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ANAESTHESIA
The Newsletter
of the
Association
of Anaesthetists
of Great Britain
and Ireland
NEWS
ISSN 0959-2962
No. 332
MARCH 2015
INSIDE
THIS ISSUE:
AAGBI Board/Council
elections 2015
The perfect storm
requires perfect standards
Challenges to the
wellbeing of the Irish
anaesthetic trainee
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03Editorial
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05
Spring is in the air and by the time this arrives on your doorstep, I expect
election fever will have gripped the political classes of the UK. The NHS
will no doubt be supported strongly by politicians of every hue. But
those of us working at the coalface know that laudable ambitions are not
always translated into better-resourced services. As Mario Cuomo put it,
‘You campaign in poetry; you govern in prose’.
05 AAGBI Board/Council
elections 2015
Emma Plunkett provides an insight into her first six months on the
GAT committee and our Irish trainee colleagues describe their work in
addressing several concerns including wellbeing and inequalities in pay
and conditions. Ireland features again in an article describing how the
activity data collected for NAP5 has informed the debate about service
provision, recruitment and retention.
There are two very different personal perspectives from trainees.
One outlines how funding from the National Institute of Academic
Anaesthesia enabled him to complete his PhD on metabolic dysfunction
and ischaemia following head injury. The other, describing a doctorpatient’s perspective on losing her baby, makes harrowing reading
but includes some excellent points about how well patients remember
details, particularly when matters have not gone well. One of the
observations that has stayed with me from my certificate in education
was the comment that ‘Teachers teach some of the time, learners learn
all the time.’ It’s the same for us as doctors – patients notice all the time,
even in our less auspicious moments. Something for the politicians to
note as well perhaps!
Nancy Redfern
08 The perfect storm
requires perfect standards
12 A history of the Committee
of Anaesthesia Trainees
15 Challenges to the wellbeing of the Irish anaesthetic trainee
We too have elections for the AAGBI Council and GAT council members.
If you would like to stand, or have a colleague who you think would
contribute well to the work of the AAGBI, this is your chance to make a
difference. I need not expand on the breadth of opportunity; education,
safety, research, wellbeing, heritage, innovation and publication.
The safety page, a new feature, includes two contributions from our
Chair of Safety, Tom Woodcock. One describes the progress of the ‘The
Small Bore Connector Clinical Advisory Group’ in encouraging standard
processes for connector design, to minimise the risk of connecting the
wrong tubes, and ensuring UK medical devices fit those used in other
countries. The other is a more light-hearted piece about safety and
the human tourniquet. The letters page this month covers anaesthetic
machines suitable for resource poor environments and one admonishing
those playing ‘revalidation bingo’ with the RCoA CPD codes. A bit of
learning for me as a member of the education committee – point taken!
FUJIFILM SonoSite, Inc. the SonoSite logo and other trademarks not
owned by third parties are registered and unregistered trademarks
of FUJIFILM SonoSite, Inc. in various jurisdictions. All other
trademarks are the property of their respective owners.
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Clinical research training fellowship in anaesthesia and intensive care medicine funded by the AAGBI
07 We invite you to stand for
election to the Group of
Anaesthetists in Training
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04
08
19 Year 2007
21 Joining the GAT Committee:
the first six months
23 Anaesthesia Digested
24 Safety Matters
26 Your Letters
12
28 Particles
16
21
Correction
In the November issue of Anaesthesia News we published
Anaesthetic training in underdeveloped countries: what is
the role of junior trainees (pps 16–17). The authors would
like to acknowledge the Tropical Health & Education Trust
(THET) for managing the Zambia MMed Anaesthesia
Programme, and the Department for International
Development (UK Aid) for financing the programme.
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London W1B 1PY
Telephone: 020 7631 1650
Fax: 020 7631 4352
Email: [email protected]
Website: www.aagbi.org
Anaesthesia News
Chair Editorial Board: Nancy Redfern
Editors: Phil Bewley and Sarah Gibb (GAT), Nancy Redfern,
Richard Griffiths, Sean Tighe, Tom Woodcock, Mike Nathanson, Rachel Collis,
Upma Misra, Felicity Platt and Gerry Keenan
Address for all correspondence, advertising or submissions:
Email: [email protected]
Website: www.aagbi.org/publications/anaesthesia-news
Editorial Assistant: Rona Gloag
Email: [email protected]
Design: Chris Steer
AAGBI Website & Publications Officer
Telephone: 020 7631 8803
Email: [email protected]
Printing: Portland Print
Copyright 2015 The Association of Anaesthetists of Great Britain and Ireland
The Association cannot be responsible for the statements or views of the contributors.
No part of this newsletter may be reproduced without prior permission.
Anaesthesia News March 2015 • Issue 332
Advertisements are accepted in good faith. Readers are reminded that
Anaesthesia News cannot be held responsible in any way for the quality
or correctness of products or services offered in advertisements.
3
Clinical research training fellowship
in anaesthesia and intensive care
medicine funded by the AAGBI
Anaesthesia and intensive care medicine
provides a valuable window into disease
models for many chronic diseases such
as neurodegeneration and dementias.
Pathophysiological processes that
evolve over a lifetime in chronic disease
are contracted to a few days or weeks
following an insult from a critical illness.
To investigate the acute pathophysiological
processes that culminate in morbidity
following a head injury I decided to take a
year out to undertake a clinical research
fellowship with Professor David Menon in
Cambridge, performing experiments and
observational studies in patients
with traumatic brain injury (TBI).
Figure 1: 18F-FMISO and 15O triple oxygen positron emission
tomography in a patient after traumatic brain injury
In my fourth year as a specialist trainee (SpR 4) in anaesthesia
and intensive care medicine, I took up a one-year research
attachment to the University Division of Anaesthesia and
Intensive Care at the University of Cambridge (funded by the
East of England Deanery and awarded by open competition). I
was then successful in obtaining a grant from the AAGBI, funded
via the National Institute of Academic Anaesthesia, to support
my fellowship for a further two years to progress towards a PhD.
The £143,419 was used for my salary and to fund the volunteer
studies (using magnetic resonance spectroscopy and diffusion
tensor imaging) required before my patient experiments.
Working with Professor David Menon and Dr Jonathan Coles, I
used magnetic resonance imaging (MRI), proton spectroscopy
(1HMRS) and positron emission tomography (PET) to investigate
patients with acute brain injury. I learned generic skills such as
interacting with clinical academics and basic scientists, collecting
and interpreting data, time management, and about funding and
research teams. I completed courses relevant to the conduct of
my proposed research, including MR and radiation safety, image
analysis, statistics, preparation of manuscripts and Good Clinical
Practice in research. The fellowship funded by the National
Institute of Academic Anaesthesia and the AAGBI enabled me to
complete my PhD in energy failure following TBI and gave me a
solid foundation from which to initiate and set up further research
activity.
To investigate the mechanisms responsible for neuronal
loss following TBI, I used PET using various ligands (11C PIB,
15
O triple oxygen and 18F FMISO; Figure 1) to demonstrate
derangements in cerebral metabolism and to elucidate long
term sequelae of ischaemia and derangement in metabolism
following head injury.1-5 I also published various articles pertinent
to current intensive care practice. I successfully optimised
44 whole brain spectroscopy for patients after TBI at the Wolfson
Brain Imaging Centre and visited collaborators at the Miller
School of Medicine in Miami, Florida. I gained experience in
performing and analysing imaging data (obtained from PET and
MRI) to demonstrate derangements in cerebral metabolism and
to investigate interventions (such as hyperoxia) to ameliorate
metabolic dysfunction and ischaemia following head injury. My
research has provided invaluable insights on the diffusion barrier
to oxygen after TBI, and ways to overcome such tissue hypoxia.
After finishing my fellowship and the remainder of my training
I obtained a substantive consultant job in Birmingham. I am in
the process of writing my thesis to be examined early next year.
By the end of the clinical research training fellowship I acquired
transferable research skills in PET, diffusion tensor imaging and
spectroscopy to investigate critically ill patients for neurocognitive
dysfunction and decline.
Dr Tonny Veenith
Consultant in Critical Care Medicine, University Hospitals Birmingham
NHS Foundation Trust
Honorary Clinical Research Fellow, University of Cambridge
References
1.
2.
3.
4.
5.
Veenith TV, Carter E, Grossac J, et al. Inter subject variability and reproducibility of
diffusion tensor imaging within and between different imaging sessions. PLoS One
2013; e65941
Veenith T, Coles JP. Anaesthesia for magnetic resonance imaging and positron
emission tomography. Current Opinion in Anaesthesiology 2011; 24: 451–8.
Hong YT, Veenith T, Dewar D, et al. Amyloid imaging with carbon 11-labeled
Pittsburgh compound B for traumatic brain injury. JAMA Neurology 2014; 71: 23–31.
Veenith TV, Carter EL, Grossac J, et al. Use of diffusion tensor imaging to assess the
impact of normobaric hyperoxia within at-risk pericontusional tissue after traumatic
brain injury. Journal of Cerebral Blood Flow and Metabolism 2014; 34: 1622–7.
Veenith TV, Mada M, Carter E, et al. Comparison of inter subject variability and
reproducibility of whole brain proton spectroscopy. PLoS One 2014; e115304.
Anaesthesia
AnaesthesiaNews
NewsMarch
March2015
2015••Issue
Issue332
332
AAGBI
Board/Council Elections 2015
In 2015, three members of the Board and Council of the AAGBI will
have completed their 4 year terms as Elected Members: Drs Nancy
Redfern, Kathleen Ferguson and Tom Woodcock. Nancy will be
staying on as Honorary Membership Secretary, and Kathleen will
continue in her role as Honorary Treasurer. In his 4 years on Council,
Tom has achieved a huge amount, not only in his role as Chair of the
International Relations Committee, but also as Chair of the Safety
Committee. He has lectured widely on IV fluids and organised
a highly successful joint AAGBI meeting with the Physiological
Society. Tom has created the National Essential Anaesthetic Drug
List (NEADL) and has championed the use of the Yellow Card
Scheme for reporting adverse drug reactions within the UK. He has
always been a wise voice of reason on Council as well as making
us laugh when no one can agree on things. Thanks go to Tom for
all of the above.
Grants). All of the meetings are on a Friday. Elected members
should expect to be at the Association’s headquarters at 21 Portland
Place, London, for at least two Fridays a month: always the first
Friday and usually one other Friday. In addition, Council members
will be expected to attend WSM, Annual Congress, the Linkman
meeting and the GAT meeting. You may also be asked to represent
the AAGBI at Core Topics/Seminars and at occasional external
meetings, such as the RCoA, which may be on a different day of the
week. You do not have to attend them all, but you do have to attend
most of them. I would strongly advise that you talk to your Clinical
Director and Medical Director before seeking nomination, to ensure
that you have departmental and Trust support for this work.
This year we need three new Board members who will be elected for
a 4 year term. Elected Board members are automatically members of
the Council. Candidates must be ordinary members of the AAGBI, in
good standing, and as Board and Council members must represent
and work for the whole speciality. Currently Council comprises
a mixed bunch of anaesthetists with a wide range of professional
interests: obstetrics, paediatrics, trauma, regional, ITU, neuro and
cardiac as well as those who excel in research, or enjoy the buzz
of working abroad. What unites us all is a great team spirit, work
ethic, time management skills and, perhaps more importantly, an
enthusiasm and a drive to make things better for anaesthetists and
improve quality of care and safety for our patients.
What has always struck me about the AAGBI is what a friendly and
effective organisation it is. In my 6 years, I have been a Council
member, Chair of Education and now Honorary Secretary. I have
learnt to ride a bike, shared a room and chamois cream with various
AAGBI members (all legit, Ed!), had tea at the Palace, tasted food
and wine at the Savoy, seen the numbers attending our education
events rise by a third, and double for our GAT meetings. I have been
involved with Learn@AAGBI, seen the launch of our fabulous AAGBI
Guideline and Anaesthesia apps, and been proud of the many
‘glossies’ that we have produced. I have become Twitter positive,
Facebook negative, LinkedIn phobic, and the queen of acronyms! I
have learnt to appreciate the details of finance spreadsheets and to
recognise a set of management accounts from a mile off! None of
this would possible, however, without the wonderful team of staff at
21 Portland Place.
The AAGBI is more than a membership organisation for over 10,700
members. It consists of two legal entities (a limited company and
a charity), employs 30 staff, with a combined turnover of over £4
million per year. Board members are automatically directors/trustees
of both company and charity and so must be eligible to serve in this
capacity.
