different sports for the same violation can vary
greatly. It is felt that this “loophole” allows some organisations to take a
“soft approach” to performance enhancement.
On home soil, Dwain Chambers, the British sprinter banned from
competition for 2 years in 2003 for using tetrahyrdrogestrinone, has
recently won his appeal against the British Olympic Association and will
now be eligible to compete in this month’s games here in London if he
qualifies for Team GB. The BOA bylaw in contention held that any athlete
receiving a sanction of 6 months or more on doping violations would
not be eligible to represent Great Britain at Olympic events at any time
in their future career. The Court of Arbitration in Sport has upheld the
appeal by ruling in support of WADA’s stance that this policy amounts
to an additional sanction on the athlete, which is in breach of its global
code of which the BOA is a signatory. The WADA code is under review
at present, amendments will come into effect in 2013, and the BOA is
now likely to concentrate its efforts on their proposal to WADA that first
offences should carry a mandatory 4-year ban as well as missing one
Olympic Games, in the wake of this decision.
Substances in use
Androgenic Anabolic steroids (AAS)
The impact of anabolic steroid use came to the public’s attention with the
disqualification of Ben Johnson, after winning gold in the men’s 100-metre
sprint in Seoul in 1988, when stanazolol was detected in his urine. Clinical
trials confirm that AAS increase muscle strength and mass through a
number of mechanisms that are dose dependant, and that these effects
are additive to resistance training alone. Athletes are known to have used
doses up to 30-times higher than the physiological replacement dose
of these hormones. AAS have a wide range of serious adverse effects
including virilisation and reduced fertility, hepatotoxicity and increased
risk of hepatocellular carcinoma, dyslipidaemia and increased risk of
myocardial infarction, depression, mania and aggression.
Erythropoietin (EPO) and Blood Transfusion
Thought to have started in the 1970’s, blood doping is a method still
utilised by elite athletes and has resulted in high profile bans recently.
Training at high altitude can induce endogenous EPO production in the
renal tubules, promoting an increase in the total red cell volume, which
increases oxygen delivery to the muscles, in turn improving performance
particularly in endurance sports. Only about 50% of competitive athletes
respond to altitude training and it is notable that non-responders do not
improve their aerobic capacity. Recombinant EPO and its analogues, or
homologous and autologous blood transfusion, are alternative methods
used by athletes to expand their erythrocyte volume. The chief risk
associated with this practice is thrombosis, but the risk of infections
associated with blood transfusion is of particular concern when this
occurs in an unregulated fashion.
Growth Hormone (GH)
GH is a naturally occurring peptide hormone produced by the anterior
pituitary gland. “The Underground Steroid Handbook” written by Dan
Duchaine in 1982 advocated its use for performance enhancement at least
a decade before endocrinologists began prescribing it for therapeutic
replacement. The startling results achieved with replacement of GH in
deficient individuals have not been reproduced to the same extent in
trials using healthy adults, but increased skeletal muscle mass leading
to increased strength and power output have been observed, as well
as increases in the bioavailability of glucose and fatty acids. The effects
are short-lived, disappearing within weeks of the cessation of GH use,
and are not necessarily matched by an increase in other performance
indices such as the maximal uptake of oxygen (VO 2
max). However, these
clinical studies may not be suited to assess the effects of GH in individual
athletes who often use higher doses than those used in the trials and who
often combine GH with other performance enhancing drugs. The specific
test utilised by WADA for GH has a limited detection window of 24 hours,
which ensures this remains a concern for doping organisations. Indeed,
a recent investigation into Major League Baseball by a US senator found
a high level of GH use among players for performance enhancement
and to speed recovery from injury. The side effects of GH use include
fluid retention leading to hypertension and headaches, diabetes and a
cardiomyopathy. Anecdotally, some athletes use doses much higher than
those required for therapeutic replacement, and it is reasonable to predict
that they may develop features of acromegaly over time. Pharmaceutically
available GH is all produced using recombinant technology, but some of
the GH available to athletes on the black market is still pituitary-derived
which introduces the risk of prion disease to illicit users.
Insulin Like Growth Factor-1 (IGF-1) and Insulin
As the tests for detecting GH abuse develop there are anecdotal reports
that athletes, for example weightlifters, are increasingly turning to insulin
and IGF-1 as alternative performance enhancing agents. The two
substances have broadly similar actions in their anabolic effects and their
action on glucose metabolism, both of which might have abuse potential.
Adverse effects are principally hypoglycaemia and weight gain, but this
may be less problematic in an individual whose diet and training regimen
are closely monitored. After concerns were raised by the Russian medical
officer at the Nagano Olympic Games, the IOC immediately banned the
use of insulin in individuals without diabetes. WADA has subsequently
endorsed this and people with diabetes requiring insulin treatment must
obtain a TUE, however this might prove a difficult area to police.
The true prevalence of doping today is unknown due to the secrecy around
it; but the advent of professional sport and the huge financial rewards that
go with being the best, coupled with an ever increasing pharmacopoeia
and the athlete’s innate drive to win may all act to encourage continued
use of these methods. This damages the reputation of sport and may
harm the health of the athletes. Stringent efforts are therefore needed to
allow athletes around the world to “play true”.
Kate O’Connor
ST6, Bristol School of Anaesthesia
Professor Richard I.G. Holt
Human Development and Health Academic Unit,
University of Southampton
References
1. The official website of the World Anti-Doping Agency: www.wada-ama.org
2. The official website of UK Anti-Doping: www.ukad.org.uk
3. Holt, R.I.G. Diabetes and Doping. Chapter 8, 167-192. In Gallen, I. Type 1
Diabetes. Clinical Management of the Athlete. (1st Ed, 2012) Springer.
4. www.wada-ama.org/en/Anti-Doping-Community/Athletes-/QA-on-
Whereabouts/
5. www.wada-ama.org/en/Science-Medicine/Prohibited-List/QA-on-2012-
Prohibited-List/
6. www.wada-ama.org/en/Anti-Doping-Community/Athletes-/QA-on-TUEs/
Anaesthesia News July 2012 • Issue 300 19

Consent in 2012
The NHS spends more than £55million per year on translation services 1 . With the
Olympic Games upon us and the influx of foreign visitors they will bring, we may find
ourselves treating more patients than usual who speak little or no English this summer.
Across a language barrier, explaining our intentions and taking informed consent
can be problematic, to say the least. This article discusses consent and how these
problems might be addressed.
Consent
“…the only difference between a surgeon
and a mugger with a knife is the consent
of the patient.” 2
It is necessary for a doctor to gain the permission of any
patient who has capacity before proceeding with examination,
investigation or treatment. This permission or ‘consent’ is often
thought of as a relatively modern idea but, in fact, Plato discussed
the concept in his work ‘The Laws’. He approved of doctors
seeking co-operation from their patients before embarking on
treatment, believing that a therapeutic relationship was more
likely to yield good health than a coercive one.
There are documented examples of rudimentary consent
processes as far back as 578 AD when Justin II, the emperor of
Byzantium, handed the scalpel to his surgeon as a symbol of his
agreement to undergo surgery 3 .
Permission or consent can either be expressed or implied and
may be given, or withheld, by any adult with capacity.
Capacity
‘Capacity’ describes the ability to understand and retain the
necessary information, to weigh it in the balance and appreciate
its implications; and to use these facts to make an informed
decision about future action. Unfortunately, there is no standard
test of capacity and the judgement as to whether a patient is
competent remains subjective. Perhaps, the simplest approach
was defined by Justice Thorpe in Re C; here, LJ Thorpe deemed
a patient to have capacity if:
1. S/he can take in and retain the pertinent information
2. S/he believes the information to be true
3. S/he can weigh up this information and make a decision 4
Under the Mental Capacity Act (MCA) 2005, people over the
age of 16 have capacity unless proven otherwise, and all people
in possession of capacity must first give their consent before
investigation and treatment can begin, no matter how minor it
may be. Capacity is decision specific, so whilst a patient may
be able to make informed choices about certain matters, for
example, whether to allow their blood to be taken, they may be
incompetent to make others, such as whether the benefits of an
operation will outweigh its risks.
Gaining consent from our patients is about much more than
simply protecting ourselves from future litigation; when we take
informed consent we respect the patient’s autonomy and right
to self-determination. If a doctor neglects to gain appropriate
consent before embarking on an investigation or treatment, they
may be found guilty of battery or negligence.
What does consent permit
The patient’s consent allows us to proceed to touch them without
fear of being sued in battery; ‘consent makes the touching lawful
and is a requirement imposed by law, not by the practices of the
profession’5. Any doctor who touches a patient without their
consent may be sued in battery. ‘The fact that the treatment
may be safe and effective and given with the best interests of the
patient in mind is irrelevant to the question of whether the patient
consented.’ 5 The tort of battery does not require an injury to be
sustained, only that intentional, non-consensual contact between
the doctor and the patient has occurred.
20 Anaesthesia News July 2012 • Issue 300
Battery or negligence
In an emergency, we can safely rely on the defence of ‘necessity’,
when it is permissible to treat patients rendered incompetent, for
whatever reason, in their best interests without consent.
A competent patient, however, may sue in negligence if the
information he received, and upon which he based his decision to
give consent, was flawed or deficient in some way. The onus is on the
patient to prove that he would not have agreed to treatment had he
known its true risks. If no consent was given at all to treatment, the
correct recourse is to battery.
This is an important distinction because the doctor who is found guilty
of battery is then liable for damages for all the events, predictable
or otherwise, that result from that unlawful touching. A doctor guilty
of negligence, however, will only be culpable for the foreseeable
consequences of his negligence. To illustrate this distinction consider
the following; if I failed to take consent for the insertion of an epidural
which caused the patient to become paralysed, I would be liable for
all the adverse events resulting from that intervention, including a
rare and unpredictable allergic reaction to the drugs in the epidural
solution. If however, I had taken some form of consent, but omitted
to warn of the risk of paralysis, I may be found guilty of negligence
for failing to warn of this risk, but it is unlikely that I will be held liable
also for damages resulting from the allergic reaction, as this is rare
enough not to warrant being discussed in the consent process.
What is the appropriate standard of disclosure
Unfortunately, there is no legal definition of ‘informed consent’.
Nebulous though it may seem, the standard of disclosure demanded
by law is that patients should be informed, ‘of any significant risk
which would affect the judgement of the reasonable patient’ 6 . This
means that we must tailor information about risk to the individual,
for example, possible voice changes following intubation would be
of particular concern to a professional singer. If a patient is deemed
to have capacity, their decisions regarding their own treatment must
be respected, even if these decisions seem irrational or ill-reasoned
to others.
Patients lacking capacity:
Minors
For those under 16 years of age, consent to treatment is given on their
behalf by an adult responsible for their care. A ‘Gillick competent’
minor describes a child who demonstrates the capacity to consent
to treatment 7 , but it is still prudent to gain consent from a responsible
adult, in addition.
Those aged 16 and 17 are deemed to have capacity under the MCA
2005 and so can consent to treatment independently. Somewhat
confusingly however, their parents still retain the right to consent
for them also. This is of practical relevance if someone of this age
group refuses life saving treatment. All minors who have tried to
refuse life saving treatment have, without exception, been found by
the Courts to lack the necessary capacity to make this decision. In
reality, children (and those aged 16 and 17) may give consent to
treatment, but may not refuse life saving treatment thought to be in
their best interests.
Adults
Under the provision of the MCA 2005, an adult who has capacity may
appoint another as his Lasting Power of Attorney (LPA). This attorney
may then make all decisions on his behalf once he has lost capacity.
Those who are permanently incapacitated may be assigned a Court
appointed Deputy by the Court of Protection, who, like a LPA may
make medical decisions in the best interests of the person who lacks
capacity. In the case of patients without capacity who have no other
representatives, the multidisciplinary medical team responsible for
their care must act in their best interests. If there are family or friends
invested in the patient, it is usual to seek their opinion, but consent
cannot be given on the patient’s behalf by another.
