Returning to work after a major illness Which logbook? John ... - aagbi

EditorialThe gentle art of feedbackAppraisal season is in full swing in myTrust (and presumably most others) as Iwrite; I have so far done two of the fourI am scheduled to do and have made noprogress towards getting mine done. Thedeadline for completing this task is twoweeks hence; so with lots of effort it shouldbe possible to get them done. Appraisingmy colleagues is generally a prettyhumbling experience; I am reminded howhard we work, how seriously we take ourwork and on occasion how little we arevalued, or more accurately perhaps, howlittle we perceive ourselves to be valued.Appraisal has given us a great opportunityto help correct this perception – I do notsubscribe to the belief that appraisal hasbeen a waste of time and money to date.Appraisal could be significantly improvedhowever, if assessment data were moreclearly available, as this would enable theappraiser to challenge appraisee’s views ofthemselves which are not in accord withthose of others. It is clearly stated as anobjective for revalidation that appraisal willbe the basic mechanism for revalidating,and that this should be informed by robustdata, including multisource feedback (MSF)[1].The recent history of various forms of MSFin my Trust and Deanery are not, however,encouraging, and I think that we faceconsiderable difficulties in implementingthis aspect of revalidation. For example; ithas recently been agreed in my departmentthat trainees would have the opportunityto provide individual feedback about theirtrainers. Not before time, many of you maybe thinking; this is hardly a novel ideaeducationally and is embedded into theeducational system in many Deaneries.However, it was accepted somewhatgrudgingly by my department, and withthe option for individual consultants to optout. Within the Deanery, evidence thatone of our trainees was in difficulty basedon consultant feedback (a form of MSF)was apparently dismissed by the Dean as‘too subjective’ at a recent ARCP review.The wholesale introduction of MSF forContents03 Editorial05 Two decades of Specialty Doctors within theAAGBI08 2010 ASRA Guidelines10 GAT - Which? Logbook12 Returning to work following a major illness15 Quality information tailored to your needs:an update on NHS Evidence17 Particles18 The History Page - Diethyl ether: down but notquite out?21 An interesting, exciting and varied role inEthiopia22 The Transfusion Alternatives Preoperatively inSickle Cell Disease Study (TAPS)24 Anaesthesia for cancer patients28 Anaesthesia Digested29 John Snow's Surviving Ether Vaporizers15 32The Association of Anaesthetistsof Great Britain and Ireland21 Portland Place, London W1B 1PYTelephone: 020 7631 1650Fax: 020 7631 4352Email: anaenews@aagbi.orgWebsite: www.aagbi.orgAnaesthesia NewsEditor: Val BythellAssistant Editors: Susan Williams (GAT),Isabeau Walker and Felicity PlaatAdvertising: Claire Elliottanaenews.advertising@aagbi.orgDesign: Amanda McCormickMcCormick Creative Ltd,Telephone: 0845 271 2883Email: mail@mccormickcreative.co.ukWebsite: www.mccormickcreative.co.ukPrinting: C.O.S Printers PTELtd – SingaporeEmail: terence@cosprinters.comCopyright 2010 The Association ofAnaesthetists of Great Britain andIrelandThe Association cannot be responsiblefor the statements or views of thecontributors.No part of this newsletter may bereproduced without prior permission.Advertisements are accepted in goodfaith. Readers are reminded thatAnaesthesia News cannot be heldresponsible in any way for the qualityor correctness of products or servicesoffered in advertisements.Anaesthesia News May 2010 Issue 274 35 18

Two decades ofSpecialty Doctorswithin the AAGBIWhen I qualified in medicine in 1973 Iintended to become a surgeon and workin one of the Third World countries. I didnot intend to get married three years later,have three children in the next three years,or move house and country of domicilenine times in seven years. Neither wasbecoming a Non Consultant Career Grade(then SAS 2002 and now Specialty Doctor2008) Associate Specialist in Anaesthesiamy ultimate career aspiration. Indeed, Ihad never heard of the grade and probablywould not have wanted to enter it if I’dknown the faintest thing about it or how itwas perceived by the rest of the profession(and some within it) in 1990. But life isa series of roads less travelled and anAssociate Specialist is what I becameand my career as one has been endlesslyrewarding; such that I do not regret for onemoment the path it has taken.Perhaps I would feel differently and beless positive if I had tried to become thesurgeon I intended to be instead of ananaesthetist (anaesthesia being the nearestspecialty to surgery I could think of) andif I did not belong to a forward thinkingspecialty with a strong sense of communityand having a supportive and egalitarianorganisation to represent it.After obtaining Fellowship in 1990, Imoved to my current post at FrenchayHospital Bristol and encountered someiconic figures in Anaesthesia such as JohnZorab and Peter Baskett (a Past Presidentand a subsequent President of AAGBI)and Peter Simpson (subsequently Presidentof the Royal College of Anaesthesia andChair of PMETB). I identify them all asbeing profoundly influential not only in mypersonal career development, but also inthe wider improvements to status, visibilityand representation of all SAS Anaesthetists.Just as I arrived in Bristol as an AssociateSpecialist, Peter Baskett became AAGBIPresident and had set up a Working Partyto produce one of the legendary AAGBI‘’glossies’’ on Non Consultant CareerGrade Anaesthetists. He did not have tolook too far across the department to finda suitable NCCG participant in myself. Thatworking party, chaired by Peter Morris,published its recommendations as an A3document in 1993. This was revised byanother group chaired by Bob Bucklandin 1998, revised again by a group chairedby Les Gemmell in 2008, and now appearsas the 2008 SAS Handbook. Each ofthese Chairmen was sincerely committedto enhancing the image of the SAS andimproving the services offered to them byAAGBI. Perhaps, as a reflection of how farwe as a group have progressed over theyears, it is worth noting that the Handbookis now A4: twice the size and, hopefullygenerating twice the impact of those earlyproductions.One thing led on to another and, by theend of the 90s, the Royal College andJohn Curran in particular, had also startedexploring how it could better identifyand engage with SAS anaesthetists andI had become involved in that arena as aknown member of the grade. An NCCGdevelopment day took place and anNCCG committee, initially ad hoc butsubsequently a recognised sub-committeeof RCoA, was established. Having startedoff the blocks slightly later than AAGBI onNCCG matters, it looked as though theKate BullenCollege had stolen a march on us by settingthis up and that more needed to be doneby AAGBI if it was to establish a continuingNCCG presence within its body.In 2000 I stood for one of the seats onAAGBI Council and, to my surprise anddelight was elected and remained inplace until 2005. As well as representingthe views of our group effectively withinour professional organisation, securing acontinuing presence that was not based onrandom electoral success, was a priorityaim.The AAGBI NCCG (SAS) committee wasestablished without dissent in 2002,chaired by me in the first instance andsubsequently by Ramana Alladi. The RCoAestablished 2 SAS seats on its Council inthe same year. We go from strength tostrength both in membership numbers andin having a voice in so many other arenas.Virtually all Royal Colleges now have SASgroups, some have Council seats and theBMA has an individual Branch of PracticeAnaesthesia News May 2010 Issue 274 5

committee (SASC). SAS have a permanentpresence in PMETB (both members areanaesthetists), MEE and there are now SASClinical Tutors and Associate Deans acrossthe nations. NHSCE regularly consults withthe SAS and our voice is heard whereverprofessional matters are discussed fromthe Trusts and Deaneries to the GMC andDepartment of Health.None of this advance would have beenachieved if AAGBI had not been thefirst organisation to take steps towardsrecognition of our group and ensuring thatwe were appropriately represented andsupported. Few of us, who have had theprivilege to speak on your behalf and worktowards SAS advancement, would havesucceeded to the same degree withoutthe vision, support and encouragement ofthose individuals I have named or the manyothers I have not named because the listwould be so long.Well done AAGBI and well done all thoseSAS who saw a gap in the wall and strodethrough it. I am confident that we willcontinue to prosper in an uncertain andchallenging future as long as we believe inourselves and in our value as SAS doctors.Dr Kate BullenGlossary of termsAAGBI: Association of Anaesthetists ofGreat Britain and IrelandRCoA: Royal College of AnaesthetistsNCCG: Non Consultant Career GradeDoctorsSAS: Staff and Associate SpecialistsSASC: BMA Staff and Associate SpecialistCommitteeBMA: British Medical AssociationPMETB: Postgraduate Medical Educationand Training BoardMEE: Medical Education:EnglandNHSCE: NHS Confederation of EmployersGMC: General Medical CouncilMeeting ReportAAGBI Current Topics, BMA House4th-5th March 2010What a meeting!!!!An extensive two day programme attractedover 200 delegates (some from overseas)was organised by the Chairman of the SAScommittee Dr Ramana Alladi to mark the10th Anniversary of the SAS committee.The first day included four sessions onthe heart and anaesthesia,an update onemergency anaesthesia, ‘SAS matters’ andconcluded with future trends in day casesurgery, fast track colorectal surgery and theWHO checklist.The second day started with a veryinteresting walk through the history of theSAS grade and development of SAS grade byKate Bullen.A wide range of topics was covered overtwo days; delegates also had the choice ofattending workshops on the difficult airway,ultrasound and TIVA.The Meeting dinner on the Thursday eveningwas a real treat for those who attended - asmall group of forty people. With an Indiantheme, the fantastic food along with liveentertainment to match made the eveningmemorable. A group of young dancersperformed an Indian classical dance“Bharatnatyam” which was thoroughlyappreciated by the crowd while enjoyingthe meal.Although it is difficult to choose a highlightfrom such a varied programme, we thinkthe best was saved till the last. Dr WilliamHarrop-Griffiths and Dr John Hardman leadus in lively discussions around some ‘TrickySituations’. In turn, they each presentedvarious ‘tricky’ situations, which they hadfaced in their own clinical practice. Theyasked a panel, and then the audience, ‘Whatwould you do?’ It was a very successfulsession, to the point that when we weregiven the option of finishing early on Fridayevening, or continuing until the plannedfinish time of 5pm, the overwhelmingmajority voted to carry on! It is a session wewould highly recommend if it were ever tobe repeated.In conclusion, it was a very interesting andinformative meeting, with good speakersand lively interactions. The meeting provedto be both productive and enjoyable andcertainly worth the trip.Maria Garside, Specialty Doctor,Bradford Royal Infirmary.Smita Oswal, Associate Specialist,Bradford Royal Infirmary6 Anaesthesia News May 2010 Issue 274

The Mersey MenuPrimary MCQ Week 18 – 23 MayAintree Hospitals, Liverpool.Final FRCA Viva Weekend 11-13 JuneAintree Hospitals, Liverpool.Private SBA Faculty Weekend 24 – 25 JulyAintree Hospitals, LiverpoolFinal MCQ Week 8 – 13 AugustAintree Hospitals, LiverpoolPrivate SAQ and E&SAQ Weekend 13 – 15 AugustAintree Hospitals, LiverpoolFinal Revision (Booker)Course Week 15 – 20 AugustLiverpool Medical InstitutionPrivate SAQ and E&SAQ Writers Club Weekend 20 – 22 AugustAintree Hospitals, LiverpoolPrimary MCQ Week 22 – 27 AugustAintree Hospitals, LiverpoolFinal E&SAQ Weekend 27 – 29 AugustAintree Hospitals, LiverpoolPrimary OSCE Weekend 3 – 5 SeptemberAintree Hospitals, LiverpoolPrimary FRCA Viva Weekend 17 – 19 SeptemberAintree Hospitals, LiverpoolPrimary FRCA OSCE/Orals Week 24 September – 1 OctoberVenue – To Be ArrangedFor Information on all MSA Courses - msoa.org.ukAnaesthesia News May 2010 Issue 274 7

