Anaesthesia_News_FEB_web

The Newsletter
of the
Association
of Anaesthetists
of Great Britain
and Ireland
ISSN 0959-2962 No. 343
FEBRUARY 2016
INSIDE THIS ISSUE:
Advice for NICE from specialists
– not just from enthusiasts
LTFT training matters
The BIG Anaesthetics
and Smartphone Survey

Editorial
Contents
07
03 Editorial
05 President's Report
07 The BIG Anaesthetics and
Smartphone Survey
10 Advice for NICE from specialists
– not just from enthusiasts
13 Anaesthesia Digested
Mobility.
Clarity.
Connectivity.
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We seem to live in ever more turbulent times (or do they just seem so
with advancing age?). In the week I am writing this, MPs voted to involve
the UK in airstrikes over Syria, yet another massacre is reported from
the USA and the junior doctors’ strike, mandated by a staggering 98% is
avoided/delayed at the 11th hour. By the time you read this the outcome
of the negotiations with NHS Employers and the Department of Health
should be known. I am very proud of our trainees: uniting when it comes
to a question of patient safety and quality of care and the future of our
profession.
Also this week, the Council of the AAGBI has been discussing fatigue
among our junior and senior colleagues. There is good evidence that
even very short periods of rest under appropriate conditions reduces
fatigue. Reducing fatigue would mean delivering safer clinical care
for our patients and safer journeys home for us. I urge you look at the
Association Guidelines on fatigue – the most authoritative publication on
the subject I have come across – http://www.aagbi.org/fatigueguideline.
Before I use up all my allocated space, I hope you agree there is
something for everyone in this issue of Anaesthesia News. We have
the results of a survey of what mobile phones apps are most popular
among anaesthetists. As an obstetric friend remarked – it must be the
ones with the most flashing lights that go ‘ping’. The National Institute
for Health and Care Excellence (NICE) explains why specialist input into
their guidelines is so important and invites you to get involved.
Many years ago I spent six months in Papua New Guinea and Indonesia.
While there I developed a fascination with the island of East Timor but
was unable to visit due to the political situation following its invasion by
Indonesia ten years before. In this issue we have a fascinating account
by an intrepid colleague who not just visited the island but undertook
a mountain bike race there. For those of you interested in practising
in austere environments we have an account of the latest piece of
equipment designed for resource poor settings Continuous positive
airway pressure for low income countries.
We always welcome your feedback on our contents or your thoughts
about unrelated subjects! So please put pen to paper or fingers to
keyboard.
I hope you enjoy this issue of Anaesthesia News as much as I have
enjoyed putting it together.
Felicity Plaat
Immediate Past Honorary
Membership Secretary, AAGBI
or correctness of products or services offered in advertisements.
Anaesthesia News February 2016 • Issue 343 3
24
10
17
19
16
17 Developing trainee management
roles
19 Affordable CPAP in
low income countries
23 LTFT training matters
24 Tour de Timor
26 Particles
28 Your letters
The Association of Anaesthetists of Great Britain and Ireland
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Anaesthesia News
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Editors: Phil Bewley (GAT), Nancy Redfern, Richard Griffiths, Sean Tighe,
Mike Nathanson, Rachel Collis, Felicity Platt, Gerry Keenan and Elizabeth McGrady
Address for all correspondence, advertising or submissions:
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Telephone: 020 7631 8803
Email: chris@aagbi.org
Printing: Portland Print
Copyright 2016 The Association of Anaesthetists of Great Britain and Ireland
The Association cannot be responsible for the statements or views of the contributors.
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Since I have no crystal ball, and by the time this is published
things will be much clearer, I will devote little more time to
speculation. Election time will be on us again soon. Elections
to the Council of the Royal College of Anaesthetists showed
the greatest turnout and number of candidates in its history,
suggesting that the pressure on SPAs and the future impact of
contract negotiations on CEAs has done nothing to dampen
enthusiasm to get involved. Indeed the contract negotiations
may actually have spurred many to stand. This Spring will see
elections to the AAGBI Board and GAT Committee, but more
importantly to the Scottish Parliament and Welsh Assembly. It
seems unlikely that Conservative administrations will be returned
in either country, but each is likely to wish to tackle contracts for
trainees and consultants, not least because of the further impact
that UK parliament decisions on austerity will necessarily have
on the devolved health budgets. I can only hope that Scottish
and Welsh Health Ministers will have watched the unhappy
process conducted in Whitehall and be eager to avoid such
public hostility from doctors, a group that maintain consistently
much higher public respect than politicians. My plea to vote in
each and every election still stands.
I’m ‘told’ that the doctors contract issue was seen by those in
power as a quick, easy win to be got out of the way quickly
before the most contentious political issue facing the current
parliament, that of Europe and the UK’s membership or not of
the European Union. If contracts were to be a ‘quick easy win’ I
shudder to imagine what the Europe debate will be like. The two
issues cannot easily be separated. The UK still fails to produce
enough ‘home grown’ doctors (when those home grown
wished to stay). Australia and New Zealand may not offer a long
term alternative to UK graduates; the last few meetings of the
Common Issues Group have consistently reported that migration
between ‘New World’ countries is getting more difficult. The EU
has most often been viewed as a source of doctors for the NHS,
rather than a potential destination for UK graduates (perhaps
because of our notorious lack of enthusiasm for languages other
than English). This may change. The European Working Time
PRESIDENT's
REPORT
I ended my report a year ago with a plea for engagement, concluding that 'apathy was never the solution'.
It’s now hard to believe that the specialty or profession could have been accused of apathy so recently,
but then it’s amazing how quickly people wake up when their own pay packets, pensions and career
futures are threatened directly. Writing this with several weeks of 2015 left I have no idea how the trainee
contract negotiations will have unfolded or whether industrial action was finally avoided. I know that in
December we got closer to such industrial action than at any point in the last 40 years, and find it difficult
to believe the government in England made sufficient concessions to avoid such action in early 2016.
The focus up to now has been on trainees, with negotiations on a new consultant contract for England
happening quietly in the background. As the BMA began unveiling the best it could negotiate, it became
difficult to see consultants in England accepting this best offer – rather like turkeys and Christmas.
Regulations are an area which has caused most irritation for
the current government. How ironic that the chair of the March
2014 ‘Independent Working Time Regulations Taskforce’, who
reported adversely on the impact of EWTR on training, became
a Special Political Adviser to the Secretary of State for Health in
October 2015. Damascene conversions are not unknown, but
Damascus has been a difficult route for other reasons for most
of that period.
Outside of the political arena other changes are worth
mentioning. Bertie Leigh stood down as Chair of NCEPOD at
the end of November 2015. Bertie is a long-standing friend of
the AAGBI and, as Senior Partner at Hempsons, was for many
years our lawyer at the AAGBI. There have been few major legal
cases affecting the NHS that he has not played a part in, and
even if he wasn’t acting for one side or the other, he always knew
what was going on. I hope he won’t mind my describing him
affectionately as one of the nicest rogues I’ve met, and if he does
I hope the damages won’t be too painful. Bertie has made a
massive contribution to patient safety and I want to thank him for
that on behalf of patients and the AAGBI, it is difficult to imagine
the medico-legal world without him.
Away from the political and legal worlds the bread and butter work
of the AAGBI continues. Updated guidance on Recommendations
for Standards of Monitoring During Anaesthesia and Recovery
has been published recently, new guidance on Pre-operative
Measurement of Adult Blood Pressure and Management
Hypertension (jointly with the British Hypertension Society)
should have just come out online and updated guidance on
consent is in its final stages. Preparations are well in hand for
the GAT Annual Scientific Meeting in Nottingham in June and
the end of this month will see the Scottish Standing Committee
meeting in Dundee. So while it’s all change, life continues as
usual.
Dr Andrew Hartle
President, AAGBI
Anaesthesia News News February 2016 2016 • • Issue Issue 343 343 55

