Management of anaphylactic shock evaluated using a full-scale anaesthesia simulator

BACKGROUND: The diagnosis of an anaphylactic reaction during anaesthesia is not the first consideration for the anaesthetist and might be missed. The aim of this study was to describe anaesthetists' management of an anaphylactic reaction concerning diagnosing, treatment and application of anaesthesia crisis resource management (ACRM) in a full-scale anaesthesia simulator. METHODS: Forty-two anaesthetists in teams of two attended training sessions with a critical incident of anaphylactic shock in a full-scale simulator. Trained observers from the study group evaluated the medical treatment according to a treatment sequence developed from the literature and graded the ACRM performance on a five-point scale where 1 is bad and 5 is best. RESULTS: None of the teams made the correct diagnosis within 10 min and treatment according to the treatment sequence was not initiated. Only 6/21 teams considered the right diagnosis but first after hints from the instructor 15 min after the start of the incident. Evaluation of the use of the total ACRM concept (that is the use of all of the ACRM expressions seen in a total connection: called general impression) gave a median value of 2.0 with a range of (1-3). CONCLUSION: Anaphylactic shock was difficult to diagnose and no structured plans were used for the treatment in the simulated incident in this study.     

Interest of mannequin based simulator to evaluate anaesthesia residents

OBJECTIVE: The aim of this study was to test simulator validity to evaluate the ability of anaesthesia residents to solve two simulated scenarios. STUDY DESIGN: Monocentre, prospective, randomized study. POPULATION: Anaesthesia residents. METHODS: All anaesthesia residents were invited to participate into the study but were free to decline to take part. The authors developed grading forms to evaluate preoperative preparation of anaesthesia room and two simulated scenarios which had been previously validated. All residents were evaluated on the preoperative preparation of anaesthesia room. A randomization was performed to select half of the residents to be tested on one of the simulated scenario. Two experienced anaesthesiologists scored the residents' performance. At the end of the simulated session, residents rated the realism of the scenarios. RESULTS: Among 72 training residents in our institution, 48 participated with 24 beginning and 24 advanced residents. Median scores were similar between beginning (first and second year) and advanced residenced (third and fourth year) for the preoperative preparation of anaesthesia room (17 vs 17 for a maximal score of 25) while scores tended to be higher in advanced residents for simulated scenarios (scenario 1 [34 vs 19 for a maximal score of 55; p = 0.0009], scenario 2 [17 vs 13 for a maximal score of 45; p = 0.58]). However, numerous management errors were observed and some of them did not improve with training. Anaesthesia residents rated the simulator scenarios as realistic. CONCLUSION: This study suggests that mannequin-based simulator appears as a reliable and valid tool to test the performance of anaesthesia residents during critical situations.     

BIS does not predict dreams reported after anaesthesia

Background: In earlier studies, between 1% and 57% of patients have been reported to dream during anaesthesia. Thus, dreaming is much more common than definite memories of real events. We wanted to examine whether dreaming during anaesthesia is related to insufficient hypnotic action, as indicated by BIS levels and, thus, may constitute a risk for awareness.
Methods: After IRB approval, 2653 consecutive surgical patients were included. BIS registrations were recorded continuously during the anaesthetic procedure. The patients were interviewed on three occasions after anaesthesia. Standard questions, according to Brice, to evaluate awareness and dreaming during anaesthesia were asked. The dreams were categorized as either pleasant/neutral or unpleasant without any further evaluation of the dream content. Episodes with a mean BIS below 40, above 60 and above 70 were identified and subdivided according to duration (1, 2, 4 and 6 min, respectively). The total time as well as number and duration of episodes for the three BIS-levels were used to analyze any relation to reported dreaming. The mean BIS was also analyzed.
Results: Dreaming during anaesthesia was reported by 211 of patients (8.0%) on at least one of the post-operative interviews. BIS data did not show any significant correlation with dreaming, and neither did any of the tested case-specific parameters (gender, age, ASA group, BMI, use of relaxants, induction agent, maintenance agent, length of procedure, omitting N₂O and concomitant regional anaesthesia).
Conclusion: Dreaming during anaesthesia seems to be a separate phenomenon, not in general related to insufficient anaesthesia as indicated by high BIS levels.     