2010 ASRAGuidelineson Regional Anaesthesia in the PatientReceiving Antithrombotic orThrombolytic TherapyThe American Society of RegionalAnesthesia and Pain Medicine (ASRA)recently convened its Third ConsensusConference on Regional Anesthesia andAnticoagulation and published updatedguidelines in the setting of antithromboticand thrombolytic therapy. These guidelinesapply to neuraxial, plexus and peripheralregional techniques in both the surgicalpatient and the parturient and can besummarized as follows:Anaesthetic management of thepatient receiving thrombolytictherapyIn patients who have received fibrinolyticand thrombolytic drugs, neuraxialtechniques should be avoided except inhighly unusual circumstances.In patients who have received neuraxialblocks at or near the time of fibrinolytic orthrombolytic therapy, neurologic checksshould be done at 2 hourly intervals.Fibrinogen levels should be measuredbefore catheter removal.Anaesthetic management of thepatient receiving unfractionedheparin(UFH)Subcutaneous UFHThere is no contraindication to the use ofneuraxial techniques in patients receivingprophylaxis with 5000 U of subcutaneousUFH twice daily.The safety of neuraxial blockade in patientsreceiving doses greater than 10,000 U ofUFH daily or more than twice daily dosingof UFH has not been established.In view of the risk of heparin-inducedthrombocytopenia, it is recommended thata platelet count is assessed before neuraxialblock or catheter removal in patientsreceiving UFH for 4 days or more.Intravenous UFHIf a patient needs intraoperativeanticoagulation with heparin,administration should be delayed for atleast 1 hour after needle placement.Indwelling catheters should be removed2 to 4 hours after the last heparin dose;re-heparinization should be delayed forat least 1 hour after catheter removal.Use of minimal concentrations of localanaesthetics in this setting will facilitate theearly detection of a spinal haematoma.Anaesthetic management of thepatient receiving low molecularweight heparin (LMWH)There is no need for routine monitoringof the anti-Xa level. Concomitantadministration of antiplatelet drugs, heparinor dextran should be avoided regardless ofLMWH dosing regimen.Preoperative LMWH – Neuraxial blockadeshould be performed no sooner than 10-12hours after a prophyactic dose or 24 hoursafter a higher therapeutic dose of LMWH.Postoperative LMWH – For twice dailydosing the first dose of LMWH shouldbe administered no earlier than 24 hourspostoperatively, regardless of anaesthetictechnique. Catheters should be removedbefore initiation of LMWH and doseadministration should be delayed for 2hours after catheter removal.For single daily dosing the first postoperativeLMWH dose should be administered 6-8hours postoperatively. Catheters should beremoved a minimum of 10-12 hrs after thelast dose of LMWH and subsequent LMWHdosing should not occur before a minimumof 2 hours.Anaesthetic management of thepatient on oral anticoagulantsOral anticoagulant therapy should bestopped 4-5 days before a procedure andthe INR should be normalized beforeinitiation of a neuraxial technique.When thromboprophylaxis with warfarin isinitiated, neuraxial catheters should ideallybe removed when the INR is less than1.5. If the INR is between 1.5-3, removalof indwelling catheters should be donewith caution and only in the absence ofother drugs that influence hemostasis, andneurologic status should be monitored bothbefore catheter removal and continueduntil the INR has stabilished at the desiredlevel. If the INR is greater than 3, warfarindose should be held or reduced in patientswith indwelling catheters.Anaesthetic management of thepatient on antiplatelet medicationThere are no specific concerns with NSAIDsin the setting of neuraxial anaesthesia .8 Anaesthesia News May 2010 Issue 274

LimitedPlacesIn patients receiving NSAIDS, the recommendation is againstthe performance of neuraxial techniques if the concurrentuse of other medications affecting clotting mechanisms, suchas oral anticoagulants, UFH, and LMWH, is anticipated inthe early postoperative period.Ticlopidine should be discontinued 14 days before neuraxialblockade and clopidogrel 7 days before. Neuraxialtechniques should be avoided in patients on platelet GP IIb/IIIa inhibitors until platelet function has recovered.Anaesthetic management of the patient on herbaltherapyThere is no need to avoid neuraxial techniques in a patienton herbal medication.Anaesthetic management of the patient receivingthrombin inhibitorsIn patients receiving thrombin inhibitors the recommendationis to avoid neuraxial techniques.Anaesthetic management of the patient receivingfondaparinuxThe actual risk of spinal hematoma with fondaparinux isunknown. Until further clinical experience is available,performance of neuraxial techniques should occur underthe conditions used in clinical trials (single-needle pass,atraumatic needle placement and avoidance of indwellingneuraxial catheters). If this is not feasible, an alternatemethod of prophylaxis should be considered.Reference: Terese T. Horlocker et al.Regional Anesthesiain the Patient Receiving antithrombotic or ThrombolyticTherapy. American Society of regional Anesthesia and PainMedicine Evidence-Based Guidelines (Third edition).Reg Anes Pain Med.2010;35(1):64-101.Editor’s noteDr Nageswaran NarayananConsultant AnaesthetistSt Vincent’s University Hospital, DublinASRA Practice Advisories are excellent sources of up to dateinformation but they are in no way binding for anaesthetistsin the UK and Eire. It is also worth noting that this guidelinedoes not really mention peripheral nerve blocks.The AAGBI has a working party in progress on "Regionalanaesthesia in patients with abnormalities of coagulation"which will most likely be producing a report (glossy)towards the end of this year. This report will not restrictitself to neuraxial blocks in patients undergoing therapeuticanticoagulation but will also address pathological conditionsand peripheral nerve blocks. Any AAGBI member who wouldlike to comment on this should contact the chair, Dr WilliamHarrop-Griffiths, via secretariat@aagbi.org marking thee-mail “FAO William Harrop-Griffiths” in the subject line.Are proud to presentKnO2wledge VLessons from life at the limitA TRULY EXTRAORDINARY TWO DAYINTERNATIONAL CONFERENCE11-12 May 2010The Royal Society of MedicineLondoneventsThirst for Knowledgewww.tfke.co.ukCPD ApprovedCONFIRMED KEY NOTE SPEAKERS:Professor John W. Severinghaus –San FranciscoThe discovery of OxygenProfessor John B. West –San DiegoAltitude Research: a historical pespectiveALSO FEATURING A REMARKABLE INTERNATIONALFACULTY OF EXPERTS INCLUDING:Professor Paulo Ceretelli – MilanProfessor Hans Hoppeller – BerneProfessor Brian Whipp – TredegarProfessor Cecilia Gelfi – MilanProfessor Jim Milledge – LondonProfessor Erik Swenson – SeattleProfessor Can Ince – AmsterdamProfessor Hugh Montgomery – LondonDr Mike Stroud – SouthamptonDr Mike Grocott – LondonDISCUSSING MANY TOPICS INCLUDING:The Caudwell Xtreme Everest ResultsTranslational implications for hypoxic patientsPlaces will be limited at this conference and weanticipate a large demand for delegate places.organised bySecure your place today by going online atwww.ebpom.orgor calling the booking hotline on0845 054 8422supported byAnaesthesia News May 2010 Issue 274 9

GATWhich ?LOGBOOKByMike MacMahonST4 in Anaesthetics and GAT representativeRecent developments in the technologymarket, especially the ubiquity of theiPhone, have changed the way in whichmany anaesthetists use their logbooks.In addition, several web-based sites havebeen developed that offer additionalbenefits to older models of logbook. Aswell as the clear need for trainees to keepan accurate and up-to-date logbook, manyconsultants who haven’t kept a logbooksince their CCT may also be interested inthe evolving technology in the context ofrevalidation looming large.The 2008 article by logbook gurusHammond and McIndoe i in the RCoA‘Bulletin’ covers most of the details aroundthe traditional logbooks available throughwww.logbook.org.uk. The newer logbooks,by comparison, make the generic RCOAmodel that many of us ‘grew up’ on look alittle cumbersome. This article presents abrief critique of some of the other optionsavailable and directs readers to sources offurther information or product download.As a starting point, it is worth consideringthe concept familiar to those studying forthe primary FRCA of ‘the ideal logbook’,the characteristics of which are:Ease of data input – Time is money, andlogbooks that are slow to input data areinstantly inferior.Safety of data – A system for backingup data that is either automatic or veryeasy to achieve. The data can be savedonto a hard-drive, portable devices, andincreasingly, the internet for safe-keeping.Data protection – Keeping patientidentifiabledata is a hot topic at present,and will be discussed below. The data-setshould be the minimum required to satisfyits purpose, and should be kept in a secureplace.Mobility – Taking lists home and typingthem up is time consuming, souldestroyingand is a potential breach ofconfidentiality. Point of care insertion ofinformation is important.Reports – The system must be able toproduce reports containing the informationneeded for ARCPs or revalidation,preferably in an attractive and user-friendlyway. Being able to isolate specialties,cases or date ranges is also valuable.Specialist Areas – The difficulty ofinputting data from areas outside theatreis a common problem with ‘traditional’logbooks. Separate data entry fields forregional anaesthesia, obstetrics, intensivecare and pain, whilst currently possibleby using separate logbooks, are usefuladditions to a generic anaesthetic logbook.Flexibility – The ability to tailor one’slogbook to individual needs is a popularrequest.Extra Data Recording – Recording thesuccess of a technique is essential toimproving practice. The CUSUM scoringfor regional techniques is one method ofintegrating such a facility into the logbook ii .Money- A logbook should be cheap or freeto install, and require little or no annualsubscription.PORTABLE LOGBOOKSiGas log 1.2This has emerged over the past year anda half as a real favourite, even for thosetechnophobes amongst us. Its ease ofuse and speed of data input coupled withthe instant access of the iPhone (in themajority of anaesthetists’ pockets) accountfor this success.It also appears to keep data relatively safe(providing you don’t lose your iPhone) asthere have been few reports of data losswith phone retention!On the downside, this system makes it alittle awkward to backup data onto a PChard drive. It can be done, but is certainlyconvoluted enough to dissuade somepeople (for details see YouTube video – thekey is to manually save the exported filefrom the web portal to the hard drive as a.csv file).The reports, whilst including all essentialinformation, are visually unattractive.10 Anaesthesia News May 2010 Issue 274

There is little flexibility in the programmeto allow for specialist areas or custom datacollection. It is also not cheap at £17.99(via iTunes applications) and you need tohave an iPhone / iPod touch.Imobilemedic are introducing an updatedmodel of iGas log in late 2009/ early 2010.The new model promises to be a usefuldatabase incorporating many of the idealcharacteristics (apart from the last one!)iGaslog 2.0 will have all of the features ofthe 1.2 version, plus automatic web-basedbackup, separate data entry fields for painand intensive care cases and even thefacility for collecting ‘outcome’ data. Inaddition, the reports should be a bit slickeras they will be generated from the webside rather than the iPhone side as they arecurrently. The downside is the cost, whichis ‘estimated’ at £10 per annum (first yearfree to iGaslog 1.2 users).HanDbase – For palm pilots, iPhones andother smart-phones.This ‘generic’ database can be used onmany smart-phones and portable devices.For the enthusiastic logger it providesthe flexibility to custom-make a logbookincluding desired additional information.For the less enthusiastic logger, the LSORAlogbook (see below) can shortcut a lot of thecustomising and provide a tidy hanDbaseplatform fairly easily. The database costsbetween £5 and £15, and whilst not aspleasant to use as its competitors, probablyprovides the most flexibility. Available viawww.ddhsoftware.comUSB Memory Stick LogbookAn excellent concept, especially as mosttheatres have a PC available. The downsidesare that memory sticks are all too easy tolose, and many trusts are in the process ofbanning all non-encrypted memory sticks.It also lacks the additional benefits of themore advanced logbooks available online.Available via www.logbook.org.ukWEB BASED LOGBOOKSOnlineanaesthesiaCredit must be given to the developer(Dr Yogosakaran) of this site, who, as adissatisfied anaesthetic SHO, developed hisown site. It is comprehensive, easy to useand allows for the input of specialist datafor intensive care, pain and obstetric cases(although not regional anaesthesia). DrYogasakaran will even input your existingdata into the logbook if you email it to him– and it’s free!The only downsides are those associatedwith all web-based logbooks: it is timeconsumingand impractical to log-in whilein theatre, and the potential for data loss ifit isn’t backed up up in a second location.Available via www.onlineanaesthesia.comAnaesthesialogbook.com and the LondonSchool of Regional Anaesthesia (LSORA)logbookAs one would anticipate, the real attractionof this free logbook is the facility torecord the detail and outcome of regionalprocedures. It can be integrated withhanDbase for use with portable devices(see above). The reports that it producesare pleasant, RCOA compatible, and inaddition it will construct CUSUM curves forall procedures. This would be impressivedata to produce at an ARCP, especiallyfor trainees awaiting their initial test ofcompetence. Additional data such as drugdosages used and nerve identificationmethods are also easy to record via dropdown menus. Available via www.LSORA.co.ukA NOTE ONDATA PROTECTIONIt is difficult to be sure how much datashould be recorded in an anaestheticlogbook. Some may argue that the logbookshould contain enough information to allowits authenticity to be verified. However, thismay be in contravention of the ‘Caldicott’principles iii which stipulate that one shouldavoid using patient-identifiable data unlessstrictly necessary and, when usage isessential, the minimum detail to serve thedesired purpose should be recorded.Ultimately each deanery will decide howmuch patient sensitive data they require.In light of the serious consequences ofdata loss (dismissal and possible criminalrecriminations) it would seem unwise tocollect any more than is strictly necessary.Of interest, iGaslog does not keep anypatient identifiable information and areunaware of any problems encounteredby their users. A wider discussion on theissues of anonymity and data protectionwith respect to logbooks can be found inthe Hammond and McIndoe article and inthe GAT handbook iv .FUTURE DEVELOPMENTSThe RCOA are in the process of developingtheir e-portfolio and plan to incorporatethe logbook summary into the model. Itis, as yet, unclear what the capabilitiesof the new e-portfolio will be and whichlogbook models will be best suited to thedata transfer process.Some anaesthetists will be very familiarwith traditional logbooks and reticent totry a newer format. I would, however,recommend looking at some of the newerlogbook models and considering thefacilities that they have to offer. They reallydo relieve the tedium of inputting cases,provide interesting ways of presenting thedata, and, most importantly, provide securelocations for data storage.Referencesi McIndoe, Hammond RCOA Bulletin51: Sept 2008 (2633-2637)ii Blanco R, Lanigan C: RCOA Bulletin 54: March 2009 (16-19)iii The Caldicott Committee (December1997). "The Caldicott Report".Department of Health. http://confidential.oxfordradcliffe.net/caldicott/reportiv Madden AP, The GAT Handbook 2009-2010 (20-31), available via www.aagbi.org/gat/publications.htmThis article has no affiliation with ‘Which?’Magazines.Anaesthesia News May 2010 Issue 274 11

