C. J. Peden

The effect of intravenous dexmedetomidine premedication on the dose requirement of propofol to induce loss of consciousness in patients receiving alfentanil

Dexmedetomidine reduces the dose requirements for opioids and anaesthetic agents. We conducted a single‐centre, open‐label, noncomparative phase II study of the effect of intravenous dexmedetomidine on the dose requirement of propofol to induce loss of consciousness in 49 ASA I and II patients. The initial dexmedetomidine infusion scheme was reduced twice because of adverse events. Forty patients who received the final infusion scheme were randomly allocated to receive one of five stepped propofol infusions; loss of consciousness was assessed after 21 min. The ED50 for the final infusion rate of propofol to suppress consciousness was 3.45 mg.kg−1.h−1 (95% CL 2.7–4.2): ED95 was 6.68 mg.kg−1.h−1 (95% CL 5.1–19.1), EC50 was 1.69 µg.ml−1 (95% CL 0.95–2.5) and EC95 was 5.7 µg.ml−1 (95% CL 3.2 to > 10). Our final dose of dexmedetomidine of 0.63 µg.kg−1 caused a reduction in the overall concentration and dose of propofol required to produce loss of consciousness, but no significant shift in the dose–response curve compared with other studies.

Feasibility of day case laparoscopic cholecystectomy in unselected patients

The feasibility of clay ease laparoscopic cholecystectomy was assessed in unselected patients using a standard anaesthetic protocol. Postoperative pain and nausea were assessed at 6 and 24 h postoperatively (visual analogue scale, range 0‐10). Thirty‐two patients were studied (23 female. 9 male, mean age 49.6 years). The mean duration of surgery was 68 mitt. At 6 h after surgery, 10 patients (31%) had no pain at rest. For the group as a whole, the median pain score was 3 at rest (range 0‐6), 4 on movement (0 9), and 5 on coughing (0 9) and eight patients (25%) were nauseated. At 24 It, 15 (46.9%) had no pain at rest. For the group as a whole, the median pain score was I at rest (0‐7), 3 (0‐6) on movement and 3 on coughing (0 9). The same eight patients were nauseated. Ten patients (31.3%) were judged fit for discharge at 6h, and 28 (87.5%) by 24h. There was no statistical difference in mean age or duration of surgery in those judged fit for early discharge compared to the study group as a whole. Nausea was an important factor in those unfit for discharge at 24 It. Selection criteria might improve these figures. Front the results of our study, 24 h admission is a more realistic goal and will be suitable for most patients requiring laparoscopic cholecystectomy.

Emergency surgery in the elderly patient: a quality improvement approach

Life of a Medical Pioneer. Edinburgh: John Donald, 2010, 10, 33, 179. 3 Simpson JY. Notes on the employment of the inhalation of sulphuric ether in the practice of midwifery. London and Edinburgh Monthly Journal of Medical Science (March) 1847; 7: 721–8. 4 Simpson JY. Account of a New Anaesthetic Agent as a Substitute for Sulphuric Ether in Surgery and Midwifery. Edinburgh: Sutherland & Knox, 1847. 5 Simpson JY. Remarks on a case of sudden death in ovariotomy while the patient was under the influence of chloroform. British Medical Journal 1870; I: 199–200. 6 Roberts WA. The late death from chloroform in Edinburgh. Lancet 1855; ii: 560–1. 7 Levy AG, Lewis T. Heart irregularities resulting from the inhalation of low percentages of chloroform vapour and their relationship to ventricular fibrillation. Heart 1911; 3: 99–112. 8 Lunt RL. Delayed chloroform poisoning in obstetric practice. British Medical Journal 1953; I: 489–90. 9 Simpson JY. Local anaesthesia: notes on its artificial production by chloroform, etc, in the lower animals, and in man. Provincial Medical and Surgical Journal 1848; S1-12: 365–71. 10 Simpson JY. Contributions to the pathology and treatment of diseases of the uterus (Part III). London and Edinburgh Monthly Journal of Medical Science 1843; 3: 1009–27. 11 Simpson JY. Memoir on the spontaneous expulsion and artificial extraction of the placenta before the child in placental presentations. Section I. Dangers of placental presentations – opinions of the authors – statistical evidence of the fatality of these presentations. London and Edinburgh Monthly Journal of Medical Science 1845; 5: 169–204. 12 Simpson JY. On the air tractor, as a substitute for the midwifery forceps. Lancet 1849; i: 236. 13 Simpson JY. Case of amputation of the neck of the womb followed by pregnancy. Edinburgh Medical and Surgical Journal 1841; 50: 104–12. 14 Simpson JY. Proposals for the Improvement and elucidation of uterine diagnosis. London and Edinburgh Monthly Journal of Medical Science 1843; 3: 701. 15 Simpson JY. On the evidence of the occasional propagation of malignant cholera, which is derived from its direct importation into new localities by infected individuals. Edinburgh Medical and Surgical Journal 1838; 49: 355–408. 16 Loudon I. The Tragedy of Childbed Fever. Oxford: OUP, 2000, 85. 17 Shepherd JA. Simpson and Syme of Edinburgh. Edinburgh: Livingstone, 1969, 198–9. 18 Simpson JY. Acupressure – a new method of arresting surgical haemorrhage. Edinburgh Medical Journal 1859–60; 5: 645–51. 19 Simpson JY. On our existing system of hospitalism and its effects. Edinburgh Medical Journal 1869; 14: 816–3

