RSS 1.0Anaesthetics
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Facet-joint injections for people with persistent non-specific low back pain (FIS) : study protocol for a randomised controlled feasibility trialBackground: The role of injections of therapeutic substances into the back as treatment for low back pain is unclear. Facet joint injections are widely used despite the absence of evidence of sustained benefit. We hypothesise that facet joint injections might facilitate engagement with physiotherapist-led, best usual care (a combined physical and psychological programme) and is a clinically and cost-effective treatment for people with suspected low back pain of facet joint origin. Methods/design: We present here the protocol for a randomised controlled feasibility trial for a main trial to test the above hypotheses. Patients referred to secondary care with persistent non-specific low back pain will be screened and invited to take part in the study. Those who meet the eligibility criteria will be invited for a physiotherapy assessment to confirm trial eligibility and for baseline data collection. All participants (n = 150) will be offered the best usual care package with physical and psychological components. Those randomised into the intervention arm (n = 75) will, in addition, receive intra-articular facet joint injections with local anaesthetic and steroids. Primary outcome data will be collected using daily and then weekly text messaging service for a pain score on a 0-10 scale. Questionnaire follow-up will be at 3, 6, and 12 months. Evaluation of trial processes and health economic analyses, including a value of information analysis, will be undertaken. The process evaluation will be mixed methods and will include the views of all stakeholders. Discussion: Whilst this trial is a feasibility study it is currently one of the largest trials in this area. The outcomes will provide some evidence on the use of facet joint injections for patients with clinically diagnosed facet joint pain. Trial registration: EudraCT identifier 2014-000682-50, (registered on 12 February 14). ISRCTN registry number: ISRCTN93184143 DOI 10.1186/ISRCTN93184143 (registered on 27 February 2014).
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The effect of increased unplanned surgical admissions at a 12 bed critical care unitPoster abstract of ESICM LIVES 2015, the European Society of Intensive Care Medicine Annual Congress, Berlin, Germany, 3-7 October 2015.
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Audit of compliance with AAGBI guidelines on coagulation screen requests for patients undergoing surgery for femoral fracturesConference abstract 67 of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) Group of Anaesthetists in Training (GAT) Annual Scientific Meeting, 17–19 June 2015, Manchester, UK.
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Aseptic precautions for caudal anaesthesiaThis correspondence piece highlights the low rate at which anaesthetists seemed to have adopted new guidelines and recommendations.
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HOCUS POCUS : hands-on cloud uploading service for point-of-care ultrasoundConference abstract 0084 for E-Poster EPM.043 of the Intensive Care Society State of the Art 2016, 5–7 December 2016, London, UK. Corrigendum at doi.org/10.1177/1751143718790728
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The use of cricoid pressure during rapid sequence induction in trauma patients – UK and European practice comparedIntroduction There is ongoing debate and conflicting evidence surrounding the place of cricoid pressure (CP) as part of a rapid sequence induction (RSI) of anaesthesia. This study investigated the current use of CP during trauma RSI and compared reported practice in the UK with the rest of Europe. Methods An anonymised, web-based survey was sent to all clinicians registered as European Trauma Course instructors. Results CP use was reported by 83.1% of UK respondents and 39.4% from the rest of Europe, with an overall reported use of 49.8%. Anaesthetists use CP less commonly (35.6%) than clinicians from other specialties (63.6%). The most common reason given for not using CP (76.7%) was a perceived lack of evidence of effectiveness. Conclusion Generally the use of CP appears to be in decline with only half of all clinicians reporting to use it; however it remains much more commonly used in the UK than the rest of Europe.
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Introducing ‘peri-operative smoking cessation’ leaflet as a part of prehabilitation : a step at facilitating the role of anaesthetists as peri-operative physiciansPoster abstract 109 of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) Annual Congress, 14-16 September 2016, Birmingham, UK.
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An audit of in-hospital death confirmationFree paper abstract 13 of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) Group of Anaesthetists in Training (GAT) Annual Scientific Meeting, 15–17 June 2016, Nottingham, UK.
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A local evaluation of prophylactic anti-emetic use in day surgery : over-prescription or good value for money?Conference abstract 7 of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) Winter Scientific Meeting (WSM) London, UK, 13-15 January 2016.
