A national survey (NAP5‐Ireland baseline) to estimate an annual incidence of accidental awareness during general anaesthesia in Ireland

As part of the 5th National Audit Project of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland concerning accidental awareness during general anaesthesia, we issued a questionnaire to every consultant anaesthetist in each of 46 public hospitals in Ireland, represented by 41 local co‐ordinators. The survey ascertained the number of new cases of accidental awareness becoming known to them for patients under their care or supervision for a calendar year, as well as their career experience. Consultants from all hospitals responded, with an individual response rate of 87% (299 anaesthetists). There were eight new cases of accidental awareness that became known to consultants in 2011; an estimated incidence of 1:23 366. Two out of the eight cases (25%) occurred at or after induction of anaesthesia, but before surgery; four cases (50%) occurred during surgery; and two cases (25%) occurred after surgery was complete, but before full emergence. Four cases were associated with pain or distress (50%), one after an experience at induction and three after experiences during surgery. There were no formal complaints or legal actions that arose in 2011 related to awareness. Depth of anaesthesia monitoring was reported to be available in 33 (80%) departments, and was used by 184 consultants (62%), 18 (6%) routinely. None of the 46 hospitals had a policy to prevent or manage awareness. Similar to the results of a larger survey in the UK, the disparity between the incidence of awareness as known to anaesthetists and that reported in trials warrants explanation. Compared with UK practice, there appears to be greater use of depth of anaesthesia monitoring in Ireland, although this is still infrequent.     

Who operates when,where and on whom? A survey of anaesthetic‐surgical activity in Ireland as denominator of NAP5

The second phase of the 5th National Audit Project of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland, concerning accidental awareness during general anaesthesia, consisted of a survey of anaesthetic activity in Ireland. A network of consultant anaesthetists co‐ordinated data collection from the anaesthetic departments of 46 public and 20 independent hospitals over seven days. Data on patients' characteristics, anaesthetic techniques, staffing, and admission and discharge arrangements were collected on all cases for which anaesthetic care (general, regional or local anaesthesia, sedation or monitored anaesthesia care) was provided. A total of 8049 cases were reported during the survey, giving an annual estimate of 426 600 cases for which anaesthetic care is provided. General anaesthesia constituted 5621 (70%), regional anaesthesia 1404 (17%), local anaesthesia 290 (4%), sedation 618 (8%) and monitored anaesthesia care 116 (1%) of the total number of cases. This survey provides unique data regarding anaesthesia services in public and independent hospitals in Ireland.     

Attitudes of anaesthetists to awareness and depth of anaesthesia monitoring in the UK

BACKGROUND AND OBJECTIVE: Awareness with postoperative recall of intraoperative events is a rare but serious complication of general anaesthesia. This survey investigated the attitude of anaesthetists in the UK to awareness and depth of anaesthesia monitoring. METHODS: Questionnaires were sent to 4927 consultant anaesthetists in 285 hospitals in the UK in September 2004. The responses were recorded in an electronic database, summarized and compared with the results of studies performed in Australia and the USA. RESULTS: The response rate was 44%. When judged against published awareness rates, anaesthetists underestimated the incidence of awareness in their own practice (median 1: 5000). One-third of respondents have dealt with patients who have experienced intraoperative recall. The majority of anaesthetists perceived awareness as a minor problem on an 11-point scale (modal score 2, median score 3, IQR 2-5). Eighty-six percent of anaesthetists considered clinical signs unreliable but 91% felt that measurement of end-tidal anaesthetic agent concentration reduces the likelihood of awareness. The majority of anaesthetists would use a monitor at least some of the time if one was available to them. Overall, the attitudes of anaesthetists in the UK, USA and Australia are remarkably similar. CONCLUSIONS: Anaesthetists tend not to view awareness as a serious problem. Although most accept that clinical signs are unreliable indicators of awareness, few believe that monitors of anaesthetic depth should be used for routine cases.     

