Preoperative anaemia adversely impacts overall survival following resection for pancreatic ductal adenocarcinoma
Preoperative anaemia is commonly present in resectable PDAC and negatively influences overall survival independent not only of established pathological factors but also of perioperative blood transfusion. These data have implications for the optimization of patients in the perioperative period in addition to longer-term risk stratification.Download
Basic Life Support training during medical school
Despite receiving Basic Life Support training during medical school, FY1 doctors reported low confidence in airway management. Simple airway techniques, if performed correctly, can be life saving in the emergency situation. We planned to provide training in basic airway management to FY1s to improve their competence and confidence.Download
The effect of peripheral access devices on intravenous infusion rate
All devices restrict flow to varying degrees. Using an access hub effectively halves maximum flow rate. Devices with integral hubs and combining devices are even worse. The “Coventry” connector appears performs the best.Download
: Efficacy and Side Effects of Different Epidural Opioids, a Local Audit of Beliefs Versus Reality.
12 Anaesthetic staff were surveyed, 8 of which Consultants and 4 Senior Trainees. One anaesthetist preferred diamorphine as epidural opioid additive, 3 anaesthetists had a preference for 4mcgs/ml fentanyl, 8 preferred 2mcg/ml fentanyl. 50% of those preferring 2mcg/ml fentanyl sited unfamiliarity with 4mcg/ml as their concern with this formulation, whereas 25% quoted respiratory depression as their concern with 4mcg/ml fentanyl.
All 67 patients had epidurals with 0.125% L-bupivacaine as the local anaesthetic base. Two patients had L-bupivacaine only epidurals, 2 had diamorphine added by the anaesthetist, 42 patients had pre-prepared bags with fentanyl 2mcg/ml, and 21 patients had pre-prepared bags with fentanyl 4mcg/ml. Only the fentanyl groups were analysed due to small numbers of other groups. There was no significant difference in the number of patients with postoperative day 1 pain scores of greater than 4 between those with added fentanyl 2mcg/ml and fentanyl 4mcgs/ml (p=0.45). Additionally, no significant difference in the number of epidural top-ups required between these two groups (p=0.92). There was no significant difference in occurrence of nausea and vomiting, respiratory depression, pruritus, nor hypotension requiring vasopressors between the groups with fentanyl 2mcg/ml and 4mcg/ml (p=0.40, 0.35, 0.28, 0.50 respectively).
Not too fast? Service evaluation after introducing change to improve fasting time for elective caesarean delivery.
Our results showed a significant improvement in fasting time for clear fluids and proportion of mother's fluid fasting for less than 4 hours. There was no improvement in food fasting. We have demonstrated even before introducing fasting bundles, improved fasting time for clear fluids by introducing a small change: encouraging mothers with antenatal education and a focus by staff on limiting fasting. We hope by incorporating fasting bundles as part of our ERAS protocol, we can also improve fasting time for food.Download
Preoperative risk scoring; Uptake and correlation with postoperative course in a tertiary teaching hospital
We divided our one hundred patients into those who had a retrospective SORT predicted mortality score of less than 2%, and those with 2% or greater. We had 60 patients in the <2% predicted mortality group, and 40 in the 2% and above group. The mean ages for both groups were 57.4 and 73 respectively. Only 3 patients in total had risk assessments performed; 1 in the <2% group and 2 in the >2% group.
Average length of hospital stay for those with a SORT score of >2% was 12.35 nights (9.73-14.97) compared to those with a SORT score of <2% of 7.32 nights (6.1-8.54). 95% confidence intervals applied show these to be statistically significant. Average high dependency stays were 2.03 nights for the <2% group, and 2.83 for those in the >2% group; these did not show statistical significance. Our lengths of hospital stay, both in critical care and downstream wards, are shown in the table below.
Perioperative Anaemia in Elective Joint Replacements
This project quantified the rate of red cell transfusion in this purely elective group of patients to be 5.8%, with an estimated cost of over £13,000 per year4 and potential for morbidity from transfusion. It was interesting to note that the majority of patients who received blood transfusion were anaemic preoperatively, and also that preoperative anaemia was associated with an increased length of stay.