So, what’s the catch? Honestly, there is only one, and that is
TIME! Elected members are expected to attend Board and Council
meetings and will be allocated to 2-3 other committees (e.g. IRC/
Safety/Education/Anaesthesia News/Wellbeing/GAT/Research and
Anaesthesia News March 2015 • Issue 332
So if you are interested in joining us….. stand for election! I would
be more than happy to chat to you about life at the AAGBI. The
closing date for nominations is 17:00 on Friday 10 April 2015 and
the successful candidates will take up their posts from the Annual
Members meeting at Annual Congress Edinburgh in September
2015.
The Election will be run by Electoral Reform Services and this year
the ballot will be online only. Please ensure that we hold a current
email address for you so that you don’t miss out on your chance to
vote. You can check and update your details by logging in to the
members’ area on the website; if you’re unsure how, please contact
[email protected] for assistance. The results will be announced
at June’s meeting of Council, although candidates will have heard
from the AAGBI President before then. I wish you luck and I look
forward to see you in Edinburgh for Annual Congress!
Dr Samantha Shinde
Honorary Secretary
5
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FOR MORE DETAILS, REGISTRATION OR ABSTRACT FORM, GO TO
www.ra-uk.org
CALL FOR NO
The Group of Anaesthetists in Training (GAT Committee)
comprises elected trainees of all grades. We are a democratically
elected body representing anaesthetic trainees at AAGBI
committees, Royal College of Anaesthetists Trainee Committee
and other national medical bodies. The GAT Committee also
works on publications, seminars and the ever-popular Annual
Scientific Meeting.
Nominations are now invited from trainee members of the
Association wishing to stand for election. In 2015 there will be at
least five seats available on the committee. Those standing for
election will be expected to serve a minimum term of two years
and be resident in the United Kingdom or Ireland. If elected,
nominees agree to fulfil the duties and responsibilities required of
them. Further information and nomination forms are available from
the AAGBI Secretariat on 0207 631 1650 (option 3), by emailing
[email protected] or can be downloaded from the AAGBI website
(www.aagbi.org/gatcommittee).
All nominees should be proposed and seconded by other trainee
members of the AAGBI and submitted to: GAT Committee, 21
Portland Place London W1B 1PY, by email to [email protected] or
faxed to 020 7631 4352.
Closing date is Friday 10 April 2015 at 17:00.
ANAESTHESIA NEWS
GAT COMMMINITATTIEOENS
www.gatasm.org
Anaesthesia News now reaches
over 10,700 anaesthetists
every month and is a great
way of advertising your course,
meeting, seminar or product.
Anaesthesia News
is the official magazine
of the Association of
Anaesthetists of Great
Britain & Ireland.
CALL
NOW FOR
A MEDIA
PACK
For further information on advertising
Tel: 020 7631 8803
We represent trainee members of the AAGBI; currently
this is over 3500 trainees and over 85% of trainee
anaesthetists within Great Britain and Ireland.
If you become a member of the GAT Committee you will be
in a position to impact nationally on how training evolves
within anaesthesia over the next decade. It is very easy to
criticise, much more difficult to suggest compromise and
solutions. If you think you can represent your colleagues
and peers, are innovative and resourceful, and can work
well within a team of enthusiastic individuals, then we
want you on the GAT Committee.
We invite you to stand for election to the
Group of Anaesthetists in Training
What do we do?
What to do next?
The Committee has 13 elected members, with an executive
comprising the Chair, Vice Chair and Honorary Secretary. We meet
three times a year at the AAGBI headquarters in London and also
at the GAT Annual Scientific Meeting (ASM).
In 2015, there will be at least five seats available for election to the
Committee. Those standing for election will be expected to serve
a minimum term of two years, up to a maximum of four years. You
need to be resident in the UK or Ireland for your term of office. Most
meetings will take place at the AAGBI headquarters in London and
are usually on Fridays. If elected, nominees agree to fulfil the duties
and responsibilities required of them. The term of office on the
Committee officially commences at the GAT ASM in Manchester
from 17-19 June 2015. As an elected committee member you
would expect to have AAGBI commitments on approximately 10
to 12 days over the course of a year in addition to the 3-day ASM.
There is also a significant amount of discussion that takes place
via email.
The Chair and Honorary Secretary are members of AAGBI Council
and voting members of the Board; the Vice Chair is co-opted to
Council. The GAT Committee members represent trainees on all
AAGBI committees and working parties; they are also co-opted
onto several external committees, including the Royal College
of Anaesthetists Trainee Committee and the BMA Junior Doctors
Committee. We provide anaesthetic trainee representation to
important national initiatives such as the Shape of Training Review
and the government’s review of the impact and implementation of
the European Working Time Regulation. The GAT Committee has
editorial control of the trainee section of the Association’s monthly
newsletter Anaesthesia News, and organises seminars and the
GAT ASM specifically for trainees.
The GAT Committee tends to attract senior trainees. We encourage
core trainees and ACCS trainees to also stand for election to ensure
that all grades of anaesthesia trainees are represented. We would
also like representation on the Committee from all parts of Great
Britain and Ireland, so we encourage nominations from Ireland,
Northern Ireland and Wales in particular, as they are currently
unrepresented.
The responsibility we are given is a privilege. As well as being
extremely interesting, this opportunity offers great scope for the
development of personal skills in management, negotiation and
committee working, authorship and presentation at a national level.
or email Chris Steer:
[email protected]
www.aagbi.org/publications
Dr Les Gemmell
Immediate Past Honorary Secretary
Anaesthesia News March 2015 • Issue 332
Further information and nomination forms are available from the
AAGBI secretariat on 020 7631 1650 (option 3), [email protected]
or can be downloaded from the AAGBI website (www.aagbi.org/
gatcommittee). All nominees should be proposed and seconded
by other trainee members of the AAGBI and submitted to:
GAT Committee, 21 Portland Place, London, W1B 1PY; by email to
[email protected] or faxed to 020 7631 4352.
The closing date is Friday 10 April at 17:00. We look forward to
receiving your nomination form.
Sarah Gibb, Caroline Wilson & Annemarie Docherty
GAT Chair, Vice Chair & Honorary Secretary
7
The perfect storm
requires perfect standards
The results of two of the largest
audits of anaesthetic services
in Ireland have recently been
published.1,2 The two surveys
were part of the 5th National Audit
Project (NAP5) of the Association
of Anaesthetists of Great Britain
& Ireland (AAGBI) and the Royal
College of Anaesthetists (RCoA)
concerning accidental awareness
during general anaesthesia. Results
of the main project were released
on 10 September 2014.3 The
College of Anaesthetists of Ireland
(CAI) collaborated closely with the
AAGBI and the RCoA for NAP5.
8
The first audit,1 was conducted in the 46 acute public hospitals
(Health Service Executive and Voluntary hospitals) and 20 acute
independent (private) hospitals during a week in December
2013. Data on anaesthetic techniques, patients’ characteristics,
staffing, admission and discharge arrangements were collected
on all cases for which anaesthetic care (general, regional or
local anaesthesia, and sedation or monitored anaesthesia)
was provided. The second paper2 details the results of a
questionnaire given to every consultant anaesthetist in
each of the 46 public hospitals in Ireland. This questionnaire
was designed to find out the number of cases of accidental
awareness under general anaesthesia that consultants became
aware of in patients under their supervision.
provisioning will also allow for the development of standards for
healthcare delivery where these do not already exist.
This is the first ever national audit carried out relating to
anaesthesia in Ireland. The anaesthetic activity survey has
complimented the work carried out by the CAI on provision of
anaesthesia services in Ireland that culminated in a document
which was publically launched in February 2014.4
The total number of anaesthetists in the UK in 2007 was 20.7 per
100,000 population and is now nearer 21 per 100,000. In Ireland
in 2012 the ratio was 18.5 per 100,000. Ireland therefore has fewer
anaesthetists than the UK but, more importantly, the makeup of
this workforce differs significantly between the two countries.
In Ireland, consultants account for 45% of the total anaesthesia
workforce, trainees 25% and non-­training NCHDs 30%. In the UK,
consultants make up 50% of the anaesthesia workforce, trainees
35% and career grade doctors the remaining 15%. What this
means in practice is that 65% of UK anaesthetists are in permanent
positions compared to just 45% in Ireland. Trainees make up the
balance of the UK anaesthesia workforce and, though individual
trainees are not permanent in terms of individual contracts, the
overall numbers and location of their posts are relatively stable in
terms of workforce provision. In Ireland, trainees make up a further
25% of the anaesthesia workforce and, similar to the UK, they are
a relatively stable workforce.
The provision of anaesthesia services and workforce in
Ireland has evolved largely in response to local requirements
rather than being centrally planned. A number of centrally
commissioned reports have made recommendations about
overall staffing requirements in anaesthesia and ICU, but none
of these has been fully implemented. Recruiting staff in this
reactive manner leads to a different type of service provision
than would have occurred had a more proactive approach and
global recruitment process been utilised. First, the workforce is
based on locally estimated service needs which often arise in
advance of the anaesthesia workforce being provided, resulting
in overstretching of available resources. In addition, the type of
workforce provided, in terms of grade and specialty, may differ
from that which is required for the long term development of
the service. Proactive provisioning of workforce should allow
recruitment of staff to meet centrally defined standards and
centrally planned growth of the entire health service. Proactive
Anaesthesia News March 2015 • Issue 332
In January 2013, the CAI and the National Clinical Programme
for Anaesthesia (NCPA) published a report on anaesthesia
workforce provision in Ireland which outlined the current workforce
challenges, documented the shortage of consultant anaesthetists
in Ireland and the difficulties in recruiting both consultants and
non-consultant hospital doctors (NCHDs).4 Jonker et al.1 provide
additional complimentary information on anaesthesia services in
Ireland. This paper also provides an indicator of how the current
staffing levels impact on delivery of anaesthesia services in Ireland
when compared with the UK.
Ireland differs from the UK in having an additional 30% of the
workforce that are neither permanent nor on training rotations.
These doctors rotate on a six monthly or yearly basis and the
impact of having to replace these anaesthesia staff is a significant
burden on anaesthetic departments.
Anaesthesia News March 2015 • Issue 332
In 2003 the Hanly Report5 recommended that this portion of the
workforce be replaced with permanent staff, increasing consultant
numbers from 8 to 11 per 100,000 population. This has not
happened and consultant numbers remain at 8.2 per 100,000.
Worsening socioeconomic circumstances and conditions of
employment for all doctors prevalent over the last few years have
resulted in major difficulties in filling non-­training NCHD posts.
The difference in training numbers
The difference in training numbers between the UK and Ireland
reflect the differences in permanent staff which trainees will
be required to fill. In the UK there are 13.7 permanent staff per
100,000 population (10.8 consultants and 2.9 career grade). There
are 7.4 trainees per 100,000 (2007 RCoA census6) which is just
over a 2:1 ratio of permanent staff to trainees. In Ireland in contrast,
there are 4.7 trainees per 100,000 population which is probably
appropriate for the 8.2 per 100,000 permanent staff in Ireland. If
and when we do increase the number of permanent staff in Ireland,
we will need a concomitant increase in training numbers. However,
the question of when to increase training numbers is problematic.
In 2012 the Department of Health introduced a 30% pay cut for
new consultants. This has had a devastating effect on consultant
recruitment in Ireland. The UK and Ireland share the problem that
we are in competition with the rest of the English speaking world
as regards retention of our trainees as consultants once they finish
training. Currently Ireland ranks very poorly in this competition and
most of our trainees leave on completion of their training. This in
itself is not new, but now they leave without intending to return in
the near future. Ireland is thus facing a ’Perfect Storm‘ in terms
of recruitment, we are increasingly unable to recruit non-­‐training
NCHDs and at the same time are losing our trainees who finish
training and are therefore unable to fill consultant posts.
In addition to the overall anaesthetic workforce differences between
Ireland and the UK, the localised nature of consultant recruitment
in Ireland results in differing staffing ratios in Irish hospitals. NAP5
9
illustrates this in terms of the workload per anaesthetic consultant.
This not only differs from the UK but also differs significantly across
Irish hospitals. In the UK, the NAP4 study7 indicated that consultant
anaesthetists deliver, on average, approximately 360 general
anaesthetics per annum and an additional 25% local/regional
procedures to give a total of approximately 450 procedures per
consultant anaesthetist per annum. The data produced by the
Irish NAP5 study indicate that Irish consultants provide a median
of 720 anaesthetic procedures per annum, 60% more than their
UK counterparts. This workload is unevenly distributed across the
health service. In four Irish hospitals the anaesthesia consultant
workload is below the UK average and in the other 37 hospitals the
workload exceeds the UK average. Ten of these hospitals are more
than twice the UK average and two are more than four times the UK
average. Given that, in Ireland, 55% of anaesthesia practitioners
are NCHDs, Irish consultants probably supervise more NCHD staff
than their UK counterparts and this may account for a fraction of
the higher workload of Irish consultants. The figures from NAP5
demonstrate the proportionally higher and disproportionate
workload among Irish consultant anaesthetists. A handful of
departments are generously staffed while most are understaffed,
some significantly so.