Accidental awareness during general anaesthesia – a narrative review

Unintended accidental awareness during general anaesthesia represents failure of successful anaesthesia, and so has been the subject of numerous studies during the past decades. As return to consciousness is both difficult to describe and identify, the reported incidence rates vary widely. Similarly, a wide range of techniques have been employed to identify cases of accidental awareness. Studies which have used the isolated forearm technique to identify responsiveness to command during intended anaesthesia have shown remarkably high incidences of awareness. For example, the ConsCIOUS‐1 study showed an incidence of responsiveness around the time of laryngoscopy of 1:25. On the other hand, the 5th Royal College of Anaesthetists National Audit Project, which reported the largest ever cohort of patients who had experienced accidental awareness, used a system to identify patients who spontaneously self‐reported accidental awareness. In this latter study, the incidence of accidental awareness was 1:19,600. In the recently published SNAP‐1 observational study, in which structured postoperative interviews were performed, the incidence was 1:800. In almost all reported cases of intra‐operative responsiveness, there was no subsequent explicit recall of intra‐operative events. To date, there is no evidence that this occurrence has any psychological consequences. Among patients who experience accidental awareness and can later remember details of their experience, the consequences are better known. In particular, when awareness occurs in a patient who has been given neuromuscular blocking agents, it may result in serious sequelae such as symptoms of post‐traumatic stress disorder and a permanent aversion to surgery and anaesthesia, and is feared by patients and anaesthetists. In this article, the published literature on the incidence, consequences and management of accidental awareness under general anaesthesia with subsequent recall will be reviewed.     

The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences,human factors,sedation, consent and medicolegal issues

The 5th National Audit Project of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland into accidental awareness during general anaesthesia yielded data related to psychological aspects from the patient, and the anaesthetist, perspectives; patients’ experiences ranged from isolated auditory or tactile sensations to complete awareness. A striking finding was that 75% of experiences were for < 5 min, yet 51% of patients (95% CI 43–60%) experienced distress and 41% (95% CI 33–50%) suffered longer‐term adverse effect. Distress and longer‐term harm occurred across the full range of experiences but were particularly likely when the patient experienced paralysis (with or without pain). The patient's interpretation of what is happening at the time of the awareness seemed central to later impact; explanation and reassurance during suspected accidental awareness during general anaesthesia or at the time of report seemed beneficial. Quality of care before the event was judged good in 26%, poor in 39% and mixed in 31%. Three quarters of cases of accidental awareness during general anaesthesia (75%) were judged preventable. In 12% of cases of accidental awareness during general anaesthesia, care was judged good and the episode not preventable. The contributory and human factors in the genesis of the majority of cases of accidental awareness during general anaesthesia included medication, patient and education/training. The findings have implications for national guidance, institutional organisation and individual practice. The incidence of ‘accidental awareness’ during sedation (~1:15 000) was similar to that during general anaesthesia (~1:19 000). The project raises significant issues about information giving and consent for both sedation and anaesthesia. We propose a novel approach to describing sedation from the patient's perspective which could be used in communication and consent. Eight (6%) of the patients had resorted to legal action (12, 11%, to formal complaint) at the time of reporting. The 5th National Audit Project methodology provides a standardised template that might usefully inform the investigation of claims or serious incidents related to accidental awareness during general anaesthesia.     

The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors

We present the main findings of the 5th National Audit Project on accidental awareness during general anaesthesia. Incidences were estimated using reports of accidental awareness as the numerator, and a parallel national anaesthetic activity survey to provide denominator data. The incidence of certain/probable and possible accidental awareness cases was ~1:19 600 anaesthetics (95% CI 1:16 700–23 450). However, there was considerable variation across subtypes of techniques or subspecialties. The incidence with neuromuscular blockade was ~1:8200 (1:7030–9700), and without it was ~1:135 900 (1:78 600–299 000). The cases of accidental awareness during general anaesthesia reported to 5th National Audit Project were overwhelmingly cases of unintended awareness during neuromuscular blockade. The incidence of accidental awareness during caesarean section was ~1:670 (1:380–1300). Two thirds (82, 66%) of cases of accidental awareness experiences arose in the dynamic phases of anaesthesia, namely induction of and emergence from anaesthesia. During induction of anaesthesia, contributory factors included: use of thiopental; rapid sequence induction; obesity; difficult airway management; neuromuscular blockade; and interruptions of anaesthetic delivery during movement from anaesthetic room to theatre. During emergence from anaesthesia, residual paralysis was perceived by patients as accidental awareness, and commonly related to a failure to ensure full return of motor capacity. One third (43, 33%) of accidental awareness events arose during the maintenance phase of anaesthesia, most due to problems at induction or towards the end of anaesthesia. Factors increasing the risk of accidental awareness included: female sex; age (younger adults, but not children); obesity; anaesthetist seniority (junior trainees); previous awareness; out‐of‐hours operating; emergencies; type of surgery (obstetric, cardiac, thoracic); and use of neuromuscular blockade. The following factors were not risk factors for accidental awareness: ASA physical status; race; and use or omission of nitrous oxide. We recommend that an anaesthetic checklist, to be an integral part of the World Health Organization Safer Surgery checklist, is introduced as an aid to preventing accidental awareness. This paper is a shortened version describing the main findings from 5th National Audit Project – the full report can be found at http://www.nationalauditprojects.org.uk/NAP5_home#pt .     