NIAA
National Institute of Academic
Anaesthesia
The John Snow Anaesthesia
Intercalated BSc Awards 2016
The National Institute of Academic Anaesthesia (NIAA) is pleased to announce details for the 2016 John Snow
Anaesthesia Intercalated BSc Awards. Awards will be offered by the Association of Anaesthetists of Great Britain
and Ireland (AAGBI)/Anaesthesia, the British Journal of Anaesthesia (BJA)/Royal College of Anaesthetists (RCoA), the
Obstetric Anaesthetists’ Association (OAA) and the Neuroanaesthesia and Critical Care Society of Great Britain and
Ireland (NACCSGBI).
The BIG Anaesthetics
and Smartphone Survey
Handheld technology has been used for decades in anaesthesia. Dr Cyril Conway, former Professor of Anaesthesia at Charing Cross
and Westminster Hospitals, used a programmable calculator in the 1970s. It was not only hefty and slow but had small programmable
magnetic strips that could be inserted to perform certain predefined calculations or to share with colleagues over a coffee. Nowadays
you are much more likely now to see a smartphone in the hands of your colleagues than a photocopy of a Sudoku. As the quote goes
‘Surgeons find iPhones very useful, because they come with an anaesthetist attached’[1]. In addition, a brief look around a hospital will
show the vast majority of healthcare professionals also have access to a mobile communication device of one sort or another, and there
is evidence that portable technology is becoming common [1]. Whether this is a positive or negative thing is yet to be shown.
●
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The scheme has been designed to encourage medical student interest in anaesthesia and its related
disciplines.
The AAGBI/Anaesthesia, BJA/RCoA and OAA are offering awards of £2,000 and the NACCSGBI an award of
£1,000.
Each institution can submit a maximum of four applications, so some co-ordination between supervisors will
be required.
Awards go to the student and not the supervisor/institution and are meant to contribute to living costs.
Project running costs will be funded by the supervisor/institution.
Applications are welcomed for suitable clinical projects.
Assessment criteria: (1) quality of the student, (2) quality of the research project and (3) supervisor and
teaching environment. Unfortunately we are unable to provide detailed feedback to applicants.
Applications should be submitted for projects that have not yet commenced and applicants may only apply
for one funding stream.
Funding should be acknowledged in any publications (i.e. funded by AAGBI/Anaesthesia, BJA/RCoA, OAA or
NACCSGBI via the NIAA as indicated in the award letter) and a final report will be required.
Intercalaters may be asked to present their work at a meeting.
The closing date for applications is 5.00 pm on Thursday, 31 March 2016.
For further information and an application form please visit the NIAA website at: www.niaa.org.uk/JohnSnow2016.
To read about some of the successful iBSc projects that have been funded in the past, please see:
http://www.niaa.org.uk/John-Snow-Anaesthesia-Intercalated-BSc-Awards
These awards are annual, so if your department misses the deadline for 2016 please do consider applying again
next year.
Best of luck!
A survey was sent out nationally using Loop Surveys® to identify the
use of smartphones by anaesthetists in the workplace, application
(app) usage, and limitations of use. This consisted of seven questions
asking the individual their grade, which smartphone (if any) they
primarily used at work, what apps they used and the biggest barriers
to smartphone usage. Anaesthetists were identified though a national
forum (doctors.net.uk) and by emailing departments and deaneries
directly.
A total of 261 anaesthetists completed the survey with a response rate
of 26%. The low response rate may be due to the untargeted nature
of the subjects, failure to follow up those asked or the vast number of
surveys that enter inboxes on a daily basis. Of those surveyed, 98.5%
owned a smartphone. The majority of respondents were trainees
(68%), followed by consultants (28%) and non-consultant grades
(4%). Of these, the majority used an iPhone (71%), Android (25%) or
iPad (4%). This percentage is also reflected in a pilot study carried out
by the authors where there was a more equal representation of grade
of doctor [2]. These figures are interesting as they oppose the world
market, which is held by Google’s Android operating system at 84.7%
compared to 11.7% by Apple’s iOS [3].
with cost; the average price of an iPhone is nearly 3 times more at
£456 compared to £169 for an Android phone [5]. These results
also reflect the pace that technology evolves. A survey published in
the RCoA bulletin in 2008 reported that the majority of anaesthetists
used Nokia’s Symbain Platform [6]. This survey reported no use of
Symbian, Blackberry or Windows phones.
Figure 1 The main subsets of apps reported and the three most reported apps for each subset
Association of
Anaesthetists
of Great Britain
and Ireland
Royal
College of
Anaesthetists
British
Journal of
Anaesthesia
Obstetric
Anaesthetists’
Association
Neuro Anaesthesia & Critical Care
Society of Great Britain and Ireland
So why do anaesthetists buck the trend? Apple has had a longer
tenure in the medical app market and anaesthetists may look at
previous performance. Alternatively it may represent the number of
apps available for each phone with only 8,000 medical apps available
in Google Play’s Android store compared to 20,000 medical apps
in Apple’s iTunes [4]. It may be that iPhones are shinier and more
user friendly than Android handsets or simply that people have brand
loyalty to Apple. One thing that is highlighted is that it is not associated
When asked which apps were used, over 114 were reported, as shown
in Figure 1. Of these, 59% were general medical apps such as the
British National Formulary, anatomy based apps, microbiology apps
or paediatric apps. Twenty-three percent were anaesthetic specific
apps such as airway guidelines or logbook apps. Non-medical apps
made up 18% and included Google, Kindle or YouTube (18%).
Anaesthesia News February 2016 • Issue 343 7

Figure 2 The 10 most reported apps across all platforms. (BNF: British National Formulary, BJA: British Journal of Anaesthesia).
The ten most used apps are outlined in Figure 2. The most commonly
used app was iGaslog, which is no longer supported by Apple’s latest
software. Alternatives identified were Medberry, the College logbook
and Online Anaesthesia, with others due to be released. iResus and
iNAP3 apps were both recommended by the RCoA for trainees but are
also no longer supported or available for download. This may have
been due to lack of income stream to maintain software or loss of
interest by the developer. The South Thames Retrieval Service Paeds
Drugs app and medcalc involve medical calculations and drug dosing.
All apps of this nature now require registration with the MHRA and a
CE mark. Of the 114 apps reported only five were solely for Android.
The average cost of these apps to the end user was £4.60 (£0–
22.49) with six being free. CLWrota is free to the end user but costs
a department approximately £220 per user depending on pricing
structure.
Apps were split evenly across those used to access guidance and
those used to perform a task such as drug calculation or logging data.
There was a trend towards the changing way that education resources
were being accessed, such as FOAMed (Free Open Access to
Medical Education) and journals (British Journal of Anaesthesia and
Anaesthesia) through handheld devices rather than in print. As no
specific closed questions were used in this survey it is impossible to
tell if this is represented more widely among the respondents.
This survey also identified many barriers to the use of smartphones.
The main reasons were lack of access to Wi-Fi and poor telephone
reception (63%). A recent freedom of information act request identified
that 64% of NHS trusts do not offer internet access to patients and
82% do not allow NHS staff to connect to the hospital Wi-Fi network
[8]. Just 10% of Trusts have a formal policy on personal device
usage. Trainees surveyed commented on the difficulty of accessing
educational resources and completing assessments without access
to the internet. This alongside the 11% reporting that they felt it was
unprofessional to use one’s smartphone at work show that there are
also cultural barriers that may prohibit further professional use.
In summary, this survey identified that smartphones are commonplace
at work and there is scope for their use to aid clinical practice, to
improve communication between teams and to access guidance or
educational materials. Apps should be aimed at both Android and iOS
platforms. Some of the most popular apps are no longer available so,
in order for apps to have ongoing support and updates, a subscription
may be the best way of achieving this. A CE mark is required for
apps that are medical devices or do calculations. Poor access to the
internet is a barrier to app use and so apps that do not require a data
connection would appear to be the most appropriate at this time.
Robert M Conway
ST5 Anaesthetics
Surprisingly social media was not well represented (Twitter 0.01%,
Facebook, Instagram, SnapChat all 0%) despite the Colleges and
Associations using Twitter as a source to release updates and alerts
(@RCoANews @AAGBI). This may represent people’s hesitancy to
declare social media use in the workplace as covered in a recent
review in this publication [7]. Messaging apps were not represented.
The authors have experience of using these apps to improve
communication between teams; however, there were no reports in the
literature to support this.
Rob Guy
ST5 Anaesthetics
St Richard’s Hospital, Spitalfield Lane, Chichester
Declaration of interest
Dr Cyril Conway was the father of RMC. RMC is also the developer of
Medberry (an anaesthetic logbook).
References
1. Dasari KB, White SM, Pateman J. Survey of iPhone usage among anaesthetists in
England. Anaesthesia 2011; 66: 630–1.
2. Conway RM, Guy R, Sloan C. BADASS: Brighton Anaesthetic Department App and
Smartphone Survey. 2014. http://j.mp/gasbadass (accessed 3/12/2014).
3. International Data Corporation. 2014. http://www.idc.com/getdoc.
jsp?containerId=prUS25037214 (accessed 3/12/2014).
4. Apple app store still leads Android in total number of medical apps. iMedicalApps
12 July 2013. http://www.imedicalapps.com/2013/07/apple-android-medical-app
(accessed 3/12/2014).
5. In Smartphone Market, It’s Luxury or Rock Bottom. Wall Street Journal 1 February
2015. http://www.wsj.com/articles/in-smartphone-market-its-luxury-or-rockbottom-1422842032
(accessed 3/3/2015).
6. McIndoe A, Hammond E. How to maintain an anaesthetic logbook. RCoA Bulletin
2008; 51: 2633–7.
7. Majid S, Naveed K. Social media networks as a learning platform – the anaesthesia
trainees’ perspective. Anaesthesia News 2014; 328: 8–9.
8. Two-thirds of UK Hospitals don’t offer Wi-Fi to Patients. Extreme Networks 7 May 2013.
http://www.extremenetworks.com/two-thirds-of-uk-hospitals-dont-offer-wi-fi-to-patients
(accessed 3/12/2014).
Unsurprisingly, as a resourceful group, anaesthetists had novel uses
for apps. These included the use of a spirit level to demonstrate
tilting beds within obstetric practice and to confirm that an arterial line
transducer was at the same level as the heart, sound recordings of the
falling beeps of saturation monitors in simulation (and to keep trainees
on their toes or frighten the life out of a supervising consultant…), the
use of FOAMed applications for education and a number of reports
on the use of games and videos for distracting children and surgeons
prior to induction. Ebooks, such as the A to Z of Anaesthesia, were
also reported as being used alongside medical podcasts. At the time
of publication the AAGBI were developing an app that was yet to be
released.
8 Anaesthesia News February 2016 • Issue 343