Evaluation of the Mediseus epidural simulator

The demand for increased patient safety has led to greater use of simulation training of health professionals performing medical procedures. The study aim was to evaluate the usefulness of the Mediseus? Epidural Simulator in teaching basic epidural needle-handling skills. Three groups of 15 anaesthetists (Novice=zero to two year anaesthesia trainees; Intermediate=three- to five-year anaesthesia trainees; Expert=consultants and regional-specialist anaesthetists) from three different medical centres participated. Each participant performed 20 simulated epidural needle insertions and was scored on several parameters (e.g. time, success of the insertion, bone collisions). Following familiarisation with the simulator and the needle insertions, participants answered seven questions on the applicability of the simulator to the teaching of basic epidural needle-handling skills. There was a clear learning effect with regard to the simulation procedure time, this decreasing throughout the experiment (P=0.037). There was no significant influence of either group or experience with the simulator in the study on the number or type of errors made. The quality of the simulation was scored 2.3 out of 5.0 (for bone simulation) and 4.7 (for loss-of-resistance simulation). All groups considered that the simulator was best suited for training prospective anaesthetists. Each group rated the usefulness of the simulator for training novices at greater than 3.0 out of 5.0. The Mediseus? Epidural Simulator seems to be an appropriate training device for an introduction to epidural needle insertion. For medical professionals with procedural knowledge, the simulation is not realistic enough and the simulator did not distinguish between the groups based on the errors made.     

Dental damage during anaesthesia and surgery

A review of the Accident Compensation Corporation (ACC) files on dental damage following anaesthesia or surgery was undertaken along with a survey of New Zealand anaesthetists asking about their practice with respect to protection of teeth during anaesthesia. These results confirm that damage is relatively common and that the majority of damaged teeth (62%) were known to have been previously restored, or weakened through periodontal disease prior to the damage occurring. The anaesthetists surveyed thought that dental damage was even more common than shown from the ACC records, and yet the vast majority of them did not routinely use specific protective guards and 45% of them did not ever use protective guards of any type.     

General practitioner anaesthesia survey 2006

A survey was posted to all general practitioner anaesthetists in Australia who are currently involved in the Joint Consultative Committee on Anaesthesia (JCCA) accreditation process known as the Maintenance of Professional Standards program (MOPS). The survey was intended to gain information regarding accreditation, continuing medical education, caseloads, on call, work practices, attitudes and future work plans. The response rate was 70% (168/240). The majority of respondents worked in a rural location (73%) where there were no specialist anaesthetists (74%). Of the respondents, 89 were category A accredited, but only 15% had this based on completion of the Advanced Rural Skills Curriculum Statement in Anaesthesia (ARSCSA) and examination. The mean number of sessions in anaesthesia worked per week was 2.8 (SD 2.2). Of the respondents, 69% administered more than 150 anaesthetics per year: 28% were on call more than 10 times per month. General surgery, gastrointestinal endoscopy, obstetrics, gynaecology and orthopaedics were the most common specialties for which anaesthesia was provided. Eight percent of respondents stated that sedation comprised 81-100% of their caseload: 92% used propofol as part of their usual intravenous sedation technique: 90% provided anaesthesia for paediatric patients with a mean minimum age of 4.1 years (SD 3.4): 64% provided epidural anaesthesia/analgesia. The majority stated that specialist anaesthetists and hospital administrations were helpful and supportive. Eighty-two percent planned to continue or increase their current anaesthetic workload over the next five years. The JCCA MOPS program appears to provide a satisfactory pathway for training, accreditation and on-going education of general practitioner anaesthetists.     

The Leiden anaesthesia simulator

We describe an anaesthesia simulator capable of simulating allpossible situations during anaesthesia. The Leiden anaesthesiasimulator (LAS) may be used with most commercially availableanaesthesia equipment and monitors, which are connected to thesimulated patient as they are to a patient. A commercially availableintubation manikin attached to an electromechanical lung modelrepresents the patient. The lung allows both spontaneous andmechanical ventilation. Compliance, resistance, tidal volumeand ventilatory frequency may be altered by a controlling computer.Carbon dioxide production and oxygen uptake are simulated. Physiologicalsignals (ECG, arterial, pulmonary arterial and central venouspressure waveforms) generated by a signal generator under softwarecontrol provide input to the monitors. All types of ECG disturbancesmay be simulated. There are facilities for simulating non-invasivearterial pressure measurement and pulse oximetry. A series ofphysiological models is being developed to control interactionsbetween the cardiovascular and respiratory variables. Duringa simulation session, a pre-defined scenario is presented tothe trainee. The task of the trainee is to diagnose and treatthe problem as if in real life. The simulator experiences onthe LAS were judged as highly realistic by 28 subjects. Thissimulator is currently being used for teaching and trainingof anaesthetists, trainees and anaesthesia personnel and forresearch.     