Returning towork followinga major illnessIntroductionThis article will try and set out a seriesof guidelines for anaesthetists thinking ofreturning to work following a major illness.The article is directed mainly at Consultantsand SAS anaesthetists, as trainees may followa different route usually being looked after bytheir local DeaneryFor the purposes of this article, illnessincludes any major physical or mental illnessthat requires time off work, often measured inmonths rather than weeks. The good news isthat on the limited available evidence, for thevast majority the return to work is uneventful.To my knowledge there is little data on howbig or complex a problem this is. Anecdotallyit would seem to occur in larger departmentsabout once every 5 years perhaps indicatinga rate of less than 1% of the workforce at anytime. However this figure may mask a muchlarger group of anaesthetists who do not letcolleagues know the severity of their illness,or who decide to take early retirementfollowing an illness. It is sufficientlyuncommon that many clinical directors willhave little expertise in this area. Advicecan however be sought from OccupationalHealth who can access a much broaderknowledge base or from national bodiessuch as the Association of Anaesthetists orthe Royal College of Anaesthetists who havegained experience over the years in advisingon these matters.Having a major illness is often a life alteringexperience. However once on the pathwayto recovery it is normal to start thinkingabout returning to work. The resumptionof a normal work routine often marks theend of the episode and the return to a morenormal existence. It is also important torecognise that for some doctors who are themain breadwinners, a return to work may beperceived as an urgent necessity.Having a major illness can often leadto periods of reflection and occasionaldepression as one comes to terms with thedisease and its after effects. A modifiedform of the ‘grief cycle’ (On Death andDying, Elisabeth Kübler-Ross, Macmillan,NY, 1969) is not uncommon, consisting ofmoving through various stages from shock toacceptance:• Shock: Initial paralysis on hearing thebad news.• Denial: Trying to avoid the inevitable.• Anger and guilt: An outpouring of anger- ‘why me?’• Bargaining: trying to find a way out of theinevitable.• Despair and Depression: Finalrealisation of the inevitable.• Testing: Seeking realistic solutions• Acceptance: Finally finding the wayforward.Adapted grief cycleAn important observation made over manyyears is that a modified form of the grief cyclecan occur following any major personal setback, not just the death of a loved one. It canoccur following the loss of a job or homeor following a major life threatening illness.It has also been noted that some peoplecan get stuck at some point in the cycleor inadequately complete a part of it thusleading to a poor outcome and an inabilityto move on. If this happens psychological orpsychiatric help may be required to help findresolution.There are a number of important aspects fordoctors returning to work that need to beunderstood and addressed. Do not try andreturn to work before you know you arephysically and emotionally ready to do so.Pay attention to the advice of friends andfamily and listen carefully and follow theadvice of the clinicians caring for you. Theyare likely to have m uch more experiencein this area than you. Do not try and shortcircuit their advice by becoming your ownphysician.You will need to negotiate your return towork with your clinical director, if necessarywith advice from occupational health. Asthere are no national guidelines, each personoften has to negotiate their own way throughthe complex culture of their departmentand hospital. In some cases this can provedifficult. Seek cooperation and mutualunderstanding rather than making demandsand pretending nothing has happened.Recognise that you may not be able to returnto exactly the same job as you had before theillness. There may be a need for a gradualreturn to work or working part-time for aperiod. Careful thought needs to be given toyour ability and stamina to undertake any on-12 Anaesthesia News May 2010 Issue 274

call work. Remember that the department has undoubtedly survived inyour absence. It will hopefully welcome you back, but would prefer ifit is done in a safe, orderly manner.If you have been away from the workplace for a prolonged period thereshould be put in place a ‘reintroduction to the workplace’ programme.This will consist of spending time in the workplace re-acquaintingyourself with patient assessment, drugs, equipment, specialisedtechniques and team working etc. For most people this will only need tobe from a few days up to a week. You should ask for this to be arrangedwith colleagues whom you trust and respect. The reintroduction shouldnot be seen as a ‘fitness to practice’ exercise. However following thereintroduction, it is not unreasonable for the clinical director to put inplace some screening process to ensure you are still competent i.e.have the skills, knowledge and behaviours appropriate for your role.This is done to ensure that patients will be safely cared for by you andshould not be viewed as a personal attack on your abilities or as anobstacle to your return. You should cooperate fully and openly withany screening process.Occasionally the assessment may throw up some doubts about yourcompetence in a specific area and lead to the requirement of a periodof re-training. For most people this can be a distressing period as itcasts doubt on your professional abilities and raises fears on whetheryou will be able to return to a normal work pattern. It is importantyou fully engage with this process and for the majority a period ofretraining usually resolves the issue.There are a number of very specific conditions which require specialmention. One is if your illness results in a serious disability such asa stroke with residual neurological deficit. It is again correct andreasonable to ensure you are able to carry out your role in a safeeffective manner. Do not try and hide or down play symptoms as this islikely to be eventually found out and may lead to your integrity beingquestioned. Experience has shown that with ingenuity and innovativethinking many problems can be overcome. One such example was adoctor with an illness resulting in a progressive weakness of their leftarm. It was felt the doctor would not be safe to intubate should the needarise. The use of the Airtraq TM laryngoscope, demonstrated a 100%ability to intubate successfully including rapid sequence inductions.If you are returning to work following a problem with addiction it isreasonable for your hospital to undertake some form of regular testingto ensure there is no relapse or to exhibit some caution in where youwork especially if the addiction has been with opiates. You should tryand accept these challenges in an open manner and seek advice ifnecessary from your psychiatrist.If you feel you have been dealt with unfairly you may need toapproach your medical director for advice. You can also considerapproaching national organisations such as the BMA, The Associationof Anaesthetists or the Royal College for advice and guidance. Thesebodies may be able to arrange site visits if it is deemed appropriate.Recognise set backs can occur. When they happen be open and honestabout them and aim to find solutions with your clinical director thatmatches both parties’ needs and expectations. Realise a degree ofemotional fragility may be normal. Do not be afraid to discuss themwith appropriate people.Lastly consider the need for a mentor or finding someone who hasbeen through a similar experience. Being able to discuss problems andpersonal challenges in an open manner can be both a supportive andtherapeutic process. Also keep your family and close friends informedof progress. They are your strongest allies. You will often need theirhelp and support.Dr James Clarke, Welfare CommitteeEd Charlton9 October 1942 – 4 April 2010Ed Charlton and Deefer DogI am sad to report the death of Dr Ed Charlton, the secondEditor of Anaesthesia News, and a long time member of theAAGBI, including a spell as Secretary to the Presidency of thelate Peter Baskett.Ed had conceived the idea of Anaesthesia News as ‘anexcuse to get the Calendar of Events out of the parent journalAnaesthesia and to free up more space for scientific articles’.He used to publish on a desk in his ‘office’ at the back of thehouse in Newcastle, a mass of cut out bits of paper and desktop publishing. Older members will remember the ascerbiccomments about Byouknowho and the many dogs involved.There was a suspicion that Deefer Dog and Hoover the CyberSpaniel might have been expressing the sometimes extremeviews of the Editor himself.I was privileged to be asked to take over the reins of AnaesthesiaNews after Ed had completed seven years as Editor. He hadalready converted it from a ‘broadsheet’ style to that of ajournal of A4 size. All I had to do was to bring in some colourand a publisher, as my desk top publishing skills are, sadly,lacking.I first ‘met’ Ed Charlton when I arrived home one night froman ODA Conference to discover a message on my answeringmachine. “Ballance, you are a prat” was the message, as I had,apparently, made a disparaging remark about the Associationduring a debate and this had been reported. I’m happy to saythat I managed later to make amends at the Association and tocount Ed, his wife Laura and family, as firm friends.There will, I am sure, be many magnificent obituaries writtenfor Ed. I would just like to record my personal thanks for hisallowing me to take on his ‘baby’ and for being a friend tomy wife and I during his latter years. A fighter to the last, Edbattled to the end, eventually succumbing at the Royal VictoriaInfirmary in Newcastle, where he worked for the greater partof his professional life.John BallanceEditor Anaesthesia News, 1999 to 2003Anaesthesia News May 2010 Issue 274 13

Final F.R.C.A. ExaminationIntensive Preparation CourseThe University Hospitals BristolMCQ/SAQPreparation CourseMonday 19th to Friday 23rd July 2010This five day course includes sessions on examinationtechnique, intensive therapy, new drugs, current topics,and practical subjects(ECGs, X-rays), as well as mock examinationsand performance analysis.Conducted by national and local experts atBurwalls Conference Centre, Bristol.For further details, please contact:Jane McLeanDepartment of AnaesthesiaBristol Royal InfirmaryMarlborough Street, Bristol BS2 8HWTelephone: 0117 928 3801 (Direct Line)e-mail: jane.mclean@UHBristol.nhs.ukCourse Director: Dr M A Taylor FRCASome Accommodation AvailableCourse Fee £450Includes course dinner, coffee, lunch and teasThe AnaesthetistsAgencysafe locum anaesthesia,throughout the UKFreephone: 0800 830 930Tel: 01590 675 111Fax: 01590 675 114Freepost (SO3417), Lymington,Hampshire SO41 9ZYemail: info@TheAnaesthetistsAgency.comwww.TheAnaesthetistsAgency.comUniversity Hospital of South Manchester6th OBSTETRIC ANAESTHESIATRAINING DAYforST/CT 1-2 WITH LIMITED OBSTETRICANAESTHETIC EXPERIENCEVENUE: UHSM Education and Research CentreDATE: Friday 9th July 2010TIME: 10am – 4pmCOST: £50.00 including lunch and refreshmentsThis will be a hands-on practical day to let you understand theprinciples of basic, safe obstetric anaesthesia – it will include:• Lectures• Simulators• Small group discussions/problem based learningFeedback from previous courses:‘useful and informative’‘good practical sessions’ well structured course’‘small group practicals surprisingly unintimidating!’‘best course I have been on!’Further details and application:Dr Fiona DoddDepartment Anaesthesia, University Hospital South ManchesterWythenshawe, Manchester M23 9LTEmail:Fiona.Dodd@UHSM.nhs.uk14 Anaesthesia News May 2010 Issue 274