Taking Consent across a language barrier
A patient whose grasp of the language is poor may have difficulty
understanding the nuances of what is being explained to them and
this may leave them unable to consent, or render their consent
invalid. A family member may have a better grasp of the language
and act as translator, but this often leaves us wondering if what we
have said has been edited or lost in translation.
It is common sense, good medicine and now enforced by the
MCA, to make every effort to help the patient to understand and
communicate. A range of options might help to make this possible:
• Request that a relative, or friend, who speaks both languages,
be present during the admission and pre-operative visit. It
is often useful to have that person accompany the patient to
theatre to translate and help allay anxieties.
• Make use of your Trust’s in-house translators, a list of whom is
usually held by switchboard
• Some trusts have a contract with LanguageLine, a 24 hour-a-day
telephone service that offers translation in over 170 languages.
• The Obstetric Anaesthetists Association have produced a
variety of information for mothers in many languages, these aids
are readily available on their website 8 .
It is sensible to know ahead of time which services are offered by
your Trust. Consent is a process of communication, one that can be
difficult when hampered by the lack of a common language. All we
can do however, is our best. It is sensible to document accurately
all discussions conducted with the patient about their treatment, and
any difficulties that have arisen.
Kate McCombe MA MRCP FRCA
Obstetric Anaesthetists’ Association
References
1. http://www.dailymail.co.uk/news/article-1078677/250-000-lost-translation-NHS
providing-interpreters.html (Accessed 02/04/12)
2. Jones M. Informed Consent and Other Fairy Stories. Medical Law Review, 1999; 7:
103-134
3. Dalla-Vorgia P., Lascaratos J., Skiadas P. & Garanis-Papadatos T. Is consent in
medicine a concept only of modern times Journal of Medical Ethics, 2001; 27: 59-61
4. Re C (adult: refusal of medical treatment) [1994] 1 WLR 290
5. Jones M.A. Commentary: The Legal Position. British Medical Journal 1995; 310: 46
6. Chester v Afshar [2004] UKHL
7. Re L (medical treatment: Gillick competency) [1999] 2 FCR 524
8. http://www.oaa-anaes.ac.uk/content.aspContentID=221(Accessed 02/04/12)
Anaesthesia News July 2012 • Issue 300 21

International
Relations Committee
Dr Ellen O’Sullivan,
International Relations Committee Chair,
AAGBI Vice President
1. What Committee do you Chair
International Relations Committee
2. What were your three biggest
achievements over the last year
LATEST
REPORT
The AAGBI Uganda Fellowship Programme. This is an ongoing
and very successful programme where we provide the funding
for training physician anaesthetists (28 so far). The outcome of
the Ugandan Fellowship Programme is there are 29 trainees to
date, with 9 obtaining MMed degrees, 8 employed and 20 still
in training. Many of these have had impressive academic
achievements.
Lifebox (new charity - collaboration between the AAGBI and
the Harvard School of Public Health and World Federation
of Societies of Anaesthesiologists). Donations of oximeters and
delivery of training to 80 anaesthetic officers in oximetry and surgical
safety in rural hospitals - the Lifebox training is being partnered
with the SAFE courses. Lifebox launched a new fundraising
campaign - ‘Make It Zero’- that will run for two years in view of
raising further money for 5000 oximeters. This was launched very
successfully at the World Congress of Anaesthesia in Argentina in
March this year. Find out more at www.lifebox.org
3. What current challenges are you facing
The IRC has been expanding its activity and becoming much more
strategic over the past few years. In addition we have developed
many ‘partners’ in developing countries. There is much we can
ents Manager
+44 (0) 20 7631 8805
ortland Place, London W1B 1PY
nicolaheard@aagbi.org
ents Manager
+44 (0) 20 7631 8805
TRAVEL GRANTS/IRC FUNDING
The International Relations Committee
(IRC) offers travel grants to members who
are seeking funding to work, or to deliver
educational training courses or conferences,
in low and middle-income countries.
Please note that 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:
http://www.aagbi.org/international/irc-fundingtravel-grants
or email secretariat@aagbi.org
or telephone 020 7631 8807
Closing date: 30 September 2012
Abstracts for presentation
at AAGBI WSM London 2013
Anaesthesia July 2012
Anaesthesia
Digested
Farrell C, Hill D. Time for change: traditional audit or continuous
improvement
What is the purpose of audit Anaesthetists are familiar with the traditional process of
audit, but participation is piecemeal, driven by revalidation worries, and seldom results
in more than apathetic identification of a problem, rather than targeted improvements
in care. Conversely, ‘continuous quality improvement’ allows for real time analysis of
performance and intervention, with the aim of continuously improving measured
outcome. Multiple interventions can be implemented and assessed simultaneously,
and importantly, as this excellent editorial points out, this process – a form of
rapid-cycle audit – tends to achieve quantifiable results within a short time frame,
engaging participants and motivating people to improve practice further. This article
implies that routine systems data collection by clinicians will become an inevitable
part of practice, and this is something that should encourage anaesthetists, who are
generally highly adept at such data collection, to become important drivers of quality
improvement in hospitals. Count something!
Smith SE, Tallentire VR, Spiller J, Wood SM, Cameron HS. The educational
value of using cumulative sum charts.
Whilst all junior doctors are familiar with summative assessment of learning, there
are few validated tools available for formative assessment during the learning process.
Cumulative summation (CUSUM) charts have been used to monitor learning in
many specialties, but in this randomised study of 82 medical students, CUSUM was
used to guide successive attempts at peripheral venous cannulation. Students in the
intervention group had access to their CUSUM charts and were encouraged to seek
further educational input when their performance fell towards or below an acceptable
rate of successful insertion. CUSUM charts were not available to control students,
who learnt cannulation in a more ‘traditional’ manner. After 6 months, intervention
students performed significantly better in a Distracted Intravenous Access (DIVA)
test. The authors suggest that use of inexpensive CUSUM charts may formatively
improve the learning of technical skills through enhanced self-regulation, reflection
and positive feedback – key components of successful workplace-based learning.
Successful piloting of the SAFE courses designed by Kate
Grady (Manchester). The SAFE (Safer Anaesthesia From now do to support our colleagues effectively. However funding ortland is Place, London W1B 1PY
Education) Obstetric anaesthesia course is a three-day course that the limiting factor. The membership of the AAGBI has been very
Canty DJ, Royse CF, Kilpatrick D, Williams DL, Royse AG. The impact of
focuses on the delivery of anaesthesia and the management of supportive but in these recessionary times the funds available are
You are invited to submit an abstract for poster
pre-operative focussed transthoracic echocardiography in emergency
leading causes of maternal death such as haemorrhage, eclampsia limited. The challenge is to prioritise and use our funds to seed nicolaheard@aagbi.org presentation at WSM London 2013. The deadline for
submission is midnight on Monday 17th September 2012 non-cardiac surgery patients with known or risk of cardiac disease.
and sepsis. Teaching is in small groups and each group has access future developments.
and full instructions, including a template abstract and
to a mentor for the duration of the course. A Training of the Trainers
submission form, can be found on our WSM microsite:
Focussed transthoracic echocardiography (TTE) is a truncated ‘bedside’ version
(TOT) course has been developed. A total of four SAFE courses and 4. What are your priorities for the
www.wsmlondon.org and on the AAGBI website:
of formal TTE that complements clinical cardiac examination. This prospective
2 TOT were piloted in Mbarara, Uganda over a two-week period in
observational study of 99 patients aged over 65 years (25%) or with suspected cardiac
coming year
www.aagbi.org/education/events
June/July 2011. 126 anaesthetists were trained on the SAFE course
disease undergoing emergency non-cardiac surgery (75%), aimed to determine
-approximately 40% of the anaesthetic workforce of Uganda. • To further expand the validated SAFE courses to other countries
After the deadline, a preliminary review of the abstracts received whether pre-operative, anaesthetist-performed focussed TTE altered peri-operative
will determine which ones are accepted for poster presentation.
Delegates attended from all regions of Uganda, mainly from small (already planned for Tanzania, Zambia and Bangladesh) and to
management. Positive TTE findings that led to a step-up in management (delayed or
rural health centres. Learner satisfaction was high. Knowledge develop other quality-assured SAFER courses e.g. paediatrics
All accepted abstracts will be published in Anaesthesia in the form altered surgery, planned ITU admission, intra-operative cardiovascular intervention)
were found in 36% of patients, whereas negative, reassuring findings that led to a stepdown
in management were found in only 8% of patients. Formal TTE in 18 patients
and skills were formally assessed before and after training and • Produce good quality research to define the exact needs
of a fully referenceable online supplement. In addition, the best
ones, selected by a judging panel at the meeting, will be printed in
showed significant improvements. 17 anaesthetists were trained • Setting standards in International work
the hard copy version of the journal. (NB Editor-in-Chief reserves
confirmed other studies’ findings regarding the accuracy of TTE interpretation
on the TOT as SAFE course facilitators. The local facilitators will • To work collaboratively with other organisations
the right to refuse publication, e.g. where there are major concerns
performed by trained anaesthetists. This proof of principle study suggests that
lead the further SAFE courses, with the aim of becoming locally • To apply for larger governmental grants to help us to roll out the
over ethics and/or content).
focussed TTE may be an accurate, accessible adjunct to clinical diagnosis and
independent as quickly as possible, such that over time external piloted programmes we have started
Authors of the best poster(s) will be awarded ‘Editors’ Prizes’.
anaesthetic management in the emergency situation, and by implication may improve
input will be required for quality assurance only. A group of senior • e-learning project—to complete the AAGBI DVD for developing
outcome without the need for formal TTE assessment in high risk surgical patients.
UK anaesthesia trainees undertook a monitoring and evaluation countries.
If you have any queries, please contact the AAGBI Secretariat on
020 7631 8812 or secretariat@aagbi.org
exercise in delegate hospitals. This included collection of logbooks,
individual Key Informant Interviews and Focus Group Discussions
S. M. White,
Copy Deadline: 17 September 2012
Editor, Anaesthesia
and inspection of hospital registers where possible. This gave
very useful feedback and confirmed the value of the course.
22 Anaesthesia News July 2012 • Issue 300 Anaesthesia News July 2012 • Issue 300 23

22nd
National
Acute Pain Symposium
Photograph by Chris Steer
Thurs 13th & Fri 14th September 2012
Crowne Plaza Hotel, Chester
The Nation's premier Acute Pain forum
Plenty of interesting content for anyone involved in Acute Pain management
An interesting and varied program with first class speakers
Extended release epidural morphine in colorectal enhanced recovery
Recent advances in acute pain management
Nerve block infusions after amputation
Neurosurgical issues relating to epidural complications
European "Pain OUT" benchmarking & European Pain Registry project
Acute pain in the A&E Department
fMRI - functional MRI scanning in acute pain
Update on NSAID's
Acute pain in the cognitively impaired patient
Co-administration of opioids and opioid antagonists
Regional anaesthesia & pain assessment in large animal veterinary practice
Presentations by Poster Competition winners
Acute Pain SIG meeting
Poster exhibition with 3 cash prizes
See what the innovators are doing around the country
Details & Bookings : Registration Fees :
Georgina Hall
Tel : (0151) 522 0259
Mob : 07901 717 380
E-mail : medsymp@btinternet.com
Comprehensive Trade exhibition
Hear about & see the new & existing Acute Pain
related products
Consultants £345
NCCG £345
SpR & SHO £275
Nurses £195
Informal Delegate Dinner - Brazilian Restaurant
A wonderful relaxed and friendly evening.
A favorite amongst those who have attended before
8 CPD points from the Royal College of Anaesthetists applied for
MASS GATHERINGS & INFECTIOUS DISEASE
This summer, Britain plays host to the highest profile sporting event on this
year’s calendar, the 2012 Olympic games. The Olympic games brings together
nations from all around the world, to compete at an elite level. People will
descend on Britain’s fair and green land from every corner of the globe including
the athletes, their support teams and thousands upon thousands of spectators.
