George Warwick Bampfylde Daniell, 1864-1937

In 1907 Dr G. W. Bampfylde Daniell was the first doctor to be appointed an anaesthetist in a South African hospital. Little is known about his work, but due acknowledgement must be made to his pioneering efforts to place anaesthesia on a sound scientific basis, and to his various contributions towards making the specialty safe and comfortable. During his career in South Africa, he played an active role in the then Cape of Good Hope, Western Branch, of the British Medical Association.     

Influence of an anaesthetist on nurse-led, computer-based, pre-operative assessment

Trained nurses using a rule-based computer program can successfully carry out pre-anaesthesia screening. All medical problems and abnormal laboratory results need to be reviewed by an experienced anaesthetist. Following the introduction of this system, there was a reduction in the frequency of cancellations of patients from elective orthopaedic operating lists from 4.8% to 1.8%, a difference that was statistically significant (p = 0.03, CI = [0.6%, 5.5%]). To minimise cancellations from booked operating lists, a booked admissions policy is essential, so that the anaesthetist who will eventually be responsible for patients with medical problems can be identified. Cancellations cannot be avoided completely because some abnormal conditions arise or deteriorate after completion of the screening process. The anaesthetist responsible for the patient's anaesthetic may have different views of the risks involved from those of the anaesthetist undertaking the screening process.     

Unexpectedly extensive conduction blocks in obstetric epidural analgesia

Life-threatening extensions of conduction block during obstetric epidural analgesia can be classified according to the risk to the mother. High blocks that occur in the presence of the anaesthetist should present a readily treatable problem. Reports of total spinal anaesthesia that occur with no anaesthetist in attendance call for a reappraisal of present practice. Changes in current anaesthetic practice, which might increase safety with epidural analgesia, are top-ups by midwives, but only when the anaesthetist is on the delivery suite; repeated assessment of the nature of the conduction block by an anaesthetist; and continuous infusions with anaesthetist-only top-ups.     

Personal and department preparation for difficult airway management

Airway strategy is influenced by the competencies of both the anaesthetist and the anaesthetic department when competence is defined as appropriate knowledge, skills and attitudes. The department needs to provide equipment, guidelines, training and skilled personnel and the individual anaesthetist should possess working knowledge, core practical clinical skills, core mannikin skills and a readiness to call for assistance. It is highly unlikely that each anaesthetist can manage all types and complexity of difficult airway and it follows that there should be an explicit understanding of the remit of an individual anaesthetist in managing a difficult airway and the circumstances in which department skills are employed.     

Anaesthesia for tracheal resection. Modified use of the Carden Tube.

Surgical procedures involving sharing of the airway between the anaesthetist and surgeon, such as bronchoscopy, microlaryngeal surgery and tracheal resection impose special problems on the anaesthetist. The surgeon requires unrestricted surgical access, whereas the anaesthetist must ensure adequate and safe pulmonary ventilation and anaesthesia. This case report describes a two stage technique for management of the airway and ventilation during tracheal resection for stenosis. Initially a modified Carden tube with a ventilating injector was used through a tracheostomy stoma and subsequently an orotracheal tube was substituted. Anaesthesia was maintained entirely by the inravenous route. The surgical access was unrestricted and there was no pulmonary contamination.     

The pregnant woman with co-existing medical disease

The principles of management of some of the more common conditions encountered by the obstetric anaesthetist have been outlined. Identification of these patients early in pregnancy facilitates communication between obstetrician, anaesthetist and physician, and enables management plans to be formulated. All maternity units should have provision for the anaesthetist to undertake antenatal assessment of the pregnant woman.     

The patients' perception of the anaesthetist in a Swiss university hospital

OBJECTIVES: The role or recognition of the anaesthetist as an independent medical specialist has been the subject of many studies. Since most of this work was performed in English speaking countries, only few data are available for Germany, Austria, or Switzerland. The goal of this study was to determine how much knowledge patients had of the training and activities of anaesthetists. The study included patients ( n=685) who underwent elective operations in all surgical subspecialties at the University Hospital of Basel. METHODS: The data were collected using a questionnaire distributed at the end of the preoperative visit, which included 14 different questions examining the role of the anaesthetist. RESULTS: Surprisingly, and in contrast to previous studies, almost all patients (99%) knew that the anaesthetist is a qualified physician. In addition, 75% of the patients were aware that the anaesthetist is also engaged in activities outside the operating room; these percentages compare favourably with previous results. However, when asked about the specifics of these activities or about how long it takes to train an anaesthetist, the Swiss patients knew little more than patients from other countries. Only one fifth of all patients estimated the duration of postgraduate training correctly and 45% thought that the anaesthesia team worked under the supervision of the surgical team. Previous anaesthetic experiences as well as additional informational material such as a booklet or videofilm did not improve the patients' knowledge with respect to the training or activities of anaesthetists. DISCUSSION: Since other even more elaborate and expensive methods such as large exhibitions, national anaesthesia days, or increased coverage on radio and television also failed to enhance patients' knowledge, the focus is once again on the relationship between the patient and anaesthetist. If we wish to improve the role and recognition of anaesthetists for patients and/or the public, the anaesthetist must be visible for the patients as a true physician in the pre- and postoperative period. To improve this important patient-anaesthetist relationship, we have begun a training program in communication skills for all physicians in our department.     