Quality informationtailored to your needs:an update on NHS EvidenceThis article charts the progress of NHSEvidence since its launch in April 2009,and outlines how it can be of practicaluse in your professional practice anddevelopment. In particular, we focus on thespecialist collection dedicated to surgery,anaesthesia, perioperative and critical care.In 2008, Lord Darzi’s “High QualityCare for All” review1 stated that “allNHS staff will have access to a new NHSEvidence service where they will be ableto get, through a single web-based portal,authoritative clinical and non-clinicalevidence and best practice”. This articlecharts the progress of NHS Evidence sinceits launch in April 2009, and outlines how itcan be of practical use in your professionalpractice and development.NHS Evidence: simple to use search toolThe NHS Evidence portal has beendesigned to be as easy to use as a regularsearch engine, but only searches acrosshigh quality information sources. This savesyou time, as information that is of dubiousquality, such as commercially-biased oropinion-based information is automaticallyfiltered out, which is a crucial element ofevidence-based practice.Since its launch, there have been severalrefinements to NHS Evidence and it isbeing continually updated. You can nowbuild up a profile, where you can save yoursearches and receive the latest news aboutareas of interest, in one place:The Specialist CollectionsA key part of NHS Evidence is the groupof specialist collections. These focus onparticular conditions or areas of practice,drawing together the best availableevidence in the field they cover.In June 2009, the expanded specialistc o l l e c t i o n“NHS Evidence- surgery,a n a e s t h e s i a ,p e r i o p e r a t i v eand critical care”was launched.This is managedas a partnershipbetween TheRoyal College ofAnaesthetists, TheRoyal Collegeof Surgeons ofEngland andUniversity Hospitals of Morecambe BayNHS Trust.Continued overThe NHS Evidence home pageAnaesthesia News May 2010 Issue 274 15

All of the content in the specialist collection is freely available.Examples of the kind of information you may find include NICEguidance, Cochrane reviews, systematic reviews from the Databaseof Abstracts of Reviews of Effects and educational material. It iseasy to find material in the specialist collection by either searching,or browsing using our custom-built subject tree.Opportunities for publicationThe specialist collection also includes original material. Guesteditorials are opinion pieces about current topics of interest andmini-topic-reviews provide an overview of the evidence surroundinga particular area. We have published material on a wide variety oftopics, including “Anaesthesia and fast track cardiac surgery” and“The development of critical care in the UK”.If you are working on a project and would like to raise awarenessamongst the anaesthesia community, or have a particular area ofinterest, writing for the specialist collection is quick and easy. Tofind out more, please get in touch with us.Spreading the wordWe are keen to connect with our existing and potential users. Inthe past, we have had a stall at conferences such as the AAGBIWinter Scientific Meeting or given presentations about the specialistcollection. If you are involved with organising events, however bigor small, and would be interested in working with us, please contactus via email at speclib@rcseng.ac.uk.References1. Darzi, A (2008). High quality care for all: NHS next stage reviewfinal report. London: The Stationery Office. Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_085828.pdf [accessed 10 March2010].The Pre‐operative Associationwww.pre‐op.orgpre‐op@aagbi.orgAnnual Conference—Thursday 30th September 2010at theRoyal College of Surgeons, LondonA inter‐professional meeting designed for anaesthetists and all healthcare workersinvolved in the preoperative process.CALL for ABSTRACTS—31st July DeadlineRegistration :£170 (members of the POA)£225 (non‐members)For further details including registration forms and abstract instructions, pleasevisit:www.pre‐op.orgor contactpre‐op@aagbi.org5 CEPD POINTSwww.pre‐op.org16 Anaesthesia News May 2010 Issue 274

ParticlesThe effect of unanticipatedperioperative death onanesthesiologistsJoanne Todesco, Nivez F Rasic, James Capstick;Can J Anesth(2010)57: 361 - 367This is a subject which is likely to be close to manyof our hearts, as 53% of the179 staff anaesthetistswho responded to this survey had experienced anunanticipated peri-operative death (UPD). Thepurpose of the study was to elicit the frequency ofUPD, more detailed information about the natureof UPD, and to canvas opinion as to appropriateaftermath management. Unanticipated death wasclearly defined, and patients who came to theatreand were not expected to survive were excluded.Only 11 of the 93 deaths (10 occurring at induction)were felt to be anaesthetic deaths. However, amuch higher proportion of the anaesthetists (25%)felt as if they were being blamed, perhaps as a resultof their role as team leader during the resuscitationattempt, or the ‘self protective’ behaviour of others.It is of particular interest that 43% of the affectedanaesthetists went on to administer further electiveanaesthetics immediately following the event,citing surgical pressure, amongst other things, asthe reason. A very small number were subject todisciplinary action and litigation.Perhaps unsurprisingly, the degree of supportprovided to the anaesthetists involved wasgenerally deemed inadequate. Possible supportmechanisms which were suggested included teamdebriefing, involvement of the anaesthetist inthe family conference, relieving the anaesthetistfrom further duties and assistance with accuratedocumentation should an investigation ensue.These measures have also been recommended bythe Association of Anaesthetists.Many of the respondents included extensivehandwritten notes with their completed survey,some drawing attention to the fact that the deathof any patient, anticipated or not, may have adevastating effect on the anaesthetist.ReferenceCatastrophes in Anaesthetic Practice – dealing withthe aftermath (2005): Association of Anaesthetistsof Great Britain and Ireland.Dr Fiona McHardyConsultant AnaesthetistVictoria Infirmary, GlasgowMagnetic Resonance Imaging Findings After Uneventful Continuous InfusionNeuraxial Analgesia: A Prospective Study to Determine Whether EpiduralInfusion Produces Pathologic Magnetic Resonance Imaging FindingsDavidson et alAnesthesia & Analgesia Vol 110, No. 1, January 2010Have you ever wondered what an MRI of the spine looks like after epidural analgesia? Well, thatis the exact question asked in a prospective study from Miami Miller School of Medicine that waspublished in the January 2010 edition of Anesthesia & Analgesia. The aim of the study was todetermine whether epidural infusion produced abnormal MRI findings.Why this study?The study aimed to define a baseline result of MR imaging following an epidural in post partumwomen. It has been suggested in previous studies that MRI done in epiduralised post partumwomen have led to confusing/uninterpretable results or even false pathologic findings mimickingthose of epidural abscess in the absence of infection.It has been said that interpretation of MRI can be difficult because of engorgement of epiduralvenous plexus, unintended epidural vein puncture, CSF leak following dural puncture andepidural catheter placement leading to signal distortion.An MRI is a valuable tool for early diagnosis especially because the classic triad in spinal abscessof back pain, fever and neurologic deficit occurred in only 13% of patients by the time they wereevaluated in one study.What did they do?A total of 30 pregnant women (15 in epidural group and 15 in non epidural group) were recruited.Those with history of spine surgery, nitrous oxide use during labour, less than 2 hours of epiduralinfusion and bloody and wet tap were excluded. The MRIs of the lumbar spine were all performedwithin 12 hours of delivery.The epidural group received a needle-thru needle CSW with a 17G Touhy needle with loss ofresistance to air technique (2ml air injected) and a 16G spinal needle. Twenty micrograms offentanyl was used for the spinal and following 10 ml of normal saline, 0.1% bupivicaine infusionwith 3 micrograms/ml fentanyl continuous infusion was administered at 10-14 ml/hour.No epidural remained for more than 12 hours.There were no unanticipated dural taps or any post epidural complications.What did they find?There were no significant fluid collections, haematomas or mass effects on the thecal sac in all30 women.Of those who had epidurals:77% of the MR images showed a small amount of epidural air (

The History PageDiethyl ether:down but not quite out?I was an anaesthetist for 37 years. As aresult of the influence of my anaesthetictrainer as a student I knew that this was thespecialty I wanted to train in. I started asan SHO in anaesthesia at King’s CollegeHospital London straight from my surgicalhouse job in 1970, and retired in 2007.Looking back I must say that this was thecorrect choice and that I enjoyed almostevery minute of my professional clinicallife. My teachers were inspirational andI was fortunate on several occasions inbeing in the right place at the right time. Inow look back over those years, and idlethoughts pop into my head about certaintopics and I hope you will allow me toshare these thoughts with you.I started to think of diethyl ether the otherevening, I am not sure why. It was rarelyused in England, even back in my earliestanaesthetic days. Nevertheless I wastrained by members of a generation forwhom ether was an important drug and whofelt that it was still one worth demonstratingand teaching. I understand that there area few places, largely in mid-Africa, whereit is still used, particularly in those placeswhere anaesthetic training is least available.It is cheap, still widely available, (primarilyfor its industrial solvent properties) andeasy to store. I was told many times it wasthe safest anaesthetic available, largelybecause of its fail-safe property of stoppingrespiration before stopping the heart.However it has largely been abandonedin the developed world because of itsinflammability, explosiveness, slow onsetand offset of action, unpleasant smell andhigh emeticity.In my early anaesthetic days most Boyle’smachines still had an ether bottle on theback-bar (fig 1), which probably wasmore a feature of the age of the Boyle’smachine than of the utility of this device,but on a few occasions one of the senioranaesthetists would fill the bottle with thepungent liquid and “show off” his abilityto induce, and maintain anaesthesia forsimple procedures using it, generally alonebut on occasions with a little halothanesneaked in alongside when we weren’tlooking! I have never seen it administeredfrom a drop bottle onto an open mask, buthave heard that technique described oftenenough that I felt I could have done it ifpush came to shove.Fig 1Fig 2My most vivid memory was the combinationof ether and a Marrett anaesthetic machine(inventor Major Rex Marrett 1945). Asthis is a piece of anaesthetic history I mustmention its major feature which was thatit had a lever which allowed the vaporizerto be moved in or out of the circle usinga quick flick (fig 2). With the vaporizerin the circle the concentration of ethercould become very high and depended forsafety on the fact that as the patient’s depthof anaesthesia increased the respirationfell and the amount of ether being addedto the gases in the circle fell. Rememberthat this was before the days of end-tidalCO 2, vapour concentration, pulse oximetryor even routine ECG monitoring! Onthis occasion the procedure was anabdominal hysterectomy and no additionalrelaxant was necessary because of thegood relaxation achieved by deep ether18 Anaesthesia News May 2010 Issue 274

Anaesthesia NewsAdvertising Ratesanaesthesia, andno diathermy wasallowed by thesurgeon because ofthe high ether levels!Were patients morerobust in those days?I last administeredether anaesthesiain 2000, during apractical session onthe Overseas andDeveloping Countriescourse in Oxford. Itwas administered viaan EMO apparatususing an OxfordBellows (à la fieldanaesthesia setup)(fig 3) using supplemental oxygen in air. All the patients,who were on a day case breast surgery list, were asked forpermission to be both used as demonstration cases and tobe given this ancient recipe, and to my surprise readily gaveit. Induction was with propofol. I visited all the cases postoperativelyand found to my satisfaction that the incidenceof nausea and vomiting was not obviously higher than withconventional modern anaesthesia; all had received antiemeticsintra-operatively. However, these patients, and theiranaesthetist, did smell of ether for several hours! That course isno longer run in the same way in the UK, so I have no recentknowledge of how any practical training is given.Anaesthesia News reaches over 10,000 anaesthetists everymonth and is a great way of advertising your course, meetingor seminar.Full PageFour ColourFull PageTwo ColourHalf PageFour ColourHalf PageTwo ColourQtr PageFour ColourQtr PageTwo ColourContact: Claire Elliott on 020 7631 8817or e-mail: anaenews.advertising@aagbi.orgOneMonthTwoMonths(5%Discount)ThreeMonths(10%Discount)SixMonths(25%Discount)TwelveMonths(50%Discount)£1360 £2585 £3684 £6121 £8161£869 £1651 £2346 £3910 £5215£707 £1345 £1912 £3186 £4248£531 £1009 £1433 £2388 £3186£354 £671 £ 956 £1594 £2125£265 £504 £715 £1190 £1588All prices shown are exclusive of VATSo did I give the last ether anaesthetic in England? I don’t know- perhaps I did, but I hope someone out there will tell me ifI didn’t. Does it matter that newly trained anaesthetists nowknow only the theory of ether anaesthesia and have probablynever seen it? I think it may. I hope that somewhere there is astockpile of ether stored in some way so that when civilizationdies and we can no longer manufacture the complexcompounds used to produce ‘modern’ anaesthesia we at leastcan continue to provide some form of painless surgery, and wedon’t have to go back to the mandrake root. If so then I hopetoo that someone knows where that stockpile is and where tofind the key.Michael WardConsultant Anaesthetist (Retired)Further Reading: Paul Fenton; An Epitaph for Di-ethyl Ether(1846 - 2009), July 2009, World Anaesthesia News; Vol 11– 1, pp3-4Anaesthesia News May 2010 Issue 274 19