Use of anaesthetic rooms in obstetric anaesthesia; a postal survey of obstetric anaesthetists and departments in the United Kingdom

BACKGROUND: Use of anaesthetic rooms has been much discussed in the UK in recent years, but attitudes and practices of obstetric anaesthetists regarding their use for caesarean section have never been sought. METHOD: A postal survey was conducted to discover the extent of use of anaesthetic rooms versus operating theatre for induction of anaesthesia and reasons for using or not using them. Questionnaires regarding individual practices were sent to 400 randomly selected members of the Obstetric Anaesthetists' Association ( approximately 25% of UK membership). Questionnaires regarding departmental policies were sent to 100 "clinicians responsible for surveys" (approximately 38% of departments providing obstetric anaesthesia in the UK). RESULTS: For elective caesarean section, 70% of individual clinicians never used an anaesthetic room, 9% rarely, 5% usually, 9% for all regional anaesthetics and 6% always. For emergency caesarean section the corresponding figures were 83%, 5%, 5%, 3% and 2% respectively. Use of the anaesthetic room was independent of the seniority of anaesthetists. In 68% of departments it was standard practice or policy to induce all anaesthetics for caesarean section in the operating room. Conversely, only 1% of departments had a policy to induce all anaesthetics in the anaesthetic room. Patient safety was the usual reason given for anaesthetising in the operating room. CONCLUSION: The majority of obstetric anaesthetists have abandoned the use of anaesthetic induction rooms, the main reason being patient safety. For the same reason, two-thirds of departments providing obstetric anaesthesia consider induction of anaesthesia in the operating room their standard practice.     

Choice of anaesthetic agents for caesarean section: A UK survey of current practice

BackgroundA national survey of current practice and preferred drug choices for both induction and maintenance of general anaesthesia for caesarean section was undertaken.MethodsFollowing approval by the Obstetric Anaesthetists’ Association, all UK consultant members were invited to respond to an electronic survey.ResultsThe response rate was 56% (691/1228). Ninety-three percent of respondents use thiopental for induction: 58% (15% definitely and 44% probably) would support a change to propofol for induction. Thiopental was used in most cases for historical reasons (37%) or to reduce awareness (31%); other considerations included a clear end-point, dose predictability, cardiovascular stability, effects on the baby and drug licence concerns. Fifty-seven percent indicated that their trainees were encouraged to use thiopental for non-obstetric anaesthesia. Fifteen percent of respondents use opioids during rapid-sequence induction. Eighty-five percent use nitrous oxide; 53% of respondents use sevoflurane (51.6%) or desflurane (1.6%) for maintenance of anaesthesia, and this would increase to over 80% if financial constraints were removed.ConclusionOur survey suggests that while thiopental remains the induction agent of choice in the UK, a reasonable body of medical opinion would support a change to propofol for induction. This is reassuring as thiopental becomes more difficult and expensive to obtain.     

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).     

Anaesthesia for day case surgery: a survey of adult clinical practice in the UK

BACKGROUND AND OBJECTIVE: In October 2000, we conducted a national postal survey of consultant day case anaesthetists in the UK to explore the range and variation in the practice of anaesthetizing a patient for day case surgery (paediatrics, urology and orthopaedics). The survey was carried out as part of a larger study that comprised a major two-centre randomized controlled trial designed to investigate the costs and outcome of several anaesthetic techniques during day care surgery in paediatric and adult patients (cost-effectiveness study of anaesthesia in day case surgery). We report the findings of this national survey of adult urology and orthopaedic day case anaesthetic practice in the UK. METHODS: The survey used a structured postal questionnaire and collected data on the duration of the surgical procedure; the use of premedication; the anaesthetic agents used for induction and maintenance; the fresh gas flows used for anaesthesia; the use of antiemetics; and the administration of local anaesthesia and analgesia. RESULTS: The overall response rate for the survey was 74% (63% for urology, 67% for orthopaedics). The survey indicated the following practice in adult urology and adult orthopaedic day case surgery: 6 and 12% used premedication; propofol was the preferred induction agent (96 and 97%) and isoflurane the preferred maintenance agent (56 and 58%); 32 and 41% used prophylactic antiemetics; 86 and 93% used a laryngeal mask. CONCLUSIONS: This survey identifies the variation in current clinical practice in adult day surgery anaesthesia in the UK and discusses this variation in the context of current published evidence.     