Although they will bring a welcome boost to the British economy
and put Britain centre stage in the sporting world for their duration,
the Olympic games will also place Britain at potential risk. With the
massive influx of people comes the potential for catastrophic health
risks. The potential for the spread of infectious agents, which could
lead to epidemics or even pandemics, is very real. In addition, the
possibility of biological terrorist activity and the malicious spread of
infectious agents does exist. Official precautions and preparations
are being made at the highest level to prepare for any health crisis
eventuality that could occur at the Olympic games.
Mass gatherings medicine
Potential terrorist threat
The British security services are taking the potential threat posed
by the mass gathering of people on our shores extremely seriously.
Various models have been proposed to look at potential disruption
strategies and more importantly the provisional plans to deal
with these circumstances. War game scenarios are set up to test
the robustness of protective planning strategies but as with all
simulation unfortunately, real life scenarios rarely emulate those
that can fit nicely into a mathematical model. Most hypothesised
scenarios are based upon organised terrorist cell activity. However
if a lone individual, sometimes referred to as a “lone wolf ”, with
unknown motivational factors and with no preformed action plan,
performs random acts of anti-social behaviour or terror this could
be a lot more difficult to predict and prepare for. President Barack
Obama has previously voiced concerns about this phenomenon
during an interview on CNN in 2011, “The risk that we’re especially
concerned over right now is the lone wolf terrorist, somebody with
a single weapon being able to carry out wide-scale massacres.”
The weapon used could well be a biological one. Intelligence
organizations around the world take all these potential threats
extremely seriously, and work collaboratively to gather the
necessary intelligence to thwart threats to social order within the
population whether the orchestrators have political or activists’
ends in mind. British Olympic Association chairman Colin Moynihan
In 2010 The Lancet organised a mass gatherings conference
in Jeddah, Saudi Arabia, that focused on the medical impact
of these occasions. This led to an emerging branch of sciencebased
medicine called “mass gathering health”. The origins can
be linked to the annual Muslim pilgrimage of Hajj, which sees the
convergence of millions of pilgrims on one place, from all corners
of the world, in a short time frame. The spread of infectious disease
does not simply stop with outbreaks at the mass gathering but
can become a pandemic when people return to their originating
country. These discussions have also raised awareness of the
health implications of heat related illnesses, and this needs to be
addressed with education programs to aid public knowledge of its
serious consequences.
has been reported to have admitted to police and security chiefs when
Anaesthesia News July 2012 • Issue 300 25

talking about the London 2012 Olympics “It just takes, and is likely to be,
one idiot...It’s not likely to be a well-orchestrated campaign through Twitter
or websites...It is likely to be someone who causes major disruption...That
is why all the security measures need to be put in place to minimise the
chance of that happening...You can never completely remove it but you
can do everything possible to protect the interests of the athletes and
spectators by minimising it.”
Social media and potential threats
In the summer of 2011 we saw that social media sites like Twitter, Facebook
and Blackberry Messenger provided a platform to aid the planning of
social unrest, for example the rioting that occurred in various areas within
Britain. Thankfully these social media sites also provided an audit trail that
the authorities were able to utilise in bringing those involved to justice.
These social media sites can be a powerful platform for dissident groups to
organise themselves and co-ordinate activities. One can only hope that the
security services stay one step ahead and intelligence gathering includes
these social media sites.
How does the health service fit
into the scheme of things
If there were any potential mass infection of the population during the
Olympic games, all modelled strategies would lead to the immediate
mobilisation of the emergency services. The National Health Service would
provide a key role in the triage, quarantine, treatment and management
of the case group. The burden on the healthcare system would fall at
the feet of frontline medical staff. This could mean potential exposure or
contamination to possible infective agents. Therefore barrier techniques
and infectious disease precautions may need to be employed to maintain
healthcare staff safety. Olympic sporting events will take place throughout
Britain therefore an orchestrated terrorist biological attack could affect many
emergency healthcare-providing institutions at one time. The implications
of heat related illnesses are unlikely to be a major concern in our usually
temperate climate, but if we have the summer we’re all wishing for this
might become a problem!
Actions to attenuate contagious
diseases at mass gatherings
There are multiple interventions that can be introduced. Data on surveillance
of infectious disease before, during and after mass gatherings needs to
be recorded to aid intelligence gathering and planning for future events.
Vaccinations can be administered which will benefit both the hosting
location of the mass gathering as well as the nations which visitors will return
to. Most importantly, understanding the science and modelling behind the
behaviour of crowds at mass gatherings will lead to greater understanding
of how to deal with major mass gathering related health emergencies.
What to do this summer - focus on
the “what ifs” or sit back and enjoy
the games
I think it’s obvious that we should be doing the latter. Although the threats
are present the best thing to do is to be prepared for any eventuality. All
hospitals have an established major incident plan in case of any serious
untoward event, our responsibility as individual healthcare providers is to
familiarise ourselves with the protocols in our place of work.
Sunil Halder,
Anaesthetic Registrar, Oxford Deanery
References
1. McConnell J. Mass gatherings health Series. Lancet Infect Dis 2012; 12: 8-9
2. Memish Z, Stephens G, Steffen R, et al. Emergence of medicine for mass gatherings: lessons
from the Hajj. Lancet Infect Dis 2012; 12: 56–65
3. Abubakar I, Gautret P, Brunette G et al. Global perspectives for prevention of infectious diseases
associated with mass gatherings. .Lancet Infect Dis 2012; 12: 66-74
4. Steffen R, Bouchama A, Johansson A et al. Non-communicable health risks during mass
gatherings. Lancet Infect Dis 2012; 12: 142-149
5. Johansson A, Batty M, Hayashi K et al. Crowd and environmental management during mass
gatherings Lancet Infect Dis 2012; 12: 150-156
6. McConnell J, Memish Z. The Lancet conference on mass gatherings medicine. Lancet Infect
Dis 2010; 10: 818–19
All you need to know about practical
airway management.
Small group workshops, simulation and interactive lectures.
Number of places limited to 16 to allow plenty of time for
practical skills. Approved for 5 RCOA CPD points.
Fibreoptic intubation Mechanics of the scope, practical techniques
The surgical airway Cricothyroidotomy, percutaneous tracheostomy
Failed intubation Failed intubation drills and scenarios using simulation
Supraglottic devices LMA, iLMA and second generation devices
Airway assessment And how to approach anticipated difficulty
Extubation How, when and where
Next course : 19 th September 2012
Course Director Dr Agnes Watson, Consultant Anaesthetist, Broomfield Hospital
Registration fee £120. Refreshments included. To book, please see our website:
www.anglia.ac.uk/EASTcourse
SIMULATION COURSE
Bradford Airway Scenario
& Simulation Course
(BrASS)
SIMULATION SIMULATION COURSE COURSE
Objectives
Anglia Ruskin University, Rivermead
Campus, Chelmsford, Essex CM1 1SQ
Course Dates:
Bradford Airway Scenario
& Simulation Course (BrASS)
28
Bradford Airway Airway Scenario
th September 2012
15 th March 2013
Practise difficult airway skills
Objectives
&
consistent
Simulation & Practise difficult with DAS airway guidance
skills Course For specific Dates: queries about
in the consistent skills lab with DAS and guidance in
aims of the course please
simulated in the skills scenarios lab and in simulated 28
(BrASS)
th September 2012
contact
scenarios
15 th Dr
March
David
2013
Craske
Aimed at
Course Consultant
Anaesthetists ST3 - Consultant Course Dates: Anaesthetist, BRI
Aimed at
For specific Dates:
david.craske@bthft.nhs.uk
queries about
Objectives
Anaesthetists ST3 - Consultant aims
Objectives
Feedback from
28 th of the course please
contact: September 28 th September 2012 2012
previous participants
15 th For General
“Excellent balance between
15 th Enquiries,
Feedback from previous Dr David March Craske March 2013
Practise Practise difficult difficult airway airway skills
2013
skills booking, and future dates
participants
skills stations and scenarios”
Consultant Anaesthetist, BRI
consistent consistent with DAS
“Good trainer with guidance
“Excellent balance to trainee DAS between ratio” guidance david.craske@bthft.nhs.uk
please contact
For
in the
For specific queries about
in skills the “Good skills lab to discuss and lab in
Name,
specific
Tracey
queries
Williams
about
skills stations and and realistic scenarios” in aims of
simulated simulated
scenarios”
aims the of course the course please
For General Course Enquiries, Co-ordinator please
“Good trainer scenarios to trainee ratio”
“More please……!”
booking,
contact tracey.williams1@bthft.nhs.uk
contact and future dates
“Good to discuss realistic please Dr David contact: Dr David Craske Craske
scenarios
Places Available Tracey Consultant Places Williams
Aimed
Consultant Available Anaesthetist, Anaesthetist, BRI BRI
“More Aimed at please……!” at 8 per course
Course david.craske@bthft.nhs.uk
8 Co-ordinator per
Anaesthetists
david.craske@bthft.nhs.uk
course
Anaesthetists ST3 Cost - ST3 £100 Consultant - Consultant tracey.williams1@bthft.nhs.uk
Cost
For £100 General
Feedback For General Enquiries, Enquiries,
Feedback the from Bradford from previous previous Centre booking,
participants
booking, and future and future dates dates
participants for Simulation please
“Excellent please contact contact
“Excellent balance balance between between Name,
skills Name, Tracey Tracey Williams Williams
skills stations stations and scenarios” and scenarios” Course
“Good Course Co-ordinator Co-ordinator
“Good trainer trainer to trainee to trainee ratio” ratio” tracey.williams1@bthft.nhs.uk
Going for Gold!
Does winning an Olympic gold medal provide
you with valuable experience that ensures you
get the most out of your medical career
In the year of the London Olympics, Richard
Dodds OBE, the captain of the gold medal
winning Great Britain Olympic Hockey Team
from Seoul in 1988 and current Consultant
Orthopaedic Surgeon and Director of Medical
Education at the Royal Berkshire Hospital,
gives us some insight into what it takes to win
an Olympic gold medal. He is no stranger to
medals, also winning an Olympic bronze medal
at the 1984 summer Olympics in Los Angeles
and silver medals at the 1986 World Cup and
1987 European Cup. Mr Dodds delivered a
lecture at the Winter Scientific Meeting of the
AAGBI in January 2012 in which he gave a
personal account of the attributes required to
achieve Olympic success and its correlation
with pursuing a successful medical career. For
those readers who missed the live version, we
hope you’ll find his thoughts engaging.
What does it take to win an Olympic gold
Firstly in any team sport, as with many
endeavours in life, it takes a great team and
plenty of cohesive teamwork to win. Some
personal qualities can aid obtaining the
highest level of success in any field. These
include preparation, determination, resilience,
aptitude and dedication. A great manager also
aids the path to success, using individualized
management techniques to make you prove
you are the best at what you do. Obviously
to achieve success, a great deal of time and
energy is required, the need to focus and put
a large amount of effort into the matter at hand
will be a important determinant of a favourable
outcome. An understanding and supportive
family is also paramount to success. The
support of those loved ones closest can
be seen at the heart of every world leading
sportsperson. In every successful Olympian’s
career there is an element of luck and Mr
Dodds is no different. Political circumstances
in the 1980’s helped form the wining team of
the 1988 Olympics. He does comment that it
seems “the more I practice the luckier I get.”
Mr Richard Dodds, WSM 2012
Lecture: What it Takes to Win!
http://videoplatform.aagbi.org
Do you need talent to win an Olympic gold
Mathew Syed has written a book entitled
“Bounce” talking about the myth of talent and
the power of practice. He commented that
you need 10,000 hours of meaningful practice
in order to achieve success but what can be
viewed as “meaningful practice” You have to
be in the right mindset to complete any task
undertaken to an Olympic standard, this does
require talent as well as perspiration and effort.
All of this preparation has a particular word,
“training”.
