The use of epidural analgesia in a New Zealand tertiary hospital before and after publication of the MASTER study

We audited the total number of perioperative epidural techniques performed at Christchurch Hospital, New Zealand, for three years, before and after The Lancet published the MASTER Anaesthesia Trial in 2002. We also looked specifically at the number of epidural anaesthetic and analgesic techniques performed in combination with general anaesthesia for colonic surgery over the same period. In both cases we found a statistically significant fall in epidural rate in the years after the publication (P < 0.001). A subsequent survey of local specialist anaesthetists, who have worked throughout this period, revealed the majority (75%) were knowingly performing fewer epidural techniques and that the findings of the MASTER Anaesthesia Trial had influenced their decisions.     

The role of the College of Medicine of South Africa Diploma in Anaesthesia in southern Africa.

OBJECTIVE: To determine the role that the College of Medicine Diploma in Anaesthesia (DA) plays in health services in southern Africa. DESIGN: A postal questionnaire. MAIN INFORMATION SOUGHT: Reasons for doing the DA, percentage of diplomates still actively involved in anaesthesia, career pathways of diplomates, perceived value of the DA, geography and type of anaesthetic practice of diplomates, and participation in continuing medical education. SUBJECTS: The 1,096 candidates who passed the DA between 1974 and 1993. METHODS: Questionnaires were sent to all 861 diplomates with known addresses. RESULTS: The response rate was 62.1% (535/861). Over 70% of diplomates are still actively involved in anaesthesia. Approximately one-third of all diplomates specialize in anaesthesia. The majority of GP anaesthetists with the DA have trained in anaesthesia for more than 1 year. Thirty-three per cent of GP anaesthetists work in small towns or rural areas. Nearly 20% of GP anaesthetists spend more than 75% of their time in anaesthetic practice. Twenty-eight diplomates are working in southern African countries outside South Africa. The DA is perceived to have been of value by the majority of specialist and non-specialist diplomates. CONCLUSIONS: Diplomates are playing a valuable role in anaesthesia throughout the southern African region.     

A survey of pre-operative fasting regimens before regional ophthalmic anaesthesia in three regions of the United Kingdom

A postal and telephone survey of the practice of fasting before regional ophthalmic anaesthesia with and without sedation was sent to 50 hospitals in three regions of the United Kingdom. Responses were received from 100% of hospitals. In most hospitals (58%), local anaesthetic blocks were performed by both surgeons and anaesthetists, with surgeons alone providing ophthalmic anaesthesia in only 14%. Eighty-six per cent of hospitals surveyed had a formal policy regarding pre-operative fasting, with 44% allowing patients to eat and drink freely until their operation. In those hospitals where a fast was imposed, the most common fasting periods were 6 h for food and 2 h for fluids. Twenty-six per cent of respondents would be prepared to give intravenous sedation to a non-fasted patient during eye surgery: small doses of benzodiazepine were the most frequently suggested method. National evidence-based guidelines for ophthalmic regional anaesthesia are needed.     

Anaesthesia crisis resource management training: an intimidating concept,a rewarding experience

Purpose

This two-part study was performed to identify and address anaesthetists’ concerns regarding anaesthesia simulation and to evaluate the response of practitioners to simulation-based Anaesthesia Crisis Resource Management Training (ACRM).

Methods

First, 150 survey questionnaires were distributed to participants of the Anaesthesia Practice ’94 meeting in Toronto and to staff and resident anaesthetists at the Sunnybrook Health Science Centre. In the second part of the study, 35 anaesthetists from the Toronto area who participated in Anaesthesia Crisis Resource Management (ACRM) workshops at the Canadian Simulation Centre completed an anonymous exit evaluation questionnaire.

Results

Among staff anaesthetists (n = 42), 19% of the surveyed respondents had never heard about anaesthesia simulation, whereas all residents (n = 17) had heard of, or seen an anaesthesia simulator. Horizontal numerical scale ratings (from 1–10, with 10 being extremely supportive) indicated support for the purchase of a simulator (8.3 ± 2.0 for staff, 9.2 ± 1.1 for residents). Staff and residents anticipated substantial anxiety while training with a simulator (6.8 ± 2.4 and 7.6 ± 1.4 respectively, with 10 indicating extreme anxiety). Participants in the ACRM workshops at the Canadian Simulation Centre enjoyed the course (1.2 ± 0.6, on a scale form 1 through 5, with 1 indicating total support and 5 representing no support), fell that it would be beneficial to most anaesthetists (1.2 ± 0.5) and should be taken, on average, every 18 mo.

