SOUTH EAST THAMES SOCIETY OF ANAESTHETISTS
SETSA MEETING
Promoting Anaesthesia in South East England
Hosted by
DARENT VALLEY HOSPITAL, DARTFORD
9th October 2013
Organising Chairman: Dr Raman Madan
SETSA Secretary: Dr Cheng Ong
SETSA President: Dr Caroline Thompsett
South East Thames Society of Anaesthetists Meeting
Organised by Darent Valley Hospital, Dartford
Venue: Hilton Dartford Bridge Hotel, DA2 6QF
Wednesday 9th October 2013
PROGRAMME
8.30-9.00 Set up -Trade Stands
8.30-9.00 SETSA Council Meeting
9.00--9.30 Registration and Coffee
9.30-9.45 Welcome AddressDrRMadan,Meeting Organiser
DrCaroline Thompsett, SETSA President
SESSION ONE CHAIRPERSON TBD
9.45-10.15 The Cardiologist and The Anaesthetist in The
Heart Centre
Dr Ed Petzer, Consultant Cardiologist
DrMSatisha, Consultant Anaesthetist
10.15-10.45 Laser Surgery for Renal Stones and Anaesthetic implications
Mr. S. Sriprasad Consultant Urologist
Dr. Anu Relwani Consultant Anaesthetist
COFFEE
SESSION TWO CHAIRPERSON Dr V Prasad
11.15-12.45 Trainee Presentations
12.45-13.00Prize QuizDr R Madan
LUNCH
SESSION THREE CHAIRPERSON Dr Mike Protopapas
14.00 -14.30 Microbes and the Anaesthetist
Dr AGonzalez Consultant Microbiologist
14.30 -15.00 Ultrasound for the Anaesthetist
Dr Richard Beese, Consultant Radiologist
15.00-15.30 Acute Kidney Injury in The ITU and
Anaesthesia for Renal Disease
Dr M Javaid Consultant Nephrologist
Dr T Kaz Consultant Anaesthetist
COFFEE
SESSION FOUR CHAIRPERSON Dr Raman Madan
15.50-16.10 Maternal Sepsis
Dr F Iossifidis. Consultant Anaesthetist
16.10-16.30 Critical Care Update
Dr M Sange Consultant Anaesthetist
16.30 – Presentation of Prizes
AN AUDIT ON VTE PROPHYLAXIS DURING PREGNANCY AND THE PUERPURIUM
Dr A. Perham, Dr S. Wade, Dr D. Moor and Dr J. Short
Queen Elizabeth Hospital, Woolwich, South London Healthcare Trust, UK
Introduction
Venous thromboembolism (VTE) remains the 3rd leading cause of direct maternal death in the UK [1]. The most recent triennium saw a significant reduction in mortality caused by VTE, which is possibly attributed to the impact of the RCOG green top guideline (no.37a). 80% of fatal pulmonary embolism in 2003-2005 had identifiable risk factors [2], and NICE estimates that prophylactic low molecular weight heparin (LMWH) reduces risk by 60-70% [3].
Aims
- To audit the compliance of VTE prophylaxis management on labour ward with the RCOG ‘green top’ guidelines
- To educate the multidisciplinary team on these guidelines and where necessary, implement changes to improve compliance.
Standards
- All women should have a completed VTE risk assessment before delivery
- All women scoring 2 or more on the risk assessment should receive LWMH
- All women with scoring 3 or more should receive LWMH plus TEDS
- LMWH showed be dosed correctly for all women
- LMWH is given at least 4 hours after spinal anaesthesia or removal of epidural catheter in all cases
Methods
Details for patients receiving anaesthetic intervention were recorded, and their notes were then prospectively audited using a specifically designed proforma. 93 sets of notes were audited in January and February 2013.
Results of first round
55 patients (59.1%) had a documented VTE risk assessment. Overall, 68 patients (73.1%) received the correct management for VTE prophylaxis. 9 (9.6%) had LMWH prescribed but it was not administered. 68% of patients receiving LMWH were administered the correct dose. All patients had LMWH administered at least 4 hours after regional anaesthesia. However, 24.5% did not receive the dose for over 14 hours post regional anaesthetic.
Action taken
The results were presented to obstetricians, midwives and anaesthetists at a joint clinical governance meeting. The presentation involved education on the current RCOG & NICE guidelines. The green top guidelines were also integrated into the new Obstetric Anaesthesia guidelines for the hospital, which were distributed to the multidisciplinary team. An alert sticker was placed on the follow up folders as a reminder to check VTE prophylaxis as part of the postnatal follow up round. It was recommended to the maternity department that a standardized VTE risk assessment form rather than multiple forms for different personnel would lead to improved compliance and less confusion. A re-audit is planned for February 2014.