Advice for NICE from specialists – not just from enthusiasts
What is NICE?
The National Institute for Health and Care Excellence (NICE) is
the independent body responsible for driving improvement and
excellence in the health and social care system. It develops
guidance, standards and information on high-quality health and
social care. NICE also advises on ways to promote healthy living
and prevent ill health.
The Institute’s aim is to help practitioners deliver the best possible
care and give people the most effective treatments, which are
based on the most up-to-date evidence and provide value for
money, in order to reduce inequalities and variation.
NICE products and resources are produced for the NHS, local
authorities, care providers, charities, and anyone who has a
responsibility for commissioning or providing healthcare, public
health or social care services.
Why does NICE need specialist advice?
NICE needs advice from specialists across the whole range
of its guidance programmes. Only practising clinicians have
the knowledge to provide advice on how procedures and
technologies best fit into clinical practice and on the real world
issues involved in their use. Specialists have the experience of
managing patients by a range of methods and may have cogent
views on the merits and potential of new techniques. They may
be able to give insights into the enthusiasm or scepticism of their
colleagues and the incentives or obstacles to adoption of new
devices and practices. All these aspects are important to NICE to
supplement published evidence, especially when that evidence is
sparse. Specialists may also offer helpful background information
about the published literature, with respect to concerns about the
conduct of studies or their interpretation.
How does NICE involve specialists in
producing guidance?
NICE needs specialists on independent advisory committees and
guideline development groups. All these appointments are by
advertisement and NICE draws the attention of relevant specialist
organisations to these advertisements. Public Health, Technology
Appraisals, Interventional Procedures and Medical Technologies
guidance is produced by standing committees on which
members serve for a number of years. Social Care and Clinical
Guidelines are each created by a group specially recruited for a
topic, typically over about two years. The Diagnostics Advisory
committee has a mixture of standing members and members
recruited for each individual diagnostic assessment.
NICE asks nominated specialists for input about specific topics.
For Technology Appraisals this involves written commentary,
attending a ’scoping workshop’ and also attending committee
meetings to answer questions. The Interventional Procedures
and Medical Technologies committees deal with considerable
numbers of procedures and depend largely on responses
to questionnaires from a number of specialists. For Medical
Technologies, advisers answer questions and proffer comments
by telephone or in person during committee meetings.
NICE also asks specialists for ad hoc advice – for example
in deciding whether to evaluate or to update guidance on
a procedure, when creating text to describe procedures or
when specific questions arise as a result of public consultation
responses.
Finally, specialists can (like anyone else) submit comments and
opinions during public consultation on draft guidance (and for
Medical Technologies, on the scopes of technologies prior to
evaluation).
How does NICE identify specialists
to ask for advice?
This is done largely via specialist organisations (Royal Colleges,
associations and specialist societies). Leaders of professional
organisations attended symposia in 2005 and in 2013 to discuss
with NICE how best to engage with them and their members. On
each occasion there has been clear consensus that they would
like to identify advisers for each topic required by NICE. That
principle suits NICE well, in ensuring that advisers are ’ratified‘
by their professional organisations, implying that their expertise
and experience is relevant to the procedure or technology.
For Medical Technologies, manufacturers can nominate
advisers and NICE may also approach technical or scientific
experts identified during discussions about specific devices and
diagnostics.
The timescales involved in asking organisations to nominate
advisers and getting their advice can be challenging. It is
one of the biggest problems that the NICE teams face in
assembling material for their advisory committees. Specialists
who are approached for advice are often slow to respond (for
understandable reasons) and some do not respond at all. There
is good reason to believe this is often because the specialists
think they have not got sufficient knowledge.
Do you need to be an expert with a
technology to advise NICE?
No – definitely not. NICE does not want advice exclusively from
enthusiasts and early adopters of technologies. Of course the
advice of the well-known leaders and proponents of technologies
are of the greatest importance, but NICE needs a broad spread
of views and opinions. For Interventional Procedures, NICE
requests at least one specialist who does not use the procedure:
10 Anaesthesia News February 2016 • Issue 343 Anaesthesia News February 2016 • Issue 343 11

ut for some novel procedures and devices it may be difficult to identify
any UK specialists with experience of their use.
Specialists who have never used a procedure or device can nevertheless
provide valuable insights. Do they see it as potentially useful? If not,
why not? Would they like to use it and if so what are the obstacles to
its adoption? What are their uncertainties about its benefits and risks,
based on the published evidence or on the prevailing attitude of their
peers? How might it best fit into clinical practice and what current
methods might it replace? Is it likely to occupy an important place in
practice in the future?
If you are asked to advise and feel that you have insufficient knowledge
to provide any insight then simply tell the NICE team – they can then
approach somebody else. A negative yet clear response is really
helpful, compared with no response at all!
Other common misunderstandings
When you are asked for advice, it is your personal knowledge and view
that is valued. Insights about the tide of opinion among your peers are
useful, but the prime focus is your own perception of the technology.
There is no need to offer any kind of literature search – NICE will be
doing that in detail – but your interpretation of the published evidence
is always valuable and your knowledge of ongoing trials and registers
can be very helpful.
Potential conflicts of interest are not a bar to offering advice so long
as your interests are fully declared (NICE has a detailed policy and
process for this) and can therefore be taken into account. NICE expects
that experts in a technology may well have commercial interests in it
and is happy to discuss individual cases. This contrasts with NICE
advisory committee members who may be excluded from discussion
of the relevant topic if they have conflicts of interest.
GAT ANNUAL
SCIENTIFIC
2016 MEETING
15-17 JUNE 2016
NOTTINGHAM
CONFERENCE CENTRE
Book your study leave today
for the ‘must attend’ event for
Trainee Anaesthetists
Educational programme
Professional development
Fun social events
February 2016
Digested
The contribution of the anaesthetist to risk-adjusted mortality after cardiac surgery
Papachristofi O, Sharples LD, Mackay JH, et al.
Asked and answered: is the mortality associated with cardiac surgery related to the
anaesthetist and should it be used to measure anaesthetic performance?
Alston RP
Although the effect of the cardiac surgeon on mortality rates
has been known for some time, successful heart surgery,
like success in all other surgery, is generally the result of
multidisciplinary team working. While cardiac surgeons
can affect mortality, for example by causing irreversible
damage to heart structures, the anaesthetist, other than
by misadventure, is less likely to cause patient death. This
prospective study of more than 110, 000 cases performed in
ten UK centres over ten years demonstrated that the impact
of patient risk was the most important factor affecting
mortality, that the surgeons impact was 4% and that the
anaesthetists impact was much lower, at 0.25%. What
surprised me was that there was no relationship between
anaesthetists’ caseload and mortality.
Peter Alston provides a balanced assessment of this paper in
an accompanying editorial, concentrating on its drawbacks,
positives and overall impact. While any patient death is a
tragedy, I am also interested in non-fatal outcomes such as
stroke, postoperative delirium and acute kidney injury, which
the anaesthetist may well influence. As Alston points out,
this is an area worth exploring in the future. For now though
the study performed on behalf of ACTA, because of the
huge size of its sample population, its multicentre design
and the use of a single fundamental outcome of mortality,
provides reassurance that variation in anaesthetist practice
contributes little to the mortality associated with cardiac
surgery. Both these papers are essential reading, even if you
are not a cardiac anaesthetist.
It is worthwhile keeping clearly in mind the type of NICE guidance you
have been asked to assist with. For example, Interventional Procedures
guidance is all about safety and efficacy and has no consideration of
cost (unlike Technology Appraisals or Medical Technologies). Medical
Technologies and Diagnostics guidance is about specific commercial
products (although it may influence adoption of other similar ones)
while Interventional Procedures are always ’generic’.
Adding advice for NICE to your busy
schedule
All specialists are busy and NICE knows that. But providing advice
gives an opportunity to influence NICE guidance, which is in turn
very influential in shaping clinical practice in the UK and beyond, and
that seems a reasonable incentive. A record of providing advice for
NICE is likely to be a worthwhile addition to a portfolio for appraisal
and revalidation and it may also be a useful adjunct in application for
ACCEA awards.
DISCOUNTS
FOR AAGBI
MEMBERS
An alarm for a false alarm
Choi SW, Lam DMH
Trials and tribulations of a meta-analyst
Choi SW, Lam DMH
You would be forgiven for thinking that all the editors
of Anaesthesia are expert statisticians, but I certainly find
myself way out of my depth very quickly. Luckily the
editorial board has outstanding help available from not
one, but two, statisticians. If, like me, you have trouble
understanding statistics look no further, because each
month we are publishing ‘statistically speaking’ a series of
papers simplifying statistics and dispersing the myths, yet
all the while providing a highly entertaining read. You will
soon be wondering why you had avoided the subject for so
long! I for one am extremely grateful that Dr Choi and her
colleague have agreed to write a year’s worth of papers. This
is an exciting new feature of the journal so please let us
know what you think by writing to us via our website.
Articulate and perceptive specialist advice provides huge value to NICE
committees in their debates and is of the very greatest importance
in evaluating novel technologies, especially when other evidence is
sparse.
Professor Bruce Campbell
Chairman, Interventional Procedures and Medical Technologies
Advisory Committees, National Institute for Health and Care Excellence
www.gatasm.org
N.B. the articles referred to can be found in either the latest issue of Anaesthesia or on Early View (ePub ahead of print)
C.R. Bailey
Editor, Anaesthesia
Anaesthesia News February 2016 • Issue 343 13

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The same reliable catheter and technique
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* Reference available on request
23 rd Annual Manchester
Paediatric Anaesthesia Update
Friday 18 th March 2016
Manchester Conference Centre
Course Organiser: Dr Davandra Patel
Perioperative fluid management
PROGRAMME
Epilepsy, anticonvulsants and anaesthesia in children
Preoperative anaesthesia assessments clinics
OSA in children – Surgeon’s perspective
OSA in children – Anaesthetists perspective
Paediatric emergency laparotomy audit
Debate: Preoperative fasting time should be reduced
Anaesthesia for children with chronic renal failure
5 CME
points
Course Fees £175
Doctors in training £85
Enquires should be directed to:
Paula or Christine
Telephone Number: 0161 701 1263 or 701 1264
Fax: 0161 701 4875
Email: paula.gardner@cmft.nhs.uk or christine.taylor@cmft.nhs.uk
2D04
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2A01, 3A02
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1I05, 2A06
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As seen at the AAGBI WSM 2016
Are you an SAS doctor seeking to visit a
place of excellence or recognised centre to:
• Broaden and expand your knowledge
• Learn about new innovative work
• Network with experts in the field
• Bring expertise back to your department
• Gain on the job training
The AAGBI invites applications for the SAS
Personal Development Grant for 2016. This
is a grant of up to £2,000 towards travel and
subsistence exclusively for SAS doctors to
visit a place of excellence of their choice for
up to two weeks. Funding can be used to visit
more than one centre. All SAS doctors who are
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ESA_February issue.indd 1 14/12/2015 14:45:40