Final FRCA Examination or the Final FCARCSI Examination in 2010Consider JoiningThe Mersey Writers ClubMembership of the Club will expose you to theSubtleties & Intricacies of the Written Papers of the Respective Examinations.As an Anonymised Number and not a Name You will be ExpectedTo Address under Examination ConditionsOne Question Paper per FortnightYou will also be expected to set Questions, to Design and to Mark AnswersThrough such intimate involvement with the challengeYou will become that much more able to copePlusYou will Benefit from the RevisionPlusYou will Acquire a Collection of Structured AnswersOne-Off Membership Fee£400Members are entitled to retain membership until successful in the ExaminationMembers are entitled to attend any or all subsequent Mersey SAQ or E&SAQ Weekend CoursesMembers are entitled to attend the Private Members-Only Writers’ Weekend CoursesAll Free of any Course Fee ChargeButInterested Trainees MUST ATTEND A Four Hour IntroductionNo Charge to attend IntroductionNo Obligation to Join the ClubIntroduction SessionsLiverpool Saturday 8 th May Aintree Hospitals 11.00 – 15.00London Friday 14 th May Kings College Hospital 14.00 – 18.00London Saturday 15 th May Kings College Hospital 10.00 – 14.00Birmingham Sunday 16 th May City Hospital 11.00 – 15.00Liverpool Saturday 22 nd May Aintree Hospitals 11.00 – 15.00Liverpool Saturday 29 th May Aintree Hospitals 11.00 – 15.00Edinburgh Sunday 30 th May Middleton Village Hall 12.00 – 16.00London Friday 4 th June Kings College Hospital 13.00 – 17.00London Saturday 5 th June Kings College Hospital 10.00 – 14.00Dublin Sunday 6 th June St Vincent’s Hospital 10.00 – 14.00If you are interested in joining the Writers ClubFRCA SAQ Examination or FCARCSI E&SAQ ExaminationPlease email Dr Graydavid.gray@aintree.nhs.ukadvising him as to which Introduction Session you will be attending20The Writers Club Motto“In the Discipline Lies the Reward”

An interesting,exciting and variedrole in EthiopiaA description of our Gondar experience and a call to get involvedGondar is located in the mountainoushighlands of Northern Ethiopia at analtitude of 2100m, with the stunning SimienMountains to the north and Lake Tana – thesource of the Blue Nile - to the south. Astwo British anaesthetic trainees, we havetaken a one-year “OOPE” to come to workin the country’s third largest city. Amharicis the local language, but fortunately for us,the language of clinical teaching is English.The hospital is a university teachinghospital with a catchment population ofover 3 million. It has a medical schooland provides BSc courses for other healthprofessionals including anaesthetists. Thereare ten BSc anaesthetists, but no physiciananaesthetists in the hospital – hardlysurprising in a country with fewer than 15physician anaesthetists. The five operatingtheatres cover surgical specialties includinggeneral surgery, gynaecology and obstetrics,orthopaedics, urology, paediatrics andophthalmology. Whilst resources arelimited, currently there are pulse oximetersin all theatres and capnography andDinamap in several.Many patients present late in the course oftheir disease and therefore a high proportionof surgery involves complex majorprocedures. Particularly common generalsurgical cases include gastrojejenostomies(for gastric outflow obstruction secondary topeptic ulcer disease) and thyroidectomies.The latter group often present with massivegoitres and distorted airway anatomy.Occasional thoracic, neonatal andneurosurgical cases are also undertaken.Post-operative care is provided by thesurgical interns in the recovery room.During our attachment here we havebeen involved in a number of differentprojects throughout the hospital. Wehave largely defined our own roles,which have included clinical and formalteaching of both anaesthetic students andgraduates, designing and introducingdrug administration charts to the hospital,conducting a number of audits, advisingon a medical HDU and constructinganaesthetic machines.One of our major roles is to develop furthertraining for the BSc graduates. The key goalsare to improve clinical practice, as well aspromoting evidence-based anaesthesia,increasing involvement in continuedprofessional development and improvingstaff retention. In order to achieve thesegoals in the Ethiopian context, an MSccourse is the most appropriate solution.We are currently finalising the curriculumand plan to start in September 2010. Onecritical feature of the proposed curriculumis that it will be very clinically relevant andtheatre-based, in contrast to the BSc whichcontains a large theoretical component.The curriculum will contain clinical blocksin the following specialties: general surgery/gynae/urology, regional anaesthesia, pain,obstetrics, paediatrics and trauma. Therewill be some seminar/workshop teachingbut most of the course will involve theatrebasedclinical teaching, rather thantheoretical or academic topics.In Gondar, there is a small community ofexpatriates contributing to a very socialand supportive atmosphere. We haveappreciated wonderful Ethiopian hospitalityand been bemused by a calendar system inwhich it is only 2002! Our excursions to thenearby Simien Mountains and Lake Tanahave been memorable highlights.Overall we have had a varied andchallenging time both inside and outsidethe hospital. However, what has madeour trip so rewarding has been the chanceto improve clinical practice, developindividual skills and to have some influenceon the direction anaesthetic practice istaking more widely in Ethiopia.To succeed, the MSc course will need tutorsfrom Britain, for periods of 3 months to ayear from September 2010. Senior trainees,consultants or retired anaesthetists in theUK would be ideal. This is an opportunity toprovide relevant clinical teaching withouthaving specific clinical commitments. Theset-up will enable an interested anaesthetistto settle in rapidly, such that their time hereis productive and rewarding. For anyoneconsidering working in a developingcountry, this is somewhere you could havea very beneficial role.There is an active and supportive linkbetween Gondar University Hospital andthe Leicester NHS Trusts and Leicesterand DeMontfort Universities. No previousconnection with Leicester is necessary forthose interested in working in Gondar. TheLink will provide general advice, additionalsupport and will co-ordinate teaching onthe MSc course. There are frequent visitsby health professionals from Leicester toGondar and vice versa.If you have any interest in this project, couldconsider working in Gondar or would justlike to know more, please contact us atb.silverman@doctors.org.uk or j.cheongleen@doctors.org.uk.The Leicester Linkwebsite is www.le.ac.uk/gondar and theadministrator Nichole Bruce is at nb50@le.ac.uk.Drs Ben Silverman and Jude Cheong-LeenAnaesthetic trainees from the Imperial andCentral London Schools of AnaesthesiaAnaesthesia News May 2010 Issue 274 21

The TransfusionAlternativesPreoperatively inSickle CellDiseaseStudy (TAPS)One of the strongly held beliefs in the management of patients with sickle cell disease (SCD) is that preoperative blood transfusion ‘is agood thing’. Many patients with sickle disease remain in very good health (albeit with chronic haemolytic anaemia), and suffer relativelyfew episodes of vaso-occclusive crisis. However, when they attend hospital for relatively minor surgery, they are routinely given a bloodtransfusion with all the attendant risks, the greatest of which is alloimunisation due to mismatch of red cell antigens between the donorand recipient populations. Modern anaesthesia care has improved the perioperative management of sickle patients so that factors thatmay precipitate a sickle crisis can be routinely avoided, for example, dehydration, cold and hypoxia. SCD has been a relatively neglectedfield of research, so it is very good news that NHS Blood and Transplant (NHSBT) are funding a study to investigate perioperativeblood transfusion in patients with sickle disease, and patients are now being recruited to this study in hospitals across the UK. Sicklehaematologists and members of the trial management group, David Rees and Jo Howard would like to explain the background to theTranfusion Alternatives Preoperatively in Sickle Cell Disease Study (TAPS), to seek your support to encourage recruitment to this importantstudy for patients with SCD.Isabeau Walker.AAGBI CouncilSCD is thecommonest severegenetic disorder in the UK,with more than 12 000 affectedindividuals. Approximately 80% ofpatients are thought to live in London,although numbers are increasing generallyacross the UK 1,2 .Children and adults with sickle cell diseasefrequently require anaesthesia and surgery,with tonsillectomy/adenoidectomy,cholecystectomy, splenectomy andtotal hip replacement being the morecommon procedures. Several studies haveshown an increased risk of perioperativecomplications in patients with SCD,including complications related totransfusion 3 .The high complication rate has led toapproaches to perioperative managementto try and minimise these. Intravenousfluids are usually started once the patientis nil-by-mouth and oxygen continuedin the post-operative period; day surgeryand tourniquets are typically avoided. Anarea of particular controversy has been22 Anaesthesia News May 2010 Issue 274

the role of preoperative blood transfusion.Transfusion offers the theoretical benefitof correcting anaemia and reducing thepercentage of sickle haemoglobin (HbS) inthe blood; exchange transfusion can reducethe HbS percentage to low levels withoutcausing a potentially damaging increase inhaemoglobin and whole-blood viscosity.However transfusion is associated witha risk of alloimmunisation, transfusiontransmittedinfection, and transfusionreactions. Alloimmunisation is morecommon in the sickle population than inthe general population as this is a groupwho are often multiply transfused, andbecause there is often a mismatch of red cellantigens between the donor population,and the sickle recipients. Alloimmunisationcan lead to delayed haemolytic transfusionreactions, hyperhaemolysis and haemolyticdisease of the newborn, and if the patientdevelops multiple red cell antibodies, canrender patients untransfusable. There isalso some evidence that transfusion mayincrease the risk of post-operative infection.Blood is an increasingly valuable resourceand ideally should only be used when thereis compelling evidence showing benefit.All patients with SCD having high-risksurgery undergo pre-operative transfusion,typically with an exchange transfusionto reduce the HbS to less than 30%.Such surgery includes operations on theheart, brain, lungs and eyes, when theconsequences of vaso-occlusion in thetarget organ would be devastating orrecovery is expected to be prolonged andcomplicated. The situation for moderateand low risk surgery is less clear. Arandomised trial of preoperative transfusionstrategies in sickle cell disease was reported1995 4 . Patients were randomised to eitheran aggressive (exchange) or conservative(top-up) regime. The two groups had equalrates of perioperative complications (31 vs.35%). This outcome was despite the HbSlevel in the top-up group being almosttwice that in the exchanged group (59%vs. 31%). The only two deaths were in theaggressively treated group, both patientsdying of acute chest syndrome. Thisabsence of benefit of exchange transfusionover top-up transfusion has generally beensupported by other observational studies.Whilst it is generally accepted thatexchange transfusion offers no benefitover simple transfusion for medium andlow-risk surgery, it is unclear whethersimple transfusion results in fewercomplications compared to no transfusionat all. Observational studies mostly suggestfairly limited benefit to transfusion. TheTransfusion Alternatives Preoperativelyin Sickle Cell Disease Study (TAPS) hasbeen established to try and answer thisquestion. It is a phase III trial in whichchildren and adults with HbSS and steadystate haemoglobin greater than 6.5g/dl arerandomised to transfusion or no transfusionprior to medium and low risk surgery. Theremainder of perioperative managementis according to the standard protocolsused in the institutions caring for theindividual. The primary outcome measureis the frequency of all clinically significantcomplications up to 30 days post-surgery;this includes problems related to sickle celldisease, transfusion, surgery and infection.Secondary outcome measures include thedevelopment of alloantibodies, length ofhospital stay, volume of transfused bloodand re-admission to hospital. The studyis funded by NHSBT, and managed bythe NHSBT/MRC Clinical Studies Unit.It is taking place in hospitals across theUK, with centres in Toronto, Amsterdamand Rotterdam, and Dublin potentiallyjoining (http://clinicaltrials.gov/ct2/show/NCT00512577). Hopefully this trial willresult in better management of peoplewith sickle cell disease in the perioperativeperiod, and a more rational use of bloodtransfusion, and we seek your support for it.Further details can be obtained from theTrial Co-ordinator, Moira Malfroy, onmoira.malfroy@nhsbt.nhs.ukDavid Rees, Department of PaediatricHaematology, King’s Health Partners,King’s College Hospital NHS FoundationTrust, London.Jo Howard, Department of Haematology,King’s Health Partners, Guy’s and StThomas’ Hospital NHS Foundation Trust,London.References1. Streetly A, Latinovic R, Hall K, HenthornJ. Implementation of universal newbornbloodspot screening for sickle celldisease and other clinically significanthaemoglobinopathies in England:screening results for 2005-7. J ClinPathol. 2009; 62: 26-30.2. Stuart MJ, Nagel RL. Sickle-cell disease.Lancet 2004; 364: 1343-1360.3. Koshy M, Weiner SJ, Miller ST, SleeperLA, Vichinsky E, Brown AK, Khakoo Y,Kinney TR, and the Cooperative Studyof Sickle Cell Disease. Surgery andanesthesia in sickle cell disease. Blood1995; 86: 3676-3684.4. Vichinsky EP, Haberken CM, NeumayrL, Earles AN, Black D, Koshy M, PegelowC, Abboud M, Ohene-Frempong K, IyerRV and the Preoperative Transfusionin Sickle Cell Disease Study Group.A comparison of conservative andaggressive transfusion regimens in theperioperative management of sicklecell disease New England Journal ofMedicine 1995; 333: 206-213.Help for Doctors with difficultiesThe AAGBI supports the Doctors for Doctors scheme run by the BMA which provides 24 hour access to help(www.bma.org.uk/doctorsfordoctors).To access this scheme call 0845 920 0169 and ask for contact details for a doctor-advisor*.A number of these advisors are anaesthetists, and if you wish, you can speak to a colleague in the specialty.If for any reason this does not address your problem, call the AAGBI during office hours on 0207 631 1650 or emailsecretariat@aagbi.org and you will be put in contact with an appropriate advisor.*The doctor advisor scheme is not a 24 hour serviceAnaesthesia News May 2010 Issue 274 23