Conclusions

Even though the majority of respondents have not been exposed to anaesthesia simulators, they appear to support their use in education strongly. Whereas substantial anxiety could delay the introduction of simulation based education, participants of ACRM workshops enjoy the courses and perceive them as very educational.     

A survey on the knowledge and attitudes of anaesthesia providers in the United States of America, United Kingdom and Singapore on visual experiences during cataract surgery

BACKGROUND AND OBJECTIVE: To assess the knowledge, beliefs and attitudes of anaesthesia providers on the patients' possible intraoperative visual experiences during cataract surgery under local anaesthesia. METHODS: Anaesthesia providers from the Ophthalmic Anaesthesia Society (USA); British Ophthalmic Anaesthesia Society (UK); Alexandra Hospital, National University Hospital, Tan Tock Seng Hospital, Singapore General Hospital and Changi General Hospital (Singapore) were surveyed using a structured questionnaire. RESULTS: A total of 146 anaesthesiologists (81.6%), 10 ophthalmologists (5.6%) and 23 nurse anaesthetists (12.8%) responded to the survey. Most respondents believed that patients would experience light perception and many also felt that patients might encounter other visual sensations such as movements, flashes, colours, surgical instruments, hands/fingers and the surgeon during the surgery. A significantly higher proportion of anaesthesia providers with previous experience of monitoring patients under topical anaesthesia believed that patients might experience the various visual sensations compared to those who have not previously monitored. For both topical and regional anaesthesia, anaesthesia providers who routinely counsel their patients are (1) more likely to believe that preoperative counselling helps or (2) were previously told by patients that they could see intraoperatively and/or that they were frightened by their visual sensations. These findings were statistically significant. CONCLUSIONS: The majority of anaesthesia providers in the USA, UK and Singapore are aware that patients may experience a variety of visual sensations during cataract surgery under regional or topical anaesthesia. Those who have previously managed patients undergoing cataract surgery under topical anaesthesia are more likely to believe this compared to those who have not.     

Evaluation of practice change following SAFE obstetric courses in Tanzania: a prospective cohort study

Anaesthesia has been shown to contribute disproportionately to maternal mortality in low-resource settings. This figure exceeds 500 per 100,000 live births in Tanzania, where anaesthesia is mainly provided by non-physician anaesthetists, many of whom are working as independent practitioners in rural areas without any support or opportunity for continuous medical education. The three-day Safer Anaesthesia from Education (SAFE) course was developed to address this gap by providing in-service training in obstetric anaesthesia to improve patient safety. Two obstetric SAFE courses with refresher training were delivered to 75 non-physician anaesthetists in the Mbeya region of Tanzania between August 2019 and July 2020. To evaluate translation of knowledge into practice, we conducted direct observation of the SAFE obstetric participants at their workplace in five facilities using a binary checklist of expected behaviours, to assess the peri-operative management of patients undergoing caesarean deliveries. The observations were conducted over a 2-week period at pre, immediately post, 6-month and 12-month post-SAFE obstetric training. A total of 320 cases completed by 35 participants were observed. Significant improvements in behaviours, sustained at 12 months after training included: pre-operative assessment of patients (32% (pre-training) to 88% (12 months after training), p < 0.001); checking for functioning suction (73% to 85%, p = 0.003); using aseptic spinal technique (67% to 100%, p < 0.001); timely administration of prophylactic antibiotics (66% to 95%, p < 0.001); and checking spinal block adequacy (32% to 71%, p < 0.001). Our study has demonstrated positive sustained changes in the clinical practice amongst non-physician anaesthetists as a result of SAFE obstetric training. The findings can be used to guide development of a checklist specific for anaesthesia for caesarean section to improve the quality of care for patients in low-resource settings.     