Paediatric regional anaesthesia,a survey of practice in the United Kingdom

Background. A variety of techniques and drugs, many unlicensed,is used in paediatric regional anaesthesia. This study is thefirst to survey paediatric anaesthetists about the techniquesand drugs used in paediatric regional anaesthesia. The aim isto provide a record and benchmark of UK practice. Methods. A postal questionnaire was sent to all members of theAssociation of Paediatric Anaesthetists residing in the UK.Information was requested on the type of hospital worked in,years of practice, paediatric anaesthesia workload, regionalanaesthesia techniques used, and drugs used in regional anaesthesia. Results. A total of 220 responses from 264 questionnaires (83.3%)were received. Of these respondents, 155 (70%) practised paediatricanaesthesia as more than 50% of their workload, and 10 had retiredor returned blank forms. Two hundred and two of 210 (96%) usecaudal anaesthesia and 151 (72%) use caudal, epidural and peripheralblock. One hundred and ninety-two of 210 (91%) have no lowerage limit for using caudal anaesthesia. One hundred and twenty-threeof 210 anaesthetists (58%) used adjuvants with local anaestheticsin caudal block, the most common being fentanyl [44/210 (21%)],clonidine [55/210 (26%)], diamorphine [27/210 (13%)] and ketamine[67/210 (32%)]. Those working in specialist centres or teachinghospitals or who had a greater paediatric anaesthesia workloadwere more likely to use a greater variety of regional anaesthesiatechniques. Conclusions. Caudal anaesthesia is widely used for patientsof all ages by almost all practitioners. Most anaesthetistsat all hospital types and experience levels use adjuvants withlocal anaesthetics when performing caudal anaesthesia. Thosewith more experience in paediatric anaesthesia and those inspecialist centres commonly use other neuraxial and peripheralblock techniques. Br J Anaesth 2002; 89: 707–10     

Substance misuse amongst anaesthetists in the United Kingdom and Ireland. The results of a study commissioned by the Association of Anaesthetists of Great Britain and Ireland

Three hundred and four departments of anaesthesia in UK and Ireland were sent questionnaires about alcohol and drug abuse in anaesthetists over the preceding 10-year period. Information was sought on the nature and extent of substance problems, their presentation and management. The survey achieved a high response rate of 71.7% and a total of 130 cases were reported, of whom 34.6% were consultants and 43.2% were trainees. Over 50% of respondents felt a lack of confidence in dealing with alcohol or drug misuse amongst colleagues. The results of this survey demonstrate that over one anaesthetist per month has presented with significant alcohol or drug misuse in the UK and Ireland over the last 10 years. It is important that those with management responsibilities for departments of anaesthesia are aware that such problems exist and are likely to impact on the professional ability and health of the affected individual. The Working Party on Substance Abuse at the Association of Anaesthetists has recently published guidance in the management of these problems. A case is made for increasing awareness in this sensitive subject to enable early recognition and treatment of an anaesthetist who is misusing alcohol and drugs since intervention can be effective.     

Anaesthesia for day case surgery: a survey of paediatric clinical practice in the UK

BACKGROUND AND OBJECTIVE: In October 2000, we conducted a national postal survey of day case consultant anaesthetists in the UK to explore the range and variation in practice of anaesthetizing a patient for day case surgery (paediatrics, urology and orthopaedics). This paper reports the findings of this national survey of paediatric day case anaesthetic practice carried out as part of a major two-centre randomized controlled trial designed to investigate the costs and outcome of several anaesthetic techniques during day care surgery in paediatric and adult patients (cost-effectiveness study of anaesthesia in day case surgery). METHODS: The survey used a structured postal questionnaire and collected data on the duration of surgical procedure; the use of premedication; the anaesthetic agents used for induction and maintenance; the fresh gas flow rates used for general anaesthesia; the use of antiemetics; and the administration of local anaesthesia and analgesia. RESULTS: The overall response rate for the survey was 74 and 63% for the paediatric section of the survey. Respondents indicated that 19% used premedication, 63% used propofol for induction, 54% used isoflurane for maintenance, 24% used prophylactic antiemetics and 85%, used a laryngeal mask. The findings of this national survey are discussed and compared with published evidence. CONCLUSIONS: This survey identifies the variation in clinical practice in paediatric day surgery anaesthesia in the UK.     