Obstetric Anaesthetists Association, the Association of Paediatric
Anaesthetists and by various reports dealing with the staffing of
intensive care in Ireland. Where standards were not available,
the CAI/NCPA have recommended new standards. These
principally revolve around workforce provisioning and include
the number of consultants per roster, a 1:1 ratio of anaesthetic
consultant to surgical list and recommendations on who should
provide anaesthesia independently in Ireland. It will be up to the
profession, both through representative bodies such as the CAI
and the AAGBI and as individual anaesthetists, to insist that the
high quality of anaesthesia in Ireland is maintained by adhering to
these standards.
Editor for
The Editorial Board of Anaesthesia is looking for a new Editor to join the current team
Patient care
Do the workforce challenges facing anaesthesia departments
impact on patient care? The paper1 did not set out to examine this
question but it does provide some indicators. The central question
of the incidence of awareness is slightly less than that reported in
the UK and so, in this respect, there is no impact. The timing of
surgery indicates that, while there is significant out of hours activity,
the majority of immediate and urgent cases are accommodated
during working hours. This is welcome and indicates that the
lessons of CEPOD are being implemented in Ireland. There is a
proportion of elective work completed out of hours. What is not
clear is what proportion of this consists of overruns of elective lists
or of scheduled out of hours elective activity.
The paper did report that one third of hospitals had theatre closures
during the study period. The reasons for this are not clear and may
have resulted from insufficient anaesthesia resources or from the
reduction in hospital budgets that have arisen over the last few
years, neither of which are mutually exclusive. Finally the data on
the site of first pre-­anaesthesia interaction between the anaesthetist
and the patient is more interesting. Only 15% were seen in pre-­
operative assessment clinics and 37% had their first contact with
the anaesthetist in theatre. It is not unreasonable to assume that
the current theatre workload is impacting on anaesthetists’ ability
to see patients either in the pre-­operative assessment clinic or on
the wards prior to surgery.
The current picture of the Irish anaesthesia workforce, drawn
from recent reports and NAP5, poses considerable challenges.
Because of changes in contractual conditions, recruitment to both
consultant and NCHD posts is becoming more difficult. Hospitals
are facing the daily challenge of delivering the same services with
fewer anaesthetic staff than before. Solutions to these problems
are not entirely within the profession’s control but we do have
an important role in safely managing the situation, both our own
and, more importantly, our patients’ best interests. The proposed
reconfiguration of hospitals into regional trusts should allow for
rationalising of anaesthetic services, such that the number of sites
requiring 24/7 services are reduced. Anaesthetists will have to
be at the forefront of discussions on reorganisation to ensure it
meets the needs of our profession. More importantly, however, we
as a profession must insist that the anaesthesia workforce meets
standards defined by, among others, the CAI, the AAGBI, the
10 The successful applicant must be able to work
well in a team, be able to keep to strict deadlines,
have a history of publication and be able to write
coherent and elegant English. Previous editorial
experience is not necessary, but experience of
acting as an assessor/referee for applications
submitted to peer-review journals would be an
advantage.
Applicants should submit a brief summary, of
up to 400 words, of what they think the Journal
does well and/or could improve, by email to
the Editor-in-Chief at [email protected],
together with a short curriculum vitae with the
following headings:
Editors typically work between 6 and 8 hours each
week on the Journal, and must also be prepared
to attend biannual Editors’ and Editorial Board
meetings and contribute to the AAGBI’s Winter
Scientific Meetings and Annual Congresses. As
well as the opportunity to work with an excellent
and cohesive editorial team, rewards include an
honorarium and free registration at major AAGBI
meetings.
•
•
•
•
Summary of current activities & professional
areas of interest
Reasons for applying
Previous editorial/assessor experience
Recent publications
Shortlisted candidates may be asked to perform
a small number of typical editorial tasks as part of
the selection process, and need to be available
to do this during May-June 2015. There will be
no interview.
Please direct any queries for further information to the Editorial Office at the above
email address. The closing date for applications is 30th April 2015.
Dr Wouter Jonker
and Dr Ellen O’ Sullivan
Dr David Mannion
Chair Training Committee, College of Anaesthetists of Ireland
Dr Wouter Jonker
National Co-ordinator National Audit Project Ireland
Dr Ellen O’ Sullivan
President, College of Anaesthetists of Ireland, LEAD National Audit
Project Ireland
References
1.
2.
3.
4.
5.
6.
7.
Jonker WR, Hanumanthiah D, Ryan T, Cook TM, Pandit JJ, O’Sullivan
EP. Who operates when, where and on whom? A survey of anaestheticsurgical activity in Ireland as denominator of NAP5. Anaesthesia 2014;
69: 961–8.
Jonker WR, Hanumanthiah D, Cook TM, Pandit JJ, O’Sullivan EP.
A national survey (NAP5-Ireland baseline) to estimate an annual
incidence of accidental awareness during general anaesthesia in
Ireland. Anaesthesia 2014; 69: 969–76.
Fifth National Audit Project of the Royal College of Anaesthetists in
collaboration with the Association of Anaesthetists of Great Britain &
Ireland. NAP5: Accidental Awareness during General Anaesthesia in the
United Kingdom. http://www.nationalauditprojects.org.uk/NAP5_home
(accessed 19/1/2015).
Providing quality, safe and comprehensive anaesthesia services in
Ireland – A review of manpower challenges. http://www.hse.ie/eng/
about/Who/clinical/natclinprog/anaesthesia/Providing_Quality_Safe_
and_Comprehensive_Anaesthesia_Services_in_Ireland.pdf (accessed
19/1/2015).
Report of the National Task Force on Medical Staffing. 2003. http://
www.lenus.ie/hse/bitstream/10147/46569/1/1680.pdf (accessed
19/1/2015).
RCoA Census Report 2007. http://www.rcoa.ac.uk/system/files/CSQ2007Censusreport-final.pdf (accessed 19/1/2015).
The 4th National Audit Project of the Royal College of Anaesthetists
and the Difficult Airway Society. Major complications of airway
management in the United Kingdom. Report and Findings. March 2011.
http://www.rcoa.ac.uk/nap4 (accessed 19/1/2015).
Anaesthesia
Anaesthesia News
News March
March 2015
2015 •• Issue
Issue 332
332
EDINBURGH
SCOTLAND
Poster/abstract submissions
deadline 01 May 2015
SAVE
THE
DATE
The EICC is Scotland’s greenest convention centre and the AAGBI are committed to
working with them to make Annual Congress as environmentally friendly as possible.
After 18 months, CAT had become well established in the College
and had sufficient prominence among trainees to hold formal
elections. There have been two subsequent committees since the
original and each has built on the success of the former, increasing
the strength of the committee and the voice of the anaesthetic
trainees.
The success of the Information Day has led to the development
of similar meetings including a CAT Consultant Interview and CV
Workshop. The committee are also involved in the College Audit
Study day and are in the process of establishing a nationwide
Trainee Research and Audit Network. The first audit, a snapshot of
EWTR compliance among trainees, achieved over 80% response
rate within two weeks.
Prehospital medicine is an area of focus for the current committee.
A substantial proportion of trainees are interested in this field but
restricted in their activities as a result of the Medical Practitioners
Act 2007. A working group has been established to review the
incorporation of prehospital medicine into anaesthesia training with
appropriate consultant supervision.
The Committee of Anaesthesia
Trainees (CAT) consists of 10 trainees
of the College of Anaesthetists of
Ireland (CAI) elected by their peers.
The committee represents the view
of CAI trainees within the College, at
a national level, and ensures trainees
play a part in shaping the future of
anaesthesia in Ireland.
CAT was established in 2011. Prior to this, trainees were represented
in the College by a small group known as the ATI (Anaesthetists in
Training of Ireland). Their involvement in the College fluctuated over
the years and was somewhat limited. As part of the accreditation
process of the CAI as a training body by the Irish Medical Council,
involvement of trainees in the College was analysed. As a result,
the then Chair of the Training Committee, David Mannion, formerly
a GAT representative, announced that the College were interested
in having a new trainee committee which would be more structured
and have fuller representation within the College.
Following this announcement, the former President of the ATI invited
interested trainees to an open meeting in the College in December
2011. This was a time of considerable change in anaesthesia and
medicine as a whole in Ireland. The introduction of the Medical
Practitioners Act, institution of the new streamlined 6 year SAT
(Structured Anaesthesia Training) scheme, and the economic
situation all had a significant impact on the structure of training,
working conditions and retention of trainees in Ireland. Recognising
the chance to influence the future of their training and professional
lives, a small group attended the first meeting, subsequently joined
by others to form the first CAT.
The first task was to establish CAT within the College and increase
awareness of their existence. Trainee representatives were assigned
to all the relevant committees in the College and CAT terms of
reference were drawn up. Over the first 18 months, CAT initiated
12 A history of
the Committee
of Anaesthesia
Trainees
various projects of its own and contributed to College proposals
to improve training and conditions throughout the country. The
proposals included liaison with trainees regarding the new SAT
scheme with feedback to the College, ensuring competencies
could be achieved within five years and minimising the number
of times a trainee would be rotated out of their base location. A
Rota Maker Policy was developed and communication with trainees
was improved by updating the CAT section of the CAI website and
establishing a CAT email address and newsletter.
CAT represented the views of anaesthesia trainees nationally through
attendance at College Strategy Days and having an input into the
College Manpower Planning Document. Through representation
on the NCPA (National Clinical Programme for Anaesthesia), CAT
also contributed to drafting of national policy proposals such as
the Transport Medicine document and Pathway for the Critically Ill
Obstetric Patient. By having a member on the trainee subcommittee
of the Forum of Postgraduate Training Bodies, CAT was able to
represent the views of anaesthesia and medical trainees in general
nationwide and suspend the introduction of a junior consultant
grade in Ireland.
In addition, CAT established education sessions of its own.
These included an Anaesthesia Information Day in 2013 for those
interested in a career in anaesthesia and a trainee session at the
Irish Annual Congress of Anaesthesia.
Anaesthesia News March 2015 • Issue 332
Our communication tools have improved and expanded. An
extended version of the newsletter, CAT News, is now circulated
to both trainees and College fellows. We have a closed Facebook
group with details of upcoming events, rotation swaps, special
interest years and Fellowships and we hope to establish Lead
Anaesthetic Trainees (LATs) in each hospital as a direct link between
trainees, departments, the CAI and CAT.
Through these forums and more, CAT has strengthened the voice of
anaesthesia trainees in Ireland. A recent example is the debate over
pay scales in Ireland, with the HSE introducing a new salary scale for
run-through training schemes without prior agreement of the IMO.
These changes affected only a small number of anaesthesia trainees
who were unfairly disadvantaged financially. CAT raised awareness
of this issue in the medical community at large via articles in the Irish
Medical Times, a trainee petition and communication with the IMO
who took steps rectify the issue.
A major influence on CAT has been the link with GAT. One of the first
undertakings of the original committee was to re-establish dormant
links with GAT and to have a representative on the Irish Standing
Committee. GAT and the AAGBI’s involvement with the Irish
anaesthesia trainees, throughout the years, has been significant.
At the AAGBI’s ASM in Dublin in 2013, Dr Nancy Redfern, Chair
of the Support and Wellbeing Committee, co-chaired a trainee
forum with CAT with the aim of highlighting trainees’ perspectives
about anaesthesia training in Ireland. At this meeting, Dr Redfern’s
approach to tackling issues caught CAT’s attention, and a sense of
optimism in these times of fiscal adversity spread throughout CAT
and the Irish trainee community in general.
Since then, CAT has continued to engage with GAT and the AAGBI
via regular GAT meetings at 21 Portland Place. Following the
success of the trainee forum, it was proposed that GAT join CAT
in Dublin for a joint meeting. The objective was to advance each
committee’s knowledge of Irish and UK training, and to discuss and
act on many pertinent issues facing both communities.
The following were topics discussed and action points created:
1. Structure of Anaesthesia Training:
o Multisource feedback for trainees in
competencies necessary from an Irish perspective
o Is combining a run-through scheme, a special interest
year and EWTD feasible for Certificate of Clinical Specialist Training in Ireland?
2. Structure of the Committees
o GAT represents both UK and Irish trainees. Should they have Irish representation on the committee and not just a co-opted CAT member?