Developing trainee
management roles
The Queen Elizabeth Hospital in
Birmingham (QEHB) is a teaching
hospital and anaesthetic trainees from
across the West Midlands undertake a
large proportion of their training at this
tertiary centre. Around 80 anaesthetic
and intensive care trainees are placed
here at any one time.
Trainee representation at management level in a department of this size is invaluable. The roles of Trainee Service Lead (TSL) and Trainee
Education Lead (TEL) are well-established in the anaesthetic department at QEHB. This year two new trainee management roles have
been introduced: Trainee Governance Lead (TGL) and Trainee Equipment Lead (TEqL). This article gives an overview of both the existing
and newer management roles and their advantages for the individual and the anaesthetic department.
The trainee management roles are open to any post-fellowship anaesthetic trainee placed at QEHB for six months or more. The roles
are appointed after a competitive application and interview process. Trainees undertaking these roles are allocated administrative time
to allow them to undertake their duties. The trainee management roles mirror the corresponding consultant roles and fit into the overall
organisational structure of the department that consists of four groups: Operations, Education, Equipment and Governance.
The General Medical Council state in their guidance that ‘being a good doctor means more than simply being a good clinician’ [1].
Additionally, the Royal College of Anaesthetists curriculum [2] sets out learning domains to be achieved during the course of advanced
training that include leadership, innovation and management (domains 3, 4 and 5). While competencies to satisfy these can of course
be achieved during the course of modular training, in the Birmingham School of Anaesthesia a specific management module has been
developed for trainees undertaking the roles we describe which can be completed alongside a clinical unit of training.
Governance
The TGL primarily works alongside the Anaesthetic Governance
Group to improve patient safety and service provision. As the
trainee representative of the governance group, the TGL gains
experience of risk management, co-ordinating audit and research,
collating, investigating and presenting incident reports, handling
complaints, as well as the discussion of mortality and morbidity. In
turn, the TGL liaises between the governance group and the trainee
body to facilitate communication in both directions. The TGL is a
new and evolving role with a broad remit so we envisage that the
trainee may select one or two of the above areas to pursue in depth
and complete a governance project. We also hope that the TGL will
act as first port of call for trainees wishing to escalate governance
issues or discuss specific incidents in confidence that may have
otherwise fallen under the radar.
Equipment
The TEqL is another new role, introduced with a view to promoting
trainees’ participation in departmental activities relating to equipment
and technology. The role provides a unique opportunity to become
involved in trialling, introducing and developing equipment in
theatres, as well as in new technology and communication projects
within the anaesthetic department. As an aide to the ‘Equipment
Consultant’ the TEqL will also attend Equipment Group meetings
and undertake an equipment/technology-related audit or service
development project. With technology rapidly advancing, we
will undoubtedly see the phased introduction of new anaesthetic
machines and a move toward a completely electronic patient
record in the near future. We envisage that the TEqL will facilitate
the participation of anaesthetists in training in successfully
implementing these and further new projects.
which can be hard to achieve during clinical training and can offer
something different for their CVs. The competitive interview process
provides the opportunity to be part of the interview panel for the next
appointment. Experience on the other side of the interview panel
is hard to get and is invaluable for improving your own interview
technique.
Moreover, for anaesthetic departments, herein lies the opportunity to
train the clinical leaders and managers of the future! Several trainees
who have undertaken these roles have gone on to be appointed
as consultants with significant managerial responsibilities. Projects
undertaken by trainees in these roles have proven valuable to
service development and improving training in our department.
We have certainly observed that these roles have enhanced
communication between management, the consultant and trainee
bodies and facilitated an enhanced culture of cohesive working.
Toni Brunning
ST5 and Former TEL
Naginder Singh
ST7 and Former TSL
Jeremy Marwick
Consultant Anaesthetist and Junior Workforce Lead
Queen Elizabeth Hospital Birmingham
Acknowledgements
We are very grateful to all of our colleagues in the Department
of Anaesthetics at QEHB for providing us with the opportunity to
undertake these roles and for supporting us in developing the TGL
and TEqL roles during our time in post.
References
1. General Medical Council. Leadership and management for all doctors.
Operations
Education
Readers in other hospitals and regions may well relate the
2012. http://www.gmc-uk.org/guidance/ethical_guidance/management_for_
responsibilities described with our trainee managerial roles with doctors.asp (accessed 6/11/2015)
The TSL works closely with the consultant designated ‘Junior The TEL role was introduced in 2012 and they work closely with
other roles variously termed, ‘Admin SpR,’ ‘Rota Registar,’ and ‘M&M 2. Royal College of Anaesthetists. CCT in Anaesthetics – Advanced Level
Workforce Lead’ as part of the Operations Group. The TSL role the College Tutors as part of the Education Group. This role is
SpR’ which previously also existed at QEHB. We hope we have Training Annex E. August 2010. http://www.rcoa.ac.uk/CCT/AnnexE
(accessed 6/11/2015).
was introduced in 2011 and its responsibilities include writing and primarily concerned with supporting the organisation and delivery
highlighted that the trainee managerial roles in the Anaesthetics
3. Plunkett E, Cullis K, Clift K. Trainee Service Lead: management experience
managing the trainee on-call rota, auditing module compliance, of the departmental education programme at every grade of
Department at QEHB have a scope extending far beyond their for trainees in the Birmingham School of Anaesthesia. Anaesthesia News
chairing bi-monthly trainee forums, updating the departmental training and for consultants. The TEL also supports the TSL in
precursors. Having recently completed six months as TEL (TB) 2013; 309: 11–2.
trainee handbook, assisting with induction, attending management running the trainee forums, maintaining the trainee handbook and
and TSL (NS), respectively, we reflect on our experience and the 4. Moore R, Miller K. The role of the trainee educational lead. Anaesthesia News
2015; 331: 20–1.
meetings and mentoring the other trainees undertaking management attending management meetings. The educational component
many benefits these positions offer to trainees and anaesthetic
roles [3]. Running an open ‘surgery’ for trainees to discuss any involves co-ordinating monthly post fellowship training afternoons,
departments alike.
issues arising in confidence with a trainee in management is coordinated
and ensuring all trainees’ educational needs are met. The TEL also
by the TSL and TGL. For this role, one day a week is ensures that trainees are allocated to attend teaching appropriate to
There are many advantages for trainees undertaking these roles.
allocated for administrative time and, during their time as TSL, the their level of training and support other educational activities within
They gain insight into management structures and, consequently,
trainee also completes a management project. This along with the anaesthetic department, e.g. simulation [4]. Half a day per week
the complex issues that arise and discussions that take place
other workplace based assessments allows completion of the of administrative time is allocated to this post. While education is
in a busy anaesthetic department. They also provide excellent
Birmingham School of Anaesthesia management module, formally the focus, this is still primarily a management role and trainees are
preparation for the type of managerial tasks taken on and expected
recognising the experience gained.
able to undertake a project and complete the formal management
at consultant level. Trainees gain practical management experience,
module if they wish.
16 Anaesthesia News February 2016 • Issue 343 Anaesthesia News February 2016 • Issue 343 17