Cardiovascular system: critical incidents

Cardiovascular incidents are a major cause of any morbidity and mortality in the perioperative period. An understanding of their causes and complications, and the management of these incidents is essential for an anaesthetist. Because of aging population with increased co-morbidities and increasing complexity of surgeries, these incidents will continue to need increased awareness on the part of the anaesthetist.     

"The Anaesthetist" 1933--an iconic Australian medical photograph

Harold Cazneaux was the greatest Australian photographer of the early 20th century. In 1933, he took this image entitled 'The Anaesthetist'. It is an important documentation of a clinical anaesthetist of the era and was exhibited internationally. Such photographs of specific medical scenarios are rare and valuable. The anaesthetist is Dr Frederick J. Bridges who worked at Royal Prince Alfred and Royal North Shore Hospitals in Sydney. He is using a Clements ether vaporizer which was Australian made. The patient is Cazneaux's daughter Cazneaux has captured perfectly the care and concern of the anaesthetist for his patient.     

Maintenance of anaesthesia

Anaesthesia enables the performance of procedures otherwise intolerable to the patient. During the maintenance period, when such procedures take place, the anaesthetist performs many simultaneous tasks in a complex environment. These tasks include maintaining physiological homeostasis, prevention of awareness and facilitation of surgical activity. In particular, constant surveillance of the theatre environment (concentrating on the patient, monitoring and surgery) is pivotal to interpret observations in the context of the clinical situation and prompts the anaesthetist to intervene when necessary. Factors that may affect the quality and safety of maintenance of anaesthesia are the personnel administering the anaesthetic, environment, equipment available and skills, both technical and non-technical, of the anaesthetist. Critical incidents often occur during the maintenance period and human error is frequently implicated. Thus constant vigilance and strategies to prevent error and deal with crises are invaluable to the anaesthetist.     

Anaesthesia for stent graft repair of thoracic aneurysm and coarctation of the aorta

We present the anaesthetic management of a patient for stenting of a thoracic aortic aneurysm at the site of an aortic coarctation. The specific challenges to the anaesthetist for this case are outlined. These include the specific problems of placing the graft, the obvious risk of aortic rupture and the unfamiliar environment of the separate radiological theatre. The advantages and disadvantages to the anaesthetist of the treatment of thoracic aortic aneurysms with stents are briefly discussed.     

The anaesthesia consult clinic: does it matter which anaesthetist sees the patient?

Purpose

The objectives of this multicentre survey were: first to ascertain whether the preoperative evaluation performed by anaesthetists in the preadmission anaesthesia consultation clinic (PACC) is influenced by the knowledge that they will or will not be the patient’s attending anaesthetist; and second to determine the agreement among anaesthetists with regard to investigations requested.

Methods

A postal survey was designed in two different versions, equal numbers of which were sent to 522 anaesthetists in 39 Canadian hospitals. The anaesthetists contacted were asked to consider how they would investigate two hypothetical patients in a PACC. One version of the survey stated that they would be the attending anaesthetist for the first patient, but not for the second patient (group A). In the second version the situation was reversed (group B).

Results

A total of 281 eligible replies were received. For each of the two patients the decision to order an echocardiogram, cardiac stress test, arterial blood gas analysis, pulmonary function tests, or internal medicine referral was not affected by the knowledge that the respondent would or would not be the patient’s attending anaesthetist. Within each of the two groups there was very little consensus with regard to the ordering of laboratory tests.

Conclusion

The extent of investigation in the PACC scenarios was not affected by knowledge of whether or not the consulting anaesthetist would be the attending anaesthetist in the operating room. However, there was minimal agreement among anaesthetists concerning the preoperative evaluation of the patients, regardless of who would be the anaesthetist on the day of operation. Efficiency in preoperative evaluation could be increased if anaesthetists saw their own patients in the PACC, or if clinical guidelines for patient assessment were introduced by departments.     

Anaesthesia for urological surgery in the elderly

Advances in minimally invasive surgery are likely to reduce the need for general or regional anaesthesia for many procedures in elderly patients. Changes in population demography will ensure that large numbers continue to require the services of an anaesthetist. Demands for day case surgery in particular are likely to increase. Urological surgery in the elderly will certainly continue to present a challange to the anaesthetist.     

Rheumatoid cervical joint disease — a challenge to the anaesthetist

Cervical joint disease in rheumatoid arthritis patients is common. These patients may be at risk for severe life-threatening neurological problems in the perioperative period and thus present’ a challenge to the anaesthetist. By understanding the various anatomical abnormalities that may occur in rheumatoid cervical joint disease, the anaesthetist can design an appropriate management plan for the patient. The destruction of normal anatomy by rheumatoid arthritis can result in atlanto-axial subluxation (AAS) or subaxial subluxation. The atlanto-axial subluxation is further divided anatomically into anterior AAS, posterior AAS, vertical AAS, and lateral/rotatory AAS. In addition to the history and physical examination of the rheumatoid arthritis patient, radiological evaluation of the cervical spine is highly recommended. With the identification of the specific anatomical lesion the anaesthetist can predict and avoid movements which may lead to, or worsen, neurological problems. In the event of an emergency where full evaluation of the cervical spine is not possible the anaesthetist must presume that the rheumatoid patient has severe cervical spine instability and use the most cautious approach.     