3. Workforce statistics
o Both groups see similar issues in consultant recruitment
4. Trainees in difficulty
o Buddying and mentoring systems already established in UK seem logical to Irish trainee welfare. Appropriate training is preferable (via the AAGBI and Dr Redfern). An Irish section for trainees in difficulty will appear in the GAT Handbook
5. Communications strategies
o CAT to refine social media policy document and appoint an e-communications role
6. Trainee Network Leads (TNL)
o CAT are working on an accurate description of this role in Ireland, whether it will be hospital or region based, and will liaise with GAT TNL’s to disseminate information between both committees appropriately
7. Pre-hospital care (PHEC)
o Irish PHEC working party may benefit from GAT representative while CAT representation on the AAGBI PHEC glossy creation was suggested
Following the success of the 2014 meeting in Ireland, a joint
collaboration in 2015 is already being discussed, with the GAT
ASM in Manchester being suggested as the ideal setting. The
combination of the two groups, as we have seen this year, is a
positive step forward in helping to further develop and nurture the
impact of CAT and GAT on their respective trainee populations.
GAT, as the trainee committee of the AAGBI, represents trainees
throughout the British Isles. In the past several Irish trainees have
held position on GAT. Following the joint meeting, it has been strongly
suggested that an Irish voice becomes established on GAT. This can
only happen democratically during the annual GAT elections in April/
May. Therefore, CAT and the CAI will be urging Irish trainees to use
their vote to establish Irish representation on GAT, something which
will inevitably be hugely beneficial not only to Irish trainees and CAT,
but in a sense creating a more geographically representative GAT.
The Irish trainee voting voice will need to be heard, and CAT will be
keeping trainees up-to-date on such developments in 2015.
Aisling McMahon
Vice-Chair, CAT
Colm Keane
CAT representative co-opted onto GAT
Through some hard work behind the scenes, the joint CAT/GAT
meeting took place at the 2014 Winter Anaesthesia Weekend, in
conjunction with the Irish Standing Committee of the AAGBI and
the CAI. The two committees collaborated on various topics, mostly
suggested by CAT. A GAT and CAT member discussed each in
detail, and action points were drawn up.
Anaesthesia News March 2015 • Issue 332
13 Society of Anaesthetists
of the South West Region
ANNUAL SPRING MEETING
Start your summer early with a
long weekend in the West Country
Thursday, 14 May and Friday, 15 May 2015
Plymouth Postgraduate Medical Centre
Derriford Hospital, Plymouth
Study Days for 2015
Confirmed speakers
Preoperative Cardiac
and Respiratory Investigations
19 May 2015
■ Dr J-P van Besouw, President, RCoA
■ Dr Ellen O’Sullivan, President, College of Anaesthetists
of Ireland
■ Professor Adrian Furnham, Professor of Psychology,
UCL and Sunday Times Columnist
Cardiopulmonary
Exercise Testing
20 May 2015
■ Professor Rob Sneyd, Plymouth
■ Dr Rupert Pearse, London
■ Dr David Grant, Bristol
Society Dinner at Royal Marines Officer’s
Mess, Stonehouse
For full details and to book your place, please visit
www.pre-op.org or call 020 7631 8896.
Location: AAGBI, 21 Portland Place, London
Anaesthesia and Perioperative Care Anaesthesia nd Perioperative Anaesthesia and Sa
Petting erioperative Care Care Priority Partnership
Anaesthesia and Perioperative Care Priority Setting Partnership
Priority Setting P
artnership
Priority Setting Partnership
Over 3 million patients an anaesthetic Over 3 million patients h ave an haave naesthetic every year. e
very year. research ould help improve care? Over What 3 mWhat pwatients hillion ave n acare? naesthetic every eyvery ear. rillion esearch ould help improve tatients heir Over 3w m
pa
have their an anaesthetic year. This famous piece of Irish poetry refers to Patrick Kavanagh’s
birth place in Monaghan – the title betrays his negative
emotions for his home county. Upon moving to the more
enlightened and cosmopolitan Dublin, he reflected on the
hardships of his youth, and the lost opportunities that stunted
his development. Kavanagh lived the rest of his life, and died,
in Dublin.
Lost the long hours of pleasure
All the women that love young men.
O can I still stroke the monster's back
Or write with unpoisoned pen.
Stony Grey Soil – Patrick Kavanagh
Delegate fees for both days including dinner
Consultants: £210, Doctors in Training £120
A wide array of reduced fee options depending on your choice of
sessions. Approved by the RCoA for 10 CPD credits.
Enquiries to: [email protected]. For full programme and
booking, please see: www.saswr.org.
All of our study days are at a subsidised price of
£75 for
members and £99 for non-members.
Challenges to the
wellbeing of the Irish
anaesthetic trainee
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naesthesia nd perioperative care care Vote ffor or fyuture our top 10 and help shape the future of aanaesthesia and perioperative you think are the biggest priorities research. Vote at: http://www.niaa.org.uk/PSPSurvey#pt Vote at: http://www.niaa.org.uk/PSPSurvey#pt Vote at: hsttp://www.niaa.org.uk/PSPSurvey#pt Vote for your top 10 and help hape the future of anaesthesia and perioperative care For more information go to our website at http://www.niaa.org.uk/PSP#pt For more information go to our website at http://www.niaa.org.uk/PSP#pt For more information to our website at http://www.niaa.org.uk/PSP#pt Vote at: gho ttp://www.niaa.org.uk/PSPSurvey#pt For more information go to our website at http://www.niaa.org.uk/PSP#pt On a daily basis, my colleagues express similar (less poetic)
commentaries on the Irish health system. The long hours, poor
management, reduced pay, inadequate training are blamed for a
malaise amongst Irish trainees. Similar to Kavanagh, a growing
number are emigrating to greener pastures, leaving their country,
their family, and their friends behind for a better life. An individual’s
‘wellbeing’ was probably a foreign concept in 1940s Ireland but, in
his poetry, Kavanagh routinely catalogues the neglected elements
of his own wellbeing.
of wellbeing. An employer will successfully retain their workforce it
they value and support their employees’ wellbeing.
Wellbeing is determined by your physical, social and mental
state.3 It depends on six domains (Figure 1). Everybody will have
slightly different requirements to satisfy their wellbeing, but most
people prioritise the domains of health, and relationships and
care. The other four domains vary in significance depending on
the individual.
Figure 1
The concept of physician wellbeing is topical in modern Irish
medicine. Our health system is in a deep recruitment and retention
crisis. The Medical Workforce Report 2014, shows a worrying trend
with another 10% of young doctors (under 30 years old) exiting
medical practice in Ireland. Today, over 30% of our doctors have
qualified in a non-EU country, compared to 7.4% in 2000.1 The
specialty of anaesthesia has been affected by the medical exodus.
Over half of the anaesthesia training graduates in 2014 have left
the country, and an unprecedented number of consultant posts lie
vacant in many anaesthetic departments.
In 2006, the Fottrell Report made recommendations about the
number of graduates required to staff our health system and ease
our reliance on non-EU doctors.2 The numbers in Irish medical
schools rose from 305 in 2007 to the target of 750 in 2011. This is a
substantial increase in supply and yet we’ve never been so reliant
on foreign doctors to support the system. This simple supply and
demand strategy failed. Medical professionals expect reasonable
working conditions and a meaningful life for themselves and their
families. These basic elements are encapsulated in the principle
Anaesthesia News March 2015 • Issue 332
The Committee of Anaesthesia Trainees (CAT) invited anaesthetic
trainees to describe the most important factors that affect
their wellbeing. Common themes emerged, with excessive
working hours, staff shortages, sub-standard training, unfair
pay arrangements and disrupted family life having a particularly
negative impact.
15 Work and participation
In 2013, Irish junior doctors went on strike over excessive working
hours. The majority of doctors were not compliant with European
Working Time Regulations (EWTR). In response to the strike, the
Health Service Executive (HSE) committed to limit shifts to less
than 24 hours by the end of 2013, and to be fully compliant by
2015. This has not happened.
The CAT conducted a survey of EWTR compliance amongst
anaesthesia trainees in November 2014 that showed 71% of
trainees continued to work over 48 hours per week, and 37% of
trainees work a shift in excess of 24 hours. The silver lining of
our survey was the significant efforts made by the anaesthesia
departments to implement more compliant on-call rotas, with 49%
of trainees on alternative rotas.
The excessive hours are taking a major toll on anaesthesia
trainees. Many reported exhaustion and burnout in the survey,
and they lacked confidence that the EWTR would be implemented
appropriately by the HSE. A smaller survey of trainees assessed
occupational stress, and 58% of trainee respondents scored as
‘high risk of burnout or mental health disorder’ due to work-related
stress. Fifty percent felt their hours were excessive and prevented
them from performing optimally.
Democracy and values
Kavanagh’s poem details all the principles he believed and trusted
in, and how betrayed he felt when these values were challenged.
A breach of trust and a perceived lack of fairness, can seriously
challenge an individual’s wellbeing.
In 2012, the HSE introduced a 30% pay cut to all new-entrant
hospital consultants. This was an isolated pay cut for one group of
public servants, in addition to all other cost containment measures
introduced over the preceding six years. This has introduced an
inequality between new and existing consultant colleagues, and
has had a profoundly negative impact on recruitment.
In July 2014, the HSE issued a directive to all HR departments to
cut the salaries of middle grade anaesthesia trainees. This breach
of contract resulted in a pay reduction of €10,000 for some trainees.
Following threatened strike action, the HSE have postponed the
introduction of these scales, but have committed to review trainee
pay in 2015.
These recent events have severely damaged trainee trust in their
employer. Irish trainees who emigrate are often struck by the
willingness of their foreign employers to honour the terms of their
contract. Such a simple principle is challenged on a daily basis in
Irish HR departments.
Relationships and care
Along with health, this is one of the key domains of our personal
wellbeing. In one of our surveys, 72% of anaesthesia trainees said
their workload affected their home, family or personal life on a
regular basis. Our EWTR survey had a response rate of 90%, but
only 1% of respondents (two trainees) were engaged in less than
full-time training. From discussions with our GAT colleagues, we
realise this is significantly less than the UK. Nearly half (45%) of Irish
anaesthesia trainees are female, and we need to support familyfriendly initiatives to improve retention. The HSE are planning to
introduce new proposals to improve the availability of less than fulltime options, job-sharing and couple-matching.
When a trainee’s wellbeing is not valued by his or her employer,
their health may suffer. In our occupational stress assessment, 44%
of anaesthesia trainees reported feeling ‘emotionally, mentally or
physically exhausted’ on a regular basis.
It is not surprising that many trainees working in such a demanding
system neglect their physical health. However, with the introduction
of initiatives like the ‘Bike-to-Work Scheme’, more doctors are fitting
physical exercise into their busy daily lives.
What can we do?
The CAT is committed to working with anaesthesia trainees and the
College of Anaesthetists to improve the wellbeing of trainees. Our
colleagues in GAT and at the AAGBI have a wealth of experience
in the area of trainee welfare, and we look forward to learning from
them as we collaborate on future projects. We have conducted
two large national surveys, examining EWTR compliance and
recruitment in intensive care medicine. The results of these surveys
will be communicated to the relevant authorities and hopefully
drive changes to improve trainee wellbeing.
We have been working hard to establish and develop an Irish
anaesthesia community. Our private Facebook page facilitates
trainee discussion. We are currently developing a ‘Lead Anaesthetic
Trainee’ network, similar to GAT’s Trainee Network Leads in the UK.
The importance of a strong community was highlighted in 2014
following the trainee pay-cuts. The CAT wrote a letter to our medical
union (IMO) requesting intervention and over 220 trainees signed
this letter. This represented a very strong response that inspired the
IMO to intervene, and successfully reverse the cuts.
The AAGBI would like to offer a Patient Safety Prize
to showcase examples of improved safety in anaesthesia.
The prize is open to members of the AAGBI. The project could involve an individual, department, medical students or allied health
care professionals, provided the project lead is a member of the AAGBI. Applicants may like to consider projects based on themes
identified in SALG patient safety updates.
You will need to demonstrate:
Clear aims and objectives
An innovative idea(s)
How the project was introduced and implemented
How performance was measured and benchmarked
How information about the project was disseminated
The sustainability of the project
Transferability of the project to other departments
The deadline for submissions is
23:59 on Friday 01 May 2015
Amount: Up to £500 (at the discretion of the awarding Committee).
There may be more than one prize.
Awarded: At the AAGBI Annual Congress, Edinburgh
Format of submissions: Poster presentation
In addition, the shortlisted entries may be expected to:
Make a brief oral presentation to the judges at Annual Congress
The winner will be expected to:
Make a five minute oral presentation during the prize giving at Annual Congress
Please visit www.annualcongress.org/content/aagbi-patient-safety-prize
for further details. If you have any queries, please contact the AAGBI Secretariat
on 020 7631 1650 (option 3) or [email protected]
What can our employer do?