The delivery of obstetric anaesthetic care in UK maternity units: a survey of practice in 2021

BackgroundAnaesthetists are crucial members of the maternity unit team, providing peri-operative analgesia and anaesthesia, and supporting the delivery of medical care to high-risk women. The effective contribution from obstetric anaesthetists to safety in maternity units depends on how anaesthesia services are organised and resourced. There is a lack of information on how obstetric anaesthetic care is resourced in the UK.MethodsThe Obstetric Anaesthetists’ Association surveyed UK clinical leads for their hospital’s obstetric anaesthetic service and examined compliance with national recommendations.ResultsThere were 153 responses by lead obstetric anaesthetists from 184 maternity units in the UK (83%). The number of consultants per 1000 deliveries was 2.2 [1.6–2.7] (median [IQR]). In 20% of units, there was a dedicated on-call rota (on-call only for obstetric anaesthesia), whilst the remainder had a ‘combined’ on-call rota (on-call for other clinical areas in addition to obstetrics). Multidisciplinary ward rounds were held in 83% of units. Twenty-five (16%) units reported having no regular multidisciplinary ward rounds, of which nine (6%) did not have any multidisciplinary ward rounds. Planned operating lists for elective caesarean sections were provided in 77% of units.ConclusionsIn the largest survey of obstetric anaesthesia workload to be reported for any health system, we found significant disparities between obstetric anaesthesia service provision and current national recommendations for areas including consultant staffing, support for elective caesarean section lists, antenatal anaesthetic clinics, and consultant support for service development. Wide national variation in service provision was identified.     

Regional anaesthesia for limb surgery--before or after general anaesthesia. A survey of anaesthetists in the Oxford region

We conducted a postal survey of 221 anaesthetists in the Oxford region to determine their views and actual clinical practice regarding regional anaesthesia in adult patients undergoing limb surgery, when a combined regional and general anaesthetic was planned. Of the 162 respondents (73.3%), 142 (87.6%) regularly practised regional blocks for limb surgery in adult patients. For all the regional anaesthetic techniques in question, more anaesthetists felt it was safer to perform these blocks before induction of general anaesthesia than after induction. However, their actual practice varied markedly from their views, with more anaesthetists performing these blocks after general anaesthesia. Overall, trainees performed blocks before induction of general anaesthesia more often than consultants (p = 0.047).     

Regional anaesthesia practice for arteriovenous fistula formation surgery

We conducted a survey and semi-structured qualitative interviews to investigate current anaesthetic practice for arteriovenous fistula formation surgery in the UK. Responses were received from 39 out of 59 vascular centres where arteriovenous access surgery is performed, a response rate of 66%. Thirty-five centres reported routine use of brachial plexus blocks, but variation in anaesthetic skill-mix and practice were observed. Interviews were conducted with 19 clinicians from 10 NHS Trusts including anaesthetists, vascular access and renal nurses, surgeons and nephrologists. Thematic analysis identified five key findings: (1) current anaesthetic practice showed that centres could be classified as ‘regional anaesthesia dominant’ or ‘local anaesthesia/mixed’; (2) decision making around mode of anaesthesia highlighted the key role of surgeons as frontline decision makers across both centre types; (3) perceived barriers and facilitators of regional block use included clinicians’ beliefs and preferences, resource considerations and patients’ treatment preferences; (4) anaesthetists’ preference for supraclavicular blocks emerged, alongside acknowledgement of varied practice; (5) there was widespread support for a future randomised controlled trial, although clinician equipoise issues and logistical/resource-related concerns were viewed as potential challenges. The use of regional anaesthesia for arteriovenous fistula formation in the UK is varied and influenced by a multitude of factors. Despite the availability of anaesthetists capable of performing regional blocks, there are other limiting factors that influence the routine use of this technique. The study also highlighted the perceived need for a large multicentre, randomised controlled trial to provide an evidence base to inform current practice.     