Bill Mapleson Courses
Developing World and Remote Locations
The Essentials for Anaesthesia and Higher Care
Tuesday 15 th March 2016
One-day, hands on practical & simulation course led by Professor Judith Hall. Faculty includes Roger Eltringham & Natalie Glover.
Course to include: - Simulated scenarios from the developing world; Pre-assessment in the developing world; Infectious diseases
and the Anaesthetist; PPE in challenging situations; Triservice and other apparatus, theory and practice; Challenges of transport;
Drugs when you can’t have everything.
Cost £300. Early bird rate £250 if booked before 23 rd February.
Personal Development Courses
Focused Intensive Care Echocardiography (FICE) - A one-day course run twice yearly on 14 th June & 11 th October 2016. Cost £150.
Cardiff Perioperative Transoesophageal Echcocardiography (TOE)
- A two-day lecture based symposium, 12 th -13 th September 2016. Cost £300.
- A three-day, hands on practical course held on several dates throughout the year. Cost £350.
Simple Statistics, Excel & SPSS - A one-day introduction / refresher run twice yearly on the 16 th March & the 21st October 2016.
Cost £100. Early bird rate £80 if paid three weeks before the course date.
Introduction to Research - A two-day course covering all research competencies. Twice yearly, 16 th -17 th June or 15 th -16 th
December 2016. Cost £180. Early bird rate £150 if paid three weeks before the course date.
Management Interview Skills - A one-day course on 25 th May 2016. Cost £100 with early bird rate £80 if paid three weeks before
the course date.
Simulation Courses
Training the Trainers - A two-day course for all those interested in Simulation Education. 26 th -27 th May 2016. Cost £290. Early
bird rate £250 if paid three weeks before the course date.
Resuscitation Update - A half-day course run twice a year on 7 th March & 18 th April 2016. Cost £75.
Neuroanaesthesia: learning through simulation - A one-day course held on May 26 th 2016. Cost £140. Early bird rate £120 if
paid three weeks before the course date.
All refreshments provided. CPD points applied for.
Click here to register: https://form.jotformeu.com/cmhabc/BMC or for more information, contact Catherine Hough. Direct Line: (029) 20743108
Email: HoughC@cardiff.ac.uk
Continuous positive
airway pressure in low
income countries
Continuous positive airway pressure (CPAP) is a form of therapy used for the treatment of a wide
variety of conditions causing respiratory distress in patients of all ages. It entails the provision of a
continuous supply of a mixture of compressed air and oxygen delivered in varying proportions, and
at flow rates and pressures according to the patient’s requirements. While it is readily achievable
in modern, well equipped hospitals, this life saving treatment is frequently unavailable in remote
hospitals in poor countries because of the expense and logistical problems involved in the provision
of medical oxygen and air. An alternative method of providing CPAP which overcomes these
disadvantages is described.
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The Diamedica Baby CPAP apparatus
The Diamedica Baby CPAP
apparatus (Fig 1) is designed
to enable CPAP to be delivered
safely and economically from
a single unit in circumstances
in which more conventional
facilities are unavailable or
unaffordable. It incorporates a
standard oxygen concentrator
which has been modified to
produce an increased output
with a variable concentration
of oxygen. The concentrator
has twin flow meters for air and
oxygen, each with a maximum
flow rate of 8.l/min -1 .
Figure 1
The oxygen/air mixture then passes over a water
humidifier and via lightweight respiratory tubing to
silicon nasal prongs or a face mask. The concentrator
has been further modified so that warm waste air from
the concentrator’s compressor is directed towards the
humidifier bottle. This increases the temperature of
the inspired gases raising the dew point of the water
thus providing enhanced humidification to the device.
Laboratory tests were carried out to determine these
effects.
Pressure is maintained throughout the respiratory cycle
by directing the gas flow to a container of water at the
distal end of the circuit via a tube with an open end at
an adjustable depth beneath the surface. The pressure
is determined using a calibrated dial which enables the
depth of the tube to be adjusted in situ. As the pressure
control is distal to the patient interface the system
provides accurate control of the pressure with minimal
pressure variation at the patient interface
Anaesthesia News February 2016 • Issue 343 19

The oxygen/air mixture then passes over a water humidifier and
via lightweight respiratory tubing to silicon nasal prongs or a face
mask. The concentrator has been further modified so that warm
waste air from the concentrator’s compressor is directed towards
the humidifier bottle. This increases the temperature of the inspired
gases raising the dew point of the water thus providing enhanced
humidification to the device. Laboratory tests were carried out to
determine these effects.
Pressure is maintained throughout the respiratory cycle by
directing the gas flow to a container of water at the distal end of
the circuit via a tube with an open end at an adjustable depth
beneath the surface. The pressure is determined using a calibrated
dial which enables the depth of the tube to be adjusted in situ.
As the pressure control is distal to the patient interface the system
provides accurate control of the pressure with minimal pressure
variation at the patient interface
Discussion
The administration of CPAP to infants and young children requires
equipment capable of delivering the following:
1. A total gas flow exceeding the patient’s maximum inspiratory
flow rate. This is to ensure that the pressure in the airway
remains above atmospheric pressure throughout the
respiratory cycle. It also prevents dilution of the inspired
mixture with atmospheric air, enabling the maximum possible
FiO 2
to be administered when required.
2. A FiO 2
that can be adjusted according to the needs of the
patient at different stages of treatment.
3. A means of adjusting the airway pressure.
4. An inspired mixture which can be warmed and humidified to
approximately ambient temperature and above 90% relative
humidity.
When administered in well equipped hospitals having reliable
monitoring equipment and centralised supplies of oxygen
and compressed air, CPAP treatment is simple, effective and
inexpensive.
For many hospitals in poor countries the situation is very different.
Oxygen and compressed air are generally supplied in cylinders
which may require transportation over long distances on roads
which may, at times, be impassable. In these circumstances the
supply may be interrupted. Even when cylinders are available the
flow requirements for CPAP are so great that the expense involved
may make the treatment unaffordable. Oxygen concentrators have
been used for many years as an inexpensive source of oxygen in
low income countries both for oxygen therapy [1,2], and during
anaesthesia and the postoperative period [3,4]. They have been
particularly useful in maintaining the supply in remote locations
where delivery of cylinders may be subject to frequent interruptions.
Figure 2
A recent study [5] compared the performance of seven concentrators
under the extreme conditions encountered in a range of developing
countries. The AirSep Elite oxygen concentrator was ranked the
highest according to its overall performance and a concentrator
from this manufacturer was selected for use in the Diamedica CPAP
apparatus.
High concentrations of oxygen, when administered to infants over
prolonged periods, can have a detrimental effect on the retina and
may lead to blindness. For this reason the percentage of oxygen
being delivered at any time is kept under constant review and
is restricted to the minimum effective level. In the absence of an
oxygen analyser the inspired oxygen concentration is displayed on
an accompanying chart located on the device (Fig 2).
Airway pressures between 3-6cm H 2
O are commonly used but in
severe cases pressures up to 10 cmH 2
O may be required. High
levels may impede venous return and diminish cardiac output
so the minimal effective level is applied and adjustments made
according to the patient’s response.
Even when cylinders of oxygen and compressed air are available,
and can be supplied in sufficient quantities, the cost of providing
high flow rates over prolonged periods may be unaffordable in low
income countries. The cost of cylinders of compressed air and
oxygen varies from country to country and even from place to place
according to the geography. However a standard E-size cylinder of
oxygen (680 litres) in most African hospitals is in the region of £5
and the cost of compressed air is approximately the same.
The provision of CPAP in paediatric patients requires high flows
of both compressed air and oxygen and a total flow of 10 l/min -1
would therefore not be unusual. At this rate a single cylinder would
last approximately 1 hour giving a total cost exceeding £100 for 24
hours. In contrast the same flows can be supplied by the oxygen
concentrator at a cost of £0.10 per hour or £2.40 for 24 hours.
R Neighbour
Managing Director, Diamedica UK Ltd
R Eltringham
Clinical Director, Safe Anaesthesia Worldwide
C Reynolds
Student, Biological Sciences University of Durham
J Meek
Support Engineer, Diamedica UK Ltd
References
1. Dobson MB Oxygen concentrators for the smaller hospital. Tropical Doctor
1992; 22: 56-8
2. Dobson MB Oxygen concentrators offer cost savings for developing
countries. A study based on Papua New Guinea. Anaesthesia. 1991;46:
217-9
3. Matai S, Peel D, Wandi F, Jonathan M, Subhi R, Duke T. Implementing an
oxygen programme in hospitals in Papua New Guinea. Annals of Tropical
Paediatrics 2008; 28: 71–8.
4. McCormick BA, Eltringham RJ. Anaesthesia equipment for resource-poor
environments. Anaesthesia 2007; 62(Suppl. 1): 54–60.
5. Peel D, R. Neighbour R, Eltringham RJ. Evaluation of oxygen concentrators
for use in countries with limited resources. Anaesthesia 2013; 68: 706–12.
Note
The AAGBI does not endorse or recommend any particular manufacturer
or device.
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The Mermaid Conference Centre, London
£395 (£295 for RCoA registered trainees)
Event organiser: Dr S Patel
The Royal College
of Anaesthetists
10
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CREDITS
Sessions will include:
Innovation in airway management
Making innovation work
NIAA Health Services Research Centre
THE JOHN SNOW ORATION:
Old myths and new designs
Annual General Meeting
Paediatric updates
Let’s get digital
What is perioperative medicine?
Presentation of College Awards
MACINTOSH LECTURE:
Improvement Science for Anaesthesia and Intensive Care
Updates in perioperative medicine
Obstetric updates
020 7092 1673 | events@rcoa.ac.uk | www.rcoa.ac.uk/events |
20 Anaesthesia News February 2016 • Issue 343