Ultimately, we depend on our government and senior managers
to implement the required changes. As a trainee committee, we
can simply highlight problems, but have little power to fix them.
Dramatic changes are required – that is certain. The government
and the HSE need to respect the wellbeing of their employees, and
not use them as simple commodities.
As an Irish citizen, it’s demoralising to observe this ‘brain drain’.
There is a long tradition of Irish medical professionals moving
abroad, but the majority harboured ambitions to return home. This
is no longer the case. Similar to Kavanagh, we must ask ourselves:
‘Can I still stroke the monster's back? Can I return to work in the
Irish health system? Is there any remaining trust or optimism?’
These are vital questions, because the future of safe, high quality
medical practice in Ireland depends on the answer.
Dr David Moore
Chair, Committee of Anaesthesia Trainees (CAT)
Anaesthesia SpR 4, St James’s Hospital, Dublin
References
1.
2.
3.
Working Group on Undergraduate Medical Education. Medical Education in
Ireland: A New Direction. Report of the Working Group on Undergraduate
Medical Education. Dublin: Department of Health and Children; 2006.
Humphries N, Tyrrell E, McAleese S, et al. A cycle of brain gain, waste and
drain - a qualitative study of non-EU migrant doctors in Ireland. Human
Resources for Health 2013 11: 63. http://www.human-resources-health.com/
content/11/1/63
National Economic and Social Council. Well-being Matters: A Social
Report for Ireland. Volume 1. NESC Report No. 119. Dublin: NESC; 2009.
http://files.nesc.ie/nesc_reports/en/NESC_119_vol_I_2009.pdf (accessed
19/1/2015).
NASGBI 50TH Anniversary Annual Scientific Meeting
Manchester 7-8th May 2015
Hilton Hotel, Deansgate, M3 4LQ
Dealing with chimps in the clinical environment
Prof Steve Peters
Consultant Psychiatrist and Chief Psychologist Sky Pro Cycling Team
Inflammation and Brain Injury: Discovery and Treatment
Dame Nancy Rothwell
President and Vice Chancellor, University of Manchester
Delayed Neurological Deficit
Prof Gabriel Rinkel
University of Utrecht
Extensive social programme to accompany the main event.
Abstract Submission now open - Deadline: 6th March 2015
£300 Members / £350 Non-members / £150 Trainees. One day rate £150 / £200
www.nasgbi.org.uk
Health
16 AAGBI PATIENT SAFETY PRIZE 2015
Registration now open
Anaesthesia News March 2015 • Issue 332
@NASGBI
#50thASM
Year 2007
BRITISH SOCIETY OF ORTHOPAEDIC ANAESTHETISTS
SPRING SCIENTIFIC MEETING
SAS AUDIT POSTER
PRIZE 2015
Thursday 04th June 2015
Etc.venues Maple House,
150 Corporation Street, Birmingham, B4 6TB
Delegate Fees:
Consultant Anaesthetist: £75 (BSoA members £70)
Registrars / Specialty Doctors / PA(A): £55 (BSoA members £50)
(See BSOA website for membership details)
www.facebook.com/pages/The-British-Society-of-Orthopaedic-Anaesthetists
Twitter: Ortho Gas Person, @Bsoa_org_uk
Peri-operative Medical Care
Speakers include:

Dr W Chimbira, Michigan, USA


Dr M Swart, Consultant Anaesthetist,
Devon
Dr W Lester, Consultant Haematologist
Dr O Bagshaw, Consultant Anaesthetist





Dr S Wharton, Consultant Respiratory
Physician
Dr K Patel, Consultant Anaesthetist
Dr H Jones, Consultant Anaesthetist
Mr M Phillips, PA(A) Lead HEFT
Contact and Registration Information:
(Application Form available from)
Joanne McCaffery
BSoA Meeting Administrator
Email: [email protected]
Phone: 07594 878 668
Anaesthetic Department
The Royal Orthopaedic Hospital
Bristol Road South
Birmingham
B31 2AP
Attracts
5 CEPD
points
(applied for)
Many of us will remember 2007 for the uncertainty of MMC
and MTAS, but for me the stress came from my personal
life. After passing my Primary exam I moved region for family
reasons and felt like an outsider. I was pregnant with my first
child and wasn’t shortlisted for an ST3 post; all quite worrying.
The AAGBI invites abstracts for the SAS Audit Poster Prize.
The prize is open to all SAS grade anaesthetists.
A preliminary review of the abstracts received will determine
which ones are accepted for poster presentation at the
Annual Congress in Edinburgh.
Prizes will be awarded to authors of the best posters and
the abstracts will be published in Anaesthesia in the form of
a fully referenceable online supplement (NB Editor-in-Chief
reserves the right to refuse publication, e.g. where there are
major concerns over ethics and/or content).
The deadline for submission is 23:59 on Friday 01 May 2015
and full instructions can be found on our Annual Congress
microsite: www.annualcongress.org/content/oral-posterpresentations
If you have any queries, please contact the AAGBI Secretariat
on 020 7631 1650 (option 3) or [email protected]
It began with a bit of pain in the back of my neck. At first, I thought it
was just a sprain or a pregnancy-related minor ache. But it gradually
got worse, and soon I had to turn my whole body to look around.
Being in the first trimester, I didn’t want to take any non-steroidals or
opioids, and restricted myself to paracetamol, which was not very
effective. I mentioned to my GP that my left carotid artery was more
obviously palpable that the right; she put it down to muscle spasm
and suggested physiotherapy. Three weeks and a few agonising
physiotherapy sessions later, I noticed a swelling on the left side
of my neck, which appeared to be getting bigger. I was referred to
ENT who ruled out a branchial cyst, performed a needle aspiration
and an ultrasound guided incision and drainage. Three weeks
later, we had a result. Acid fast bacilli; I had tuberculosis. An urgent
MRI provided the final diagnosis – tuberculous osteomyelitis of the
cervical spine, with changes from C1 to D1 vertebrae, along with a
large prevertebral abscess.
Having a diagnosis was an immense relief after three months of
pain, nausea and appetite and weight loss. But I still shudder when
I remember what the TB nurse said ‘I know two patients with this
condition in the lumbar spine, and they are both paraplegic’. For me
it all resolved after nine months of treatment.
In spite of everything, my pregnancy seemed to be progressing
well, with good fetal growth. As I got better, I looked forward to
the baby. I went into spontaneous labour and all was well until
I had my epidural and an ARM, after which the CTG showed fetal
decelerations. Delivery was expedited with ventouse, but the baby
had severe meconium aspiration and had to be intubated. After 10
hours in SCBU, support was withdrawn and she died.
The night she died, as I tossed and turned in bed, I could hear
babies crying in the next room and wanted to run away, to escape
the cruelty of it all. The following morning, a tactless anaesthetic
registrar doing his follow up ward round asked me how the labour
and epidural experience was. He didn’t know I had lost my baby. To
me, this seemed very insensitive.
The target: The AAGBI wants to raise £96,000 which will buy 600 Lifebox Pulse Oximeters over the
next 2 years - the same as the number of Team GB athletes attending the Olympic and Paralympic
Games in Rio de Janeiro in 2016.
During the days that followed, the pain, shock and grief were
unbearable, and I was an emotional wreck. Sleep deserted me, I
could barely function in the day, and I refused to talk to anyone. But
life had to go on, and I needed a job. I approached my college tutor,
who arranged for me to return to an SHO job for a month. During this
time, I was offered a LAT post.
The aim: To save thousands of lives around the world where patients are at risk of death from hypoxia.
Help us to reach the target! Join the campaign and become a Lifeboxes for Rio fundraiser
Bake, bike ride, run or walk – or devise your own fundraising concept.
From the employer’s perspective, I was a liability. I had been off
sick, on maternity leave, and was emotionally fragile. Not the ideal
candidate to take on the new responsibilities of the specialist registrar
role. Six years and two delightful children later, I am now a final year
trainee, and to this date, I remain grateful for their trust and kindness.
www.aagbi.org/lifeboxesforrio
AAGBI Foundation: Registered as a charity in England & Wales no. 293575 and in Scotland no. SC040697
Lifebox: Registered as a charity in England & Wales (1143018)
Rio_Poster.indd 1
19/01/2015 10:31
Anaesthesia News March 2015 • Issue 332
Returning to work was hard. Although I was relatively new to the
hospital, most people knew I had been pregnant, and the inevitable
question was asked, ‘How is the baby?‘ or even ‘Why have you
returned so soon?’ The people in the anaesthetic department knew
everything and did not ask questions. Knowledge of the tragedy
seemed to make it difficult for them to greet me, and some just
avoided eye contact. I would have preferred them to talk to me. To
paraphrase the lines of a famous poem: What is this life, if, full of
care, we have no time to talk and share! My department provided
practical support, and offered to change my rotation so I didn’t have
to work in the maternity unit where I lost my baby.
Working in the labour ward was never the same. I now visit any
mothers awaiting delivery of an intrauterine death and help in any
way I can, especially with pain relief.
I found that keeping busy was the best way to cope with my loss.
Staying at home just made me irritable, brooding and, worse still,
insomniac. Focusing on other people’s problems made mine less
stressful, and made me forget, if only temporarily.
Dealing with a colleague who has had bereavement can be
challenging, and it is crucial to try and get it right. Here are a few
suggestions:
Hints and tips
•
•
•
•
•
•
Returning to the same place of work after bereavement is hard.
Don’t avoid someone who has had a tragedy. Make eye
contact when you see them. Send a card or email to say you
know what’s happened and offer your sympathy.
If you have suffered a stillbirth or neonatal death, people will
ask ‘How’s the baby’ or ‘Why are you back so soon?’ Be
prepared for this; give a brief answer and explain what you
would find helpful from them now.
It is normal to have flashbacks, to feel irritable, and to find it
hard to sleep. Keeping busy by coming to work and focusing
on other people’s problems can be helpful. Being alone at
home makes some people feel worse.
Practical support from the department is vital, e.g. helping
them get back to work even on a part-time basis, ensuring
they don’t work alone in case they feel wobbly, changing
someone’s rotation so they don’t have to work in the unit
where the bereavement occurred. Ask what would be helpful.
People need company, even if they may not feel they do at the
time. If you know them, offer to meet up. Gently encourage
them to talk about events. If they’ve lost a child, ask them if
they have a photograph.
19 NIAA
National Institute of Academic
Anaesthesia
Director, UK
Perioperative Medicine Clinical Trials Group
The National Institute of Academic Anaesthesia (NIAA) wishes to appoint a Director to lead the development of a national Clinical
Trials Group (CTG) for perioperative medicine, capable of supporting world-class multi-centre trials from idea to publication and
dissemination.
The postholder will be expected to develop a national network of hospitals and investigators to recruit to trials and develop
and implement a transparent and robust process for identifying and selecting studies to be considered by the CTG. He/she will
also need to engage the appropriate stakeholders in the project and work effectively with the NIAA and its founding and funding
partners and trainee research networks.
The post is a three-year, fixed-term appointment, subject to annual review.
Further information about the NIAA, the job description, person specification and details on how to apply is available on the NIAA,
RCoA and AAGBI websites.
Closing date for applications:
Friday, 1 May 2015 at 12 noon
Shortlisted candidates will be contacted and interviews will be held on:
Tuesday, 9 June 2015
Pain
Foundation
LIVERPOOL COURSE ON CLINICAL
MANAGEMENT OF CHRONIC PAIN :
A PRACTICAL APPROACH
Limited to 30 participants
RCoA CPD Matrix 2E03 and 3E00
FEE £450 (Register after 2nd May 2015 £500)
All delegates
will receive a
complimentary
copy of the
handbook
‘Practical
Management
Of Complex
Cancer Pain’
Demonstration Joint Pain Clinics • Imaging for Spinal Interventions • Cancer Pain Management •
CRPS Management • Neuromodulation • Pain Management Programme • Demonstration Theatres •
Hands on Manakin Spinal Injection • Ultra Sound Guided Pain Interventions • Botox Injections and
Capsaisin Patch Application • Physiotherapy Assessment and External Neuromodulation
Contact:
Mrs Brenda Hall, Pain Relief Foundation, Clinical Sciences Centre, University Hospital Aintree,
Lower Lane, Liverpool L9 7AL UK. Tel +151 529 5822 [email protected]
www.painrelieffoundation.org.uk
Registered Charity Number: 1156227
Anaesthesia News is always looking for articles of
relevance to trainees. As recently elected members to
the committee we thought it might be interesting to give
an account of our first few months on the committee.