Awake fibreoptic intubation skills in obstetric patients: a survey of anaesthetists in the Oxford region

A survey of anaesthetists in the Oxford region was conducted to determine their skills and practice in performing awake fibreoptic intubation. Forty-two consultant obstetric anaesthetists (group O), 21 consultant anaesthetists with an interest in difficult airway management (group D) and 20 anaesthetic specialist registrars in their final training year (group S) were sent a questionnaire on management of a patient with a known difficult airway for elective caesarean section. All but one responded. If regional anaesthesia was unsuccessful or contraindicated, 75/82 respondents (91.5%) would choose to secure the airway by awake intubation. Of the remaining seven, six would use general anaesthesia and spontaneous respiration, five (6.1%) with the laryngeal mask airway and one (1.2%) with mask and airway and one (1.2%) local infiltration by the surgeon. Although awake fibreoptic intubation was the technique chosen by 98.7%, only six (8.1%) had experience of its performance in an obstetric patient. Of the 68 anaesthetists without such experience, only 12/31 (38.7%) group O compared to 13/18 (72.2%) group D and 12/19 (63.2%) group S would be confident to perform awake fibreoptic intubation in an obstetric patient. Only one anaesthetist in the survey practised awake fibreoptic intubation in non-obstetric patients regularly (>3/month). However, 69/82 respondents replied that all consultant obstetric anaesthetists should be experienced in performing awake fibreoptic intubation. We conclude that despite the value of awake fibreoptic intubation, consultant obstetric anaesthetists are less confident in performing it than those with an interest in difficult airway management and final year specialist registrars.     

Gender issues among South African anaesthetists.

OBJECTIVE: To study gender issues among South African anaesthetists. SUBJECTS AND DESIGN: A postal survey of all registered anaesthetists in South Africa in December 1999. RESULTS: There were 385 respondents out of a potential 960, giving a response rate of 40%; 77 respondents (20%) were female and 308 (80%) were male. The largest group of males was over 50 years old whereas most females were under 50 years. Most respondents chose anaesthesia because of academic appeal or career opportunities. More females reported experiencing sexual harassment and felt discriminated against in terms of job selection during the training period and with regard to referral practices. Most respondents felt that their colleagues did not treat them differently on account of gender but more females felt that both patients and female nurses treated them less favourably than their male colleagues. More males felt supported in their career by their life partners. More females felt that having children adversely affected academic and promotional aspects of their careers. Despite this, females were more likely to have experienced positive benefits from combining parenting with a career and were also more likely to have worked part time, mainly because of domestic commitments. Most respondents were satisfied with their careers, and would choose both medicine and anaesthesia again. CONCLUSIONS: Our study suggests that female anaesthetists are generally satisfied with their career choice. However, they are exposed to significant gender-related stresses in the workplace, which are exacerbated by time conflicts for those with children. Allowing part-time employment options and creating a less discriminating environment would enable female doctors to achieve their potential.     

The laryngeal mask airway in obstetrical anaesthesia

The laryngeal mask airway (LMA) has been used extensively to provide a safe airway in spontaneously breathing patients who are not at risk from aspiration of gastric contents. The role of the LMA in the event of a failed intubation in an obstetrical patient, and its place in a failed intubation drill remains unclear. Two hundred and fifty consultant obstetric anaesthetists in the United Kingdom were asked to complete an anonymous questionnaire regarding their views about using the laryngeal mask airway (LMA) in obstetrical anaesthesia. The LMA was available in 91.4% of obstetric units. Seventy-two per cent of anaesthetists were in favour of using the LMA to maintain oxygenation when tracheal intubation had failed and ventilation using a face mask was inadequate. Twenty-four respondents had had personal experience with the LMA in obstetrical anaesthesia, eight of whom stated that the LMA had proved to be a lifesaver. We believe that the LMA has a role in obstetrical anaesthesia when tracheal intubation has failed and ventilation using a face mask proves to be impossible, and it should be inserted before attempting cricothyroidectomy.     

Canadian anaesthesia physician resource planning — is it possible?