References:
- Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011; 118(Suppl. 1):1–203.
- Reducing the Risk of Thrombosis and Embolism during Pregnancy and the Puerperium, green top guideline no. 37a, RCOG, Nov 2009
- Venous Thromboembolism: Reducing the Risk of Venous Thromboembolism in patients admitted to hospital, NICE Clinical Guideline 2010
ANTIBIOTIC PROPHYLAXIS IN NEUROSURGERY - IMPROVING COMPLIANCE
Dr Pele Banugo, Dr Harpreet Sodhi, Dr Ben Thorpe, Dr Divna Batas, Dr Katy Laver, Dr Gowri De Zylva
King’s College Hospital, London
Aim:
To assess compliance with local antibiotic prophylaxis guidelines and surgical site infection (SSI) rate within a major London Neurosurgical unit, and subsequent influence of targeted education on these endpoints.
Methods:
SSIs are amongst the commonest healthcare associated infections (incidence 5-20%).1 Prophylactic antibiotics, appropriately timed and dosed, and chosen to take into account local resistance patterns, play an integral role in reducing the risk of SSI.2
Phase 1: data proforma used to audit antibiotic administration by anaesthetists (choice, dose and timing). Phase 2: survey of anaesthetists and neurosurgeons to assess awareness of existing antibiotic guidelines.
Phase 3: first re-audit to evaluate educational value of phase 2.
Phase 4: 12-month period of targeted education e.g. WHO checklist, laminated guidelines, trainee induction. Phase 5: second re-audit (retrospective and prospective limbs) to evaluate efficacy of phase 4.
Results:
Chart 1. Results summary showing compliance and SSI rates for different phases of the audit. / Phase 1 (initial audit): 62 cases evaluated. Correct antibiotic used in 40% of cases. Eight percent of patients developed a surgical site infection.
Phase 2 (survey): 17 respondents. Only 18% fully aware of guidelines.
Phase 3 (1st re-audit): 40 cases. Correct antibiotics: 90%. SSI rate: 0%
Phase 4 (2nd re-audit): retrospective limb: 40 cases. Correct antibiotics and timing: 80% and 68%, respectively. SSI rate: 7.5%. Prospective limb: 24 cases. Correct antibiotics and timing: 96% and 62%. SSI rate: 0%.
Conclusions:
Compliance with local antibiotic guidelines and, in turn, reduction of SSIs, can be improved through education and audit, and maintained through periodic reinforcement. The anaesthetist’s role is paramount in achieving these endpoints.
References:
- Gifford C, Christelis N, Cheng A. Preventing post-operative infection: the anaesthetist role. Continuing Education in Anaesthesia, Critical Care & Pain. Volume 11, number 5, October 2011.
- NICE. Prevention and treatment of surgical site infection. Clinical Guideline 74, 2008.
HOW LOW DO WE FLOW?
A. Mussad and M. Puchakayala,
Guys and St Thomas’ Hospital, London, SE9 1RT, UK
In a trust where over 50,000 patients are anaesthetised a year the cost of volatile anaesthetic agents constitutes a significant proportion of the trust’s expenditure. Our perception was that in our department there is a trend towards the use of moderate to high fresh gas flow rates. As cost reduction in hospitals is a major objective, we conducted an analysis of individual theatre performance auditing the total FGF rates, choice of anaesthetic agents and their consumption. The aim was to feedback the results and reassess the usage of volatile agents following change in practice as a means of improving our performance.
Methods
Data from 129 anaesthetised cases was collected from the Dräger Primus anaesthetic machine at Guy’s Hospital during November 2012 and February 2013. The following data was recorded: the duration of anaesthetic, the flow rates of oxygen, air and nitrous oxide and the volatile agent used with its consumption and uptake. Data was collected from fourteen operating theatres with their corresponding anaesthetic rooms. Cost expenditure on volatile agents was obtained from the pharmacy department.
Results
Sevoflurane was the most popular volatile agent used during induction and maintenance of anaesthesia and was used in 77% of cases compared to usage of Desflurane in 10% and Isoflurane in 11%. Volatile anaesthetic agent consumption was noted to be highest in the maxilla-facial, emergency, renal, dental and orthopaedic theatres. This was demonstrated by a high volatile ratio indicating use of high FGF in these theatres. The average VR for all agents was 3.6 (VR range of 1.2- 17.8). The average VR for Sevoflurane and Desflurane were 3.9 and 2.4 respectively.