Perhaps naïvely, we didn't quite appreciate the breadth
of trainees’ involvement in AAGBI activity and it has
been a busy, but rewarding, six months so far.
For most of us, our first experience of an AAGBI meeting was
the Joint AAGBI Board and GAT Strategy meeting in Newcastle.
We got straight into discussing the objectives for GAT during
2014/15. Even from the very beginning our opinions were sought
and considered, and we were made to feel part of the team. Of
course it is by design that the newly elected members join the
committee at the ASM. It was useful to attend the meeting, not
only because it is full of great educational content (and very good
value for money!) but also because it is a great chance to get to
know fellow committee members and learn about how a major
medical conference is run.
Relief
2ND TO 4TH JULY 2015
An advanced practical course in clinical pain medicine for Pain
Professionals and Trainees aiming to further develop skills of
assessing and treating complex chronic pain patients, specialists
and pain specialists in training.
Joining the
GAT Committee:
the first six months
In association with The Walton Centre for Neurology & Neurosurgery NHS Foundation Trust
Meetings
Our first face-to-face meeting was in September 2014. GAT
committee members are offered the opportunity to do an
Advanced Management Module and part of each committee
meeting is set aside to address some of these learning objectives.
In line with this we take turns to chair our own committee meetings.
This is a new skill for most of us and, as is often the case when
doing something new, has been associated with varying degrees
of apprehension. This has been eased with excellent chairing
resources form senior council members, and plenty of support
from fellow committee members! A buddy system to link each
GAT committee member with an AAGBI council member has also
been developed so we have someone to turn to for additional
advice if necessary.
We have now had several other meetings; including a joint
meeting with the Trainee Committee of the College of
Anaesthesia News March 2015 • Issue 332
Anaesthetists of Ireland in Dublin. Although we discuss many
issues by email, we are learning fast how useful it is to have a faceto-face discussion where ideas can develop. Recurring themes
at our meetings are education (in particular the GAT ASM and
seminars), communication, reports from our co-opted members
(the RCoA, BMA, CAI and the military) and any external meetings
at which we represent GAT. We normally have at least a couple
of members teleconferencing in or on Skype and we are learning
to make sure we include those members as much as possible.
It is often easier to discuss ideas in a less formal environment,
so we make sure there is time to chat outside of the meeting
itself. With so many new members in the committee this is an
important part of getting to know one another, providing valuable
peer-support and improving our ability to work as a team.
External representation
As well as our internal committee meetings, some of us represent
GAT at external meetings such as the series of Shape of Training
workshops that were held across the country. We are also due to
represent anaesthetic trainees at a RCoA Perioperative Medicine
Stakeholder event and a NIAA meeting to improve trainee access
to research. Before attending meetings like these we canvas the
opinions of the whole committee, helping the person attending
to give a balanced view. Following any meeting we attend, we
prepare a report to share with the GAT committee, often done
on the train journey home! All meeting documents and reports
are shared via Dropbox, which we are fast becoming experts at
navigating.
21 Committee work
Other opportunities
Members of the GAT committee are actively involved in many
AAGBI and external committees. Since joining in June we have
been representing anaesthetic trainees on a number of key
issues:
• Commenting on the government’s response to the Review
of the Impact of EWTD in the NHS (a letter was sent to the
Rt Hon Jeremy Hunt)
• Health Education England Workforce planning call for
evidence and a survey by the European Commission on
the impact of the EWTD (we contributed to the AAGBI
response)
• Providing trainee evidence for a response to the Doctors
and Dentists Review Board on contract negotiations
• The Shape of Training Review and how we should respond
to and engage with the Steering Group
• Improving links with medical students and trainee research
networks
• Provided input to the AAGBI members’ survey
• Options for locations for future GAT ASMs (Manchester in
2015 and Nottingham in 2016)
• Potential topics and articles for the GAT issue of
Anaesthesia News, (we decided on a Wellbeing theme –
look out for it in June) and a trainee session at the 2015
AAGBI Annual Congress (Edinburgh)
In addition to everything we’ve mentioned so far, we have
been involved in many other projects. We have contributed to
the National Essential Anaesthesia Drug List and will help edit
future editions of publications such as the GAT Handbook. We
have also been asked to participate in working parties, to be on
National Organising Committees for conferences, and to provide
trainee representation on bursary and awards panels. Thankfully
we have a diverse range of interests and skills between us and
the work seems to be naturally shared according to these.
Sometimes it has been difficult to know exactly what the right
answer is and how best to comment. However, the point of being
on the committee is to consider different viewpoints, and it is
through discussion that we get to know each other better and
find a way forward. In addition to the GAT committee emails, we
also receive emails from the other committees we sit on. Some of
these generate more email traffic than others and something we
are all learning from being on the committee is time-management
and the effective management of large volumes of emails.
Impression so far
So we attend meetings and send a lot of emails. What is it all for?
This is probably a good moment to reflect on whether being on
the GAT committee is meeting our expectations? Thinking back
to our nomination statements we all identified various issues and
mentioned how we wanted to make things better for our fellow
anaesthetists and this is what we as a committee are trying to do.
Be it via education, promoting peer-support or our more political
activities, it all comes down to helping anaesthetists to do their job
as well as they can. So yes, this meets our expectations. Perhaps
what we didn’t realise was the extent of trainees involvement in
the AAGBI. This was probably naïve as, after all, trainees make
up a third of the membership. We have learnt that although the
range and breadth of GAT and the AAGBI activities are wide, the
overall aim is simple: to make anaesthesia as safe as possible.
This needs not only safe and effective anaesthetists who are
knowledgeable and adequately rested, but also safe and effective
systems for them to work with.
What about the amount of work involved? Having written it all down,
it does seem like rather a lot. However, the work is interesting and
feels worthwhile and the volume of it is made easier by us all
working as a team and the support of the AAGBI staff. As already
mentioned, at times it can feel daunting. At the beginning we all
felt under-prepared and often like we had Imposter Syndrome,
however this has lessened as we have become more involved.
We have all thrown ourselves into our roles with the support of our
fellow GAT committee and AAGBI council members.
It is an amazing privilege to represent our colleagues and to meet
like-minded colleagues who want to make a difference. We have
lots to learn from each other, as well as from the inspirational
leaders in our field, and it has been eye-opening to discover what
goes on outside the hospital in the world of anaesthesia.
We are only six months in so perhaps it is a bit early to say, but
would we recommend it? Definitely.
If you would like to join the GAT Committee, nominations are
open and close on Friday 10 April at 17:00. Please see page 7 for
more information.
Although it may seem like lots of work, there is also time to talk
about other events in our lives. We all recognise the importance of
our lives outside of work. Many of us have young children and in
the last six months there have been two additions to the families
of committee members.
22 Emma Plunkett, ST6, Birmingham School of Anaesthesia
Phil Bewley, ST3, Bristol School of Anaesthesia
Anna Costello, ST7, Oxford School of Anaesthesia
Sally El-Ghazali, ST3, Imperial School of Anaesthesia
Rowena Clark, ST6, South East Scotland School of Anaesthesia
Lyndsey Forbes, ST4, Tayside School of Anaesthesia
Surrah Leifer, ST6, North West School of Anaesthesia
Digested
March 2015
Cranial nerve injuries with supraglottic airway devices: a systematic review of
published case reports and series
Thiruvenkatarajan V, Van Wijk RM, Rajbhoj A.
Cranial nerve injuries are unusual complications of supraglottic airway
use, and may well occur but go unrecognised or misdiagnosed as they
are so uncommon. The authors of this review took great pains to seek
out and collate case reports and case series of cranial nerve injuries
associated with the use of supraglottic airway devices. They found that
lingual nerve injury was the most commonly reported (22 patients)
followed by recurrent laryngeal (17 patients), hypoglossal (11 patients),
glossopharyngeal (three patients), inferior alveolar (two patients) and infraorbital (one patient). Although information on the mechanism of injury
was not presented in many of the reports, it was often usually thought to
be due to pressure neuropraxia from either the cuff or the shaft of the
device. Injuries to most of the nerves are usually mild and self-limiting, but
recurrent laryngeal nerve injuries could be much more serious, sometimes
presenting with respiratory distress. Contributing factors to injury may
include an inappropriate size or misplacement of the device and too high
a pressure in the cuff of the device. The authors go on to suggest that
cranial nerve injuries may not be completely preventable and should not
always be assumed to represent sub-standard care. Nevertheless, it seems
sensible to limit cuff pressure to a maximum of 60 cm H2O, use a gentle
insertion technique and correct misplacement promptly.
The impact of autonomic dysfunction on peri-operative cardiovascular
complications
Lankhorst S, Keet SWM, Bulte CSE, Boer C.
Even for anaesthetists, to whom the autonomic nervous system is more
familiar than many doctors, it is still the poorly understood relation of
the somatic nervous system. This narrative review examines the possible
anaesthetic implications of autonomic neuropathy. Cardiovascular
autonomic neuropathy is frequently observed in patients with diabetes
mellitus. As a lead-in to exploring the relationship between such neuropathy
and possible complications, the authors first describe commonlyused tests of autonomic function. The most frequently used seeks
abnormalities of heart rate variability measured at rest for 5 min or 24h.
There are different frequency bands within heart rate variability, reflecting
sympathetic and parasympathetic activity differently. The authors suggest
that, depending on the type of anaesthesia, the presence of cardiovascular
autonomic neuropathy in surgical patients can markedly affect perioperative haemodynamics and postoperative recovery. However, there are
few data to support the use of a particular drug regimen or anaesthetic
technique in this regard. Nevertheless, it may well be beneficial to use
preoperative testing of the extent of autonomic dysfunction in particular
patients, such as diabetics, as this would then allow more careful handling
and greater cardiovascular support for patients who might be more prone
to haemodynamic instability.
Defining and developing expertise in tracheal intubation using a GlideScope®
for anaesthetists with expertise in Macintosh direct laryngoscopy: an in-vivo
longitudinal study
Cortellazzi P, Caldiroli D, Byrne A, Sommariva A, Orena EF, Tramacere I.
There are some existing studies that suggest that the number of attempts at
videolaryngoscopy needed to achieve competence is in single figures. This
paper complements such work by posing a slightly different question; how
many attempts does it take to become expert? The authors observed the
performance of nine trainees during 890 intubations, with an additional
72 intubations performed by expert anaesthetists used as a control group.
Statistical techniques were used to search for potential predictors of
successful intubation and define the number of intubations necessary for
a trainee to achieve expertise. Herein lies one of the central problems of
such work – defining what is meant by ‘expertise’. The authors defined
this by specifying a greater than 90% probability of optimal performance.
They found that it took 76 intubations to achieve this likelihood of
success, but also noted the limitations of a simple measurement of
success rate: ‘The suggestion is that expertise cannot be equated to a
single, successful completion of a complex task, but rather that expertise
is demonstrated by such outcomes as speed, accuracy, lack of excessive
force, lack of complications, a subjective rating of competence and, most
importantly, a high success rate over a prolonged period.’ So there’s more
to it than simply ‘getting the tube through the cords’!
N.B. the articles referred to can be found in either the latest issue of Anaesthesia or on Early View (ePub ahead of print)
Anaesthesia News March 2015 • Issue 332
A.F. Smith
Editor, Anaesthesia
SAFETY MATTERS
Safety point: needlestick injuries
Here’s another pearl for you to reflect upon and consider how
safe your own practice is.
In December 2014, the AAGBI Safety Committee found itself
consulting the Health and Safety (Sharp Instruments in Healthcare)
Regulations 2013.1 This little bit of legislation was needed to
implement aspects of the European Council’s ‘Sharps Directive’
20102 that were not specifically addressed in existing UK law,
which you can find at the Control of Substances Hazardous to
Health website.3 It is only six pages and deserving of 10 minutes
of your time. It reminds us that your employer has a duty of care
to you and your co-workers to make your working environment
as safe as is ‘reasonably practicable’ (they like that formulation).
The principles to delivering that objective are sensible, and the
most obvious is not to use sharps when a blunt instrument will
do, for example drawing up drugs or taking blood from an arterial
line port. A close second comes the advice to use ‘safer sharps’
whenever possible. I have to admit that I still prefer the traditional
unsafe needle, and I am going to have to reflect carefully on that
over the weekend. The Regulations say that if a suitable safer
sharp is not available to reduce the risk of injury, the employer
should ensure that safe procedures for working with and disposal
of the sharp are in place. The specific question that the Committee
was contemplating was whether a ‘human tourniquet’ to help us
put up a drip in the anaesthetic room is a safe procedure. I was
a little surprised to see that the Royal College of Nursing have
a Tourniquet Standard,4 and that it equally recommends singleuse disposable non-latex pinching bands, or multiuse potentiallycontaminated single-handed release tourniquets. This illustrates
the point that a risk-assessment precedes each venepuncture.