We have introduced a protocol to investigate patients with preoperative anaemia by checking ferritin and C-reactive protein (CRP) levels. In cases consistent with iron deficiency, a letter will be forwarded to the patient’s GP and they will be commenced on iron supplementation. If anaemia of chronic disease is suspected, patients will be given intravenous iron and reviewed on admission.
Data are being collected on an ongoing basis following the introduction of this protocol to review any impact on transfusion rates, length of stay and any associated benefits from treating and prompting investigation of preoperative anaemia.
LUNG PROTECTIVE VENTILATION
Lung protective ventilation (LPV) is a ventilation strategy employing low tidal volumes (6-8ml/kg predicted body weight (PBW)) to reduce risk of ventilatory induced lung injury (VILI). There is increasing evidence that high tidal volumes (10ml/kg) is more injurious to previously healthy lungs1,2.
We retrospectively audited ventilation practice for 191 emergency abdominal laparotomies at DGRI over an 18-month period, and compared the tidal volumes given versus a lung protective strategy.
We found that during 37% (n=70/191) of laparotomies, the mean tidal volume was over 8ml/kg PBW (Figure 1). Furthermore, we demonstrated that relatively higher tidal volumes were given to the subset of patients under 160cm in height: 87% (n=34/39) received mean tidal volumes over 8ml/kg PBW (Figure 2).Download
Pre-operative CPET Utilisation and Outcomes in South Glasgow
There are many methods of assessing the high risk patient pre-operatively. Cardiopulmonary exercise testing (CPET) has been shown in a recent review to be a predictor of mortality, length of stay, morbidity and critical care admission in the post-operative period for a variety of different surgical specialities . However there is no consensus on who to refer for CPET testing as well as differing cut off points for risk depending on the type of surgery. CPET testing has been available in the South of Glasgow for over a year but referrals are currently from a small pool of anaesthetists/surgeons. To encourage referrals the records of patients that had already underwent CPET testing were examined to identify if management plans had changed post-CPET testing.Download
Partitioning of lipid soluble drugs in intralipid; A potential rescue therapy for Non-local Anaesthetic Drug toxicity?
Intralipid emulsion (ILE) was first recognized as a treatment for local anesthetic systemic toxicity (LAST) in animal studies by Weinberg et al. in 1998. An important mechanism of action is the “lipid sink” theory, a process in which lipid soluble drugs establish a new pharmacokinetic equilibrium in an expanded lipid volume leading to a reduction in free plasma concentration. Subsequent case reports and research have suggested ILE may have a role in overcoming toxicity in other lipid soluble drug overdoses.Download
Botulism, Scotland 2015: are we recognising it?
Botulism is a rare condition caused by the toxin produced by Clostridium botulinum, or germination of C. botulinum spores in wounds. Across Europe, most wound botulism is now associated with drug injection, especially muscle popping . Between 21.12.14 and 20.02.15, there were 24 confirmed, or probable cases of botulism in people who inject drugs (PWIDs) in Scotland. All had recent history of heroin injection with accidental or intentional subcutaneous or intramuscular injection.Download
An audit into the use of nebulised saline to manage symptoms of cough and sore throat in recovery after ENT surgery.
Post operative sore throat (POST) is a common side effect following general anaesthesia. Its symptoms may also present as cough, hoarse voice and respiratory distress. POST can occur frequently in patients after ENT surgery. Various pharmacological methods have been used to prevent POST. We audited the use of nebulisers in recovery to treat symptomatic patients.Download
Clonidine: Improving preoperative sedation
Preoperative anxiety in children can lead to difficulties inducing anaesthesia safely. Moreover, this can result in maladaptive behaviour in the immediate and delayed postoperative period. Use of a sedative premedication is one component of a multimodal approach to prevent this. We aimed to survey our department’s knowledge of clonidine and to develop a local health board approved guideline to facilitate its safe and effective use in our hospital as an alternative to oral midazolam.Download
Anaphylaxis under anaesthesia in NHS Lothian
Anaphylaxis under anaesthesia is a rare but life threatening complication with a reported incidence of 1 in 6000 to 1 in 20 000 cases. Early recognition and treatment may avoid morbidity and permanent disability. We conducted an audit comparing practise in NHS Lothian over the past five years with the 2009 AAGBI Guideline.Download