LTF T training
matters
Less than full time (LTFT) training remains a
popular option for anaesthetists. The most
recent data from the GMC survey in 2014 show
that 12.8% of anaesthetic trainees worked LTFT,
up from 8.5% in 2011. Unsurprisingly the vast
majority of these trainees are female, although
the number of male trainees has now increased
to nearly a fifth of those anaesthetists training
LTFT. Anaesthetics is the seventh most popular
specialty for LTFT training by percentage, and
of the overall 6,010 trainees working LTFT we
represent 7.4% (27% are GP trainees).
There are challenges associated with training
generally, and of course many of these are
shared with LTFT training. However there are
also issues unique to working LTFT: some related
to access to and application for posts, funding
and rota writing; some related to managing
training over a prolonged period and others
about maximising opportunities at work while
balancing this with the reason you work LTFT.
The most recent article on LTFT training in
Anaesthesia News was in 2011 and we thought
it was time for an update. The eligibility criteria
and process for application for LTFT training
remains the same, so here we report on some
of the recent initiatives to increase access to
information about LTFT training for trainees and
those who support them. This has improved in
recent years but could still be better, especially
for those training LTFT in Intensive Care
Medicine (ICM), and those training LTFT for
health reasons. These represent the minority of a
minority group and we are keen to work out ways
that we can support these groups better.
A-Z of LTFT training in
Anaesthesia and ICM
This is a fantastic resource for LTFT trainees. It has been written by
a team from the Northern School of Anaesthesia and has recently
been updated. As its name suggests it is a comprehensive guide
to LTFT training and the latest version has an expanded section
for those training LTFT in ICM. It is available to download from
both the AAGBI and the RCoA websites and is a good place to
start when looking for information about LTFT training.
https://www.aagbi.org/professionals/trainees/training-issues/ltft-training
http://www.rcoa.ac.uk/careers-training/training-anaesthesia/special-areasof-training/ltft-anaesthesia-z-guide
LTFT advisors, lead trainees
and the LTFT network
The RCoA has a Bernard Johnson advisor for LTFT training who
supports trainees and trainers and is responsible for confirming
CCT dates. Dr Carolyn Evans was the previous advisor and
stepped down in 2015. With Dr Sarah Gibb from GAT, Dr Evans
worked tirelessly to support LTFT trainees and improve the return
to work process, and we will continue to build on their good work.
Most regions also have a local LTFT Specialty Advisor and lead
trainee who are experienced in negotiating LTFT training and can
listen to, advise, direct and be an advocate for trainees. GAT has
recently set up a network of LTFT contacts across Great Britain
and Ireland. This includes the Lead LTFT trainees in each school
as well as many of the consultant advisors and the representatives
from ICM. We send regular emails to network members to keep
them updated on LTFT issues. We know it is not always easy to
find out who is LTFT training in a School, so if you want to get in
touch with your local LTFT representative you can find out who
they are on the AAGBI LTFT web pages on the LTFT network
map. If you would like us connect you with them, please email
us at ltft@aagbi.org. As well as the names on the map, some of
the regions have also put together a summary of useful pointers
regarding LTFT training in their region, which you can download.
http://www.aagbi.org/professionals/trainees/training-issues/ltft-training
Shape of LTFT Training 2015
In May 2015 the RCoA hosted the 2nd National LTFT day, which
was jointly organised with the AAGBI. It was a great opportunity to
meet other LTFT trainees, consultants and supervisors, to discuss
topical issues and to attend a selection of workshops. The first
joint endeavour from the LTFT network was to put together a
summary of the meeting for those who couldn’t make it, which is
available on the LTFT training pages of the AAGBI website, along
with all the resources from the meeting. As the meeting was such
a success we are hosting a similar event this year on the 26 May
2016 at 21 Portland Place, London. Booking will be available
online and we hope to meet many of you there.
Parent and baby room
Having a parent and baby room is now routine at all AAGBI
conferences and it is regularly frequented. All lectures are streamed
to the room and we ensure that there is a good supply of tea and
coffee so you can catch up on CPD and meet other parents while
looking after your baby. This is particularly well used by people on
maternity leave, and is a good use of Keeping in Touch days. We
are hoping to have a parent and baby room at the LTFT seminar in
May, to enable those embarking on LTFT training to attend.
Returning to work
We appreciate that returning to work after a break is not just an
issue for LTFT doctors, although it is likely that someone working
LTFT has had time away from work at some point. In recent years,
following the establishment of the popular GAS Again course
(www.gasagain.com), increasing numbers of locally run return to
work courses have been established. We have highlighted which
areas they are currently available in on the LTFT network map on
the AAGBI website. The AAGBI previously held a return to work
seminar, and we would be interested to know if there was demand
for this to be run again. In the meantime we will continue to provide
a parent and baby room at conferences and to highlight the
regional courses available. Again, if you would like to find out more
please get in touch.
Contracts
By the time this article is published we may have more information
about how the new contract will impact on those working LTFT.
The AAGBI has voiced serious concerns about the fact that pay
progression will be reduced and the gender gap for pay in medicine
is likely to widen as a result. This feels like a backward step for
many and over the coming weeks and months we will be closely
following the contract negotiations and will continue to highlight
this issue.
AAGBI and RCoA LTFT
webpages
We regularly re-organise and update the LTFT pages on the AAGBI
website and the same occurs at the RCoA. Links to all of the
information above can be on our websites, so please take a look:
www.aagbi.org/professionals/trainees/training-issues/ltft-training
www.rcoa.ac.uk/training-and-the-training-programme/
less-fulltime-training-ltft
Finally, the GAT committee currently has four LTFT trainees as elected members, so we hope to provide representation at a national level. As
we hope is evident from this article, this is an area where the AAGBI and RCoA work closely together. Please do join us on the 26 May 2016 for
our LTFT seminar and in the meantime if you have any questions at all, you can either email the AAGBI (ltft@aagbi.org) or the RCoA (training@
rcoa.ac.uk) and we will do our best to help.
22 Anaesthesia News February 2016 • Issue 343
Emma Plunkett and Anna Costello
AAGBI GAT Committee LTFT Leads
Susan Underwood
RCoA Bernard Johnson Advisor for LTFT Training
Anaesthesia News February 2016 • Issue 343 23

Tour de Timor
Timor-Leste (or East Timor), situated in south-east Asia, became the first new sovereign state of the 21st century
following troubled times under Indonesian rule. The country experienced further instability in its early years. The
UN officially ended its peacekeeping mission in Timor-Leste at the end of 2012. This young country is keen to
move forward and put itself on the world map by thinking big. Despite mass infrastructural destruction following
years of war the country is the proud host of an annual 5 day mountain bike race – Tour de Timor. Think rugged
Tour de France for mountain bikes, going through the country's beautiful tropical mountains and coastline.
The race is in its sixth year. Medical cover is provided by the
Australian Medical Assistance Team (AUSMAT), which deploys
multidisciplinary health teams to disaster zones. AUSMAT have
used the race as a deployment training exercise since 2011 as it
offers a unique opportunity for members to work within a team,
familiarise themselves with equipment and to get an insight into
what a real deployment would be like.
I was lucky enough to join them in 2014 as part of the UK International
Emergency Trauma Register (UKIETR) team; the UK equivalent to
AUSMAT. Launched in 2011 it is a relatively new entity bringing
together health professionals, coordinating responses to overseas
emergencies and providing relevant training for members. The UK
team of four consisted of an anaesthetist (myself), a paramedic,
a physiotherapist and a nurse. We joined the comprehensive
AUSMAT team of 20, comprising doctors, nurses, logisticians,
police first aiders, a heat specialist, an environmental health expert
and an epidemiologist.
The week started with a visit to the AUSMAT cache in Darwin,
northern Australia. This impressive warehouse is well equipped and
manned by a dedicated ground staff ensuring a state of readiness
at all times. We were each allocated our own bag with personal
items such as uniforms made of quick drying, lightweight material
suitable for the tropics, food rations, insect repellent, sun block and
camping kit. The supplies were so comprehensive that we didn’t
need to take many personal items. In fact we were limited to 7kg of
hand luggage for the week long trip to Timor-Leste.
We were briefed on the country demographics, our duties, security
and even a quick (but useful) Tetum language lesson. This was
followed by a heat acclimatisation exercise where we had to
complete a 5km walk within a set time in the tropical heat and
humidity. Being from Malaysia myself I always forget how the sticky
humidity can affect people who are not used to it. The Australians
are well prepared – taking a heat specialist with them. During the
walk he also conducted some research involving team members
swallowing capsules allowing their core body heat to be measured.
The next day we were off to Dili, the capital of Timor-Leste, on a
short early morning flight. Immediately on arrival we were put to
work offloading the cargo container full of kit. This was followed by
communication equipment training where we familiarised ourselves
with using the radio, satellite phone and GPS tracker. The team
was then split, with some of us helping with the pre-race weighing
in. All the riders were weighed daily post-race as a method of
detecting dehydration and heat-related illness. The rest of the team
had a chance to check out the local medical facilities including the
ambulance and aircraft in case of the need for medical evacuation.
The long day ended with a detailed briefing of the team breakdown
and responsibilities for the race. Half of the team was to travel
daily in a convoy to the finish point to set up our medical facilities,
including a resuscitation tent and camp site. The rest of the team
was divided to man the mobile units consisting of three medical
cars and two police bikers. We were all rotated to different roles
daily when possible to gain maximum exposure and this created a
good team dynamic.
We were on the road and camping for the rest of the race period.
I was expecting to rough it but was pleasantly surprised by how
comfortable it was. Every night all the Tour de Timor riders and their
entourage set up camp at different villages picked as the finishing
point of the day. The villages provided hot meals allowing us to
sample the local cuisine. We also had our calorific food rations –
the dehydrated strawberry ice cream was a surprise hit! Every effort
was made by the logisticians who spoiled us with a portable shower
with hot water – no need for wet wipes. The campsite can get a bit
claustrophobic at times and it is hard to find any privacy.
We soon got used to the daily routine of a 4am wake up call to
dismantle the tents and pack up, followed by the drive and setting
up in a new place. It was hands on for everyone in the team and not
just the logisticians. This made us quickly familiar with the clinic tent
set up and we got quicker by the day. The task highlighted the need
to be flexible and embrace different roles within a team. During the
week I took the role of the team doctor, and was in charge of resus
and the mobile units, but my most important role was as the team
translator. I was excited that my language skills finally proved handy.
Bahasa Indonesia was spoken by many of the local riders, villagers
and organisers. Although I might not know much about dressing
saddle sores I was able to put the local riders at ease by speaking a
familiar language.
The reduced number of riders this year (less than 100) meant we
were less busy clinically. We treated and evacuated one patient with a
suspected c-spine injury following a fall from his bike into a ditch. The
rest were treated for minor injuries and mild heat-related illnesses.
The presence of an international medical team boosts confidence
and encourages foreign interest in the race. Many of the international
riders I spoke to said they felt safer participating knowing that we
were there to provide assistance if needed.
The final day in Dili was spent sorting out and cleaning all the
equipment and doing an inventory before everything was shipped
back to Darwin. The strict customs law in Australia meant that we
spent hours scrubbing all the dirt off every bit of kit. This was probably
the toughest day as we were all tired and it was a dull but necessary
task.
By the end of the week we had a good insight into what a real
deployment would be like – a lot of early mornings and hard labour
rather than clinical work. Although we were not challenged clinically,
the exposure to the logistical side of a deployment was invaluable.
Having the opportunity to set up the medical centre daily was
good practice and will hopefully stick in our minds. I learnt a lot
about matters that are often overlooked. The environmental health
specialist made us all think more about personal and food hygiene
as well as vector control. These are simple things that can contribute
significantly to team wellbeing.
Apart from being an educational trip, I was also taken aback by
this beautiful country and its people. The tour took us through
breathtaking scenery of mountains, coffee plantations and remote
villages. All along the route the locals and their herds of animals lined
up to greet the riders with such enthusiasm, making everyone feel
like a winner. Although I don't own any Lycra even I am tempted to go
back as a rider to experience it all again – this time not in a 4-wheel
drive chasing the action.
To those keen cyclists out there who are up for a challenge, check out
http://www.tourdetimorlorosae.com for information on Tour de Timor
2015 and don't forget to drop in and say hi to the AUSMAT team.
Nur Lubis
Consultant Anaesthetist, Whipps Cross Hospital
24 Anaesthesia News February 2016 • Issue 343 Anaesthesia News February 2016 • Issue 343 25