A national survey of propofol infusion use by paediatric anaesthetists in Great Britain and Ireland

Background:  Since the introduction of propofol in 1977, it has been widely used for the induction and maintenance of anaesthesia and for sedation on the intensive care unit. Recently, case reports of suspected propofol infusion syndrome (PRIS) following short term infusions have been published. We set out to obtain a picture of the current use of propofol infusions by paediatric anaesthetists in Great Britain and Ireland.
Methods:  A questionnaire concerning the use of propofol infusions was sent to 388 paediatric anaesthetists.
Results:  A total of 242 (62%) replies were received. 26% of anaesthetists used propofol infusions with at least a monthly frequency. 136 (56%) anaesthetists thought that propofol infusions were of benefit in reducing postoperative nausea and vomiting. The majority of anaesthetists did not state a maximum infusion rate or length of infusion. Of those anaesthetists who answered the questions the maximum rate used was 30 mg·kg⁻¹·h⁻¹ and the longest time considered for an infusion was 72 h. Only 5 (2%) anaesthetists regularly used BIS monitoring, although 106 (44%) expressed a desire to use it if it was freely available in their hospitals. Modifications to infusions from 1% to 2% propofol were used by 38 (16%) anaesthetists and 28 (12%) used glucose infusions intra-operatively.
Conclusions:  There is a wide variety in the use of propofol infusions by paediatric anaesthetists. The mechanisms underlying PRIS are poorly understood and require further work to ensure propofol infusions are used appropriately for anaesthesia in children.     

Delegation in paediatric anaesthesia: a postal survey

BACKGROUND: We wished to determine a consensus view from UK paediatric anaesthetic consultants of what practical skills are safe and appropriate for an anaesthetic trainee to perform during an initial 3-month module in paediatric anaesthesia. METHODS: A postal survey was sent to all UK and Ireland members of the Association of Paediatric Anaesthetists (APA). This questionnaire was designed to determine which tasks were delegated to trainee anaesthetists. Two hundred and four questionnaires were despatched, replies were received from 165 consultant anaesthetists (80% response rate). RESULTS: More than 50% of the APA respondents would always or regularly allow an anaesthetic trainee in their first 3-month module in paediatric anaesthesia to perform; an ilioinguinal block, a penile block and a caudal (but not in a neonate). CONCLUSIONS: Anaesthetic registrars undertaking an initial module in paediatric anaesthesia should learn basic airway management, ilioinguinal blocks, penile blocks and caudals (but not neonatal caudals).     

Arterial oxygen saturation during induction of anaesthesia

Three groups of 10 ASA 1 patients were studied to determine the incidence of hypoxaemia (oxygen saturation less than or equal to 90%) using pulse oximetry during induction of 'mask' anaesthesia, and whether simple oxygenation techniques could prevent its occurrence. We also surveyed all anaesthetists in three major hospitals to ascertain their techniques for this method of anaesthesia. Anaesthesia was induced in all patients with thiopentone and maintained with nitrous oxide and isoflurane. The first group received 33% oxygen in nitrous oxide as carrier gases, a second group a few normal breaths of 100% oxygen during thiopentone administration followed by 33% oxygen in nitrous oxide, while a third group received 100% oxygen after loss of eyelash reflex until spontaneous breathing was established. No patient received positive pressure ventilation before spontaneous breathing was established. Six of the 10 patients in the first group became hypoxaemic compared to none in the second group, and three patients became hypoxaemic in the third group. Thirty-seven percent of anaesthetists who responded to the survey either did not apply positive pressure ventilation before establishment of spontaneous breathing, or only did so if apnoea was prolonged. Only one anaesthetist fully pre-oxygenated patients lungs. We conclude that to avoid the likely occurrence of hypoxaemia during induction of mask anaesthesia, a minimum of a few breaths pre-oxygenation is necessary.     