National Research Strategies: what outcomes are important in peri‐operative elderly care?

Outcomes are essential measures of healthcare effectiveness and efficiency. Traditional measures of outcome, such as mortality and length of stay, are important and easy to measure but have significant limitations when evaluating the peri‐operative care of elderly patients. Alternative measures, including clinician‐described (e.g. complication rates, functional status, frailty) and patient‐reported outcome and experience measures, are important to provide a comprehensive description of peri‐operative outcome in the older patient. However, few measurement tools have been developed or validated specifically for the elderly surgical patient. This paper describes the outcome measures currently in use, explores how they might be used to improve the quality of care provision, and indicates priority areas for peri‐operative outcomes research in the elderly surgical patients.

Postoperative morbidity survey, mortality and length of stay following emergency laparotomy

Thirty‐day mortality following emergency laparotomy is high, and greater amongst elderly patients. Studies systematically describing peri‐operative complications are sparse, and heterogeneous. We used the postoperative morbidity survey to describe the type and frequency of complications, and their relationship with outcomes for 144 patients: 114 < 80 years old, and 30 ≥ 80 years old. Cumulative postoperative morbidity survey scores and patterns of morbidity were similar (p = 0.454); however, 28‐day mortality was higher in the elderly (10/30 (33.3%) vs 11/114 (9.6%), p = 0.008), and hospital stay was longer (median (IQR [range]) 17 (13–35 [6–62]) days vs 11 (7–21 [2–159]) days, p = 0.006). Regression analysis indicated that cardiovascular, haematological, renal and wound complications were associated with longer hospital stay, and that cardiovascular complications predicted mortality. The postoperative morbidity survey system enabled structured mapping of the number and type of complications, and their relationship with outcome, following emergency laparotomy. These results indicate that rather than a greater propensity to complications following surgery, it was the failure to tolerate these that increased mortality in the elderly.

Anaesthetists and sedation in the radiology department: involved or left behind?