This study was undertaken with the objective of assessing current sources of information for anaesthesia Physician Resource Planning (PRP). Four major data bases, the annual reports of Health and Welfare Canada (H&W), the education statistics from the Canadian Post-M.D. Education Registry (CAPER), the Royal College of Physicians and Surgeons of Canada (RCPSC) and the Physician Resource Data System of the Canadian Medical Association (PRDS), were examined for the period 1982 to 1991. The ratio of the number of surgical (S) to anaesthesia (A) clinicians decreased over this period despite an increase in the S:A ratios for trainees and certificants. The number of female anaesthetists has progressively increased. A steady decline in the number of rural anaesthetists has occurred. Age distribution of active certified anaesthetists revealed marked inter-regional differences. Little change was noted in the total mean hours worked per week. Each database provided valuable, but limited, data. The PRDS data is useful in assessing trends (age, sex and practice activity). Information provided by H&W tends to underestimate anaesthesia resource information by at least 10%. While information obtained from RCPSC and CAPER is accurate, the current mode of presentation of data limits their usefulness. Integrating data from all the databases appears to provide a meaningful assessment for PRP rather than assessing each database in isolation. Interpretation of the information and its value must take into account the limitations of the data being provided. Assessing present and planning future needs based on the current information structure will prove extremely difficult.     

Induction agents for day-case anaesthesia A double-blind comparison of propofol and midazolam antagonised by flumazenil

Early postoperative recovery was studied using sedation scoring, measurement of flicker fusion frequency and completion of Trieger test figures in 60 male patients who presented for vasectomy under general anaesthesia as day patients. Anaesthesia was induced in groups 1 and 2 (20 patients each) with mean (SD) doses of 0.16 (0.04) mg/kg or 0.16 (0.03) mg/kg midazolam respectively; group 2 received flumazenil 0.55 (0.19) mg after completion of surgery. The remaining 20 patients (group 3) received propofol 1.50 (0.24) mg/kg. Anaesthesia was maintained with isoflurane vaporized in 33% oxygen and nitrous oxide in all patients. Flumazenil tended to improve tests of recovery after midazolam anaesthesia, but early recovery after propofol anaesthesia was associated with better psychomotor test results and less impairment of mental state as judged by sedation and amnesia scoring.     

A national survey of anaesthetists (NAP5 Baseline) to estimate an annual incidence of accidental awareness during general anaesthesia in the UK

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 and staff and associate specialist anaesthetist in the UK. The survey was designed to ascertain the number of new cases of accidental awareness that became known to them, for patients under their direct or supervised care, for a calendar year, and also to estimate how many cases they had experienced during their careers. The survey also asked about use of monitoring designed to measure the depth of anaesthesia. All local co‐ordinators responsible for each of 329 hospitals (organised into 265 ‘centres’) in the UK responded, as did 7125 anaesthetists (82%). There were 153 new cases of accidental awareness notified to respondents in 2011, an estimated incidence of 1:15 414, lower than the 1–2:1000 previously reported in prospective clinical trials. Almost half the cases (72, 47%) occurred at or after induction of anaesthesia but before surgery, with 46 (30%) occurring during surgery and 35 (23%) after surgery before full recovery. Awareness during surgery appeared to lead more frequently to pain or distress than at induction and emergence (62% vs 28% and 23%, respectively). Depth of anaesthesia monitors were available in 164 centres (62%), but routinely used by only 132 (1.8%) of anaesthetists. The disparity between the incidence of awareness as notified to anaesthetists and that reported in trials warrants further examination and explanation.     

Vaskulärer Zugang in der Kindernotfallanästhesie

There is very little literature to guide the young practitioner in caring for a child that needs emergency surgery and has difficult venous access. Questionnaires were sent to 89 members of the Swiss Paediatric Anaesthesia Society and to the heads of Anaesthesia Departments of Swiss teaching hospitals. Two typical case records were presented, both of which were characterised by the fact that 2-3 peripheral venous cannulation attempts were unsuccessful. Case A: a young child with a fracture of the radius and case B an infant with upper gastrointestinal ileus. The anaesthetists were then questioned regarding their preferences for optimal treatment. The majority would proceed with further attempts and, if these still failed, intramuscular or inhalational induction of anaesthesia was suggested as a reasonable choice for case A. However, for case B, a femoral venous or intraosseous access to the venous system was judged to be the safest method. On the basis of our inquiry and a literature search, a priority list was developed to suggest the best possible techniques for vascular access and alternative anaesthesia induction techniques for emergency paediatric procedures.     

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     

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.     