The RCN Standard makes no mention of the human tourniquet,
which is clean (gloves or decontaminated hands) and atraumatic
(vulture nails aside), as well as reassuring and kind.
I have reflected; I am going to change my practice to safer sharps
whenever a colleague is being kind enough to squeeze the
patient’s arm. How about you?
Tom Woodcock
Chair, Safety Committee
References
1. Health and Safety (Sharp Instruments in Healthcare)
Regulations 2013. www.hse.gov.uk/pubns/hsis7.htm
(accessed 19/1/2015).
2. European Council Directive 2010/32/EU. http://eur-lex.
europa.eu/legal-content/EN/TXT/?uri=CELEX:32010L0032
(accessed 19/1/2015).
3. Control of Substances Hazardous to Health. http://www.
hse.gov.uk/coshh/ (accessed 19/1/2015).
4. Standards for infusion therapy. Royal College of Nursing,
2010. p. 22. http://www.bbraun.it/documents/RCNGuidlines-for-IV-therapy.pdf (accessed 27/1/2015).
24 Ephedrine or suxamethonium?
Figure 1.
Only connecting: extra vigilance is
needed during a period of transition
A box of ephedrine ampoules
had been mistaken for
suxamethonium and placed in
the fridge alongside two other
boxes of suxamethonium.
Due to the similar packaging
and the storage location, it
would have been very easy
to mistake the ephedrine for
muscle relaxant, particularly if
tired, or reaching for the drug
‘in anger’.
• A 71-year old lady died of air embolism after the inflating tube
of an automated blood pressure cuff was connected to her
intravenous catheter
• A child died of pneumonia after an enteral feeding supply was
connected to her tracheostomy tube
• An expectant mother died after her enteral feeding solution
was given intravenously
These awful events, occurring in various countries around the
world, have inspired work by the International Organisation for
Standardization (ISO) to develop global standards for non-Luer
small-bore connectors which, hopefully, will prevent such tragedies
in future. The work of the National Patient Safety Agency’s External
Reference Group on Neuraxial Devices has been passed on to
NHS England, who have convened the Small Bore Connector
Clinical Advisory Group under the Chairmanship of Dr Paul Sharpe
(Consultant Anaesthetist in Leicester). ‘Neuraxial connectors’ is
now just one of several fields of practice that Dr Sharpe’s group are
advising on. The list is the 80369 International Standard series to
introduce new designs for small-bore connectors:
•
•
•
•
•
•
Part 1: Is the introduction to the standards listed below
Part 2: Connectors for breathing systems and driving gases;
Part 3: Connectors for enteral applications;
Part 4: Urinary collection
Part 5: Connectors for limb cuff inflation applications;
Part 6: Connectors for neuraxial applications;
• Part 7: Connectors with 6% (Luer) taper for intravascular or
hypodermic applications.
While working a night shift
in the local emergency
theatre, we noticed the
drug arrangement in our
anaesthetic room fridge as
shown in Figure 1.




 


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Paul Sharpe
Chair, Small Bore Connector Clinical Advisory Group
Anaesthesia News March 2015 • Issue 332
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The concept of ‘involuntary automaticity’ or ‘seeing what we
expect to see’ is well documented within human factor and
patient safety documents, and to reduce the incidence of these
actual or potential drug errors we feel we should work with
the pharmaceutical companies to help us achieve this and so
improve patient safety. After circulating details of this ‘near miss’
to colleagues in our department to ensure vigilance, a senior
colleague shared his own image (Figure 2) of drug boxes he
found placed next to each other in a theatre anaesthetic machine
drawer.
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Tom Woodcock
Chair, Safety Committee
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We write to you to highlight this potential for drug error and
the subsequent disastrous consequences of not administering
muscle relaxant in a rapid sequence induction and instead
injecting a high concentration of ephedrine. It also raises again
the question - should we insist on better differentiation in the
packaging of agents used in clinical practice so as to ensure a
reduction in human factor drug errors?
NHS England and the Clinical Advisory Group support the
introduction of devices with ISO design connectors, so that medical
devices used in the UK are harmonised with those used in other
countries, and there is a controlled connector design standard
process to minimise the risk of cross connection of devices
intended for different clinical applications. There is, however, a
transition period when such changes occur during which we can
expect difficulties to arise. Some devices, like enteral giving sets
and feeding tubes, will have short transition periods. Other ‘legacy’
devices, like anaesthetic machines, will pose challenges for
several years.
Anaesthetists are often safety experts and champions in their Trusts
and organisations, so we urge you to do your bit in rolling out the
essential connector changes safely. The Small Bore Connector
Clinical Advisory Group plans to publish information and updates
on the NHS England website, which we encourage you to follow
(http://www.england.nhs.uk/ourwork/patientsafety). We will also
be pleased to receive your reports of problems that arise at your
place of work. Please contact the Clinical Advisory Group by email
([email protected]).
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Figure 2.
Dr Gemma Phillips
ST4 Anaesthesia
Dr Haitem Maghur
Consultant Anaesthetist
Dr Mike Oliver
Consultant Anaesthetist
University Hospital of Wales, Cardiff
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CA
AB LL
STR FO
AC R
TS
Abstracts for presentation
at Annual Congress
Edinburgh 2015
You are invited to submit an abstract for oral (free paper) or
poster presentation at the Annual Congress. The deadline for
submission is 23:59 on Friday 01 May 2015 and full
instructions can be found on our Annual Congress microsite:
www.annualcongress.org/content/oral-poster-presentations
After the deadline, a preliminary review of the abstracts
received will determine which ones are accepted for
presentation at the Annual Congress in Edinburgh. Some
authors will be invited to present their work orally, under the
following three categories: audits and surveys, case reports,
and original research. The remaining successful authors will
be invited to present a poster.
All accepted abstracts will be published in Anaesthesia in the
form of a fully referenceable online supplement (NB Editor-inChief reserves the right to refuse publication, e.g. where there
are major concerns over ethics and/or content).
Authors of the best poster(s) will be awarded ‘Editors’ Prizes’.
If you have any queries, please contact the AAGBI Secretariat
on 020 7631 1650 (option 3) or [email protected]
Dear Editor
I use the RCoA CPD matrix as supporting documentation at appraisal, and
find the AAGBI listing the appropriate codes in its event material extremely
useful in keeping it up to date.
However, in the Harrogate Annual Congress programme I noticed the
educational equivalent of salami publication is creeping in, with the use of
multiple codes, some only tenuously relevant to the lecture delivered. The
worst offender (you know who you are) suggested 14 codes for an hourlong lecture! When I have to decide for myself, I usually only enter each
event under a single code, with a possible second. I would like to suggest
that a maximum of four codes for any individual presentation will be more
than sufficient – otherwise it gets extremely tedious (and increasingly
meaningless) for those of us trying to keep our CPD matrix up to date.
Hilary Aitken
Consultant Anaesthetist, Paisley
Dear Editor
Having worked for a considerable time in Africa, I read Professor Fenton’s
article1 with great interest and agreement. However, there was no mention
of the Glostavent machine which has most of the desirable features he
mentions, and has been in use in many countries for over a decade. A
serious comparison of the two machines would be interesting and helpful.
He also did not name Professor Mackintosh’s EMO machine, which is still
in use in many African hospitals though, sadly, I understand that production
has now stopped due to lack of demand. Not only is this a robust, simple
and safe machine, ether, though denigrated, remains a very safe and
effective anaesthetic!
Tuppin Scrase
Volunteer Lecturer at the School of Anaesthesia,
St Mary’s Hospital, Lacor, Gulu, Uganda
No conflicts of interest declared
Reference
1.
MINATIONS
CALL FOR NOEL
ECTIONS 2015
BOARD/COUNCIL
Nominations are now invited
from members of the Association
wishing to stand for election.
Further information and nomination
forms are available from the AAGBI
secretariat on 020 7631 1650 (option 3),
[email protected] or can be
downloaded from the AAGBI website
www.aagbi.org/about-us/council
your Letters
Matrix codes
Fenton PM. Designing an International Anaesthesia Machine. Anaesthesia News
2014, 325: 13–15.
Dear Editor
Professor Fenton raises some important issues in his article,1 but I am
not convinced. We have six operating theatres and an eight bed ICU in a
very remote area of northern Uganda where we are continually challenged
by loss of electricity, limited funds, a large workload and few skilled staff.
We have one Manley Multivent still performing after 10 years and five
Diamedica Glostavents. Dr Manley’s brilliant vision and design for the
Manley Multivent, a machine driven by an oxygen concentrator, lives on in
the Diamedica Glostavent.
The machine can be used both in the ICU and theatre. Peri-operative and
postoperative ventilation is now a necessity in any of the referral hospitals
even in resource limited countries.2 Its simplicity facilitates the training of
non-physician anaesthetists to assist respiratory support in intensive care.
It has an excellent track record and after sales service, truly remarkable for
Africa.
Raymond Towey
Consultant Anaesthetist, Department of Anaesthesia,
St Mary’s Hospital, Lacor, Gulu, Uganda
No conflicts of interest declared
SEND YOUR LETTERS TO:
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Dear Editor
Dear Editor
‘Faulty, beyond economic repair, only for Africa’
I am pleased to reply to the three responses to my article from
August 2014.1
I would like to add to Professor Fenton’s article.1 During my time working as a volunteer
anaesthetist in East Africa, a fair proportion of general anaesthesia was provided
with demand flow draw-over vapouriser apparatus. I was impressed by its reliability
and simplicity; however I also came across many continuous flow, compressed
gas dependent machines. With the exception of a small number of government
hospitals where use of continuous flow machines was appropriate, the remainder of
the healthcare system was ill-equipped for its safe use. Many such machines were
donated with faults either present prior to donation or new faults that could not be
rectified locally within the existing infrastructure, making them effectively unrepairable.
Some continued to be used despite their faults.
This donation of anaesthesia equipment is not only unsafe, it is a waste of money,
environmentally unfriendly, producing an anaesthesia machine graveyard that
should stop. In one major hospital in East Africa, I saw an entire corridor of disused
anaesthesia machines, defunct diathermy machines and a redundant radiology
C-arm. I was embarrassed to find tagged onto one such anaesthesia machine an
original label from the medical engineering department of a NHS hospital which read
‘faulty, beyond economic repair, only for Africa’. Africa deserves better than second
user, faulty, end of life kit that our NHS departments no longer need.
One low income country procured over 100 new compressed gas dependent
anaesthesia machines, effectively useless in operating theatres with neither a reliable
electrical power supply nor compressed gas. It is difficult to follow the decision making
process that led to this contract being placed using high level international money on
which interest will be charged. Gradian Health (UAM) and Diamedica (Glostavent)
should be credited for the good work they do to support the speciality of anaesthesia
in the developing world. In the event of electrical power / UPS battery failure and nonavailability of compressed gas, their machines can still provide anaesthesia vapour in
both spontaneous ventilation and IPPV modes with atmospheric air used as the carrier
gas. A critical safety feature needed for operation in the developing world. The after
sales support is of a very high standard, with both manufacturers genuinely interested
in how their machines perform locally. In one instance, a fault was reported on a Friday
afternoon and, after a weekend of exchanging emails, an in-country technician was
dispatched on Monday morning to a rural area of the country 6 hours’ drive away. The
machine was repaired that same afternoon. Contrast this with the large multinational
companies who have no further involvement once the ink has dried on the cheque.
Moiz K. Alibhai
Locum Registrar in Anaesthesia, Royal Liverpool University Hospital
No conflicts of interest declared
Reference
1.
Fenton PM. Designing an International Anaesthesia Machine. Anaesthesia News 2014, 325:
13–15.
References
1.
Fenton PM. Designing an International Anaesthesia Machine. Anaesthesia News
2014, 325: 13–15.
2.
Towey RM, Anyai JB. Intensive care medicine in rural sub-Saharan Africa - who to
admit? Update in Anaesthesia 2012; 28: 18–21. www.wfsahq.org/archive-update-inanaesthesia/update-in-anaesthesia/update-028/download (accessed 28/9/2014).
Closing date is Friday 10 April 2015 at 17:00.
Please note: Several of these letters were edited after initial submission
Anaesthesia News March 2015 • Issue 332
Ray Towey, a respected colleague, writes from Lacor
Hospital, Gulu, which I knew from the 1980s. Though located
in a poor and remote part of Africa it was then, and remains
today, a well-supported and rare centre of excellence where
equipment is kept in service much longer than the African
norm. His perspective on anaesthesia equipment design
(which he admits is ‘for me’) is not necessarily shared by
anaesthetists elsewhere in Africa, and especially not in Asia.
