A middle-aged ASA II patient with obstructive sleep apnoea and a BMI of 35 kg.m required a total thyroidectomy. The patient had limited cervical spine mobility, tracheal deviation and it was noted that a surgical airway would be difficult. A spontaneously breathing general anaesthetic was performed using propofol and remifentanil. Direct laryngoscopy showed a grade 3 view and during repositioning complete airway obstruction followed with inability to mask ventilate despite six-handed ventilation. Several unsuccessful attempts at needle cricothyroidotomy, both fine and large bore, were made and the airway was finally secured after a difficult tracheostomy. The patient spent 20 minutes with oxygen saturations of less than 50% and received elective ventilation to manage cerebral hypoxia. A full recovery was reported. NAP4—Major Complications of Airway Management in the UK.
The WHO analgesic ladder, with its emphasis on ‘by the clock’ oral analgesia, forms a useful framework for the initial pharmacological management of patients with cancer pain. It is reported to be successful in 80–90% of patients. However, of the 10–20% of patients with pain that is poorly responsive to opioids, or where side-effects are particularly problematic, some may greatly benefit from invasive procedures designed to interrupt pain signals along neural pathways from periphery to the brain. It should be emphasized that such procedures should not be seen as the ‘4th step’ of the WHO analgesic ladder, but can and should be considered at each step depending on patient preference and need. There is opportunity to interrupt nocioceptive traffic at peripheral and central levels via destructive neuroablatory or non-destructive techniques. All interventions designed to relieve cancer pain carry attendant risk, and these must be weighed against potential benefits on a case-by-case basis. Overall, 8% of patients with cancer pain may require nerve blocks, 3% neurolytic blocks, and 3% neuraxial techniques.
Chronic abdominopelvic pain is a debilitating problem that presents challenges to patients and clinicians alike. Symptoms of abdominopelvic pain are among the most commo symptoms presenting to primary care and fall within the scope of a large number of medical specialities, especially gynaecology, gastroenterology, and urology. Such pain can be a warning sign of serious pathology, but chronic abdominopelvic pain must be recognized as a disease in its own right, since it can exist as a chronic condition without identifiable pathology. Traditionally, the management of pelvic pain has focused on biomedical mechanisms such as infective, inflammatory, or malignant conditions; it is now understood, however, that many of the mechanisms are attributable to modulation of pain processing within the nervous system. Although a peripheral stimulus such as inflammation may initiate pelvic pain, the condition or syndrome may become persistent as a result of these mechanisms. Chronic pain syndromes are associated with a variety of cognitive, behavioural, social, sexual, and functional phenomena. These form the basis for diagnosis and must be addressed through multidisciplinary care. Functional disorders, for the purpose of this article, are disorders characterized by disturbance of function (such as urinary urge/frequency in bladder pain syndrome). The term is not used in the sense of a psychiatric functional disorder. Associated psychological disturbances should be considered a result of the disease rather than a cause and there must be an associated conceptual shift, in healthcare providers who work with these patients, to acknowledge this. The authors acknowledge that ongoing organ pathology, such as endometriosis, can produce persistent pain, but the management of specific diseases is beyond the scope of this article. This article will focus on pain syndromes in which no identifiable cause can be found.
Diagnostic cardiac catheterization was reported in the nineteenth century and interventional cardiac catheterization was first described by Rubio-Alvarez in 1954 for the treatment of pulmonary valve stenosis. In some centres, MRI is increasingly used for diagnostic imaging. To ensure safety and quality images, the majority of these procedures in children require general anaesthesia. Cardiac catheterization may be challenging when dealing with complex congenital cardiac lesions. Good communication between the team members is essential, so that cardiovascular changes can be anticipated and minimized as far as possible. This includes the full team: anaesthetist and assistant, cardiologist, scrub team, radiographer, and a cardiac physiologist. It is a challenging and high-risk field of anaesthetic practice and requires consultant-led care by specialists in paediatrics and congenital heart disease (CHD).
The General Medical Council (GMC) defines patients approaching the end of life as being those ‘likely to die within the next twelve months’. Decisions surrounding the withholding or withdrawal of life prolonging treatment can be particularly difficult. End-of-life care encompasses more than such treatment decisions and the provision of good end-of-life care falls within the duties of a doctor outlined by the GMC.