Anaesthetists' attitudes towards awareness and depth-of-anaesthesia monitoring

Advances in technology have resulted in the development of several depth-of-anaesthesia monitors. Whether any of these monitors can reduce the incidence of awareness is an important issue for anaesthetists and their patients. We therefore surveyed a random selection of anaesthetists, asking for their opinions of awareness and depth-of-anaesthesia monitoring in current clinical practice. Approximately half (52%) of the anaesthetists surveyed had experienced a patient with awareness. Anaesthetists considered that they had a lower incidence of awareness in their own practice when compared with others, 1:5000 vs. 1:10 000 (p < 0.001). Anaesthetists rated awareness on an 11-point scale as only a moderate problem, median (interquartile range) 5 (2-7). Older anaesthetists were less likely to rate the importance of awareness highly (p = 0.009) and to use awareness monitoring (p = 0.001). Anaesthetists are prepared to use depth-of-anaesthesia monitoring more widely if it can be shown to prevent most cases of awareness in routine practice.     

Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre,prospective cohort study

General anaesthesia for obstetric surgery has distinct characteristics that may contribute towards a higher risk of accidental awareness during general anaesthesia. The primary aim of this study was to investigate the incidence, experience and psychological implications of unintended conscious awareness during general anaesthesia in obstetric patients. From May 2017 to August 2018, 3115 consenting patients receiving general anaesthesia for obstetric surgery in 72 hospitals in England were recruited to the study. Patients received three repetitions of standardised questioning over 30 days, with responses indicating memories during general anaesthesia that were verified using interviews and record interrogation. A total of 12 patients had certain/probable or possible awareness, an incidence of 1 in 256 (95%CI 149–500) for all obstetric surgery. The incidence was 1 in 212 (95%CI 122–417) for caesarean section surgery. Distressing experiences were reported by seven (58.3%) patients, paralysis by five (41.7%) and paralysis with pain by two (16.7%). Accidental awareness occurred during induction and emergence in nine (75%) of the patients who reported awareness. Factors associated with accidental awareness during general anaesthesia were: high BMI (25–30 kg.m^-2); low BMI (<18.5 kg.m^-2); out-of-hours surgery; and use of ketamine or thiopental for induction. Standardised psychological impact scores at 30 days were significantly higher in awareness patients (median (IQR [range]) 15 (2.7–52.0 [2–56]) than in patients without awareness 3 (1–9 [0–64]), p = 0.010. Four patients had a provisional diagnosis of post-traumatic stress disorder. We conclude that direct postoperative questioning reveals high rates of accidental awareness during general anaesthesia for obstetric surgery, which has implications for anaesthetic practice, consent and follow-up.     

The Montgomery T-tube: anaesthetic problems and solutions

The Montgomery T-tube is a device used as a combined trachealstent and an airway after laryngotracheal surgery. The deviceis used mostly in specialist centres for head and neck surgery,and therefore, many anaesthetists may be unfamiliar with itsuse. The Montgomery T-tube presents the anaesthetist with challengesboth during its surgical insertion when acute loss of the airwaymight occur and also during induction of anaesthesia in patientswho have such a tube in situ. Anaesthetists who are unfamiliarwith the tube may have to resort to ingenious ways of copingwith the problems of a shared airway with a T-tube, which doesnot have a suitable adaptor for a standard catheter mount, aswell as controlling and maintaining ventilation through thedevice. Safe management of such patients requires careful planning.We describe the anaesthetic management of two cases to illustratethe problems associated with Montgomery tubes. Br J Anaesth 2001; 87: 787–90     

Pediatric anesthesia practice in France: a survey of 1,526 anesthesiologists

OBJECTIVES: To assess the individual activity of anaesthetists in paediatric anaesthesia (PA), and collect their wishes about continuing education and recommendations in PA. STUDY DESIGN: Transversal, prospective study. METHODS: A questionnaire of 33 items, sent to 4,360 anaesthetists, spread over 15 health districts, working in a public or private institution. RESULTS: We gathered 1,526 replies (35%) of which 34% university hospitals, 32% public institutions and 31% private institutions. 943 physicians (63%) had no specific structure, and 1,119 (87%) considered a specialized nurse to be essential for PA. 1,127 physicians (74%) had undertaken a specific session during their formation. The practice of PA depends upon age and context. Above 1 year old, the surgery that is performed weekly was ENT (38%), abdominal and urologic surgery (28%). Mask induction was performed by 60% of the physicians in children under 5 years. 63% of the anaesthetists dreaded a laryngospasm during induction. 625 physicians undertook regional anaesthesia in children under 5 years (87% caudal anaesthesia, 48% peripheral nerve blocks). 1,029 physicians (67%) wished for recommendations in PA in children under 12 months. CONCLUSIONS: This survey showed that most of the anaesthetists wished for recommendations in their paediatric anaesthesia practice.