A survey of paediatric dental anaesthesia in Scotland

A postal survey of NHS hospital-based anaesthetists providing out-patient anaesthesia for dental procedures in children under 10 years of age was conducted in February 1999. Information was sought about quality of care and common practice in Scotland. The experience of the anaesthetists involved in such work was substantial, but the monitoring used did not meet current standards, with only 16% of respondents indicating use of a full range of standard devices. Separate recovery facilities were available to 99%, and all had access to a defibrillator, but the qualifications of dedicated assistant and recovery staff were lacking in 14 and 30%, respectively. Intravenous access was not obtained routinely after inhalational induction of anaesthesia by up to 71% (49%, never; 22%, sometimes). Systemic analgesia or local anaesthesia was used by 88%. Discharge times ranged from 10 min to 6 h.     

A survey of inhalational anaesthetic abuse in anaesthesia training programmes

This study aims to assess the prevalence and outcomes of inhalational anaesthetic abuse among anaesthesia training programmes. Online surveys were completed by chairpersons of academic anaesthesia training programmes in the United States. The response rate was 84% (106/126 programmes). Twenty-two percent of the departments had had at least one incident of inhalational anaesthetic abuse. Forty-eight percent (15/31) of the persons abusing inhalational anaesthetics were sent for rehabilitation. Only 22% (7/31) of those found to be abusing inhalational anaesthetics were ultimately able to return successfully to anaesthesia practice with sustained recovery. The mortality rate among individuals found abusing inhalational anaesthetics was 26% (8/31). The majority of the anaesthesia departments (97/104, 93%) did not have any pharmacy accounting of inhalational anaesthetics. This is the first published survey of inhalational anaesthesia abuse. Inhalational anaesthetic abuse should be considered in at-risk individuals or those with a history of substance abuse. The concern about substance abuse is not unique to American anaesthetists. Countries around the world deal with similar substance abuse issues.     

Granisetron prevents nausea and vomiting during spinal anaesthesia for caesarean section

Background: Nausea and vomiting during spinal anaesthesia for caesarean section are common and unpleasant complications. This study was undertaken to evaluate the efficacy of granisetron, a selective 5-hydroxytryptamine type 3 receptor antagonist, for prophylactic treatment of nausea and vomiting in parturients undergoing nonemergent caesarean section under spinal anaesthesia.
Methods: In a randomized, double-blind, placebo-controlled trial, 100 patients, 21–38 years, received either placebo (saline) or granisetron at 3 different doses (20 μg · kg^-1, 40 μg · kg^-1 or 80 μg · kg^-1) (n=25 for each) intravenously immediately after clamping of the foetal umbilical cord. Nausea, vomiting and safety assessments were performed during spinal anaesthesia for caesarean section.
Results: The treatment groups were similar with regard to maternal characteristics and operative management. The incidence of nausea and vomiting was 64%, 52%, 14% and 12% after administration of placebo and granisetron in a dose of 20 μg · kg^-1, 40 μg · kg^-1 and 80 μg · kg^-1, respectively ( P <0.05; overall Fisher's exact probability test). No clinically important adverse effects were observed in any group.
Conclusions: Prophylactic use of granisetron in a minimum dose of 40 μg · kg^-1 is effective for preventing nausea and vomiting during spinal anaesthesia for caesarean section.
© Acta Anaesthesiologiat Scandinavica 42 (1998)     

