LMITransactions&Report2014-15

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LMI Transactions and Report 2014 - 2015 battle for safety in anaesthesia had now been largely won and thought that is was time to take this further outside the operating theatre. He discussed preoperative assessment which tried to predict patients who may have poor surgical outcomes. He highlighted cardiopulmonary exercise testing, one area in which he was currently researching. He quoted a paper by Musallam K et al 3 which highlighted the incremental risk of anaemia with other comorbidities such as cardiac disease, COPD, renal impairment, all being associated with a higher mortality. Therefore, as Shander A et al 4 had highlighted, perioperative patient blood management is vital for good outcomes. This includes optimising haemopoiesis, minimising blood loss and bleeding and the improvement of tolerance of anaemia. He wondered how many of us have been presented with a patient on the day of surgery who had been inadequately optimised but we all felt the pressure to continue. Almost always we manage to get the patient through anaesthesia and surgery but the real problems seem to start a couple of days afterwards where inevitable consequences often become complications. Therefore individualised care must be the aim of pre-operative assessment. Professor Pearse then looked at the surgical event and highlighted the importance of checklists and the variable use of the WHO checklist across Europe. He spoke about other factors that may help to improve outcomes such as minimally invasive cardiac output measurements and the use of epidural anaesthesia. He thought that these were very important and anaesthetists in general were not very good at highlighting the necessity of putting their case across strongly for pieces of equipment or better nursing care. Professor Pearse discussed events occurring early after surgery and reminded the audience that acute organ injury can be a cause of long-term harm. This can include acute lung injury, sepsis-related myocardial injury and loss of muscle function. He quoted a paper Squadrone V et al 5 which showed that the early use of CPAP (Continuous Positive Airway Pressure) for the treatment of post-operative hypoxaemia can significantly reduce post-operative respiratory complications. He also highlighted the association between post-operative troponin levels and mortality. Post-operative rises in troponin were associated with a much higher mortality than similarly raised levels found in patients admitted through A&E. Professor Pearse went on to look at events later after surgery and showed a paper by Khuri et al 6 which demonstrated those with either pulmonary or wound complications had a significantly lower 5 and 10 year survival after surgery. This was again demonstrated for acute kidney injury after cardiac surgery 7 . Acute kidney injury was a key cause of chronic kidney disease as a result of loss of nephrons during each episode. He reminded the audience that the serum creatinine actually falls after surgery and therefore if it is raised, this is evidence of a much bigger injury than a rise associated with no surgery. Finally, he thought that anaesthetists should see some patients in postoperative clinics because they tend to be better at looking at the whole patient rather than just the outcome of surgery. They can then refer patients to relevant specialists if organ dysfunction has worsened as a result of these surgical episodes. Professor Pearse thought that surgery could often be a sentinel event with this being the first contact that many patients will have with a doctor. This can lead to the unmasking of many co-morbidities which often need to be treated prior to surgery and anaesthesia. He highlighted a number of quality improvement initiatives, such as the publication of performance data for individual surgeons and the way that cardiological services have been reorganised over the last 10 years showing a major improvement in 30 day survival following STEMI. He spoke about the EPOCH trial (Enhanced Perioperative Care for High Risk Patients) which is a project to implement an integrated care pathway for patients scheduled for emergency laparotomy. He described how healthcare can learn lessons from other industries and highlighted the way that the building of Crossrail in central London had changed building culture to greatly improve the safety of workers on the project. Finally he thought that the Royal College of Anaesthetists should be renamed that Royal College of Perioperative Medicine and reminded the audience that the College was soon to roll out its initiative in this area. 1 Lancet 2008;372:139-44 2 NEJM 2009;361:1368-75 3 Lancet 2011;378:1396-407 4 BJA 2012;109:55-68 5 JAMA 2005:293;589-95 6 Ann Surg 2005:242;326-343 7 Hobson C et al, Circulation 2009:119;2444 Ewen Forrest 28
LMI Transactions and Report 2014 - 2015 Minutes of the Sixth Ordinary Meeting Held on Thursday 22nd January 2015 ‘What I’ve Learnt from Cleveland’ Dr G P Wyatt, The James Cook University Hospital, Department of Paediatrics, Middlesborough Dr G Wyatt and Mr M McCormick The meeting started with the President of LMI, Mr Max McCormick, introducing our guest speaker Dr G P Wyatt who was in fact a Liverpool Medical Graduate. He had graduated in 1973 the same year as our President and several other LMI members. Dr Wyatt was one of the two paediatricians involved in the 1980s child abuse scandal in Cleveland. He gave a very emotional and somewhat disturbing account of his involvement in the matter. Indeed he told us that it was the first time in the ensuing 17 years that he had spoken openly in public about it. He summed up his talk in his first slide. “After Discovery comes Discredit, then Discipline, then Discussion, then Delay, then Denial, then Damage, then Defiance, then Dismissal.” Dr Wyatt used the Cleveland report to illustrate his talk and went through it in fine detail. He was a newly appointed consultant paediatrician in 1987 and wanted to improve his knowledge of managing sexual abuse in children. He therefore discussed the topic with his colleague Dr Marietta Higgs. One of the clinical signs they relied upon was ‘Reflex Anal Dilatation’. The first wave of admissions of children was in May 1987. In all some 121 children were taken into temporary local authority care. This led to widespread media coverage and the local MP Stuart Bell made a statement in the House of Commons. The Tory government set up an inquiry under Lord Justice (Elizabeth) Butler-Sloss which sat for a year and published its report in 1988. Dr Wyatt pointed out that at NO time did the inquiry look into the accuracy of the doctors’ diagnoses. Dr Wyatt gave evidence to the inquiry in December 1987. He returned to work in March 1988 with a restriction on his practice which he described as a loss of his clinical freedom. Points about this were raised by members of the audience. The two paediatricians were accused of compromising the work of social workers and demands for action were made in July 1988. Dr Wyatt read an extract from the minutes of a meeting held at The Royal Society of Medicine at which Lord Justice Butler-Sloss was asked whether the inquiry should have considered the individual cases to see if abuse had 29
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