He commends his preferred brand of machine but that choice
takes no account of the ever-increasing burden of obtaining
ISO and CE compliance and manufacturer’s insurance liability
cover, all needed if an anaesthesia machine is to achieve my
stated aim of equivalence between Europe, North America
and the rest of the world.
Dr Alibhai observes the uselessness of second-hand
anaesthesia machine donations, and cautions against
loan-funded purchase of machines which require a reliable
electrical power supply and compressed gas to function. His
poor opinion of placing such machines in hospitals without
such resources is shared by most anaesthesia professionals.
He points out the importance of a speedy repair service,
using locally available technicians and spare parts and I thank
him for mentioning the good service he experienced with one
UAM in his care.
Dr Scrase suggests that a comparison of the UAM and the
Glostavent would be helpful and that we should not forget
the EMO. The aim of my article was to stimulate interest in
a generic demand-flow system, accredited for worldwide
use, not to compare one machine with another. It was written
independently, out of personal conviction and a passion for
the concept which existed long before Gradian existed or any
machine was made.
Ether is an excellent and life saving agent. I have previously
written about its virtues2 and used it continuously for over 15
years, when it was available. It is safer than more modern
agents for certain situations. However, it is almost unavailable
today and thus the EMO has effectively passed into the
history books, except where used as a door stop.
Finally, I should add that, following editing, the final printed
version of my article differed somewhat from the original.
Paul Fenton
1.
Fenton PM. Designing an International Anaesthesia Machine.
Anaesthesia News 2014, 325: 13–15.
2.
Fenton P. An epitaph for di-ethyl ether (1846-2009). World
Anaesthesia News 2009; 11: 3–4. http://www.aagbi.org/sites/default/
files/WA11.1july2009.pdf (accessed 19/1/2015).
27 Particles
Myles PS, Leslie K, Chan MT et al.
Peake SL, Delaney A, Bailey M et al. (on behalf of the ARISE Investigators)
Olsen F, Kotyra M, Houltz E, Ricksten S-E
The safety of addition of nitrous oxide to
general anaesthesia in at-risk patients having
major non-cardiac surgery (ENIGMA-II): a
randomised, single-blind trial
Goal-directed resuscitation for patients
with early septic shock
Bone cement implantation syndrome in
cemented hemiarthroplasty for femoral neck
fracture: incidence, risk factors, and effect on
outcome
The Lancet 2014; 384: 1446–54
Background
Nitrous oxide is a commonly used anaesthetic agent which is known to increase
risk of postoperative nausea and vomiting, although concerns relating to
increased risk of postoperative cardiovascular complications remain unclear.1
The original ENIGMA study observed a non-significant increase from 0.7% to
1.3% (p = 0.26) of ischaemic cardiac complications within 30 days of surgery,
with a follow up study finding a significant increase from 4.5% to 6.4% (p = 0.04)
of late myocardial infarction.2,3 Despite these findings the ENIGMA study was
not designed to monitor for cardiovascular complications and was therefore
underpowered to draw these conclusions.
This study aimed to establish whether addition of nitrous oxide to an anaesthetic
gas mixture increases occurrence of death and cardiovascular complications in
at-risk patients undergoing non-cardiac surgery.
Methods
A randomised, single-blind trial was undertaken with data collected
prospectively from 45 centres across ten different countries between May 2008
and September 2013. Inclusion criteria included adults at least 45 years of
age, receiving general anaesthesia for non-cardiac surgery expected to
last more than two hours in duration. Participants also had to be at risk of
cardiovascular complications, which included a history of coronary artery
disease, heart failure, cerebrovascular disease, peripheral vascular disease or
be greater than 70 years of age with other comorbidities. Any patients in whom
supplemental intraoperative oxygen was expected (such as those requiring
one lung ventilation), at high risk of postoperative emesis or with significantly
impaired gas exchange were excluded.
Patients were randomised to receive a carrier gas mixture of either 70% nitrous
oxide with 30% oxygen, or 30% oxygen in air, to ensure that all participants were
exposed to equal intraoperative inspired oxygen concentrations.
The primary outcome measure was a composite of death and cardiovascular
events (non-fatal myocardial infarction, cardiac arrest, pulmonary embolism and
stroke) within the first 30 postoperative days.
Results
From 10,102 eligible patients, 7112 were enrolled and randomised to the study,
with 3543 assigned to receive nitrous oxide and 3569 assigned to not receive
nitrous oxide. Of these, 6992 patients were assessed for the primary outcome
measure.
The primary outcome occurred in 283 (8%) patients receiving nitrous oxide and
in 296 (8%) patients not receiving nitrous oxide (relative risk 0.96, 95% CI 0.831.12; p = 0.64).
A tertiary outcome measure of severe nausea and vomiting occurred in 506
(15%) patients receiving nitrous oxide and 378 (11%) patients not receiving
nitrous oxide (p < 0.0001).
Discussion
The ENIGMA-II study demonstrates that in patients having general anaesthesia
for major non-cardiac surgery, the addition of nitrous oxide to the gas mixture
does not affect the risk of death and major cardiovascular complications. In
findings consistent with previous studies, administration of nitrous oxide has
again been shown to put patients at increased risk of severe postoperative
nausea and vomiting, although results suggest reduced symptoms in those that
received prophylactic antiemetics. Despite this, nitrous oxide is best avoided in
those at high-risk of postoperative nausea and vomiting.
New England Journal of Medicine 2014; 371: 1496–1506
Background
Early-goal directed therapy (EGDT) has been promoted for severe sepsis since
the publication of Emanuel Rivers’ landmark paper in 2001,1 despite subsequent
controversy regarding the study’s methodology and interpretation. The ARISE
(Australasian Resuscitation in Sepsis Evaluation) study is one of three large
international, randomised controlled trials that aim to determine if providing
EGDT reduces mortality compared to ‘usual care’ for adult patients with septic
shock.
Methods
The study was a multicentre (51 hospitals, predominantly in Australia and
New Zealand), unblinded, intention-to-treat, equally-randomised control trial.
Patients presenting with septic shock (infection, two or more SIRS criteria, and
refractory hypotension) were enrolled to receive either EGDT or ‘usual care’.
‘EGDT’ included insertion of arterial and central lines, ScvO2 measurement, and
the use of oxygen, mechanical ventilation, vasopressors, fluids and red-cell
transfusions to achieve pre-defined physiological targets. The primary outcome
was all-cause mortality at 90 days; secondary outcomes included length of stay
(in ED, ICU and the hospital), and the need for organ support.
British Journal of Anaesthesia 2014; 113: 800–6
Background
Bone cement implantation syndrome (BCIS) is a well-known and potentially
fatal complication of orthopaedic surgery. It is characterised by hypoxia,
hypotension, arrhythmias, pulmonary hypertension, and loss of consciousness
occurring around the time of bone cementation. It is most often seen in
cemented hemiarthroplasty but also occurs in total hip replacement and knee
replacement surgery. The pathophysiology of BCIS is not fully understood, but it
may be caused by pulmonary embolisation, complement activation, and release
of histamine. These may act together to increase pulmonary vascular resistance
causing ventilation/perfusion disturbances with hypoxia, right ventricular failure,
and cardiogenic shock.
Aims
This study aimed to estimate the incidence of BCIS in cemented hemiarthroplasty
for hip fractures using a severity classification recently proposed by Donaldsson
and colleagues:
Results
1600 patients were enrolled; 796 received EGDT and 804 received ‘usual care’.
Baseline characteristics (age, APACHE II score, site of infection, initial lactate,
time to first dose of antibiotics) were very similar between groups. At 90 days,
there was no significant difference in mortality between the EGDT and usualcare groups (18.6% vs 18.8%, p = 0.90). Patients in the EGDT group received
greater volumes of IV fluid, and more vasopressors, red-cell transfusions
and dobutamine (p<0.001 for all comparisons). There were no significant
differences in length of ICU or hospital stay, in-hospital mortality, or duration of
organ support.
Grade 0
No BCIS
Grade 1
Moderate hypoxia (arterial oxygen saturation < 94%) or hypotension (decrease in systolic arterial pressure > 20%)
Grade 2 Severe hypoxia (arterial oxygen saturation < 88%) or hypotension
(decrease in systolic arterial pressure > 40%), or unexpected loss
of consciousness
Grade 3 Cardiovascular collapse requiring cardiopulmonary resuscitation.
Conclusion
The authors conclude that for adult patients presenting with early septic shock,
EGDT does not reduce all-cause mortality at 90 days.
Methods
A total of 1016 consecutive patients were included. Data on non-invasive systolic
blood pressure, heart rate, and arterial oxygen saturation was recorded every 5
minutes. This data was obtained from anaesthetic charts and used to calculate
the BCIS score. Medical history and medications were also determined from
charts.
Discussion
This is a large, appropriately powered and well-executed multicentre trial with
a sound methodology. Data for the primary outcome was available for 99% of
patients, and it specifically addressed the EGDT algorithm described by Rivers
in 2001. Along with the ProCESS study2 published in May 2014, this paper adds
to the growing weight of evidence against EGDT in severe sepsis. The third
large multicentre randomised-control trial into EGDT (ProMISe) is expected to
be published in December 2015.
Dr Liam P Scott
CT2b Cheltenham General Hospital
References
1.
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the
treatment of severe sepsis and septic shock. New England Journal of
Medicine 2001; 345: 1368–7.
2.
Yealy DM, Kellum JA, Huang DT, et al. A randomised trial of protocolbased care for early septic shock. New England Journal of Medicine
2014; 370: 1683–93.
Results
BCIS was a commonly occurring phenomenon in the group of patients studied,
with an incidence between 25% and 30%. Mortality in Grade 1 BCIS was not
different to Grade 0 (p < 0.15). Severe BCIS (Grades 2 or 3) occurred in 5–7%
of the patients and was associated with a significant increase in mortality (p <
0.001). Men with severe BCIS had a 16-fold higher 30-day mortality than those
with Grade 0 or 1. The excess mortality from BCIS was seen intra-operatively
and in the immediate postoperative period: thereafter the survival curve of those
experiencing BCIS was similar to those who did not. Independent predictors
for development of severe BCIS were: ASA grades III–IV, pre-existing chronic
obstructive pulmonary disease and medication with diuretics or warfarin.
Discussion
The authors concluded that BCIS is common and that severe episodes carry
significant excess mortality. Efforts should be made to identify those at risk of
BCIS, so as to guide intra-operative preventive measures which may decrease
the risk of developing it to improve survival in these patients.
Dr Chris James
CT2 Severn Deanery
Mark Callaghan
ST5 Anaesthesia, Northern Deanery
References
1.
Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for the
management of postoperative nausea and vomiting. Anesthesia &
Analgesia 2014; 118: 85–113.
2.
Myles P, Leslie K, Chan MT, et al. Avoidance of nitrous oxide for patients
undergoing major surgery: a randomized controlled trial. Anesthesiology
2007; 107: 221–31.
3.
Leslie K, Myles PS, Chan MT, et al. Nitrous oxide and long-term morbidity
and mortality in the ENIGMA trial. Anesthesia & Analgesia 2011; 112:
387–93.
28 Anaesthesia News March 2015 • Issue 332
Anaesthesia News March 2015 • Issue 332
29 A AGBI
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First update in early Ma
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New award for excellence
in sustainability
Developing a green
anaesthesia agenda
The AAGBI recognises that our actions have an impact on the environment and regards global warming and
climate change as pressing issues. In 2013 the Environmental Task Group of the AAGBI was formed to develop
the idea of sustainable practice and to promote greener anaesthesia. The Task Group and the Association have
linked with Barema, the Association for Anaesthetic and Respiratory Device Suppliers, representing companies that
manufacture or supply anaesthetic and respiratory equipment in or to the UK, to establish the Barema & AAGBI
Environment Award. This will recognise excellence in sustainability within the speciality and engage with industry
partners to further develop a greener anaesthesia agenda.
Apply for the NEW Barema & AAGBI Environment Award!
Applicants will have to demonstrate how their activity, project, campaign or other work (including original research),
related to anaesthesia, intensive care or pain management, has had (and will continue to have) a measurable
beneficial effect on the environment.
The award will be for the single best initiative or project and will consist of £200 to the individual(s) or
body(ies) concerned, in addition to a grant of £800 for support and development of the initiative or project.
The deadline for applications is 30 April 2015 with the winners being announced
at Annual Congress in Edinburgh in September.
To find out more about the award and the application process visit
www.aagbi.org/about-us/environment
or email [email protected]