Anaesthesia for cancerpatients: The prognosticimplications of anaesthetic techniqueWe are delighted to publish this Wylie Medal-winning essay by a medical student, which was chosen from an excellent field.Cancer is the second leading cause of death in the developedworld, with metastatic disease developing in up to 50% of thosediagnosed (1). It is estimated that 30-40% of breast cancer deathsare attributable to this ability to establish secondaries, makingmetastatic recurrence the main cause of mortality (2). In 2008, theAmerican Cancer Society reported a one in five risk of breast cancerrecurrence within ten years, after five years of adjuvant therapy (3).Surgery, whether to de-bulk, or to treat adverse consequences ofmalignancy or indeed its previous treatment, remains recognisedas offering the most promising prognosis for many cancers (4).Nonetheless, surgery carries with it the induction of a profound‘neuroendocrine stress response’, instituting a compromisedimmunological status. Coupled with the risk of tumour celldissemination and release into lymphatic and blood systems,surgical intervention has been labelled a ‘double-edged sword’ (5).Even with the best surgical technique cancer recurrence ratesremain high; so improvements must be sought in other aspects ofmanagement of the surgical cancer patient. The immune system isthe body’s main defence against malignancy, so suppression viaanaesthesia occurs at a rather inopportune time. Acknowledgementof the ability of regional anaesthesia to attenuate the neuroendocrinestress response (6) has provoked investigation into the true potentialof anaesthetic technique to affect cancer outcome.As a result of the in vitro, animal and retrospective in vivo datadiscussed below, results of prospective randomised trials such asthe large multicentre trial currently underway at the ClevelandClinic (7) are eagerly awaited. This is an exciting time: if resultsfrom large human prospective randomised trials are in accordancewith currently observed trends, an adjustment to anaestheticmanagement may significantly reduce the risk of cancer metastasis.Minimal residual disease (MRD)At the time of surgical intervention, many cancer patients harbourmicrometastases, and if tumour cells have not yet disseminated,physical manipulation of the tumour on the operating table increasesthe risk of tumour cell release into the circulation.Minimal residual disease (MRD) refers to those tumour cells whichresist therapy to remain and survive in a protected, quiescentstate (8). Inherent genetic instability in partnership with selectivepressure of therapy encourage the development of more complex,and permanent acquired-resistance phenotypes; catalytic to diseaserecurrence.The ability of disseminated tumour cells and MRD to establishmetastases is determined by a complex, interrelated network offactors, not least the efficacy of the host immune responses. Keycomponents of perioperative management play an integral role(Figure 1). In addition to the neuroendocrine stress response,anaesthetic agents and opioids, there are numerous othercontributors to perioperative immunosuppression; namelyhypothermia, psychological stress, and blood transfusion (9).Figure 1: Clinical metastases develop from minimal residual disease (MRD)dependent on a number of variables within the perioperative period.Natural killer (NK) cells are a particular subset of lymphocytes,which provide frontline defence against malignancy. NK cellsspontaneously recognise and kill neoplastic cells, giving thema critical role in the control of circulating tumour cells andmicrometastases.Perioperative immunosuppressionFor multiple reasons, the cancer patient can present particularchallenges for the anaesthetist. The cancer itself is responsible forcachexia, (in approximately 50% of all cancer patients), weaknessand impaired immune function (10). Secondly, chemotherapycarries with it not only the risk of respiratory complications (5-10%suffer an adverse pulmonary reaction), but unsurprisingly, a degreeof myelosuppression; making neutropaenia a common finding (11).Further contributing to immunosuppression is cancer pain, whichoccurs in 25% newly diagnosed malignancies, and in 75%patients with advanced disease (11), and its appropriate treatment.Pain suppresses cell-mediated immunity, and has been shown toenhance the tumour promoting effects of surgery, which highlights24 Anaesthesia News May 2010 Issue 274

the need for optimum perioperative analgesia (12). However,opioids, a mainstay treatment for post-surgical acute pain, as wellas numerous types of chronic pain such as that which is cancerrelated,have received considerable attention recently concerningtheir immunomodulatory properties (13). For example, morphinehas been shown to potentiate breast tumour growth via its promotionof survival-enhancing factors, and proangiogenic properties (14).Finally, anaesthetic drugs themselves have demonstrated theability to impair a variety of immune components. This includesneutrophils, T cells, and NK cells (15).The neuroendocrine stress response to surgeryFurther transient immunosuppression is induced by surgery.The ‘stress response’ to surgery is characterised by a profoundneuroendocrine (Table 1), metabolic and cytokine reaction.Increased:Decreased:ACTH, cortisol, ADH, GH, catecholamines, renin,angiotensin-II, aldosterone, glucagon, IL-1, TNF,IL-6Insulin, testosteroneTable 1: The neuroendocrine response to surgery [modified from (16)]; categorisedinto catabolic (top row) and anabolic (second row) mediators.Crucially, the stress response increases sympathoadrenal andneuroendocrine activity, increases cytokine production, and impairsnumerous immune functions. This includes a marked suppression ofNK cell function (17).Regional anaesthesia has repeatedly been shown to attenuate thisneuroendocrine response to surgery (9). This inhibition of adverseimmunosuppression is believed to be mediated via blocking of bothafferent and efferent neural transmission; preventing transmissionfrom reaching the central nervous system, (hence activating thestress response) as well as blocking efferent transmission of thesympathetic nervous system (6). Consequently, NK cell functionshould prevail.Regional anaesthesia & natural killer (NK) cell functionIn a rat study that compared the effects of general anaesthesia,systemic morphine, and spinal block (regional anaesthesia),with and without surgery, Bar-Yosef et al. (2001), concluded thatthe addition of spinal blockade to general halothane anaesthesiamarkedly suppressed the promotion of metastasis by surgery (9).In an attempt to elucidate the mechanism of this effect, the numberand activity of NK cells was investigated. There was one control,three groups who received anaesthesia without surgery, andthree upon whom surgical laparotomy was performed. Numbersof NK cells were significantly different between the spinal groupand general anaesthetic group only. Curiously however, NK cellnumbers in the spinal group were significantly lower than that ofthe general group. This is particularly interesting as lower numbersof NK cells are associated with an unfavourable prognosis regardingmetastatic potential (9).NK cell activity, like cell number, did not show a favourableresponse to spinal anaesthesia over general; both methods wereassociated with a decrease in NK cell activity; more so with spinaland general, than general anaesthesia alone. This NK cell activitywas assessed from the blood. Given metastatic potential of this cellline to the lungs, assessment of pulmonary NK cell activity may bemore informative.General versus regional: retrospective findingsIn 2006, Exadaktylos et al. (4) compared local recurrence andmetastases in breast cancer patients who underwent mastectomyand axillary clearance with, and without paravertebral anaesthesiaand analgesia.After a follow-up of 32±5 months, the results suggest thatparavertebral anaesthesia and analgesia reduces the risk ofmetastasis during the initial post-surgery years . Recurrence-freeand metastasis-free survival was 94% (95% confidence interval 87-100), and 82% (95% CI 74-91) at 24 months, and 94% (95% CI87-100) and 77% (95% CI 68-87) at 36 months in the paravertebraland general anaesthesia groups respectively, P = 0.012.A retrospective analysis looking at prostate cancer outcome showssimilar results. In 2008, Biki et al. (6) reported a 57% (95% CI 17-78) reduction in risk of biochemical recurrence in men who hadundergone radical prostatectomy under GA with an epidural,compared to a general anaesthesia and opioid analgesia group.The main limitation of these retrospective studies is that patientscould not be randomised. However the authors’ conclusions stronglysupport the hypothesis that anaesthetic technique influences canceroutcome. These findings help to generate further hypotheses, andestimated effect sizes for future larger trials.Prospective trials have been underway recently: an Americantrial published some promising results earlier this year (2). In thissmall study, 22 breast cancer patients undergoing surgery wererandomised to receive either a combined general and paravertebralanaesthesia-analgesia, or general anaesthesia with opioid analgesia.The authors then evaluated the effect of serum from these patients,on breast cancer cell function in vitro. An oestrogen receptor (ER)-negative breast adenocarcinoma cell line MDA-MB-231 was usedto test the hypothesis that serum from patients who had receivedpropofol/paravertebral anaesthetic would attenuate MDA-MD-231cellular proliferation and migration to a greater extent than that frompatients receiving standard general anaesthesia and opioids.The principle finding of this study was that cellular proliferation ofthe human breast carcinoma cell was significantly reduced whencells were treated with postoperative vs preoperative patient serumfrom the propofol/paravertebral group, compared to the generalanaesthetic and opioid group (-24% vs 73%, P = 0.01).No significant difference was seen between mean percentage pretopostoperative change in cellular proliferation at 2% and 5%patient serum, between the two treatment groups. However at both2% and 5%, the mean percentage change in cell proliferation washigher in the propofol/paravertebral group than the group treatedwith sevoflurane/opioid.No significant difference was found between the two treatmentgroups regarding cell migration.ConclusionSummarised in Figure 2, there are multiple ways in whichthe anaesthetist may influence the extent of perioperativeimmunosuppresion:Anaesthesia News May 2010 Issue 274 25