Development of a difficulty score for spinal anaesthesia

Background. Multiple attempts at spinal puncture may be hazardous.Accurate preoperative prediction of difficulty adds to the deliveryof high quality care. This clinical trial was designed to: (i)determine the predictive performance of difficulty variables;(ii) compare senior and junior anaesthetists; (iii) developa score to predict difficulty during the performance of spinalanaesthesia. Methods. A total of 300 patients subjected to urological proceduresand scheduled for spinal anaesthesia were independently assessedand stratified according to the categories of the difficultypredictors of spinal anaesthesia into one of nine grades (0–8)and randomized according to the experience of the anaesthetistinto two groups (group A, staff with more than 15 yrs’experience; group B, resident with more than 6 months but lessthan 1 yr in training). The number of attempts and levels, andsuccess rate of the technique were the outcome variables. Datawere analysed by multivariate analysis and receiver operatingcharacteristic (ROC) curves. Results. The bony landmarks of the back and the radiologicalcharacteristics of the lumbar vertebrae were two independentpredictors of difficulty. Multivariate analysis indicated differencesbetween junior and senior staff but ROC curves indicated nodifference. Grade 4 was the difficulty score at or above whichdifficulty was expected whether or not radiological characteristicsof the vertebrae were included. Conclusions. Spinal bony landmarks and radiological characteristicsof the lumbar vertebrae are independent predictors of difficultyduring spinal anaesthesia. There is no difference between seniorand junior anaesthetists. Grade 4 is the difficulty score ator above which difficulty is expected. Br J Anaesth 2004; 92: 354–60     

Anaesthesia training and development in Nepal 1985–1990

In 1985 a diploma program in anaesthesia was established in Kathmandu, Nepal, as a joint venture between the Institute of Medicine in Kathmandu and the University of Calgary. Development of the program and of the specialty in the capital city of Kathmandu was continuously documented during the next five years by local and visiting faculty. In 1990 teams of two Nepali and one Canadian anaesthetist also conducted a survey of each of the seven 50-100 bed zonal hospitals which did not previously have a trained anaesthetist and which are now staffed by graduates of the diploma program. In 1985 Nepal, with a population of 16 million, had seven trained Nepali anaesthetists all of whom worked in two hospitals in Kathmandu. By the end of 1989, 19 physicians had graduated. Seven of these continue to work in Kathmandu hospitals, nine work in zonal hospitals throughout the country and two are taking higher anaesthesia training in the United Kingdom. Additional Nepali anaesthetists have returned from training abroad, and the Society of Anaesthesiologists of Nepal, which joined the World Federation of Societies of Anaesthesiologists in 1988, now has 34 members. An annual anaesthesiology symposium is held, and weekly clinical meetings are organized in the major hospitals in Kathmandu. Anaesthetists who work in the zonal hospitals have limited supplies of drugs and equipment and opportunities for continuing medical education are virtually nonexistent.(ABSTRACT TRUNCATED AT 250 WORDS)     

Dental damage in anaesthesia

Damage to the teeth during general anaesthesia is a frequent cause of morbidity for patients and a source of litigation against anaesthetists. Most injuries occur as a result of laryngoscopy. To prevent damage during emergence from anaesthesia, bite blocks should be placed between molar teeth. However oropharyngeal airways may not prevent damage. Patients should be advised about the possibility of dental trauma during anaesthesia and should be advised to have preoperative dental treatment to minimize dental factors that increase the risk of injury. Those with pre-existing dental problems and children in the mixed dentition phase (normally between the ages of 5 and 12 years) are at particular risk. Anaesthetic departments should have local protocols in place to refer patients for dental treatment postoperatively in the event of trauma.     

A survey of obstetric anaesthesia practice in British Columbia

Hospitals and anaesthetists in British Columbia were surveyed by means of questionnaires to assess patterns of obstetric anaesthesia practice, qualifications and numbers of obstetric anaesthesia personnel, hospital obstetric facilities and facilities and protocols for neonatal resuscitation. It was apparent that a large proportion of the obstetric anaesthesia service in this province was being provided by physicians who were not trained, nor certified, as anaesthesia specialists. Preanaesthetic assessment in the obstetric units differed in attitude and practice from the standards expected in the general operating rooms. There was also in community hospitals a significant incidence of failure to follow certain accepted safe practices (in obstetric patients), such as preinduction hydration and oxygenation, cricoid pressure during intubation and prevention of aortocaval compression. However, administration of general anaesthesia without endotracheal intubation, was rare in this survey. Post-anaesthetic recovery facilities in obstetric units were conspicuously deficient, even in the larger hospitals. The majority of community hospitals lacked written protocols for neonatal resuscitation; and the number of institutions reporting that the neonatal heart rates and temperatures were not routinely monitored is of concern. It is recommended that minimum standards for training in obstetric anaesthesia should be clearly defined; and provision should be made for revision and upgrading of knowledge and skills for physicians practicing anaesthesia in smaller community hospitals.