The time taken for the MAC to fall to a value <0.6 or to decrease by more than 30% was on average 7.9 minutes. This duration was noted to be 8.2 minutes where Desflurane was used as compared to 7.8 minutes with Sevoflurane.
The trend of expenditure on volatile agents over the last 6 years demonstrated a continuous gradual rise in the consumption of volatile agents.
Discussion
Utilizing a Volatile Ratio allows assessment of the anaesthetist’s efficiency on a case by case basis. In addition it allows comparison of performance between various theatres based on the surgical speciality. The great variation in efficiency in our study, as measured by the Volatile Ratio, could be partly attributed to differing case mixture between theatres, which included dental theatres where gas induction is commonly used.
The high number of VR obtained can also be due to the common practice of employing higher FGF than necessary via semi-closed circle breathing systems despite the availability of validated and optimal initial flow and vaporiser setting regimens as set by manufacturer1,2,3. As such, inclusion of the data from the anaesthetic rooms may have led to falsely high figures.
In theatres where lower FGFs were utilised notably a lower VR was obtained when compared to theatres with a higher average FGF. The time to “low-mac”, defined as the time between switching off a volatile agent to the mac value falling to 80% of the previous, was higher with Sevoflurane than Desflurane in contrast to their known pharmacological profiles.
The lack of enthusiasm to the use of low FGF has been affected by technical issues, which are now largely historical. With the advance in technology, machines with highly sensitive systems allow accurate use of lower FGF. As such, implementing change in our practice can lead to a significant reduction in the expenditure of volatile agents.
Recommendations
- Utilising a logbook on the anaesthetic machine for each individual anaesthetist as a reflection of their practice and expenditure. This would be valuable in determining an operator’s efficiency aiding to improved practice by use of lower fresh gas flow and subsequently reduction in costs.
- The use of low fresh gas flows aiming for a Volatile ratio of <3. In the next phase of the audit, we will aim to feed back the data on individual performance against departmental standards.
In conclusion, collective change in practice can lead to significant reduction in volatile drug cost so that we able to maintain a complement of wide range of volatile agent availability.
References
- How low can you flow? Dräger 2011.
- Mapleson WW. The theoretical ideal fresh-gas flow sequence at the start of low-flow anaesthesia. Anaesthesia 1998; 53: 264–72.
- erou JG, Verheijen R, Booij LH. Model-based administration of inhalation anaesthesia. 4. Applying the system model. British Journal of Anaesthesia 2002; 88: 175– 83.
AUDIT OF THE DIFFICULT AIRWAY SOCIETY EXTUBATION GUIDELINES IN A LONDON TEACHING HOSPITAL
R. Krol ST4
Background
In 2011 the Difficult Airway Society (DAS) produced their extubation guidelines.
During the anaesthetic novice period training is focused on intubation rather than extubation.
Airway complications during extubation are three times more frequent than those occurring during intubation (12.6 % verses 4.5%). The Anaesthetic Incidents Monitoring Society has estimated that 1% of patients require an intervention on extubation over and above supplemental oxygen.
These findings have been confirmed by the Royal College of Anaesthetist’s National Audit Project 4 in which 38 per cent of complications were related to extubation alone, including two deaths.
Aim
To survey the awareness of the DAS extubation guidelines amongst the consultants of Kings College Hospital (KCH), London and to audit their extubation practice against the DAS guidelines.
Method
Forty consultants at KCH were asked to describe their extubation practice for a fit and well patient with no airway concerns. Their responses were compared to the DAS extubation guidelines.
Results
Ninety per cent of consultants were unaware of the DAS extubation guidelines.
Only fifty per cent of consultants would routinely use neuromuscular reversal and only thirty per cent would use train of four to assess neuromuscular recovery. Fifty per cent routinely use a positive pressure breath on extubation and only thirty per cent would wait until a patient could obey commands to extubate them.
Conclusion
The DAS extubation guidelines are poorly adhered to at KCH. Most consultants were unaware of their presence. In order to address this, a poster presenting the extubation guidelines is planned with multidisciplinary teaching of novice anaesthetists and recovery staff. The local extubation complications should be audited.
Reference
Karmarker S, Varshney S, Trachel Extubation, Continuing Education in
Anaesthesia, 8 (6), 2008
SURVEY OF GLIDESCOPE USE IN A LONDON TEACHING HOSPITAL
R. Krol ST4
Background
Airway complications are a leading cause of anaesthetic morbidity and mortality according to UK defence societies and the ASA closed claims data.