What is training
The Oxford English Dictionary gives a definition
of “to bring or come to a desired standard by
instruction and practice”. However what is the
desired standard In the case of an Olympic
athlete, the desired standard is certainly an
Olympic gold medal. To achieve this aim
one needs to set targets in order to achieve
success. It should also be noted that you need
good training to become an effective trainer.
What is success in the eyes
of an Olympic gold medallist
An appropriate definition is given by an
American author and poet Maya Angelou
(1928) “success is liking yourself, liking what
you do, and liking how you do it.” However,
any professional athlete will also feel empathy
with the definition offered by Winston Churchill
(1874-1965) “success is the ability to go
from one failure to another with no loss of
enthusiasm.”
What are the similarities between Olympic
training and medical training
Mentors are used extensively in Olympic
training to aid learning and development, as
they are in medical training. The attributes
of a great mentor include enthusiasm for
their subject, the ability to lead and teach by
example and to provide inspiration for trainees
to want to emulate in their own careers.
Another outstanding mentoring technique is
the passion for attention to detail. Attention
to detail in whatever is undertaken will always
lead to greater success. If you get the details
right you play and work better. A quote by a
British biologist Thomas Huxley (1825-95)
summarises the similarities between Olympic
and medical training: “perhaps the most
valuable result of all education is the ability to
make yourself do the thing that you have to
do, when it ought to be done, whether you like
it or not; it is the first lesson that ought to be
learned; and however early a man’s training
begins, its probably the last lesson he learns
thoroughly”. Perhaps all of us should be
learning these lessons throughout our practice
as medical practitioners
Have you got any pearls of wisdom
for someone who is preparing to
undertake a challenge within their
sporting or medical life
One has to be prepared to put your head on
the block and potentially fail in order to be able
to go forward and succeed. Without pushing
yourself you will never achieve your goals.
As the American actor Mickey Rooney (1920)
stated “You always pass failure on the way to
success” and the inspirational American football
coach Mike Ditka (1939) stated, “Success isn’t
permanent, and failure isn’t fatal”.
Any final thoughts
Always remember whatever your goals are in
your life, whether sports-related or not: “Have
you gone training today - the opposition have!”
Transcribed by Sunil Halder, SpR
Oxford Deanery
Anaesthesia News July 2012 • Issue 300 27

Vascular Anaesthesia Society
Of Great Britain and Ireland
ANNUAL SCIENTIFIC MEETING
Monday 10th and Tuesday 11th September 2012
Action Stations, Historical Dockyard, Portsmouth
CALL FOR ABSTRACTS
- RESEARCH
- AUDIT
- CASE REPORTS
Have you performed any research or audit, or do you have an interesting case
report that you would be interested in presenting
This would also be an ideal opportunity for your trainees to get involved.
There is a prize of £200 for the best verbal presentation and £100
for the best poster presentation.
For further information please contact:-
Dr Simon Logan, Chairman of the Education Committee, Consultant
Anaesthetist, University Hospital of Wales, Heath Park, Cardiff, CF14 4XN
Tel: 02920 743106
E-mail: Simon.logan@wales.nhs.uk
Cardiopulmonary
Exercise Testing
Workshop
September 20th 2012
The Royal York Hotel, York
A combination of lectures, interactive small-group
tutorials and demonstrations relevant to risk
assessment for the surgical patient.
Lectures:
Assessing surgical risk
Current pre-assessment strategies and techniques; the importance of functional capacity
The physiological response to exercise: why it matters for the surgical patient
The physiology and biochemistry of exercise and how limitations impact on surgical outcomes
What to measure for the surgical patient
The parameters from pre-op CPET that influence outcome, and CPET diagnostic markers of
heart failure and ischaemic heart disease
Tutorials:
All components taught by a highly experienced faculty.
3 Structured tutorials on the technical interpretation and clinical relevance of real-life
CPET examples.
Places limited- maximum 8 delegates per group.
Feedback from last year’s course:
“Obtained an excellent insight into carrying out a CPET test, and interpretation of results to make
clinical decisions on high-risk patients”
!
Exertional heat illness
in half marathon runners
– Experiences of the Great North Run
Exertional heat illness is a well described phenomenon
in the prehospital environment, both in military and
sporting events. 1 It is defined as a core temperature
> 40ºC 10 minutes after cessation of exercise, and
covers a broad range of clinical conditions from minor
heat cramps and symptoms of lethargy to severe heat
exhaustion, multiple organ failure and death.
The pathophysiology of hyperthermia is well
understood 2,3,4 but the evidence base around its
treatment is still limited. 5 Severe heat illness is a poorly
documented problem in half marathons and presents a
different biochemical profile to full marathon runners. 6
Closing Date: Friday 27th July 2012
Vascular Anaesthesia Society
Of Great Britain and Ireland
Sixteenth Annual Scientific
Meeting
Monday 10th & Tuesday 11th September 2012
Action Stations, Historical Dockyard, Portsmouth
Guest Speakers to include:-
Professor Mike Irwin
Professor Nick Curzen
Dr Paul Kalra
Dr Iain Moppett
Dr Rupert Pearse
Speaker TBC
Speaker TBC
Major General Gordon Messenger
Dr Gordon Craig
Professor Mike Grocott
Dr Tom Woodcock
Dr Paul Moore
Dr Dafydd Thomas
Dr Mike Swart
Dr Simon Howell
Dr Peter McQuillan
Pro Con Debate:
“Ischaemic pre-conditioning”
“Acute coronary syndrome”
“Heart failure”
“Cardiac output monitoring”
“Enhanced recovery/fast-track”
“Coagulopathy”
“Historical lessons from the battlefield”
“Leadership”
“Nelson’s death”
“Risk stratification”
“Patient communication”
“Situation awareness”
“Patient blood management”
“Quality improvement framework/amputation”
“How we run a vascular MDT”
“Update in fluids”
“This house believes that open AAA repair is now obsolete”
For: Speaker TBC
Against: Simon Howell
WORKSHOPS:
Cardiac Output Workshop, Ultrasound Workshop,
Shared Decision Making for High Risk Vascular Surgery
FREE PAPERS
(Abstracts for oral/poster presentation to be submitted by 27th July)
“Very clear explanations, clear messages, excellent tutors, great to have clinical examples & to keep
going over the same messages, great to have all evidence displayed, thank you”
Apply at
www.survivingsurgery.net
School of Medicine
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DATE: Wednesday 5 – Friday 7 September 2012
DATE: DATE: Wednesday 5 – Friday 7 September 2012 2012
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DATE: Wednesday 5 – Friday 7 September 2012
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This group tutorials
is a tutorials directed
3-day directed by
course devoted by experienced to intensive teachers
VIVA and and
OSCE preparation, individual appraisal, and small &
examiners.
group OSCE tutorials preparation, directed individual by experienced appraisal, teachers and small and
examiners. group tutorials directed by experienced teachers and
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Division of Anaesthesia, Critical Care & Pain Management, Leicester Royal Infirmary
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DATE: Wednesday 5 – Friday 7 September 2012
VENUE: Clinical Education Centre, Leicester Royal
Infirmary
FEE:
REGISTRATION FEE (including lunch): Before 31st July 2012: Members £345.00 & Trainees £225.00
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group tutorials directed by experienced teachers and
Division of Anaesthesia, Critical Care & Pain Management, Leicester Royal Infirmary
examiners.
Division of Anaesthesia, Critical Care & Pain Management, Leicester Royal Infirmary
Division of Anaesthesia, Critical Care & Pain Management, Leicester Royal Infirmary
Heat Illness
In the normal physiological state, the human body has highly regulated
homeostatic mechanisms that keep the core temperature tightly
controlled between 36.5-37.5ºC. Heat illness results when there is
imbalance in this homeostatic control and there is either excessive
heat gain (from the environment or secondary to muscle activity) or a
reduction in heat loss, and once the compensatory mechanisms are
exceeded the core temperature rises.
Increasing heat load results in peripheral vasodilation and diversion of
blood flow to cause increased sweating and heat loss by evaporation.
This results in reduction of central venous pressure, a hyperdynamic
circulation and progressive reduction in perfusion to the gut, kidneys
and brain with resulting confusion and agitation, and electrolyte
imbalance. This may progress to high output cardiac failure, hypoxia,
cellular dysfunction, rhabdomyolysis, acidosis, disseminated
intravascular coagulation, multi organ failure and death. Predisposing
factors for exertional heat illness include obesity, lack of physical fitness,
concurrent viral illness, recent alcohol consumption, thyrotoxicosis,
certain prescribed or recreational drugs, skin disorders affecting
sweating or inherited skeletal muscle abnormalities e.g. Malignant
Hyperthermia.
Exertional Heat Illness at the Great North Run
The BUPA Great North Run (GNR) is the world’s largest half marathon
with over 54,000 entrants in 2012. It is a road race, for adult runners of all
standards. Runners lose body heat by radiation, evaporation (sweating)
and convection. However, in markedly hyperthermic dehydrated
runners sweating may cease as the body limits skin perfusion to
preserve circulating volume (dry hyperthermia). The course is roughly
West to East, in the same direction as the prevailing wind and maximum
temperatures rarely peak above 18ºC.
Heat loss by evaporation and convection are in proportion to the square
root of the airflow over the runner’s body, and experience has shown
that the most significant factors in determining numbers of hyperthermic
casualties are wind direction, and relative humidity, rather than
ambient dry-bulb temperature. A cool dry headwind provides optimum
conditions, while a warm humid tail wind results in the largest numbers
of hyperthermic casualties. In this respect the GNR varies from other
mass participation runs with circular or figure-of-eight courses.
The simple system we describe ensures that athletes are treated
effectively and very few require treatment beyond the field hospital.
The treatment pathway and availability of near patient biochemistry
testing has had a crucial impact on minimising the need for Emergency
Department attendance. The vast majority of athletes are treated
successfully on location and very few require hospital admission.
Medical Set Up
Entrants receive pre-event information on health, training and
circumstances in which they should not run. New runners and those
with existing medical conditions are advised to take advice from their
GP. As most collapses occur within the final 2km, the Field Hospital
is situated at the finish line. On their arrival, runners are immediately
triaged by Paramedics using a system based on MIMMS. 7 Teams are
arranged to receive large numbers of patients in rapid successioneach
consisting of 6 medical and nursing personnel overseeing 3
trolleys, set out in a star formation with the heads together. This allows
for accommodation of patients admitted in sequence in different stages
of treatment. On occasion, combative delirium means that several
members of the team are required for one casualty.
As water is involved in cooling, electrical equipment is kept to a minimum
and patient monitoring is based on clinical examination and mercury
rectal thermometers, the most accurate measure of core temperature
in the prehospital setting. 8 3 resuscitation bays are equipped to an
Emergency department standard, for patients that do not respond
rapidly to initial treatment or require additional support.
In addition the Physiotherapy team treat the severe muscle cramps that
accompany reperfusion of the lower limbs.
Anaesthesia News July 2012 • Issue 300 29

Treatment
Management involves an ABC approach: including the insertion of a large bore
IV cannula and venous blood sampling9 for serum electrolytes and glucose.
Infusion of 1L of 0.9% Saline occurs concomitantly with removal of clothing
and copious tepid sponging. Cooling ceases at 39ºC to avoid ‘overshoot’.
This phase typically takes 30mins. Patients rarely need more than 2000ml
intravenous fluids to replace their depleted volume. Observations continue
until the GCS has returned to 15 and cardiorespiratory parameters are within
normal limits. If recovery is not complete within 2 hours, hospital admission is
arranged. Most patients are discharged to the recovery area within 60 mins of
arrival and discharged home, accompanied, within 2 hours.