In most hospitals, interventional radiologists perform complex procedures on sick patients using sedation with little anaesthetic involvement. Sedation techniques can make unpleasant procedures more acceptable to patients but they have the potential to cause life-threatening complications, particularly when administered by non-anaesthetists [1]. NCEPOD 2000 [2] provided evidence for radiology-related sedation problems in the UK. This report stated that the gold standard for patient monitoring during interventional vascular procedures should be pulse oximetry, blood pressure and ECG. In addition, someone other than the radiologist should be responsible for the patient. Three hundred and three deaths were identified during the period surveyed. Of the patients that died 19 were not monitored at all, 60 did not have pulse oximetry monitoring and 40 did not have their blood pressure taken. Sixteen patients died who were monitored by a radiographer, and 97 died who were monitored by the operator alone. Would anaesthetists tolerate this level of practice if these were obstetric patients? Do radiologists want our support? The answer appears to be that they do. A rather embarrassing editorial in the British Journal of Radiology in 2002 [3], stated that ‘‘out of hours with a very sick patient, and no anaesthetic cover, the radiology department can feel like being in a far flung corner of the British Empire – with a level of airway and pain control that would not be out of keeping with the time of Queen Victoria’’. Patients undergoing neuroradiological procedures are much more likely to have general anaesthesia or sedation administered by an anaesthetist [2]. These patients are much fitter when compared with the patients in a vascular radiology group who have a large number of comorbidities. The former group’s prognosis depends upon their neurological grading, based in turn on their Glasgow Coma Score. Of the 36 deaths investigated by NCEPOD in this group, 35 had an anaesthestist present. However, five of these anaesthestists were working without a trained assistant. The presence of a trained assistant is particularly important in the X-ray department, a more difficult environment than the operating theatre [4], which is often distant from other immediate anaesthetic assistance. Even with an anaesthetist present or a trained nurse transfer team, the radiology department is a potentially dangerous place for the emergency patient. A survey of critically ill patients transported between Intensive Care Units and radiology by specially trained nurse transfer teams showed a 15.5% overall complication rate, with 2.8% of those complications classed as severe [5]. A document was produced in 2001 by the Academy of Medical Royal Colleges chaired by the Royal College of Anaesthetists entitled ‘‘Implementing and ensuring safe sedation practice for healthcare procedures in adults’’ [1]. The intercollegiate board was concerned that the literature at the time of their report provided evidence that existing guidelines for safe sedation by non-anaesthetists were not being followed and that patients were being exposed to unnecessary risk which could result in serious morbidity and, indeed, mortality. Death rates of up to 1 in 2,000 had been reported [6]. While the intercollegiate document drew together the established principles of the general management of sedated patients undergoing a variety of healthcare procedures and gave guidance on the safe use of sedative drugs to non-anaesthetists, it did not offer specific specialty advice. The intercollegiate working party felt that each specialty should be responsible for developing their own guidelines and that this approach would be most effective in overcoming the barriers to change in practice. Guidelines for Sedation and Anaesthesia in Radiology already existed and were produced in 1992 jointly by the Royal College of Radiologists (RCR) and the Royal College of Anaesthetists [7]. However, these were outdated, making no mention of magnetic resonance imaging (MRI) or interventional radiology (IR) and taking no account of the increasing scope and number of procedures performed in today’s radiology suites [8]. In addition, a small audit of British interventional radiologists [9] suggested that the joint colleges’ fears were correct and that these guidelines were not being met; selection of patients for sedation was informal and there was little collaboration with anaesthetists. Only 46% of interventional radiologists had received resuscitation training in the previous year, and 5% had received no training for more than 10 years. Updated guidelines were therefore needed to cover new procedures, to redefine standards and to help departments acquire resources to improve the safety and availability of sedation. These new guidelines entitled ‘‘Safe sedation, analgesia and anaesthesia within the Radiology department’’ [10] produced by a working party which included two anaesthetists and circulated to radiologists in 2004, appear to have made little impact on anaesthetists in general. The loss of the ‘‘joint college’’ label has meant that, while exciting much comment amongst radiologists, these guidelines have sunk without trace in the anaesthetic literature. It would be impossible for the specialty of anaesthesia to perform all sedation procedures in radiology but we should have an advisory role to enhance patient safety. Indeed the Joint Colleges’ document of 2001 [1] states that every hospital should have a consultant Anaesthesia, 2005, 60, pages 423–425 .....................................................................................................................................................................................................................

Anesthesia for Emergency Abdominal Surgery

Emergency abdominal surgery has a high mortality, with an incidence of around 15% for all patients. Mortality in elderly patients is up to 25%, and 1-year mortality for emergent colorectal resection for patients over 80 years is around 50%. Patients presenting to hospital are often given low priority. Definitive surgery is not always possible and it may be more important to control the septic focus and to revisit surgery later. The literature is poor for such a common procedure, but there is evidence that a standardized pathway focusing on rapid diagnosis; resuscitation; sepsis treatment; and, if appropriate, urgent surgery followed by admission to intensive care improves outcomes.

From harm to hope and purposeful action: what could we do after Francis?

Responses to the reports on the inquiry into Mid Staffordshire have resulted in calls from politicians, NHS leaders and the public to improve care across the NHS in England. However, the substance of what needs to be done remains unclear. In this paper, we offer seven key ‘ingredients’ required to sustain improvement of care, supported by evidence drawn from published literature. We believe that empowering and upskilling the front-line workforce in understanding and implementing improvement techniques, supported by changes at system and policy level and reinforced by what leaders say and do, will result in sustainable benefit for patients and families, as well as greater satisfaction for staff.

The science of improvement as it relates to quality and safety in the ICU

This paper seeks to explain some of the science and concepts used in quality improvement, including the use of run charts and control charts, the development and use of ‘bundles’ and the need to reduce variability to improve quality in critical care.

Traumatic pulmonary pseudocysts

We describe a case of a 19‐year‐old man who developed traumatic pulmonary pseudocysts after a rollover road traffic crash. These were associated with significant pulmonary haemorrhage requiring a period of mechanical ventilation, but resolved without specific intervention. Review of the literature confirms that this rare complication of blunt chest trauma occurs usually in young adults and, although normally benign, can be associated with life‐threatening haemoptysis and secondary infection.