ImmunosuppresionFigure 2: The fine balance of immunomodulation may be tipped heavily in favourof a suppressed immune system, by variables within the anaesthetist’s control.The pivotal role a patient’s immune status appears to play in thedevelopment of postoperative cancer recurrence and metastasis, hasled to parallels being drawn with the process of wound healing. Theway in which the capabilities of the immune system dictate whetheror not contamination of a wound manifests as a clinical infection,may be analogous to the progression of inherently unstable cancercells in an immunologically disrupted microenvironment with aweakened host defence system (4).The FutureThere is currently a wealth of laboratory and experimental data insupport of the hypothesis that firstly, immunosuppression is a keyfactor mediating the promotion of metastasisby surgery. Secondly, there is evidence thatthe protective effects conferred by regionalanaesthesia are attributable, at least partly,to dampening of the neuroendocrine stressresponse to surgery and hence to a reductionin the accompanying immunosuppression.Perioperative immunosuppression:-impaired neutrophil, macrophage, T cell andNK cell functionPain:-suppresses cell-mediated immunityOpioids:-dose-response effect withmorphine and immunosuppression-pro-angiogenicPrimary effect of regional anaesthesiaCrucially, there must be someacknowledgement of the limitations ofcurrent evidence for an association betweenanaesthetic technique and cancer prognosis.At the cellular level, the hypotheses proposedby Bar-Yosef et al. (9) need to be investigated; either to support ordisprove the current theorised pivotal role of natural killer cells.Although not deemed statistically significant, the differencesobserved in mean percentage change in cell proliferation at lowerserum concentrations (2% and 5%) between those receiving generalanaesthesia and those receiving paravertebral block needs furtherinvestigation (2). It may be that only particularly aggressive cancers(if any at all) are receptive to a variable outcome dependent onanaesthetic technique.An obvious limitation is the size of the populations studied in thetrials presented above. A sample size of twenty-two for example (2),may greatly underpower any potential associations. Conversely, asexciting as any observed links may be, the strength of conclusionsdrawn from such small sample sizes is slight.Improved systemic blood flow, reduced plateletaggregation, reduced inhibition of fibrinolysisReduced perioperative blood lossImproved coronary blood flowReduced duration of ileusReduced risk of respiratory depressionImproved lung mechanicsTargeted neuronal local anaestheticepidural or paravertebral anaesthesia/ analgesia, or mastectomywith sevoflurane anaesthesia and morphine analgesia, the resultsare eagerly anticipated. It is evidence from trials such as this whichwould hopefully elucidate the importance of anaesthetic techniqueand the possible role of peripheral opioid μ receptor antagonists inthe perioperative period.An accurate understanding of the underlying mechanisms remains tobe determined; there is some evidence to suggest that the purportedprotective effects of regional anaesthesia on cancer recurrence maydepend on tumour type. Specifically regarding colorectal cancer,there seems to be an acknowledgement that there is no associationbetween the use of epidural anaesthesia and decreased recurrence(18). Gottschalk et al. (2009) found that the use of epidural analgesiafor postoperative pain control during colorectal surgery was notsignificantly associated with cancer recurrence after adjusting forconfounding variables (19). It is thus yet to be determined whetherthis difference in reported cancer types reflects a true difference ormay be attributable, for example, to publication bias.Regional anaesthesia has been shown to attenuate the neuroendocrineresponse to surgery, to reduce the amount of general anaestheticrequired, to provide effective analgesia, to hasten recovery ofgut function, and to reduce any opioid requirement. In short, itsmultiple physiological advantages over general anaesthesia are wellacknowledged (Table 3). Despite this, the role of anaesthetic drugsin carcinogenesis remains unclear.Benefit compared to general anaesthesiaReduced incidence of DVT, less risk of PELower rate of blood transfusionLower incidence of postoperative N&V,Earlier return to normal bowel functionImproved oxygen concentration in blood, earlyextubation, less risk of pulmonary infectionExcellent postoperative pain control, faster recoveryTable 3: The physiological advantages of regional anaesthesia compared to generalanaesthesia [adapted from (20)].A greater understanding of the underlying mechanisms needs to bedeveloped, alongside the acquisition of stronger, longer-term followupdata from large scale randomised controlled clinical trials. Thesetrials need to look at a range of cancer types. Lastly, considerationmust be made for the risks associated with paravertbral block, andthese balanced with any benefits verified in the future. In additionto the most feared pleural puncture and pneumothorax, it isimperative to investigate any potential adverse effects from adaptinganaesthetic technique or regimen for the purpose of achieving bestcancer prognosis.I would like to thank Dr Mahesh Parmar for his support andguidance throughout my anaesthetics placement, and in thewriting of this essay.Consequently, current evidence suggests that large prospectiverandomised controlled trials, with long-term follow-up are necessary.One such trial now underway is due to publish its results in 2013(7). As a Phase III, multicentre prospective trial, randomising breastcancer patients to undergo mastectomies either with a thoracicAmanda RhodesAn expanded version of this essay and the references are availableon the AAGBI website. http://www.aagbi.org/foundation/grants/undergraduate.htm26 Anaesthesia News May 2010 Issue 274

A Date for your Diary4th—5th October 2010NEUROMODULATIONSOCIETY OF UK & IRELANDAnnual Scientific Meeting@The Leeds Royal ArmouriesMuseum (RAM), LeedsWebsite: www.neuromodulation.comTel: 020 7631 8804 Email: nsukiasm2010@aagbi.orgad.landscape.leeds 1/3/10 14:30 Page 113th EuroSIVAMeeting on Intravenous Anaesthesia11th June 2010Hilton Strand HotelHelsinki, FinlandTopicsSession 1: Why should we use intravenous anaesthesia?Topics: Better anaesthesia with intravenous drugs?Non-anaesthetic benefits of intravenous anaesthesia.The magic of using opioids (cardio protection and more)Session 2: How should we use intravenous anaesthesia?Topics: How should we use intravenous anaesthesia?A simplified and common sense approach to kinetic modelling.Pharmacokinetic drug interactions in the perioperative period.Smart TCI: Applying pharmacodynamics in clinical practiceSession 3: Supporting actors: The important adjuvants.Topics: Is there still a role for muscle relaxants in today’s practice?The big little problem: What to know about PONV prophylaxis and treatment.Looking beyond the end of anaesthesia: Post-operative pain and outcome.Session 4: Seeing is believing (Video presentations):Topics: How do I use TCI in thea) Neuro patient: Francisco Lobob) Cardiac patient: Stefan Schraagc) Paediatric patient: Frank Engbersd) Sedation: Gavin KennyFor information contact:Mrs Silvia LenzOrthopädische Universitätsklinik Balgrist/ ZürichForschstrasse 340CH- 8008 ZürichSwitzerlandTel: +41 1 386 38 32Fax: +41 1 386 16 09Email: registration@eurosiva.orgOr visit www.eurosiva.orgTHE INTENSIVE CARE SOCIETYTHE ANNUAL SPRING MEETING 2010TUESDAY 18 – WEDNESDAY 19 MAY 2010 | ROYAL ARMOURIES MUSEUM, LEEDSRegister now!Programme topics include:• Key paper reviews from the last 12 months.• What have we learnt from Swine Flu? Including the SWIFTstudy and ventilatory support.• Weighty issues in ICU. Management of the obese andmalnourished patient.• Towards zero nosocomial infections.• Pro Con Debates: ‘Large vs. small ICUs’ and ‘is ECMO indicatedin refractory hypoxaemia in ALI’.• CME sessions on core intensive care topics.In addition there will be the Trainees, Members, Nurses andAHP forums, the Gilston Lecture and an industry exhibitionshowcasing all the latest developments.ICS Dinner and Dance – Tuesday 18 MayThe 2010 Dinner and Dance will also be held at the RoyalArmouries and promises to be a fabulous event with a liveperformance in the Oriental Gallery, a red carpet entrance,live music and delicious food.ICS Fun Run – Wednesday 19 May at 7amThere will be an opportunity to support the ICS Foundationby participating in a 5K charity run. Full details and race entrycan be found at www.ics.ac.uk.CPD accreditation: 10 points pendingKeep an eye on our website. More topics will beadded as they are confirmed. Registration, abstractsubmission, a full programme and further meetingdetails are available at www.ics.ac.uk or you canemail events@ics.ac.ukAnaesthesia News May 2010 Issue 274 27

Anaesthesia DigestedAnaesthesia May 2010The world of clinical research is demanding at the best of times; increasingconstraints on clinicians’ time, complex ethical processes, variations insupport from Research and Development departments and the MentalCapacity Act have all contributed to the increasing difficulties faced by‘jobbing’ clinicians who wish to study their profession from a more scientificperspective. It is no wonder, therefore, that we are seeing an increase in thenumber of telephone and e-mail based surveys auditing national practice.There are those who feel that such surveys are a poor substitute for highquality research and that they should be discouraged. However, there canbe no doubt that nationwide responses to specific questions on importantclinical issues can provide invaluable clinical information which can rapidlytranslate into improved clinical practice. A rare beast perhaps but, whenidentified, a governance goldmine.Such is the paper in this month’s Anaesthesia from Georgiou and colleagueswhich concludes that airway monitoring and management for patientsrequiring mechanical ventilation in the critical care units of the UK andIreland are substandard; once again the low use of capnography in ourICUs has been highlighted. Some would respond to this by questioningwhether evidence exists for such standards. My response to this wouldbe that a lack of evidence is no substitute for common sense; particularlywhen patient safety is at risk.There is a common view in medicine that widespread clinical practicetakes about five years to change in response to new recommendations.There are many possible reasons for this: doubt over evidence; requiredinfrastructural changes; time for information dissemination; and also, sadly,apathy. I recommend reading Georgiou’s article, digesting its implications,and then contemplating: whether we really need evidence to supportthe recommendations; the infrastructural changes would be minimal;dissemination of information should be as quick as the ‘click of a mouse’.Are we prepared to justify five years of substandard practice due to ourapathy in the management of our profession’s most important clinicalentity: the patient’s airway?Georgiou, Gouldson and Amphlett Anaesthesia 2010;66.........Induced hypothermia has been widely recognised as having theoreticalbenefits on the ischaemic brain for many years; but what of its effects onother organs? This is the focus of the article by Kelly and Nolan in thismonth’s Anaesthesia which reviews the effects of induced hypothermia onthe myocardium. Like so many reviews, it doesn’t provide the answers (nordoes it claim to), however it successfully brings together the heterogeneousanimal and human evidence in an attempt to make sense of this complexphysiological phenomenon. In so doing, they provide an eloquent focus onpotential novel benefits from current management, and on an importantarea for future research.Kelly and Nolan Anaesthesia 2010;66.......The provision of sedation is pivotal in the management of critically illpatients and the past decade has seen an increased appreciation of theimpact that drugs, and the manner in which they are used, can have onpatient outcome. Nowhere is this challenge more evident than in the worldof paediatric intensive care medicine. Children respond to the experience ofcritical illness in many different ways from adults; sedation is an importanttherapy aimed at reducing fear and anxiety, and maintaining compliancewith other interventions including invasive mechanical ventilation.However, over-sedation is complicated by greater physiological impact andboth increased time on mechanical ventilation and length of stay in theICU. Monitoring the adequacy of sedation is thus a crucial aspect of carefor the critical ill patient.In this issue of Anaesthesia, Lamas and Lopez-Herce review the mechanismsfor monitoring sedation in critically ill children. In so doing, they highlightthe challenges and inadequacies of our current practice but also makesuggestions as to the preferred methods of monitoring under differingclinical conditions. The ability to accurately monitor hypnosis and sedationhas been a ‘Holy Grail’ for anaesthetists for decades; yet it remains elusive.Nevertheless, this month’s review highlights that appropriate knowledge ofthe tools available, and their limitations, allows us to use them in the mostappropriate and calculated manner.Therapeutic hypothermia is another area of practice which has takenconsiderable time to become widely adopted. There can be little doubt thatconflicting evidence and past disappointments from early clinical trials havecontributed greatly to this. However, over the past decade, evidence oftherapeutic hypothermia following cardiac arrest has increasingly favouredits use.Lamas and Lopez-Herce Anaesthesia 2010;66....Dr Jonathan HandyEditor, AnaesthesiaCorrectionIn Paul Fenton’s article in last month’s AN there was an error; the statement about money donated by the UK government for anaesthesia machines beingwasted was inaccurate. The author had received this information in good faith. However, further enquiries have shown the statement to be inaccurateand it should be disregarded"28 Anaesthesia News May 2010 Issue 274