Numbers
Total numbers of medical contacts may be up to 1000, but his number
includes relatively trivial contacts along the course, for example those requiring
Vaseline. Numbers of hyperthermic casualties vary, but in 2009, 55 runners
in roughly similar male:female proportions to entry numbers were admitted to
the Field Hospital with core temperatures >41ºC. All but 4 were discharged
home within two hours. These were admitted to hospital and discharged
within 24hrs. Nearly all patients with core temp >41ºC had some cognitive
dysfunction and delirium was common. This was transitory in the majority of
patients but, rarely, has been severe enough to require sedation. Diarrhoea and
muscle cramps occurred frequently with cooling and reperfusion. There has
never been a death or ICU admission from hyperthermia. Runners invariably
have high/normal serum sodium and haematocrit (>50%), suggesting
dehydration. Hyponatraemia is an anomalous finding. Bicarbonate is low
and anion gap demonstrates a metabolic acidosis. Long-term follow up has
been difficult as race entrants travel from around the UK and internationally
and submission of GP details is voluntary.
Discussion
The incidence of heat illness in GNR runners is high compared to other UK
half marathons and several factors are postulated. As mentioned above, the
course follows the same direction as the prevailing wind, and its evaporative
and cooling effects are therefore diminished, compounded by the ‘mass
effect’ created by the large numbers of entrants, resulting in a packed
course and reduced airflow between runners. For some of the course the
ambient air temperature perceived by a runner in the middle of the ‘pack’
can be up to 2º higher than on the side. The majority of patients suffering
from hyperthermia were not fun runners nor elite athletes but well prepared
club runners, who possibly over-exert themselves to achieve a personal best,
overheat, lose decision-making ability and the situation deteriorates. During
the course of a half marathon, runners have insufficient time to drink enough
water to become hyponatraemic, which limits their metabolic derangement
and perhaps facilitates the rapid recovery times. When the GNR started 30
years ago, hyperthermia in female entrants was rare. Over the last 25yrs of
the run the proportion of hyperthermic female runners has gradually risen to
approach that of the male runners. Explanations for this are speculative but
it may partly reflect a more aggressive attitude to obtaining a good time on
the part of the female runners.
Conclusion
We have found the above method to be simple, safe, effective, minimising the
need for ED attendance and easily reproducible with minimal resources in the
prehospital environment.
Rachel Hawkes, SpR Anaesthesia, Northern Deanery
Chris Vallis, Medical Director Great North Run
References
1. The British Military Surgery Pocket Book 2004. AC 12552.
2. Lloyd E. Temperature and Performance – II: Heat. BMJ 1994 309, 587-590
3. Hunt PAF, Smith JE. Heat Illness. J R Army Med Corps 2005:151,234-242.
4. Hopkins PM. Is there a link between malignant hyperthermia and exertional heat illness British J
of Sports Med 2007;41:283-284.
5. Bouchama A, Knochel JP. New England Journal of Medicine 2002; 346: 1978-1988
6. Cuthill JA et al. Hazards of ultra-marathon running in the Scottish highlands: exercise associated
Hyponatraemia. EMJ 2009 26, 906-7
7. Major Incident Medical Management and Support. Second edition, BMJ Publishing 2002.
8. Ash CJ, Brengelmann GL. Annals of Emergency medicine 1997: 29(5): 693
9. iSTAT monitoring, ABBOTT Laboratories.
Intensive exam preparation for the
Primary FRCA SOEs and OSCEs.
Realistic practice, exactly as in the real exam.
Day One: A full day of SOE practice. Personal feedback on your
exam technique. How to handle the ‘trickier’ bits of the syllabus.
Day Two: A full day of OSCE practice (two full cycles).
Realistic experience of real scenarios, ideal for honing technique.
Structured debrief to consolidate knowledge.
Next course : 17 th & 18 th September 2012
Course Director Dr Nick Wilson, Consultant Anaesthetist, Broomfield Hospital
Registration £150 per day or £280 for both days. To book, see our website:
www.anglia.ac.uk/PREPcoursePrimaryFRCA
Anglia Ruskin University, Rivermead
Campus, Chelmsford, Essex CM1 1SQ
University of Oxford, Nuffield Division of Anaesthetics
Anaesthesia in Developing
Countries 2012
Course dates: 26 th -30 th November 2012
Location: American Recreation Association, Kampala,
Uganda
This residential five-day course offers the opportunity for
anaesthetists from the developed world to learn about the
specific challenges of working in resource-poor environments. It
has run for over thirty years in Oxford and Uganda and is
particularly recommended for those planning visits to the
developing world in short and long-term contexts.
The registration fee (£1000 / £900) includes accommodation,
food and transfers as well as the conference costs. Flights are
not included.
Bookings open from July 2012; for further information or to be
added to the mailing list please email
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Further information: www.oxfordanaesthesia.org.uk
www.ndcn.ox.ac.uk
Cardiopulmonary Exercise Testing:
Thresholds of Success
The cardiopulmonary exercise test (CPET) is used in
surgical pre-assessment to identify patients at increased
risk of postoperative complications following major
elective surgery. In 1993, Older and colleagues showed
that decreased physical fitness, measured by CPET, was
associated with poor outcome following intra-abdominal
surgery 1 . Since then, several studies have supported
these findings in gastro-intestinal, hepatobiliary, and
vascular surgery 2 . CPET in patient populations was
developed from protocols originally designed to unravel
the physiology of healthy individuals and trained athletes.
The focus of this article is to provide a overview of the
cardiopulmonary exercise test, to explain the key values
that infer cardio-respiratory fitness and - in the spirit of
the Olympics - to provide insight into the physiological
requirements of the elite endurance athlete.
Why CPET
Exercise places a metabolic demand upon the body that requires
an integrated response from the cardiovascular, respiratory and
musculoskeletal systems to transport and utilise oxygen for energy
synthesis. The greater the intensity of the exercise, the greater the
metabolic demand and thus the harder these systems are required
to work to sustain oxygen delivery. Limitation by one of the systems
to meet the metabolic demands of exercise results in the rapid onset
of fatigue and exercise cessation. The CPET provides measures of
oxygen consumption, carbon dioxide production, heart rate, and
the work performed by skeletal muscles; these measures are then
used to describe the combined functional capacity of the cardiac,
respiratory and musculoskeletal systems.
What is CPET
CPET involves symptom-limited incremental exercise to exhaustion
over a period of approximately 8 to 12 minutes; it is usually conducted
on an exercise bike or treadmill to engage large muscle groups.
Exercise begins lightly and is gradually increased in a continuous
or graded fashion until the subject reaches volitional exhaustion or
exhibits symptoms which merit the premature stopping of the test.
The rate at which the difficulty of the exercise increases is preselected
and based on the gender, age and physical fitness of the subject.
During CPET, the subject wears a soft rubber mask, fitted around
their nose and mouth, or a mouthpiece with nose clip, to enable
analysis of inspired and expired gas (O 2
and CO 2
concentrations).
Additionally, electrocardiogram (ECG) monitoring is used to monitor
cardiac rhythm and ST segment changes; a peripheral oxygen
saturation probe measures arterial oxygen saturation; and blood
pressure is measured intermittently during exercise and recovery.
Breath-by-breath gas measurements are collected on a computer for
analysis after completion of the test. Graphical displays of the data in
a ‘nine panel plot’ assist data interpretation and aid diagnosis through
recognition of typical pathophysiological patterns.
Oxygen Consumption
As exercise intensity increases, so does the requirement of energy
at the muscle. Energy is released within the muscle by the splitting
of a phosphate bond in the energy rich compound adenosine triphosphate
(ATP). The most efficient method of energy synthesis
during exercise is aerobic metabolism (oxidative phosphorylation),
which yields considerably greater amounts of ATP when compared
.
to anaerobic metabolism. Oxygen consumption (VO 2
), measured in
ml/min or ml/kg/min, increases proportionally to the exercise intensity.
.
As VO 2
rises, oxygen delivery must increase proportionally to avoid
.
anaerobic respiration. The Fick equation (CO = VO 2
/ (CaO 2
– CvO 2
))
reminds us that the key components of oxygen delivery that must be
.
augmented to support an increase in VO 2
are cardiac output (CO),
arterial oxygen content (CaO 2
) and tissue oxygen extraction (CaO 2
– CvO 2
). Expired carbon dioxide (VCO 2
) increases at a similar rate
.
to VO 2
during exercise, as long as aerobic metabolism remains the
dominant energy source.
What is maximum oxygen uptake
.
Maximum oxygen uptake (VO 2
max) is the greatest amount of
oxygen that can be utilised at the muscle during very heavy ‘whole
body’ exercise and therefore sets the upper limit of aerobic exercise
capacity. It is therefore a validated measure of physical fitness, with
.
higher values representing a greater level of performance. VO 2
max
.
is defined as a plateau in VO 2
despite further increases in exercise
intensity, a phenomenon that is only observed in approximately 50%
.
of adults 3 . It is widely accepted that VO 2
max is limited by the delivery
of oxygen to the muscles, however this proposal has generated
healthy debate with those who believe that the muscle 4 or brain 5 limit
.
.
VO 2
max. Peak oxygen consumption (VO 2
peak) is the term used when
.
a subject’s greatest VO 2
is not associated with a plateau. In a patient
.
population a plateau in VO 2
is rarely observed and therefore VO 2
peak
is used to report fitness. Exercise can be performed at intensities
. .
above that achieved at VO 2
max/VO 2
peak (for example during a 100m
or 200m sprint) however, the duration of the exercise will be very short
due to the limited ability to sustain anaerobic metabolism for long
time periods.
What is the anaerobic threshold
The anaerobic threshold (AT) occurs during incremental exercise when
the energy requirements of performing exercise cannot be met by
aerobic metabolism alone. Exercise beyond the anaerobic threshold is
associated with an increase in the production of lactate and hydrogen
ions. Hydrogen ions are buffered by plasma bicarbonate resulting
in excess metabolic CO 2
production. Central chemoreceptors
provide feedback to stimulate an increase in ventilation to remove
the excess CO 2
. Further increases in the intensity of exercise require
a greater contribution of the anaerobic energy systems to sustain
exercise, resulting in greater increases in metabolic CO 2
and lactate
production. This threshold can be determined through invasive and
non-invasive methods. Capillary or arterial blood sampling will identify
the inflection point at which there is a marked increase in blood lactate
concentration, termed the lactate threshold. Non-invasive expired gas
analysis during CPET can also determine the anaerobic threshold by
ventilatory means. By plotting VCO2 against VO2, identification of the
inflection point at which VCO2 increases more rapidly than VO2 is a
validated technique for measuring AT6.
Anaesthesia News July 2012 • Issue 300 31

How does this relate to clinical populations
In the immediate postoperative period following major abdominal
.
surgery, it is estimated that resting VO 2
rises by up to 50% 7 . An
increase in cardiac output and ventilation is required to meet the
oxygen demands, a response not dissimilar to that associated with
the initiation of exercise. Failure of the cardio-respiratory system
.
to respond to the increase in VO 2
with an equivalent increase in
oxygen delivery will result in sustained anaerobic metabolism
in tissues and subsequent physiological demise. An AT of less
than 11ml/kg/min is predictive of poor postoperative outcome in
patients undergoing intra-abdominal surgery 1 . Furthermore, a low
physical fitness is associated with higher all-cause mortality 8 . In
.
heart failure, VO 2
peak is used to classify the severity of heart failure,
assess suitability for heart transplant, and determine the efficacy of
therapeutic interventions 9 .
How does this relate to athletes
The relationship between oxygen consumption and endurance
exercise performance has been established for almost a century. In
.
the 1920’s, AV Hill identified that VO 2
was greater at higher running
speeds but reached a limit, beyond which it could rise no further.
.
It was noted that those with the greatest capacity for VO 2
were the
.
faster middle distance runners and proposed that VO 2
was limited
by the systems involved in delivery of oxygen to the muscle. These
observations still hold true today and have stimulated research
and debate over determinants and limitations of endurance
.
performance 3 . In elite endurance athletes, VO 2
max values of 70-85
ml/kg/min have been reported in men and are approximately 10%
lower in women 10 . This is approximately double the value expected
.
for age matched healthy individuals. The highest recorded VO 2
max
is currently held by Espen Harald Bjerke, a Norwegian crosscountry
skier, at 96 ml/kg/min. In healthy individuals VO 2
.
at the AT
occurs at approximately 50% of VO 2
peak, however, in endurance
.
athletes training shifts the AT to a greater proportion of VO 2
peak
.
in order to enable a greater power output at a sub-anaerobic VO 2
.