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Complications of regional anaesthesiaComplications of regional anaesthesia can be divided into those specific to central neuraxial blockade, those specific to peripheral nerve blockade, and those that pertain to both. Fortunately, severe complications – namely, spinal cord damage, vertebral cord haematoma and epidural abscess – are rare. Here we have given an overview of these complications, with reference to updated incidences available following the 3rd National Audit Project (NAP3) of the Royal College of Anaesthetists. A thorough knowledge of anatomy and pharmacology, and a meticulous, unhurried technique are essential to prevent such complications. When considering the use of a regional anaesthetic technique, the risks and benefits for that patient should be assessed on a case-by-case basis. Keywords: Central neuraxial block, complications, nerve damage, peripheral nerve block, regional anaesthesia
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Incidence of acute kidney injury after elective lower limb arthroplastyStudy objective: The aim of this study was to establish the incidence of acute kidney injury (AKI) in patients undergoing elective hip and knee arthroplasty. Design: This was a retrospective cohort study. Setting: The study was conducted in a district general hospital in the United Kingdom. Patients: All patients undergoing elective hip and knee arthroplasty over a period of 6 months were included in the study. Measurement: Preoperative and postoperative serum creatinine concentration was recorded in all patients. AKI was defined according to the Acute Kidney Injury Network classification as an increase of serum creatinine concentration of >26.5 μmol/L (≥0.3 mg/dL) or increase to 1.5-fold from baseline. Main results: Three hundred thirty-seven patients were included in the study. Forty-eight had preexisting stage 3 chronic kidney disease (CKD). The overall incidence of AKI in our study was 6.2%. The incidence in patients with preexisting stage 3 CKD (estimated glomerular filtration rate <60 mL/[min 1.73 m(2)]) was 16.3%, whereas in patients without preexisting stage 3 CKD, the incidence was 4.5%. Conclusion: We identified stage 3 or higher CKD as a major risk factor for developing postoperative AKI. Preexisting CKD raised the risk of developing AKI 4-fold. We recommend that all patients undergoing lower limb arthroplasty should have renal function assessed preoperatively. In the perioperative period, renal function should be monitored in all patients. This is of particular importance in patients with estimated glomerular filtration rate <60. Keywords: Acute kidney injury; Lower limb arthroplasty.
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Front of neck access : a survey among anesthetists and surgeonsBackground and aims: Emergency front of neck access (FONA) is the final step in a Can't Intubate-Can't Oxygenate (CICO) scenario. In view of maintaining simplicity and promoting standardized training, the 2015 Difficult Airway Society guidelines recommend surgical cricothyroidotomy using scalpel, bougie, and tube (SBT) as the preferred technique. Material and methods: We undertook a survey over a 2-week period to evaluate the knowledge and training, preferred rescue technique, and confidence in performing the SBT technique. Data were collected from both anesthetists and surgeons. Results: One hundred and eighty-nine responses were collected across four hospitals in the United Kingdom. The majority of participants were anesthetists (55%). One hundred and eleven (59%) respondents were aware of the national guidelines (96.2% among anesthetists and 12.9% among surgeons). Only 71 (37.6%) respondents indicated that they had formal FONA training within the last one year. Seventy-five anesthetists (72.8%) knew that SBT equipment was readily available in their department, while most surgeons (81.2%) did not know what equipment available. One hundred and five (55.5%) respondents were confident in performing surgical cricothyroidotomy in a situation where the membrane was palpable and only in 33 (17.5%) where the cricothyroid membrane was not palpable. Conclusion: This survey has demonstrated that despite evidence of good training for anesthetists in FONA, there are still shortfalls in the training and knowledge of our surgical colleagues. In an emergency, surgeons may be required to assist or secure an airway in a CICO situation. Regular multidisciplinary training of all clinicians working with anesthetized patients should be encouraged and supported. Keywords: Airway management; anesthetists; surgeons; survey and questionnaires; tracheostomy.
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Intravenous fluid prescribing : a survey of final year medical students and foundation level doctorsConference abstract 12 from the Association of Anaesthetists of Great Britain and Ireland AAGBI GAT Annual Scientific Meeting, Cardiff, UK, 5–7 July 2017.
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Benefit of a dedicated obstetric theatre practitioner to theatre efficiencyFree paper abstract P45 presented at the annual meeting of the Obstetric Anaesthetists' Association, Brussels, Belgium, 18-19 May 2017.
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hocuspocus.org.uk: a web-based platform enabling critical care ultrasound accreditation via remote mentoringNew Generation presentation abstract NG.001 from the Intensive Care Society State of the Art Meeting 2017, Liverpool, UK, 4–6 December 2017.