Fig 1.Snow’s Ether Vaporizer (RCP model)by Henry Connorand David ZuckAs far as we are aware, there are onlytwo original ether vaporizers in existenceconstructed to the design and specificationsof John Snow. Astonishingly, both layunrecognised for a considerable number ofyears, one in the museum of the Royal Collegeof Physicians, the other, less excusably, inthe Wood Library - Museum of the AmericanSociety of Anesthesiologists. The latterwas bought from a London dealer for thebargain price of £540 in 1979. This wasbefore the Association had its own premisesand somewhere to display the Charles KingCollection, so presumably, and sadly, itwasn’t on the lookout for historic items ofapparatus. The story of the identification ofthe vaporizer in the Wood Library- Museum(WL-M) was told with admirable candour bythe late Rod Calverley [1].The RCP apparatus has a moreuncertain history. At onetime it belongedto Sir BenjaminWard Richardson,Snow’s friend andbiographer, andthere is a strongi n d i c a t i o nthat it wasSnow’s ownvaporizer. Itwas seen byone of us (HC) ondisplay in the museum of the Royal Collegeof Physicians, labelled as the chloroforminhaler used by Snow to administeranalgesia to Queen Victoria during the birthof her last two children. He recognised it forwhat it was, and was able to arrange for us toexamine it closely and photograph it (Fig.1).Unfortunately there is no record of how itcame into the possession of the College,but it seems likely that it was presented byRichardson’s daughter at the same time asother items, which were recorded. We foundthat it had been on loan to the WellcomeMuseum in 1946, when it was displayed,correctly catalogued and labelled, in anexhibition set up to celebrate the centenaryof the introduction of inhalation anaesthesia.The misleading labels it currently bears mayhave been attached by members ofRichardson’s family after his death in1896.We were particularlyinterested to see wherethe vaporizer fitted intothe classificationdescribed by thelate Richard Ellisat a meetingof the Historyof AnaesthesiaSociety atHuddersfield in1990. His paper was published in theHAS Proceedings in bare summary only,but enquiry of his widow Elizabeth Ellisdisclosed that all his history of anaesthesiapapers had been donated to the WellcomeInstitute, where we were able to see them.He described his specifications for four‘marks’ of Snow ether vaporizer, but fromour examination of the apparatus in theRCP, and from detailed measurements ofthe W L-M example very kindly suppliedby the Curator, Dr George Bause, we havereached the conclusion that between Snow’sfirst version, the abortive miniature third,from which some features were retained,and the definitive fourth, he was modifyingvarious aspects of the design so frequentlyin accordance with his growing experienceand his desire for simplification, that it isnot possible to say that there was a definitiveversion of the Mark Two.A full description of the RCP vaporiser isavailable in the Proceedings of the HAS [1].The principal features of the apparatus canbe seen in the illustrations. The variationsSnow describes of the vaporizing chamber,(Fig.2) which was designed to stand ina warm water bath, were of its depth; butsince he would have been well aware thatvaporization depends on surface area, it isdifficult to understand why he would havegone to the expense of having chambersmade, if he did, that varied in depth byFig 2. The Vaporizing ChamberAnaesthesia News May 2010 Issue 274 29

only half an inch. It maybe significant that with theexception of the breathingtube, the dimensions of thetwo known apparatuses arevirtually identical. Snowfirst modified what EllisFig. 3. Interior of Face Maskcalled the ‘Mark 2’ towardsthe end of March, when heobtained a wider bore breathing tube, which the RCP apparatus has,while the W L-M has the earlier narrow version.The most interesting developments, however, were at the patient’send of the breathing circuit, and went hand in hand. Between theend of January and early May 1847 Snow used a rather large valveassembly and a mouthpiece to deliver the airethermixture. He then experimented with afacemask described by his friend Sibson, beforefinally designing his own. (Fig. 3) It is excitingto us that the RCP apparatus, unlike the W L-M,has a facemask, but with the lining so crudelysewn that it gives a strong indication of beinga home-made prototype, which strengthens thepossibility that this was Snow’s own apparatus.Also the mask bears an internal stud to which aflap valve could have been attached, making therather cumbersome valve assembly redundant.While examining several rather dilapidated Snowfacemasks in the Science Museum store, we didfind one complete, with the valve flap attachedas we expected.A most unexpected find, in its own slot in thecarrying case, but not present with the W L-Mvaporizer, and never previously described,is a thermometer (Fig. 4) calibrated to showthe volume of ether taken up at differenttemperatures. This is labelled as Dr Snow’sThermo-etherometer. (Fig. 5)Examination of the RCP apparatus, togetherwith the information provided by Dr Bause, hasgiven us a better understanding of the thoughtprocesses that guided Snow to the developmentof his definitive ether vaporizer. We are grateful tothe RCP for allowing us to examine the apparatusin such detail, and to the Science Museum forproviding access to the facemasks.Reference:1. Calverley RK. An early ether vaporiserdesigned by John Snow. In Fink BR et al. TheHistory of Anaesthesia – Third InternationalSymposium Porceedings. Park Ridge Ill.1992;91-99Fig. 4. Snow’s Thermo-etherometeryourLettersDear Dr Bythell,I agree with the proposal for a national anaesthetic record madeby Richard Griffiths and Alex Goodwin in February's AnaesthesiaNews (Anaesthesia News February 2010 Issue 271, p.9).The same thoughts occurred to me last year when listening tospeakers at the highly informative AAGBI Anaesthesia & The LawI & II Seminars. I was moved by the revelation by medicolegalexperts that they find it difficult to defend an anaesthetist whenthere is little recorded in the preoperative assessment section,even if there are no positive findings to document! Our defenceis facilitated by recording all the negative findings during thepreoperative visit. This is clearly easier to achieve using tickboxeswhen seeing patients in a tight time-frame.With the aim of creating a national standard chart, I have securedfunding from the Medical Protection Society to be able toundertake a national survey of anaesthetic charts. During thisproject, I will liaise with Richard Griffiths of AAGBI Council,several expert anaesthetic witnesses, NPSA and the MPS toproduce a 'national standard' anaesthetic chart which will beavailable to all. As Richard & Alex mentioned, this will enableeasier auditing and is one less unknown quantity for colleagues todeal with when rotating between hospitals or undertaking locumduties.May I make a plea that each anaesthetic department responds tomy soon-to-arrive request by returning a copy of their anaestheticchart in the accompanying S.A.E?Dr Helen HartleyConsultant AnaesthetistGuy's & St Thomas' NHS Foundation TrustMadam,Your correspondent, Scoop O'lamine, is a genius for demonstratingthe fruits of years of hard work by 'those who can't do'. His/heronly niggling omission is a little arrow joining the traditional andnew MMC charts labelled ‘Millions and millions of pounds of taxpayersmoney’.If Scoop is short of work perhaps a time-flow tracer chart ofeducational system development could be of interest. I'm lookingforward to seeing the number of 'competitive process' steps.Plus ça change, plus c'est la même chose.Edward BickST6,Bristol30 Anaesthesia News May 2010 Issue 274

Dear Editor,Adverse reaction to ‘Ametop’ (tetracaine) creamAmetop is a topical local anaesthetic widely used in the paediatric age group before venous cannulation. Adverse reaction to Ametop has rarely beendescribed in the literature.We had a child who had an adverse reaction after topical application of Ametop.A 3 year old healthy child weighing 17 Kg was scheduled to undergo adenotonsillectomy and insertion of grommets. The nursing staff applied the usualdose of Ametop cream to the dorsum of both hands pre-operatively. The child had been fasting for 5 hours when Ametop was applied. After 15 minutes,the child became drowsy, pale & unresponsive. I adopted the ABC approach. On examination the heart rate was 60 beats/min & the blood pressurewas 90/40. The chest was clear and there was no obvious rash visible. Ametop was immediately removed from the hand and the on-call paediatrictrainee was called; however the child regained full consciousness within 5 minutes of the cream being removed. The child had not received any otherpremedication or any other drugs apart from the topical application of Ametop.On examination, the skin where Ametop had been applied was normal.On detailed questioning of her parents, a similar reaction had occurred previously following application of Ametop, but a link with Ametop had notbeen considered on that occasion. The child was not allergic to any other medications and there was no other significant past medical history.Though there have been several case reports of adverse reaction to EMLA cream and other topical local anaesthetics it has been rarely described withregards to Ametop.We believe the most likely explanation for this event is topical absorption of local anaesthetic. There have been case reports of reactions to mucosalapplication of topical anaesthetic, but not to our knowledge any of peripheral transcutaneous absorption.We would be interested to know whether anyone else has witnessed this type of reaction.References:1) Contact dermatitis and bradycardia in a preterm infant given tetracaine 4% gel. Taddio A, Lee CM, Parvez B, Koren G, Shah V.Ther Drug Monit. 2006 Jun;28(3):291-4.PMID2) Purpura after application of EMLA cream in two children.Neri I, Savoia F, Guareschi E, Medri M, Patrizi A. Pediatr Dermatol. 2005 Nov-Dec;22(6):566-8.PMID3) Hyperpigmentation following the use of EMLA cream.Godwin Y, Brotherston MBr J Plast Surg. 2001 Jan;54(1):82-3. No abstract available.PMID: 111213304) Acute myocardial dysfunction after nasal infiltration with cocaineDatino T, Martínez-Sellés M, Quiles J, Suárez M, Sarnago Cebada F, Osende JI. Rev Esp Cardiol. 2003 Jun;56(6):629-30. Spanish. PMID:127837415) Fatality secondary to misuse of TAC solution.Dailey RH.Ann Emerg Med. 1988 Feb;17(2):159-60.PMID: 3337432 [PubMed - indexed for MEDLINE]6) Rapid mucosal absorption of topical lidocaine during bronchoscopy in the presence of oral candidiasis. Ameer B, Burlingame MB, Harman EM.Chest. 1989 Dec;96(6):1438-9.PMIDDr.Mruthunjaya.D.Hulgur SpR Anaesthesia, Hull Royal Infirmary . Email:mdhulgur@hotmail.comDr.Bret Claxton Consultant Anaesthetist Bradford Royal InfirmaryDear Editor,I would like to congratulate Drs Carle, Ashworth, Jones and Barker on their excellentletter (1) extolling the virtues of iPhone ownership. As someone who has fully boughtinto the iPhone culture, I have recently had my bubble burst somewhat.The only reason for a huddle of people around the traditionally lonely place thatis the anaesthetic machine is when a group of like minded iPhone owners meetto discuss the latest 'Apps'. This occurred recently in my theatre when along withmyself, my registrar, our CT1 trainee and our ODP, we were joined by a fourthyear medical student. As the four of us were showing off our recent purchases, ourstudent pulled out her BlackBerry (Research in Motion, Waterloo, Ontario, Canada ).With mild scorn, my registrar questioned her choice of smartphone - she raised oneeyebrow and retorted "Yes, but professional people use Blackberrys; school childrenuse iPhones."The silence was deafening.Dr Nick Crombie , Consultant Anaesthetist, Selly Oak Hospital(1) Carle et al. iPhone do you?. Anaesthesia News. 2010. 272; 27.SEND YOUR LETTERS TO:The Editor, Anaesthesia News,AAGBI, 21 Portland Place,London W1B 1PYor email: anaenews.editor@aagbi.orgAnaesthesia News May 2010 Issue 274 31

Depth of Anaesthesiamonitor for iPhoneFrom our correspondent Scoop O’LamineA recent winner of the NHS Innovation of2009, the “iPhone Depth of AnaesthesiaApplication” will shortly become availablefor purchase. The AAGBI is delighted toreveal that this application for the iPhonewill allow real-time monitoring of depth ofanaesthesia at minimal cost. The inventorDr Ivan O’Brain claims that awarenesswill become a “never event” with the useof the new technology.“The device uses Vogal analysis to integrateauditory stimulation responsivenesswith changes in cerebral impedanceas measured by a unique algorithm”explained Dr O’Brain.The auditory stimulation is provided viaheadphones connected to the iPhoneand the impedance algorithm measuredvia a Vox electrode connected directlyabove the pre-frontal area F235a. “Thesignal strength is dependent on a goodsignal, and careful application of a specialelectrode preparation KWhy is advised forbest results”.Figure 1 shows an awake patientundergoing anaesthesia induction with thecorresponding changes which occurredduring surgery and anaesthesia.“The sensitivity of the new technologyis easy to see” explained Dr O’Brain.“A period of light sedation precededinduction and was followed byanaesthesia for surgery. Note the deeperanaesthesia produced as the inductionpropofol effect was replaced by isofluraneand remifentanil”.AAGBI Council is to convene a workingparty with the NPSA during 2010 toissue guidance in the use of this newtechnology. “I have no doubt this willbecome a routine aspect of patient care!”explained a spokesman.Induction