Occupational exposure of healthcare workers to blood-borne viruses (HIV, Hepatitis B and C) in the healthcare setting is a growing concern that has prompted the Department of Health and Health Protection Agency to instruct a nationwide surveillance scheme, develop a national policy, and implement guidelines. Apportioned equal consideration, although far less common, is the risk of blood-borne viral transmission from infected healthcare workers to patients, which has also warranted Department of Health guidance, to assist infected healthcare workers, and to minimize the risk to patients.
Clinical errors are common. They occur in at least 10% of hospital admissions and result in patients suffering through injury and worry. Clinical errors prolong hospital stay, increase costs, and lead to loss of confidence in the organization. For many cases, this will result in complaints and litigation, particularly if the situation is not managed well. In the UK, there are around 900 000 incidents or near misses every year and 2000 patient deaths as a result. Causes include human error, poor organization, lack of clear patient management plans, and inadequate communication between clinical teams. Medical errors have been highlighted throughout history as a cause of harm to patients, but came to prominence in 1999 after the publication of To err is human: building a safer health system by the US Institute for Medicine. This was followed by the Department of Health’s publication An Organisation with Memory in 2000. Since then numerous systems have been developed to minimize harm to patients and improve the quality of care. The 2010 publication by the Department of Health, Equity and Excellence: Liberating the NHS, highlights the need to focus on outcomes and quality standards, not targets. The recent report by Professor Berwick (https://www.gov.uk/ government/uploads/system/uploads/attachment_ data/file/226703/Berwick_Report.pdf) and the Francis Inquiry (http://www.midstaffspublic inquiry.com/report) made numerous recommendations focusing on providing high-quality care to patients, in particular continuous learning from errors, making patient safety and quality of care a top priority, and the importance of patient and public involvement. This will require a variety of institutional and cultural changes, including a contemporary audit process with review of outcomes, engaging staff in the complaints process, and also a high standard of professional training. All these are integral to risk management (https://www.gov.uk/government/ uploads/system/uploads/attachment_data/file/ 226703/Berwick_Report.pdf, http://www.midstaffs publicinquiry.com/report). A clinical error can be defined as a clinical incident that has deviated from the intended treatment, intervention, or diagnostic plan, which may or may not result in an untoward outcome (http://www.clinical-governance-toolbox.com/ risk-management). Clinical risk is the potential for the error to occur and this requires both an active error and contemporaneous conditions that allow it to occur. Although risks are impossible to eliminate completely, they can be reduced by minimizing error and improving latent conditions (e.g. equipment). Clinical risk management (CRM) provides a multidisciplinary team system to identify, record, analyse, and monitor clinical incidents, and reduce harm to patients. Although serious incidents are rare in anaesthesia and the theatre environment, both areas have a relatively high risk of clinical errors. A recent Quality and Safety update by the Royal College of Anaesthetists reported 4057 anaesthesia-related incidents over 3 months, of which 68.5% were near misses and 7.9% resulted in moderate-to-severe harm or death (http://www. rcoa.ac.uk/document-store/patient-safety-updateoctober-december-2012). CRM therefore forms a key aspect for anaesthetists in improving patient safety and quality of care. Risk management is the systematic process by which NHS boards are responsible for the management and monitoring of risk within their organization. These range from corporate to personal risk. Risk management is covered by a wide range of legislation and is a key component of Clinical Governance. The process aims to identify risk and to reduce incidence of injury, faults, errors, accidents, and improve overall quality of patient care (http://www.clinical-governance-toolbox.com/ risk-management, http://www.clinicalgovernance. scot.nhs.uk/section3/riskmanaged.asp). This article will review CRM in anaesthesia. The definitions have been described in a previous article published in this journal and will not be covered here. Key points Clinical errors are common. Anaesthetists work in environments where the potential for serious harm is high. Clinical risk management is a systematic process for reducing and managing harm to patients.