Particles
Andrews PJD, Sinclair L, Rodriguez A, et al.
Hypothermia for intracranial hypertension after
traumatic brain injury
N Eng J Med 2015. Epub ahead of print http://dx.doi.org/10.1056/NEJMoa1507581
Background
Traumatic brain injury (TBI) is a leading cause of death and severe disability in young
adults. Despite its high societal impact, it is underrepresented in medical research and
there is limited evidence for many of the routinely used interventions [1]. Hypothermia can
reduce intracranial pressure (ICP) in patients with TBI, however its effect on outcome is
unknown: some trials have demonstrated benefit [2] but others have shown trends towards
harm or were prematurely stopped [3,4]. The aim of this study was to test the effect of
hypothermia on functional outcome.
Methods
This was an international, multicentre, randomised, controlled trial (Eurotherm3235),
which ran from 2009 to 2014. Participants were patients admitted to ITU following primary
closed head injury, with raised ICP after initial treatment. Hypothermia was induced by a
bolus of cold intravenous 0.9% NaCl and maintained with the cooling method usual for
the particular site. The primary outcome measured was the Extended-Glasgow Outcome
Score (GOS-E) at 6 months. Serious adverse events, ICP control and 6-month mortality
were also recorded.
Results
In total, 287 patients were randomised. The study was stopped early after there were
indications of harm with hypothermia treatment. Although not reaching statistical
significance, at 6-months post injury the hypothermia group had worse GOS-E scores:
adjusted common odds ratio for GOS-E score was 1.53 (95% CI, 1.02–2.30; p = 0.04).
Serious adverse events were more frequent in the hypothermia group (33 vs 10).
Discussion
Hypothermia plus standard care to reduce ICP did not result in outcomes better than
standard care alone. Early termination of the trial due to safety concerns will have
introduced the risk of bias and reduced validity, but results suggested worse outcomes in
the treatment group.
Conclusion
This is overall a well-designed, rigorously-conducted study which utilised a sensitive and
valid outcome measure [5]. It attempts to answer an important question to which there is
currently equipoise: whether hypothermia should be used to reduce ICP in TBI.
There are a number of weaknesses. Hypothermia was placed at an early stage in the
treatment algorithm, before osmotherapy. This may have affected timing of these other ICPlowering
treatments and caused confounding. Standard care and method of cooling were
not prescribed in the protocol which will have resulted in treatment variation in both groups;
however this allowed the study to be pragmatic and practical. Although outcome scoring
was blinded, there was lack of blinding to the intervention, which may have contributed to
the higher reporting of adverse events in the hypothermia group.
Despite these limitations, the study has produced a valuable result that will impact on clinical
management of patients with TBI. Further research may consider the role of hypothermia
later in the treatment sequence, in patients with refractory intracranial hypertension who
have exhausted other treatment options.
Lindsey Arrick
ST5 Anaesthetics, Derriford Hospital, Peninsula Deanery
References
1. Ker K, Perel P, Blackhall K, Roberts I. How effective are some common treatments
for traumatic brain injury? BMJ 2008; 337: a865.
2. Crossley S, Reid J, McLatchie R, et al. A systematic review of therapeutic
hypothermia for adult patients following traumatic brain injury. Critical Care 2014;
18: R75.
3. Clifton GL, Valadka A, Zygun D, et al. Very early hypothermia induction in patients
with severe brain injury (the National Acute Brain Injury Study: Hypothermia II): a
randomised trial. Lancet Neurology 2011; 10: 131-9
4. Clifton GL, Miller ER, Choi SC, et al. Lack of effect of induction of hypothermia after
acute brain injury. New England Journal of Medicine 2001; 344: 556–63.
5. Levin HS, Boake C, Song J, et al. Validity and sensitivity to change of the extended
Glasgow Outcome Scale in mild to moderate traumatic brain injury. Journal of
Neurotrauma 2001; 18: 575–84.
Freeman LM, Bloemenkamp KW, Franssen MT, et al.
Patient controlled analgesia with remifentanil
versus epidural analgesia in labour:
randomised multicentre equivalence trial
BMJ 2015; 350: h846
Background
Epidural analgesia and intravenous opioids are both utilised methods of pain
relief during labour, with the former previously considered to be the most
effective method [1]. However, with various studies showing comparable
maternal satisfaction with patient-controlled remifentanil [2,3], this was felt to
be a suitable alternative. However, these studies had limitations and the authors
wanted to conduct a study to accurately assess comparisons in analgesia.
Methodology
This was a multicentre randomised clinical trial within the Dutch consortium
for women’s health and reproductivity. Before the onset of active labour,
consenting women were randomised to either patient-controlled remifentanil or
epidural analgesia if pain relief was requested. However, patients were able to
receive the other analgesic strategy if they had inadequate pain relief. During
labour, women were asked to rate both pain scores as well as satisfaction with
pain relief on a visual analogue scale hourly from the onset of labour. This was
summarised using the area under the pain satisfaction curve with a higher
AUC representing higher satisfaction. Randomisation was performed through
a web-based randomisation program.
Results
A total of 1414 women were randomised into two comparable groups with 709
to the remifentanil group and 705 to the epidural group. Due to loss of follow
up, the analysis was based on 687 women in the remifentanil group and 671
in the epidural group with pain relief ultimately being used in 65% and 52%
of women, respectively. The area under the curve for total satisfaction with
pain relief was 30.9 in the remifentanil group vs 33.7 in the epidural analgesia
group. Results were only significant in subgroup analysis but not found to be
significant using intention to treat
Discussion
The total satisfaction with pain relief was better in the epidural analgesia
group than the remifentanil and this was significant in the subgroup of women
who actually received analgesia. Of note, oxygen saturation was significantly
lower (SpO2 65 years, undergoing elective non-cardiac surgery requiring
anaesthesia, anticipated to stay in hospital for >48hrs were included in the study.
Anaesthetists were blinded to the study hypothesis. Blood pressure changes were
defined as relative hypotension if there was a 20%, 30%, 40% decrease below the
patient’s pre-operative baseline for either systolic blood pressure (SBP) or mean
arterial pressure (MAP) or an absolute blood pressure decrease below 50 mmHg.
Fluctuations in blood pressure during surgery were quantified by calculating the
variance from the patient’s record. Delirium was assessed pre-operatively and on
the first two days postoperatively using the Confusion Assessment Method.
Results
No significant association was found between intra-operative hypotension and
postoperative delirium. There was a MAP decrease of >40% below the baseline for
more than 5 minutes in 12% of patients who did not develop delirium and in 10% of
those patients that developed delirium (p value