Exercising above AT is unsustainable for long periods of time. In
those athletes in whom sprinting predominates (such as the 100m)
the primary energy source is anaerobic metabolism, thus this burst
exercise can only be sustained for very short periods and requires
a different training strategy to endurance athletes. The ability to turn
over energy through aerobic metabolism at high exercise intensities
enables athletes to travel at fast speeds for long time periods, for
example elite marathon runners are able to sustain speeds of 20
km/h for >2 hours.
So what makes an athlete elite
Cardiac
It is widely accepted that the primary limitation to VO2max is
convective oxygen delivery to the muscles. Of the delivery system
components, cardiac output is the most plausible limitation in the
healthy person 3 . The heart of an endurance athlete can generate
extremely large cardiac outputs, and can be greater than 30 l/
min. Maximum heart rate does not change markedly with training,
suggesting that enhanced stroke volume accounts for the
.
increased cardiac output and improved VO 2
max 10 . This is achieved
by increasing left ventricular mass, internal chamber diameter
and diastolic function; left ventricular hypertrophy is a common
finding in highly trained athletes and can lead to long-term cardiac
problems (athletic heart syndrome). The size of the heart is strongly
.
correlated with VO 2
max in athletic populations 11 . Improved diastolic
function allows fast expansion of the left ventricular cavity, drawing
blood into the ventricle from the atrium, maximising preload and
thereby enhancing stroke volume in keeping with Starling’s law.
system to limit exercise performance 10 . At peak exercise arterial oxygen
saturation is usually maintained above 95% suggesting that haemoglobin
oxygenation is not limited within the lungs. Unlike peripheral muscles, the
capillary bed surrounding the lungs does not appear to be enhanced with
exercise training. It is thought that the diaphragm and external intercostal
muscles, which are placed under great stress during very heavy exercise,
may cause some degree of limitation to exercise performance and time
to fatigue can be improved with training 10 .In some elite endurance trained
individuals there are reports of arterial oxygen desaturation at peak
exercise. It is postulated that the extremely large pulmonary flow through
the lungs during very heavy exercise shortens transit time thus reducing the
saturation of oxygen in the blood (pulmonary diffusion limitation).
Haematological
Haemoglobin concentration per se is not vastly greater in elite athletes,
however, blood volume and total haemoglobin mass are significantly higher.
.
Haemoglobin mass is strongly correlated with VO 2
max, but does not predict
performance in an elite group of athletes. Large blood volumes however do
enable a considerable increase in cardiac output. Haemoglobin mass and
blood volume can now be readily measured in exercise laboratories using
a carbon monoxide re-breathing technique 12 .
Musculoskeletal
.
Oxygen delivery to the muscle limits VO 2
max, yet there must be
concomitant adaptations within exercising skeletal muscles to improve
performance. Capillary to muscle fibre ratio improves with training as does
the mitochondrial volume density. Furthermore, exercise training results
in type 2 “fast twitch” muscle fibres adopting the oxidative profile of type
1 “slow twitch” muscle fibres. The ability to recruit muscle fibres also
improves, sharing the work and increasing the surface area for oxidative
metabolism 10 .
Genetics
.
Approximately 50% of an individual’s VO 2
max is accounted for by genetic
inheritance, thus to a certain degree you are limited by the potential fitness
that you inherit. Training can improve this by approximately 20 to 25%
but usually no more. The ability to improve VO2max is also determined
by genetic factors with wide variation in individual response to exercise
training. The angiotensin converting enzyme (ACE) 13 and ACTN3 14 gene
polymorphisms have been linked to differential improvement profiles in elite
athletes and military personnel. The I-allele of the ACE gene polymorphism
has consistently been demonstrated in association with improved
endurance performance whilst the D allele is associated with strength
and power performance. Interestingly the I-allele also favours improved
tolerance to the hypoxia experience, both at extreme high altitude and
survival in patients diagnosed with adult respiratory distress syndrome.
Respiratory
(Continued on the next page)
The lung is said to be ‘overbuilt’ to cope with the great oxygen demands
that occur during exercise; thus it is rare in health for the respiratory
32 Anaesthesia News July 2012 • Issue 300 Anaesthesia News July 2012 • Issue 300 33
Summary
CPET provides a dynamic assessment of cardiorespiratory function,
which is valuable in the assessment of patients and athletes alike. High
performance endurance athletes have high VO 2
max values that are
achieved through the development of significant cardiovascular and
metabolic advantages, which result in the delivery of large volumes of
oxygen to a highly tuned musculoskeletal system. Whilst patients fall short
of the physical fitness displayed by athletes, their performance in terms of
morbidity and mortality is in part determined by functional reserve. Thus
programmes of perioperative fitness training guided by CPET may yield
significant improvement in patient outcome. While the nation is focused on
the peak performance of a handful of elite athletes this summer, it would
be a positive legacy of the Olympic Games if some of this enthusiasm for
fitness was redirected to the spectators. Patients need to understand that
their engagement in physical fitness regimens may save their life one day.
Alasdair O’Doherty, Exercise Physiologist and Daniel Martin, Director
Centre for Altitude, Space and Extreme Environment Medicine, University
College London.

References
1. Older P, Smith R, Courtney P, Hone R (1993) Preoperative evaluation of cardiac failure
and ischemia in elderly patients by cardiopulmonary exercise testing. Chest. 104(3):
701-704.
2. Hennis PJ, Meale PM, Grocott MP (2011) Cardiopulmonary exercise testing for the
evaluation of perioperative risk in non-cardiopulmonary surgery. Postgraduate Medical
Journal. 87(1030):550-557
3. Bassett DR & Howley ET (1999) Limiting factors for maximum oxygen uptake and
determinants of endurance performance. Medicine and Science in Sports and Exercise.
32(1):70-84
4. Richardson RS, Harms CA, Grassi B, Hepple RT (2000) Skeletal muscle: master or slave
of the cardiovascular system Medicine and Science in Sports and Exercise. 32(1):89-
93
5. Noakes TD. (1998) Maximal oxygen uptake: “classical” versus “contemporary”
viewpoints: a rebuttal. Medicine and Science in Sports and Exercise. 30(9):1381-98.
6. Wasserman K, Hansen JE, Sue DY, Stringer WW, Whipp BJ (2005) Principles of Exercise
Testing and Interpretation, Including Pathophysiology and Clinical Applications.
Lippincott Williams & Wilkins. Fourth Edition.
7. Older P, Smith R (1988) Experience with the preoperative invasive measurement of
haemodynamic, respiratory and renal function in 100 elderly patients scheduled for
major abdominal surgery. Anaesthesia and Intensive Care. 16(4):389-95.
8. Myers J, Kaykha A, George S, Abella J, Zaheer N, Lear S, Yamazaki T, Froelicher V
(2004) Fitness versus physical activity patterns in predicting mortality in men. The
American Journal of Medicine. 117(12):912-
9. Arena R, Myers J, Guazzi M (2011) Cardiopulmonary exercise testing is a
core assessment for patients with heart failure. Congestive Heart Failure. 17(3):115-9.
10. Joyner MJ, Coyle EF (2008) Endurance exercise performance: the physiology of
champions. The Journal of Physiology. 586(1):35-44.
11. Steding K, Engblom H, Buhre T, Carlsson M, Mosén H, Wohlfart B, Arheden
H (2010) Relation between cardiac dimensions and peak oxygen uptake. Journal of
Cardiovascular Magnetic Resonance. 12:8-17
12. Schmidt W, Prommer N (2010) Impact of alterations in total hemoglobin mass on VO
2max. Exercise and Sport Science Reviews. 38(2):68-75.
13. Montgomery HE, Clarkson P, Dollery CM, Prasad K, Losi MA, Hemingway
H, Statters D, Jubb M, Girvain M, Varnava A, World M, Deanfield J, Talmud
P, McEwan JR, McKenna WJ, Humphries S (1997) Association of angiotensin-converting
enzyme gene I/D polymorphism with change in left ventricular mass in response to
physical training. Circulation. 96(3):741-7
14. Puthucheary Z, Skipworth JR, Rawal J, Loosemore M, Van Someren
K, Montgomery HE (2011) Genetic influences in sport and physical performance. Sports
Medicine. 41(10):845-59
ASA’s 71 st National
Scientific Congress
29 September - 2 October 2012, Hobart, AUSTRALIA
INTERNATIONAL SPEAKER
KA Kelly McQueen, M.D., M.P.H.
Dr McQueen has special interests in the
global burden of surgical disease, the
global anaesthesia crisis and the provision
of surgical care following disasters and
humanitarian crises.
INTERNATIONAL SPEAKER
Prof. Pierre Diemunsch
Dr Diemunsch is head of the Anaesthesia
Department at the University Hospital
of Hautepierre in Strasbourg, France.
Until June 2010 he was president of the
European Society of Airway Management
and is currently head of the Experimental
Anaesthesia Unit at the Institute for
Research on Cancers of the Digestive Tract.
For more information please visit www.asa2012.com
INTERNATIONAL SPEAKER
Dr Warren M Zapol, M.D.
Dr Zapol is the emeritus Anesthetist-in-Chief
at Massachusetts General Hospital and the
Reginald Jenney Professor of Anaesthesia
at Harvard Medical School. He is currently
the Director of the MGH Anesthesia Center
for Critical Care Research.
AUSTRALASIAN INVITED SPEAKER
Assoc. Prof. Simon Mitchell
Dr Mitchell is Head of the Department
of Anaesthesiology at the University of
Auckland. He is widely published in both
his fields of interest and his book chapters
include contributions to current editions of
Harrison’s Principles of Internal Medicine
and the American Physiological Society
Handbook of Physiology.
C
M
Y
CM
Important info:
ACCEA awards
NSC 2012 - AAGBI Anaesthesia.indd 1
Nicola Heard
Educational Events Manager
The 2012 round opened (eventually) on 28th May,
and closes at 1700 on Friday 17 August 2012.
ACCEA’s guides to the 2012 Round can be
downloaded from:
http://www.dh.gov.uk/health/2012/05/accea-guidance/
The online system can be accessed here:
Direct Line: +44 (0) 20 7631 8805
21 Portland Place, London W1B 1PY
T: +44 (0) 20 7631 1650
F: +44 (0) 20 7631 4352
E: nicolaheard@aagbi.org
w: www.aagbi.org
SAS Travel Grant 2012
The Association of Anaesthetists of Great Britain and Ireland
invites applications for the SAS Travel Grant for 2012. This is
a grant (up to a maximum of £2000) exclusively given for SAS
doctors to visit a place of excellence of their choice for two
weeks. This is not meant for attending a meeting or a conference.
All SAS doctors who are members of the AAGBI are eligible to
apply for the grant.
5/11/2012 10:37:59 AM
MY
CY
CMY
K
https://www.nhsaccea.dh.gov.uk/Pages/Default.aspx
All applicants should register and submit their CVQs
at the earliest opportunity.
Renewals: You must submit an application in this
round if your current award expires in 2013. ACCEA
has emphasised that those who are due to submit
a renewal application in the 2012 Round but fail to
submit an application or provide inadequate evidence
will not get a further opportunity to submit a renewal
application.
Applicants should complete an application form and return it to
the AAGBI. The successful applicant will be expected to submit a
report of the visit which may be published in Anaesthesia News.
If alternative funding becomes available for a project already
supported by the AAGBI, the AAGBI should be notified
immediately.