Anaesthesia in connective tissue disorders

Patients with the more common connective tissue disorders require surgical operations more frequently than has been realized. They may present the anaesthetist with many potential problems. A few minutes of careful questioning and examination pre-operatively may prevent a tragic situation. A history of drug therapy is essential pre-operative information, particularly since many of these patients will need augmentation or coverage with steroid drugs. The anaesthetist must be aware of the patient's general state of health and must search for evidence of pulmonary, cardiac or haematological abnormalities.     

Patientenorientierte Anästhesie

Goals of this study were to quantify patients' preferences for anaesthesia care and to identify what they know about various tasks of an anaesthetist. On the day before surgery, 122 patients scheduled for elective procedures were interviewed using a structured questionnaire. A reliable pain relieve and unawareness as well as stable vital functions have priority in patients' preferences. Patients are also concerned with good postoperative pain relieve and the avoidance of nausea and vomiting. Not important are short preoperative soberness, rapid awakening and initial wide awakeness. Not informed about typical tasks of an anaesthetist are 28-51% of the patients. In order to obtain maximum patient satisfaction, a thorough education plus further continuous training are the essential items for a patient orientated health care management in anaesthesia, along with good medical and technical equipment. The wide spectrum of tasks of an anaesthetist must be better represented in order to strengthen the position of anaesthesia in the competition for rare resources. A postoperative visit, which is judged of 77% of the patients as important, offers a beginning.     

Anesthesiology problems in the surgery of cervico-mediastinal goiter. Our clinical experience]

The Authors, after explaining the difficulties that an anaesthetist finds in cervical-mediastinum goitre surgery, report their own experience. Even if limited, it shows the full validity of a methodology of using a very efficacious drug for good cardiovascular stability. Moreover, we must take into account the constant attention the anaesthetist must pay in some essential moments of general anaesthesia such as intubation, patient position and monitoring.     

Consequences of running more operating theatres than anaesthetists to staff them: a stochastic simulation study

Background: Numerous hospitals implement a ratio of one anaesthetist supervisingnon-medically-qualified anaesthetist practitioners in two ormore operating theatres. However, the risk of requiring anaesthetistssimultaneously in several theatres due to concurrent criticalperiods has not been evaluated. It was examined in this simulationstudy. Methods: Using a Monte Carlo stochastic simulation model, we calculatedthe risk of a staffing failure (no anaesthetist available whenone is needed), in different scenarios of scheduling, staffingratio, and number of theatres. Results: With a staffing ratio of 0.5 for a two-theatre suite, the simulatedrisk that at least one failure occurring during a working dayvaried from 87% if only short operations were performed to 40%if only long operations performed (65% for a 50:50 mixture ofshort and long operations). Staffing-failure risk was particularlyhigh during the first hour of the workday, and decreased asthe number of theatres increased. The decrease was greater forsimulations with only long operations than those with only shortoperations (the risk for 10 theatres declined to 12% and 74%,respectively). With a staffing ratio of 0.33, the staffing-failurerisk was markedly higher than for a 0.5 ratio. The availabilityof a floater for the whole suite to intervene during failurestrongly lowered this risk. Conclusions: Scheduling one anaesthetist for two or three theatres exposespatients and staff to high risk of failure. Adequate planningof long and short operations and the presence of a floatinganaesthetist are efficient means to optimize site activity andassure safety.     

Interobserver reliability between a nurse and anaesthetist of tests used for predicting difficult tracheal intubation

We examined the interobserver reliability, between a nurse and anaesthetist, of five tests used to predict difficult tracheal intubation: mouth opening; thyromental distance; head and neck movement; mandibular luxation; and assessment of oropharyngeal view. For each test, an anaesthetic nurse and a specialist registrar anaesthetist were trained to use a standard method of examination. Most of the tests had either good or very good reliability. Assessment of mouth opening demonstrated only moderate reliability and assessment of oropharyngeal view demonstrated poor reliability. The interobserver reliability estimates between a nurse and an anaesthetist are similar to those previously demonstrated between two anaesthetists.     

Acute and chronic airway obstruction in children

Airway management is one of the fundamental skills of any anaesthetist. Considerable anatomical changes occur between birth and adulthood during the development of the paediatric airway. Knowledge of these changes will influence airway planning during childhood. Airway obstruction complicates airway management and any anaesthetist working with children should be able to assess the airway for the presence of obstruction and generate a differential diagnosis of cause. This article aims to summarize key anatomical features of the paediatric airway, common causes of airway obstruction in children and provide suggestions for how to manage these patients.