TRAVEL GRANTS/IRC FUNDING
The International Relations Committee (IRC)
offers travel grants to anaesthetists who
are seeking funding to work, or to deliver
educational training courses or conferences,
in low and middle-income countries.
Please note that grants will not normally be considered for
attendance at congresses or meetings of learned societies.
Exceptionally, they may be granted for extension of travel
in association with such a post or meeting. Applicants
should indicate their level of experience and expected
benefits to be gained from their visits, over and above
the educational value to the applicants themselves.
Dear Editor
BYOD for video laryngoscopy?
The cost, accessibility and portability of technology enables different and
arguably more effective ways of working. Recently we stumbled on an
interesting and innovative approach to using a mobile phone and USB
inspection camera. This simple DIY video laryngoscope system with a
potential cost of less than £10 comprises of:
1. An Android-based smartphone with micro-USB connection
(commonly found in operator's bag or pocket): £0.00
2. An on-the-go cable (to convert micro-USB port into USB port): £0.69
3. An Andoer 6 LED water resistant (IP66) 7mm 2m USB endoscope
inspection video camera: £8.99
4. CameraFi - USB Camera/Webcam app: £0.00
5. Tape to secure endoscope to the laryngoscope
Dear Editor
your Letters
SEND YOUR LETTERS TO:
The Editor, Anaesthesia News at anaenews.editor@aagbi.org
Please see instructions for authors on the AAGBI website
It was very interesting to read the letter on epidural failure published in Safety
Matters [1].
We noticed the group has recommended wrapping the filter and the EpiFuse
connector in order to maintain the sterility of the catheter proximally. We have
been using an alternative technique to achieve the same outcome in our trust.
This not only protects the filter but also prevents the inadvertent dislodgment of
the catheter from the EpiFuse connector.
Dear Editor
We were impressed with the beauty of the Malignant Hyperthermia
Crisis Task Allocations cards in use at Surrey and Sussex Healthcare
NHS Trust [1], but wanted to put our cards forward as a contender.
For further information and an application form
please visit our website:
http://www.aagbi.org/international/irc-fundingtravel-grants
or email secretariat@aagbi.org
or telephone 020 7631 1650 (option 3)
Closing date: 14 March 2016
Figure 1
Figure 2
2016 SPRING SCIENTIFIC MEETING
Thursday, April 21 st , 2016
PerioPerATive
Medicine for orThoPAedic
AnAesThesiA
Meliá White House, Albany St, Regents Park,
London NW1 3UP (Great Portland Street station)
For registration, fees and further
information please visit our website at
www.bsoa.org.uk
SAVE THE DATE!
We identified a number of potential areas for its application if appropriate
medical device standards are met:
• A readily available video laryngoscopy training tool
• An extremely portable system in situations of extremis; pre-hospital,
remote and field anaesthesia
• A cost-effective solution for difficult airway management in low income
countries and poorly resourced healthcare facilities
• A disposable and single use video laryngoscopy solution
We have not used this technique on any real patients.
Declaration of interest
YWL is a SCATA committee member.
Alexander Yashchik
Specialty Registrar
Yat Wah Li
Consultant in Anaesthesia and Intensive Care Medicine
The Royal Wolverhampton Hospital NHS Trust
This technique involves the use of the sterile plastic sheath for the epidural
catheter in the sterile pack (Epidural minipack, Smiths Medical, Watford, UK).
To use the sheath, an oblique cut is made to allow the filter end to come out and
to be connected to the epidural infusion set. Also, as shown in the picture, a
fold is made at the catheter end and the epidural sticker is used as an adhesive
(Figure 1).
The benefit of this technique includes the use of a sheath that is already part
of the sterile pack (Figure 2). The whole unit sits in one sterile cavity, which is
transparent and easily visible in case of any damage to the filter. The epidural
adhesive provides an additional safety for identification of a neuraxial catheter
and also acts as seal for the plastic sheath. Finally, it reduces the cost of an
extra TegadermTM sandwich as this sheath is provided as part of the epidural
pack and is otherwise redundant once the pack has been used.
Dr Arihant Jain
CT2 Anaesthesia
Dr Rangaswami Chandra
Consultant Anaesthetist
Reference
1. Pearson J, Maund A, Meek T. Epidural failure. Anaesthesia News 2015;
339: 21.
When developing our cards (in conjunction with Dr Phillips when
she was a trainee at Frimley), we based the colours, format and
wording on those in use in the AAGBI guideline itself [2] in the hope
that this might improve familiarity and reduce mental workload in the
event of a case of malignant hyperthermia. The AAGBI recommends
a specific layout for a Malignant Hyperthermia trolley such that, in
theory, a trainee moving from hospital to hospital or a consultant
working across a number of sites can expect to know what kit is
ready for use in a crisis. In the same way, it would probably be useful
if the task allocation cards were standardised. Perhaps the AAGBI
would consider producing standardised task cards to accompany
guidelines that relate to the management of complex emergency
situations?
References
Yuvraj Kukreja
Clinical Fellow in Simulation and Anaesthesia
Marika Chandler
Specialist Registrar
Elizabeth Combeer
Consultant Anaesthetist
Frimley Health NHS Foundation Trust
1. Phillips S, Lamb F, Mackenzie M. How beautiful are your malignant
hyperthermia task cards? Anaesthesia News 2015; 341: 32
2. AAGBI. Malignant Hyperthermia Crisis Task Allocations. August
Note
2011. http://www.aagbi.org/sites/default/MH%20task%20
The AAGBI does not support the use of non-CE marked equipment.
allocations%20for%20web.pdf
28 Anaesthesia News February 2016 • Issue 343 Anaesthesia News February 2016 • Issue 343 29

The Nasal Alar SpO 2 Sensor
Accurate long-term pulse oximetry monitoring with greater patient
comfort, lower cost and application beyond the ICU.
The Nasal Alar SpO 2
TM
Sensor
Attached to the nasal ala, the fleshy part of the side of the nose, a
unique monitoring site for pulse oximetry. This site is fed by both the
external and internal carotid arteries; the latter also supplies blood to
the brain. The rich vascular supply to the ala provides a strong, reliable
signal, even when it is difficult to get a signal at the fingertips.
This new sensor is compatible with the majority of pulse
oximetry monitors used in many healthcare settings. Established in the
USA as a first choice for a variety low perfusion conditions. Pentland
Medical is now marketing this product in the UK.
Oxygen Supplementation in Patient Treatment
Many acute and chronic medical conditions are associated with
hypoxia and require supplemental oxygen therapy. Acute conditions
include asthma attacks, pneumonia or respiratory distress syndrome
(RDS) and oxygen bronchopulmonary dysplasia (BPD) in premature
babies; chronic conditions include chronic obstructive pulmonary
disease (COPD), heart failure and sleep apnoea. Supplemental oxygen
is usually administered through a nasal continuous positive airway
pressure (NCPAP) machine, a nasal tube or a ventilator.
Pulse Oximetry in the Evaluation of Blood Oxygenation
It is essential to monitor the requirements for and effects of oxygen
supplementation as both insufficient oxygen and excess oxygen can
be harmful. Pulse oximetry is a non-invasive method used to measure
oxygen saturation in peripheral tissues, usually using a sensor attached
to the fingertip.
The pulse oximeter consists of a clip-like sensor housing
a light source, a light detector, and a microprocessor. Passing two
wavelengths of light (red and infra-red) through the fingertip to the
photodetector, the device measures the changing absorbance. As
oxygen-rich haemoglobin absorbs more infrared light and oxygenpoor
hemoglobin absorbs red light, the microprocessor calculates the
difference and converts it oxygen saturation.
Use and Advantages of the Nasal Alar SpO 2 Sensor
Unlike fingertip sensors, where signals can easily be lost (1), the Nasal
Alar SpO 2 Sensor detects changes in oxygen saturation from the nasal
ala, a highly vascular region that is fed by both the external and internal
carotid arteries, providing strong and reliable photoplethysmography
signals that respond rapidly to changes in arterial oxygen saturation.
The nasal alar site is very robust and offers the following advantages:
• Lack of sympathetic tone means no signal loss due to reduced
temperature or anxiety.
Minimal effects by diminished peripheral perfusion.
Less susceptible to sensor interference from ambient light.
Consistent accuracy at very low oxygen saturations.
Less likely to be dislodged.
Easily accessed during surgery.
• Comfortable and easily removed and reapplied for use during
the patient’s hospital stay (2).
• Easily repositioned due to non-adhesive attachment.
Clinical Evaluation of the Nasal Alar SpO 2 Sensor
Several recent studies support the feasibility and accuracy of Nasal
Alar SpO 2 Sensor beyond its role in the operating theatre, for patients
with acute, chronic or long-term medical conditions (3).
A usability and acceptance study in a non-hospital setting
showed that 50 subjects could wear the sensor for seven days (4), and
when compared to a finger pulse oximeter, the Nasal Alar SpO 2 Sensor
was more comfortable and interfered less with daily living activities (4).
Furthermore, there were no reported complications associated with
skin pressure complications (5,6).
Cost: Nasal Alar SpO 2 Sensor
The Nasal Alar SpO 2 Sensor costs less than £20), patient studies
have shown that they are durable, indicating a significant long-term
cost saving (6); although digital and forehead sensors can initially cost
less, respectively, with the average stay in ICU being 3.8 days (in the
USA), these devices normally require replacement (6) incurring greater
costs long-term. The Alar sensor is a single patient device good for
continuous use up to 28 days. Simply, check the sensor every 8 hours
and change sides every 24 hours.
In conclusion, these results indicate that the Nasal Alar SpO 2
Sensor can be used comfortably, safely, effectively and at relatively low
cost, not only in the operating room during anaesthesia or in intensive
care but also in a variety of situations within and outside the hospital.
For further information on the benefits Alar can offer your facility, Phone: 0131 467 5764 E-mail: mail@pentlandmedical.co.uk

New award for excellence
in sustainability
Developing a green
anaesthesia agenda
The AAGBI recognises that our actions have an impact on the environment
and regards global warming and climate change as pressing issues. In
2013 the Environmental Task Group of the AAGBI was formed to develop
the idea of sustainable practice and to promote greener anaesthesia. The
Task Group and the Association have linked with Barema, the Association
for Anaesthetic and Respiratory Device Suppliers (representing companies
that manufacture or supply anaesthetic and respiratory equipment in or
to the UK), to establish the Barema & AAGBI Environment Award. This
will recognise excellence in sustainability within the speciality and engage
with industry partners to further develop a greener anaesthesia agenda.
The award will be for the single best
initiative or project and will consist of
£200 to the individual(s) or body(ies)
concerned, in addition to a grant of
£800 for support and development of the
initiative or project.
The deadline for applications is 29 April 2016 with
the winners being announced at the AAGBI Annual
Congress in Birmingham, 14-16 September 2016.
Apply for the NEW Barema & AAGBI Environment Award!
Applicants will have to demonstrate how their activity, project, campaign or other work (including original
research), related to anaesthesia, intensive care or pain management, has had (and will continue to have)
a measurable beneficial effect on the environment. The wider applicability (to other departments) and the
sustainability of the initiative are important parts of the award and will be assessed by the judges.
To find out more about the award and the application process visit
www.aagbi.org/about-us/environment
or email secretariat@aagbi.org
ANNUAL CONGRESS
BIRMINGHAM
14-16 September 2016
• KEYNOTE LECTURES • PARALLEL SESSIONS
• WORKSHOPS • ABSTRACT SUBMISSIONS
• EXTENSIVE INDUSTRY EXHIBITION
...AND MUCH MORE!
AC_Flyer 2016.indd 1 24/11/2015 14:07