A mixed‐methods evaluation of the Association of Anaesthetists of Great Britain and Ireland Uganda Fellowship Scheme

The Association of Anaesthetists of Great Britain and Ireland and the then Uganda Society of Anaesthesia established the Uganda Fellowship Scheme in 2006, to provide scholarships to encourage doctors to train in anaesthesia in Uganda. We conducted an evaluation of this programme using online questionnaires and face‐to‐face semi‐structured interviews with trainees who received scholarships, as well as with senior surgeons and anaesthetists. Focus group discussions were held to assess changes in attitudes towards anaesthesia over the last 10 years. Interviews were recorded, transcribed and analysed using the constant comparative method. A total of 54 Ugandan doctors have received anaesthesia scholarships since 2006 (median funding per trainee (IQR [range]) £5520 (£5520–£6750 [£765–£9000]). There has been a four‐fold increase in the number of physician anaesthetists in Uganda during this time. All those who received funding remain in the region. The speciality of anaesthesia is undergoing a dramatic transformation led by this group of motivated young anaesthetists. There is increased access to intensive care, and this has allowed surgical specialities to develop. There is greater understanding and visibility of anaesthesia, and the quality of education in anaesthesia throughout the country has improved. The Uganda Fellowship Scheme provided a relatively small financial incentive to encourage doctors to train as anaesthetists. Evaluation of the project shows a wide‐ranging impact that extends beyond the initial goal of simply improving human resource capacity. Financial incentives combined with strong ‘north‐south’ links between professional organisations can play an important role in tackling the shortage of anaesthesia providers in a low‐income country and in improving access to safe surgery and anaesthesia.     

Classification of a traumatic brain injury: the Glasgow Coma scale is not enough

Background: Classifying the severity of a traumatic brain injury (TBI) solely by means of the Glasgow Coma scale (GCS) is under scrutiny, because it overlooks other important clinical signs. Clinicians treating patients with acute TBI are well placed to suggest which variables, in addition to the GCS, should concur in a new classification of TBI. Methods: In Italy, acute TBI patients are treated by anaesthetists, and so we asked them, in a questionnaire survey, to rate the weight they give to the GCS and to other clinical variables in their approach to TBI. Because sedation may underestimate GCS scores, we also inquired whether anaesthetists select sedatives that allow drug‐free GCS scores. The questionnaire was distributed to 1334 anaesthetists attending courses on neurotrauma; the response rate was 63%. Results: Two thirds of the respondents believe that the definition of severe TBI should include, in addition to GCS scores, pupil reactivity to light and computer tomogram (CT) findings, the variables that guide Italian anaesthetists in TBI management. Most respondents (68.2%) administer sedation which allows prompt neurological evaluation and reliable GCS scoring. A minority of respondents (9.3%) withhold or antagonize sedation, delay tracheal intubation or allow patient–ventilator asynchrony. Conclusions: Italian anaesthetists would welcome a definition of TBI severity that includes CT findings and pupil reactivity in addition to the GCS.     

The value of the Internet to anaesthetists

Purpose

To determine which anaesthetists are using the Internet, which resources they find most valuable, and whether the Internet provides useful information which changes the way in which they practice anaesthesia. Method: The survey was posted on the World Wide Web and publicised by e-mail messages to the major anaesthesia ciscussion lists on the Internet.

Results

Two hundred and five valid replies were received from 22 countries. The typical respondent was an American male specialist who worked in a university or teaching hospital in a city with a population of over one million. The most popular World Wide Web site was GASNet, and the Anesthesiology Discussion Group was the most popular discussion list. Eighty-one percent of anaesthetists had changed their practice of anaesthesia based on information obtained via the Internet. Ninety-six percent recommend that other anaesthetists join the Internet.

Conclusion

The Internet is a valuable resource for anaesthetists but, at present, it is used mainly by anaesthetists m universities and other major centres, especially in North Amenca.     

Obstetric epidural services in rural South Australia.

A survey of sixty South Australian country hospitals found that 35 units had more than 25 deliveries per year (total deliveries 4,247, which is 21.5% of total live births in South Australia during 1989). Twenty-five of these units had an epidural service (71%) and the overall epidural rate was 16.7%, 9.5% provided by general practitioner anaesthetists and 7.2% by specialists. General practitioner anaesthetists were involved more in the medium-sized units (50-200 deliveries per year), whereas specialists provided more services in the larger regional units and the small units as visitors. The epidural rate varied between 6-20% depending on the size of the unit. Most country regions in South Australia have reasonable access to an epidural service. The more geographically isolated areas are being serviced by general practitioner anaesthetists.