For further information and an application form
please visit our website:
http://www.aagbi.org/research/awards/sas-grade-anaesthetists
or email secretariat@aagbi.org
or telephone 020 7631 8807
Closing date: Monday 22nd October 2012

Particles
G McCartney, S Thomas, H Thomson, J Scott, V Hamilton, P Hanlon, D
Morrison, L Bond
The health and socio-economic impacts of major
multi-sport events: a systematic review (1978-2008)
British Medical Journal 2010 May 20;340:c2369
Over the next two years the United Kingdom will host the Olympic,
Paralympic and Commonwealth Games (London 2012, Glasgow 2014). The
massive expenditure involved in hosting such an event is difficult to justify
on the basis of entertainment and national showcasing alone1. A major
consideration for these cities when bidding to be hosts was the potential for
the games to generate a wide range of longer term benefits2-5 (the “legacy”).
These benefits include improvements in employment, the economy,
housing, the environment, sports provision and national and local pride.
These outcomes are key socio-economic determinants of health6, suggesting
that the investment involved has the potential to improve health. However
a recent re-examination of the likely benefits and relative costs of hosting a
major sporting event led the previous Olympics minister Tessa Jowell to say
“Had we known what we know now, would we have bid for the Olympics
Almost certainly not”1. The aim of this systematic review was to assess the
impact of major sporting events on the health, and determinants of health,
of the host population.
Methods
The authors searched all relevant sources for studies of any design that
assessed the health and socioeconomic impact on the host population of any
major multi-sport event occurring between January 1978 and January 2008.
Results
Fifty four studies met the review criteria and were included however the
quality of these studies was low. Only five studies reported on health related
outcomes and overall they did not indicate any clear negative or positive
health impacts of major sporting events on the host population. Eighteen
studies reported on economic outcomes; however the overall impact of
hosting such an event on economic growth and employment was unclear
from these studies. Six studies on transport showed that event related
interventions were associated with significant short term reductions in traffic
volume, congestion, or pollution in four out of five host cities.
Conclusions
The review found little evidence to suggest that the major multi-sport events
held between 1978 and 2008 led to health or socioeconomic benefits for
the host population, however there are only a small number of poor quality
studies. The authors conclude that until the long term evaluation of these
benefits is included in the design and implementation of major multi-sport
events the costs cannot be justified in terms of benefits to the host nation.
Dr Sarah Gibb
SpR4, Northern Deanery
References
1. Wintour P. We would not have bid for games during recession, says Jowell.
Guardian 13 November 2008. www.guardian.co.uk/uk/2008/nov/13/
olympics2012-recession
2. London candidate file. London 2012 Ltd, 2004.
3. People Place Passion. Glasgow 2014 Commonwealth Games candidate city
file. 2007.
4. The Scottish Government. Glasgow 2014-delivering a lasting legacy
for Scotland. A consultation paper. 2008. www.scotland.gov.uk/
Publications/2008/02/14115955/0
5. Department for Culture, Media and Sport. Before, during and after. Making
the most of the London 2012 Games. www.culture.gov.uk/images/publicati
ons/2012LegacyActionPlan.pdf
6. Dahlgren G, Whitehead M. Policies and strategies to promote social equity
in health. Institute of Future Studies, 1991.
Kim et al
Cardiac arrest during long-distance running races
New England Journal of Medicine 2012; 366: 130-40
The number of people participating in long-distance running has doubled
within the United States (US) over the last ten years. To date, studies have
demonstrated cardiac dysfunction following the race1,2 and cases of
cardiac arrest after only one or two events.3,4 This study aimed to determine
the incidence, aetiology and outcomes of cardiac arrests for all US longdistance
races during a ten-year period.
Methods
Data was collected prospectively from The Race Associated Cardiac Arrest
Event Registry (RACER), which was designed for the purposes of this study.
All cardiac arrests that occurred during running of a marathon (26.2 miles) or
half-marathon (13.1 miles), or within an hour after completion, between 1st
January 2000 and 31st May 2010 were studied. The clinical characteristics
of the arrests were identified from interviews with survivors and the next of
kin of non-survivors, the review of medical records and from post-mortem
data.
Results
10.9 million runners took part in marathons or half-marathons during the
study period. 59 participants suffered a cardiac arrest, giving an incidence
rate of 0.54 per 100,000 participants. Of those who suffered a cardiac arrest,
42 (71%) died. The incidence rate was significantly higher during marathons
(1.01 per 100,000) than half-marathons (0.27 per 100,000) and among men
(0.90 per 100,000) rather than women (0.16 per 100,000). Cardiovascular
disease accounted for the majority of cardiac arrests, with hypertrophic
cardiomyopathy the leading cause followed by coronary artery disease.
The two predictors of survival were an underlying diagnosis other than
hypertrophic cardiomyopathy and bystander CPR. Male marathon runners
had an increased risk of cardiac arrest during the second half of the study
decade compared with the first half (2005-2010, 2.03 per 100,000; 2000-
2004, 0.71 per 100,000).
Conclusions
The overall risk of cardiac arrest during long-distance races within the US
is low. The risk is higher during marathons than half-marathons. Cardiac
arrest is more likely to occur in male runners and is most commonly due
to underlying cardiovascular disease. One might expect survival rates to
improve with time although the opposite was shown, with an increase in
the incidence of cardiac arrests in male marathon runners. One reason
suggested was that higher risk men are starting to participate in these races.
These men may therefore benefit from pre-exercise screening, although the
cost of this may outweigh the benefit.
Dr Caroline Wilson
ST5 Anaesthetics, Oxford Deanery
References
1. Neilan et al. Myocardial injury and ventricular dysfunction related to
training levels among nonelite participants in the Boston Marathon.
Circulation 2006; 114: 2325-33
2. Mousavi et al. Relation of biomarkers and cardiac magnetic resonance
imaging after marathon running. American Journal of Cardiology 2009;
103: 1467-72
3. Roberts WO, Maron BJ. Evidence for decreasing occurrence of sudden
cardiac death associated with the marathon. Journal of the American
College of Cardiology 2005; 46: 1373-4
4. Maron BJ, Poliac LC, Roberts WO. Risk for sudden cardiac death associated
with marathon running. Journal of the American College of Cardiology
1996; 28: 428-31
Andre La Gerche, David L Prior, Hein Heidbuchel
Strenuous endurance exercise: is more better for
everyone Our genes won’t tell us.
Br J Sports Med 2011; 45:162-4
This editorial acknowledges that there is much compelling evidence for
the benefit of mild and moderate exercise on cardiovascular health and
mortality, but goes on to question whether the relationship continues into
intense competitive sport.
Blair et al [1] derived “strenuous exercise” from middle-aged non-athletic
populations, and predicted the maximum benefit at 9 METS in women and
10 METS in men (35ml/kg/min O2 consumption) - a mere 50% of a welltrained
athlete’s capacity. This is well below exercise levels that induce
cardiac remodelling. Studies [2,3] have found endurance athletes have
longer life expectancy than age-matched controls; however lifestyle factors
such as alcohol, cigarette smoking and body weight were all lower in the
athletes, and there were no studies in cardiovascular matched controls.
Farahmand et al [4] described a reduction in expected mortality among
competitive skiers in Sweden, but found no difference between the least and
most trained athletes.
Potential cardiac morbidity among competitive endurance athletes:
Permanent changes in cardiac structure
The changes in an athlete’s heart are in keeping with a proportional response
to the physiological load, but there is expansion of the extracellular matrix
resulting in permanent structural changes that may increase the risk of
arrhythmias. Ventricular dilatation progresses with continued training, and
may not regress with de-training [5]. Electrophysiological changes are also
in part due to intrinsic tissue changes.
Increase in cardiac arrhythmias
Strenuous endurance exercise is associated with an increased prevalence
of atrial fibrillation. There is also an increase in ventricular ectopy and/
or ventricular tachycardia. Heidbuchel et al [6] found serious arrhythmic
sequelae and sudden death among elite endurance athletes who presented
with complex ventricular arrhythmias. This was particularly associated with
right heart structural abnormalities.
Functional impairment
Multiple studies have demonstrated troponin and natriuretic peptide rises,
and changes in ventricular function post intense prolonged exercise. Whilst
left ventricular dysfunction is usually mild, right ventricular dysfunction Nicola Heard is
more frequent and severe. The authors question whether these Educational repeated Events Manager
insults could explain the chronic right ventricular injury and arrhythmias
Direct Line: +44 (0) 20 7631 8805
described in elite athletes.
Conclusion
21 Portland Place, London W1B 1PY
Although today’s sedentary western lifestyle is vastly different from T: +44 the (0) daily 20 7631 1650
activity required by humans of previous millennia, the editorial F: +44 argues (0) 20 7631 4352
that there is no precedent for the levels of sustained exertion E: nicolaheard@aagbi.org
demanded
by modern endurance sports, and that the human heart is programmed for
moderate exercise rather than inactivity or extreme exercise. w: www.aagbi.org
Dr Annemarie Docherty
ST5, Edinburgh
References:
1. Blair SN, Kohl HW, 3rd, Paffenbarger RS, Jr et al. Physial fitness and allcause
mortality. A prospective study of healthy men and women. JAMA
1989;262:2395-401
2. Sarna S, Sahi T, Koskenvuo M, et al. Increased life expectancy of world class
male athletes. Med Sci Sports Exerc 1993;25:237-44
3. Kujala UM, Tikkanen HO, Sarna S, et al. Disease-specific mortality among
elite athletes. JAMA 2001;285:44-5
4. Farahmand BY, Ahlborn A, Ekblom O et al. Mortality amongst participants
in Vasaloppet” a classical long-distance ski race in Sweden. J Intern Med
2003;253:276-83
5. Pelliccia A, Maron BJ, De Luca R et al. Remodelling of left ventricular
hypertrophy in elite athletes after long-term deconditioning. Circulation
2002;105:944-5
6. Heidbuchel H, Hoogsteen J, Fagard R, et al. High prevalence of right
ventricular involvement in endurance athletes with ventricular arrhythmias.
Role of an electrophysiologic study in risk stratification. Eur Heart J
2003;24:1473-80
Evelyn Baker Medal
An award for clinical competence
The Evelyn Baker award was instigated by Dr Margaret Branthwaite in 1998, dedicated
to the memory of one of her former patients at the Royal Brompton Hospital. The
award is made for outstanding clinical competence, recognising the ‘unsung heroes’
of clinical anaesthesia and related practice. The defining characteristics of clinical
competence are deemed to be technical proficiency, consistently reliable clinical
judgement and wisdom and skill in communicating with patients, their relatives
and colleagues. The ability to train and enthuse trainee colleagues is seen as an
integral part of communication skill, extending beyond formal teaching of academic
presentation. Nominees should normally still be in clinical practice.
Dr John Cole (Sheffield) was the first winner of the Evelyn Baker medal in 1998,
followed by Dr Meena Choksi (Pontypridd) in 1999, Dr Neil Schofield (Oxford) in
2000, Dr Brian Steer (Eastbourne) in 2001, Dr Mark Crosse (Southampton) in 2002,
Dr Paul Monks (London) in 2003, Dr Margo Lewis (Birmingham) in 2004, Dr Douglas
Turner (Leicester) in 2005, Dr Martin Coates (Plymouth) in 2006, Dr Gareth Charlton
(Southampton) in 2007, Dr Neville Robinson (London) in 2008, Dr Fred Roberts
(Exeter) in 2009, Dr Sudheer Medakkar (Torquay) in 2010 and Dr Keith Clayton
(Coventry) in 2011.
Nominations are now invited for the award to be presented at WSM London in
January 2013 and may be made by any member of the Association to any practising
anaesthetist who is also a member of the Association. Examples of successful
previous nominations are available on request, and should include an indication that
nominee has broad support within their department.
The nomination, accompanied by a citation of up to 1000 words,
should be sent to the Honorary Secretary at
honsecretary@aagbi.org
by 5pm on Monday 17th September 2012.