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Bridging the logistical gap between ultrasound enthusiasm and accreditationPoint-of-care ultrasound is increasingly recognised as a valuable adjunct to patient care. Trainees in intensive care medicine are expected to accredit in focused intensive care echocardiography, but the availability of trained mentors and logistical/geographical factors make this difficult within the time constraints required. As a result, many trainees who are enthusiastic about point-of-care ultrasound find it difficult to achieve accreditation. We present a secure, web-based, multi-user system which mitigates many of these difficulties and allows for clinical mentorship to take place without geographical barriers, and at a time convenient for the participants. Keywords: Ultrasonography; accreditation; intensive care; medical education; online systems.
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Decision making in a cannot-intubate, cannot-oxygenate scenarioThis correspondence reports a small study suggesting that the decision-making process is as least as important as the technical skills required in anaesthetists trained to perform surgical front-of-neck access (FONA).
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Dexamethasone use in suspected bacterial meningitis : a multi-centered auditConference abstract 85 of the AAGBI Annual Congress, 23–25 September 2015, Edinburgh, UK.
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Facet joint injections for people with persistent non-specific low back pain (Facet Injection Study): a feasibility study for a randomised controlled trial.Background: The National Institute for Health and Care Excellence (NICE) 2009 guidelines for persistent low back pain (LBP) do not recommend the injection of therapeutic substances into the back as a treatment for LBP because of the absence of evidence for their effectiveness. This feasibility study aimed to provide a stable platform that could be used to evaluate a randomised controlled trial (RCT) on the clinical effectiveness and cost-effectiveness of intra-articular facet joint injections (FJIs) when added to normal care. Objectives: To explore the feasibility of running a RCT to test the hypothesis that, for people with suspected facet joint back pain, adding the option of intra-articular FJIs (local anaesthetic and corticosteroids) to best usual non-invasive care is clinically effective and cost-effective. Design: The trial was a mixed design. The RCT pilot protocol development involved literature reviews and a consensus conference followed by a randomised pilot study with an embedded mixed-methods process evaluation. Setting: Five NHS acute trusts in England. Participants: Participants were patients aged ≥ 18 years with moderately troublesome LBP present (> 6 months), who had failed previous conservative treatment and who had suspected facet joint pain. The study aimed to recruit 150 participants (approximately 30 per site). Participants were randomised sequentially by a remote service to FJIs combined with 'best usual care' (BUC) or BUC alone. Interventions: All participants were to receive six sessions of a bespoke BUC rehabilitation package. Those randomised into the intervention arm were, in addition, given FJIs with local anaesthetic and steroids (at up to six injection sites). Randomisation occurred at the end of the first BUC session. Main Outcome Measures: Process and clinical outcomes. Clinical outcomes included a measurement of level of pain on a scale from 0 to 10, which was collected daily and then weekly via text messaging (or through a written diary). Questionnaire follow-up was at 3 months. Results: Fifty-two stakeholders attended the consensus meeting. Agreement informed several statistical questions and three design considerations: diagnosis, the process of FJI and the BUC package and informing the design for the randomised pilot study. Recruitment started on 26 June 2015 and was terminated by the funder (as a result of poor recruitment) on 11 December 2015. In total, 26 participants were randomised. Process data illuminate some of the reasons for recruitment problems but also show that trial processes after enrolment ran smoothly. No between-group analysis was carried out. All pain-related outcomes show the expected improvement between baseline and follow-up. The mean total cost of the overall treatment package (injection £419.22 and BUC £264.00) was estimated at £683.22 per participant. This is similar to a NHS tariff cost for a course of FJIs of £686.84. Limitations: Poor recruitment was a limiting factor. Conclusions: This feasibility study achieved consensus on the main challenges in a trial of FJIs for people with persistent non-specific low back pain. Future Work: Further work is needed to test recruitment from alternative clinical situations. Trial Registration: EudraCT 2014-000682-50 and Current Controlled Trials ISRCTN93184143. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 21, No. 30. See the NIHR Journals Library website for further project information.
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Beyond the pleura : bedside ultrasound evaluation of extravascular lung water in patients undergoing haemodialysisThis poster abstract from the British Thoracic Society Winter Meeting 2019 presents the results of a study into the use of bedside ultrasound evaluation of extravascular lung water in patients undergoing haemodialysis.