The Royal College of Anaesthetists National Audit Project 4 concluded that airway problems arose when difficult intubation was managed by multiple repeat attemptsat intubation, stating that it is well recognised that a change of approach is required rather than repeated use of a technique that has already failed. A device such as a glidescope may present an alternative approach as per the Difficult Airway Society’s intubation guidelines. Such devices have been shown to improve the Cormack and Lehane grade of intubation.
King’s College London has recently invested in ten new glidescope devices across the trust including remote areas.
Aim
The aim of this project was to survey the current glidescope use across the trust and to increase awareness of their presence and encourage their routine use to avoid airway incidents and improve patient safety.
Method
All anaesthetists were asked to complete a proforma each time they used the glidescope, describing their location and the use of the glidescope and whether it had helped with successful airway management between March to June 2013.
Results
Twenty seven surveys were returned from three of the trust’s ten sites. During the period of March to June 2013 the glidescope was used twelve times in an anticipated difficult airway and three times for an unanticipated airway. Many senior anaesthetic trainees and consultants were unaware of the presence of the glidescopes. Many of us were not using them regularly and few of us had had formal training on it.
Conclusion
Despite King’s College Hospital’s recent investment in ten new glidescopes they are not being routinely used. Teaching and encouragement of glidescope use is taking place. The survey will then be repeated to demonstrate an improvement in the use of the glidescope across the trust.
Reference
The GlideScope Video Laryngoscope: randomized clinical trial in 200 patients, D. A. Sun, C. B. Warriner*, D. G. Parsons, R. Klein, H. S. Umedaly and M. Moult, BJA 94, 381
IMPROVING EFFICIENCY AND REDUCING COSTS IN ELECTIVE CAESAREAN SECTIONS
R Campbell, S Bapat, S Sharafudeen, N Parry, V Skelton, D Abell
King’s College Hospital, London
Aim
In a time of austerity and increasing financial pressures on the NHS, cost saving within the bounds of patient safety is paramount. The National Institute of Clinical Excellence has issued guidelines regarding requirements for preoperative blood tests[i]; however there has been little guidance on essential postoperative investigations. Therefore we felt it was important to retrospectively analyse data collated during and after elective caesarean sections performed at King’s College Hospital and the practice of postoperative analysis of full blood count.
Methods
As part of the MASIMO trial, (ethical approval obtained) both pre-operative and post-operative formal laboratory haemaglobin tests and ‘at point of care’ Hemacue tests were performed on patients undergoing elective caesarean sections. Dats was also collected regarding intraoperative blood loss, transfusion requirements, and day 1 formal laboratory haemaglobin tests perfomed. Data was collated and analysed in Microsoft Excel in order to ascertain if guidance could be given on the use of formal laboratory tests post elective caesarean section.
Results
Estimated Blood Loss <500ml (n=49)Hb Preop / Hemocue pre-op / Difference between Lab/Haemocue / EBL/ml / Hb Post op / Hemocue post-op / Hb Day 1 / Difference between Lab/Haemocue / Number transfused
12.3 (1.33) / 12.4 (1.42) / 0.6 (0.81) / 424 (83.6) / 11.0 (1.16) / 10.8 (1.29) / 11.1 (1.35) / 0.4 (0.41) / 1
Estimated Blood Loss >500ml (n=35)
Hb Preop / Hemocue pre-op / Difference between Lab/Haemocue / EBL/ml / Hb Post op / Hemocue post-op / Hb Day 1 / Difference between Lab/Haemocue / Number transfused
11.6 (1.26) / 11.8(1.73) / 0.6 (0.72) / 844 (308.4) / 9.7 (1.22) / 9.8 (1.04) / 9.7 (1.14) / 0.3 (0.36) / 2
All numbers shown as mean (+/- SD)
Conclusion
There was no significant difference between the haemoglobin measured immediately in recovery and on day 1 post elective section. . In otherwise uncomplicated, elective caesarean sections, with minimal postoperative blood loss, it would appear that a further FBC taken on the first postoperative day could be omitted with little clinical significance. The benefits of this could be several fold. Hemacue can be taken from the lower limb while spinal anaesthesia remains effective, thereby avoiding patient discomfort. Delayed discharge while awaiting laboratory blood tests and time taken for phlebotomy, analysis and review could also be reduced; potentially reducing postnatal workload. In addition, each full blood count (FBC) costs approximately £2.78. In our institution there are approximately 500 elective caesarean sections each year, potentially saving £1390/year. If a hemocue (£0.5/cuvette + £390/yr for calibration solution) is taken in recovery and found to be within acceptable limits our data suggests an additional full blood count could be avoided, saving a further £750/year. This data is to be presented to the obstetric audit meeting with a view to developing guidelines regarding the appropriateness of post-operative formal laboratory tests.