36 Anaesthesia News July 2012 • Issue 300 Anaesthesia News July 2012 • Issue 300 37

“Traditionally it has been felt that diabetics, especially those over 35 years of age, cannot
succeed at the highest level of athletic endeavour. However, there is now a sufficient
number of professional athletes, Olympic gold medallists and world champions, with
type 1 diabetes to make us question the limits of the disease process.” 1
DIABETES
AND SPORT:
MORE THAN
JUST GOOD
GLUCOSE
CONTROL
If you ask the vast majority of doctors about
the outpatient management of diabetes they
will think primarily of glucose control for
both short term quality of life and prevention
of longer term complications. They would
espouse exercise as part of improving general
health, but is exercise with diabetes quite that
simple 2 Both Type 1 and type 2 diabetes
are becoming more prevalent throughout
the western world. 3 Management of type 1
diabetes has improved dramatically over
the past 20 years leading to both improved
morbidity and improved quality of life. 4
Exercise and sport is considered good for the
health of both healthy and diabetic individuals
however even simple exercise as a diabetic is
fraught with challenges. 5
all of the four previous Olympic games. He
was in the peak of his sporting career when
he developed insatiable thirst, polyuria,
weight loss and a marked loss of athletic
performance. He was diagnosed with
diabetes and started on a treatment regime of
rapid and intermediate acting subcutaneous
insulin.
Challenges
Originally he started on a basal bolus regime
that would be familiar to most clinicians: twice
daily Isophane insulin (e.g. Insulatard) and
Lispro insulin (e.g. Humalog) with meals;
which resulted in ‘good’ glycaemic control
with a low HbA1C and daytime blood sugars
ranging from 4-10. Improving glycaemic
control has previously been shown to
improve general physical performance 7 . After
the first month on this regimen significant
problems were encountered- he suffered
from hypoglycaemia after extended exercise
(not an insignificant issue for a rower) and
suffered a marked loss of performance and
unexpectedly high heart rate whilst exercising.
These symptoms are attributed in the article to
three different causes:
for exercise, especially if unscheduled. Gallen
describes severe hypoglycaemia after rowing
with otherwise good glycaemic control and
no significant hypoglycaemic episodes
outside exercise periods. This was attributed
to excessive intermediate acting insulin with
conversely too little rapid acting insulin.
Crucially if the long acting insulin dose is too
high (and shorter acting too low) for the given
activity level, then blood glucose levels will
trend downwards unless additional food is
eaten. However this can result in a relatively
normal HbA1C as the blood glucose rises
again after a meal and results in a relatively
“normal” average.
Table 1 shows the duration (in minutes)
of each activity that would require 15g of
extra carbohydrate to prevent blood sugar
from falling- assuming the insulin regimen
is the same as on a non- exercising day. 9
Therefore preventing hypoglycaemia during
exercise requires either an increased
carbohydrate intake pre-exercise (commonly
used in the general population) or a decrease
in the dose of intermediate acting insulin - the
latter was the most appropriate option for
Steven Redgrave as his daily exercise levels
were both high and comparatively consistent.
This can also be achieved by using an insulin
pump, capable of storing sufficient different
settings, to vary the basal insulin rate – more
on this later.
Hyperglycaemia would perhaps be less
expected during strenuous exercise, however
it is a high-risk state for DKA due to the high
intracellular glucose usage and relative
dehydration. There must be enough insulin
available to stimulate glucose absorption into
the muscles either from rapid acting insulin or
a slightly higher basal rate regimen. 10
Table 2 illustrates the energy expenditure
during an hour of exercise in different
sports by a typical adult. Rowing is
markedly more intense than the examples
below and training to Olympic standard
even more so. Steven Redgrave ate
around 7,000 calories a day pre- diabetes
diagnosis and weighed 105kg, very little of
which was fat!
Poor Hepatic Glucose Mobilisation
Steven Redgrave proved an ideal subject in
whom to investigate the effects of diabetes
on sporting performance, as detailed records
of his pre-diabetic performance existed. His
cardiovascular, respiratory and muscular
response to exercise remained unchanged.
However the mobilisation of glucose in the
liver through gluconeogenesis was impaired.
In diabetes, the high level of peripheral insulin
required to maintain normoglycaemia can
suppress central fuel mobilisation during
exertion, and storage of glucose in the liver
during rest periods. Equally the counterregulatory
hormone response to exercise,
essential for gluconeogenesis and lipolysis,
may be impaired in type 1 diabetes with a
notable decrease in glucagon release. 12,13 In
Steven Redgrave, 25% of the energy required
for intense exercise previously came from
his liver and this was not being achieved in
post diagnosis exercise. Therefore additional
glucose stores needed to be laid down in the
liver. This was achieved by taking in additional
carbohydrate and insulin immediately after
exercise so as to take advantage of the
relative insulin resistance of skeletal muscle
at this time.
Variability in Insulin Absorption
One final issue not addressed by Gallen is
variability of absorption of subcutaneous
insulin. 14 Under similar conditions, most
insulins are absorbed from the subcutaneous
tissues at a reasonably predictable rate.
However in the exercising body increased
temperatures, increased muscle movement
and accidental massage of the injection site
can cause increased insulin absorption and
unexpected hypoglycaemia.
the disadvantage of needing to be connected
at all times and run a much higher risk of DKA
if the pump (or tubing) fails. 8
Key Points
• Diabetic athletes are capable of
achieving a similar level of sporting
prowess that they could achieve without
diabetes – with the right support.
• More than simple “good glycaemic
control” is required for optimum sporting
performance.
• Multiple injections of rapid acting insulins
or a pump is generally necessary.
• Careful attention to both insulin and diet
are important.
• Diabetes affects the entire blood sugar
homeostasis system.
Conclusion
Diabetes is a chronic disease that greatly
impedes a person’s capability to lead a
“normal” life but the achievements of Steven
Redgrave are a testament to the fact that it
does not have to prevent sporting excellence.
The disadvantages can be overcome with
careful planning, support and perseverance.
Steven Redgrave is an advocate for diabetics
in sport and his achievements encourage
everyone living with the disease to achieve
their own potential.
Michael Harrison FY2
Michael Macmahon
Anaesthetic SpR
Edinburgh Royal Infirmary
Recommended reading
• http://www.runsweet.com/
A site for people with diabetes with a focus on sport,
providing information on diabetes and sport as well as
other diabetic issues.
• Type 1 Diabetes in children, adolescents and young
adults. Dr Ragnar Hanas (8)
References
1. Pierce NS. Diabetes and Exercise. British Journal of
Sports Medicine. 1999; 33: 161-173
2. Scottish Intercollegiate Guidelines Network. Management
of Diabetes: a national clinical guideline. www.sign.ac.uk
- March 2010.
3. Patterson et al. Variation in trends and incidence of
childhood diabetes in Europe. The Lancet. 355: 873-876
4. Harjutsalo V, Forsblom C, Groop PH. Time trends in
patients with type 1 diabetes: nationwide population
based cohort study. BMJ 2011 Sept 8
5. Dube M, Lavoie C, Galibois I, Weisnagel S. Nutritional
strategies to prevent hypoglycaemia at exercise in
Diabetic adolescents. Medicine and Science in Sports
and Exercise. February 2012 (e-publication)
6. Gallen I, Redgrave A, Redgrave S. Olympic diabetes.
Clinical Medicine. 2003;3: 333–7
7. Barkai L, Peja M. Impaired work capacity in diabetic
children with autonomic dysfunction. Lecture, ISPAD,
atami, Japan 1994.
8. Hanas R. Type 1 Diabetes in children, adolescents and
young adults. 4th edition. Class publishing, London.
9. Riddell M, Iscoe K. Physical activity, sport and paediatric
diabetes. Pediatric diabetes. 2006;7:60-70
10. Wasserman D, Zinman B. Exercise in individuals with
IDDM. Diabetes Care. 1994: 17924-37
11. Riddell MC, Bar-Or O, Gerstein HC. Heigenhauser GJ.
Physical activity, sport and paediatric diabetes. Pediatric
Diabetes. 2006;7:60-70
12. Ahlborg G, Lundberg JM. Exercise-induced changes in
neuropeptide Y, noradrenaline and endothelin-1 levels in
young people with type I diabetes. Clinical Physiology.
1996;16:645–55.
13. Koivisto VA, Sane T, Fyhrquist F, Pelkonen R. Fuel and fluid
homeostasis during long-term exercise in healthy subjects
and type I diabetic patients. Diabetes Care 1992;15:1736–
41.
14. Frid A, Gunnarsson R, Gunther P, Linde B. Effects of
accidental intramuscular injections on insulin absorption
in IDDM. Diabetes Care 1988; 11:41-45
Ian Gallen, Ann Redgrave and Steven
Redgrave published their account of the
challenges faced by the oarsmen as a new
diabetic - not only to continue exercising but
Insufficient Carbohydrate
also to achieve sporting performance similar to
The usual approach when managing
his prestigious pre-diabetic level, and indeed
diabetes is to aim for normoglycaemia. In
go on to win a fifth Olympic gold medal! 6 They
an athlete this may render the blood sugar
discuss the commonly addressed issues of
close to normal but the total carbohydrate
good glycaemic control and exercise induced
intake may not be sufficient to fuel their level Alternative Options
hypoglycaemia but also the complexities of
of activity. Steven Redgrave was originally Steven Redgrave originally considered using
glucose mobilisation during exercise and Too much or too little insulin
eating 4 meals a day including about 6-8 an insulin pump, but decided against it due
sustaining high performance. This article Most common basal bolus regimes use long
units worth of carbohydrate. However he to bulk and lack of comparable experience.
uses the experience and challenges faced by acting insulin injections once a day to provide
began to experience a profound drop off in However insulin pumps have moved forward
Steven Redgrave to examine the issues faced a continuous background level of blood insulin
performance during sustained exercise in the such that small, waterproof devices exist,
in diabetes and sport.
through the day, and injections of faster acting
absence of hypoglycaemia. It was felt that indeed there are some with connections to
insulins to absorb the carbohydrates ingested
he was simply not eating sufficient calories continuous interstitial blood glucose monitors.
Background
at meals. 8 This can allow good variation in
and they increased the amount of both Pumps allow a much easier adjustment of
Steven Redgrave was 35 and a successful insulin doses depending on carbohydrate
carbohydrate and rapid acting insulin used to basal insulin rates depending on exercise
rower who had won Olympic gold medals at intake but is much harder to vary to account
5-6 injections of up to 16 units.
and allow for many smaller boluses without
the need for additional injections; but have
38 Anaesthesia News July 2012 • Issue 300 Anaesthesia News July 2012 • Issue 300 39
Activity
Body Weight
20kg 40kg 60kg
Basketball game 30 15 10
Cross country skiing 40 20 15
Cycling (15km/h) 45 25 15
Ice-hockey 20 10 5
Tennis 45 25 15
How much energy is spent exercising (kcal per hour) (11)
Slow walking 100-200
Cycling 250-300
Dancing 300-400
Tennis 400-500
Gym 500
Jogging & downhill skiing 500-600
Cross country skiing 800-1000

The Association of Anaesthetists of Great Britain & Ireland
19-21 Sept 2012
ANNUAL CONGRESS
BOURNEMOUTH
Bournemouth International Centre
This year’s Annual Congress comes to one of England’s
most vibrant and cosmopolitan seaside resorts.
Bournemouth has seven miles
of beaches, award winning
gardens and a vast variety of
shops, restaurants and bars.
Lecture topics include:
• National Audits (including NAP5) • The older patient
• Pain management • Shared decision making in high risk surgical patient
• Law and Ethics • Obstetrics • Revalidation • Papers you should know about
• Wellbeing • Problem-based learning and Critical Incident case reports
• Plus sessions organised by the Association of Surgeons of Great Britain
and Ireland (ASGBI) and the British Geriatric Society
www.annualcongress.org
Scientific programme
Multiple streams of lectures
Debates
Hands-on workshops
Industry exhibition
Poster and abstract presentations
CPD approved
Annual dinner and dance
SAVE THE DATE! 18-20 SEPTEMBER 2013