Physiotherapists are an integral part of the multidisciplinary team in the critical care unit and are skilled in the multisystem patient assessment and treatment of both intubated and spontaneously breathing patients. In addition to respiratory management, other key roles include the management of neurological and musculoskeletal complications of critical care. Historically, the main focus of physiotherapy in critical care had been the management of respiratory complications; however, there is now evidence that survivors of critical care have long-standing weakness and limitations of functional capacity that has led to exercise rehabilitation being incorporated into standard practice. Respiratory pathologies are among the most common cause of admission to critical care. A number of patients will also progress to respiratory failure during their admission; this could be secondary to postoperative respiratory failure, the development of pneumonia, in particular ventilator-associated pneumonia (VAP) or after a failed extubation. While the exact role of the physiotherapist varies across critical care units within the UK and also worldwide, many of the techniques outlined below are likely to be used. There is a lack of randomized controlled trials to support the role of the physiotherapist, but there is a long history of physiotherapists playing a pivotal part in critical care teams. The aim of this article is to provide an overview of these techniques.
In 2012, a fire broke out in the intensive care unit (ICU) of the Royal United Hospital, Bath, when a faulty oxygen cylinder placed on a patient bed ignited. The patient sustained burns to the lower limbs, the cubicle sustained substantial structural damage, and the ICU rapidly filled with smoke, necessitating evacuation. Recent studies have highlighted weaknesses in a number of London ICUs due to failures of unit design, equipment, escape routes, drills, and evacuation planning. In the 11 yr between 1994/5 and 2004/5, some 10 662 fires were reported in National Health Service (NHS) facilities costing an estimated £14.6 million. Roughly 500 per annum involved acute care facilities and resulted in 651 injuries and 17 fatalities. In addition to burns and smoke inhalation, a number of other traumatic injuries were sustained during evacuations. These incidents show that environmental emergencies such as power failure, fire, and explosion have the potential to lead to substantial patient morbidity and mortality, and also endangering staff and facilities. Key to the successful management of these environmental emergencies are comprehensive and regular staff training and credentialing, inspections and auditing for environmental risks and evacuation obstacles, and simulations and exercises designed to reveal shortcomings in institutional protocols.
This review will provide an overview of supraventricular tachycardias (SVTs), their classification, diagnostic features, and management in the perioperative period of adult non-cardiac surgery. The term ‘SVT’ refers to paroxysmal tachyarrythmias that require atrial or atrioventricular (AV) nodal tissue, or both, for their initiation and maintenance. The incidence of persistent SVT is 2% before operation and 6% in the postoperative period. In non-cardiac surgery, perioperative arrhythmias are more likely to be supraventricular than ventricular in origin. Atrial arrhythmias occur most frequently 2–3 days post-surgery similar to perioperative acute coronary syndromes and are likely related to sympathetic stimulation associated with an inflammatory response. Other precipitants of SVT often associated with high sympathetic tone are summarized in Table 1. Such arrhythmias are important for the anaesthetist; in particular, atrial fibrillation (AF) is associated with haemodynamic derangement, postoperative stroke, perioperative myocardial infarction, ventricular arrhythmia, heart failure, and longer hospital stay.
In the late 1950s and early 1960s, the devastating series of thalidomide-induced birth defects raised awareness of the imperfect state of the placenta as a barrier to drug transfer. Subsequent research has sought to elucidate the precise nature and mechanisms of transplacental drug passage. There has also been increasing interest in the deliberate use of maternally administered drugs designed to cross the placenta and provide therapeutic effects on the fetus. This article reviews the structure and key functions of the placenta. It also summarizes our current understanding of placental drug transfer, particularly of drugs used for anaesthesia and analgesia in pregnancy.
A difficult airway as defined by the ASA Task Force on Management of the Difficult Airway is ‘the clinical situation in which a conventionally trained anaesthesiologist experiences difficulty with facemask ventilation of the upper airway, difficulty with tracheal intubation, or both’. In a retrospective review of 11 219 paediatric procedures, the risk of difficult laryngoscopy was estimated as 1.35%. The risk was found to be higher in neonates and infants, children who are underweight, ASA physical status III and IV, or have Mallampati score III and IV. 1 However, the reliability of the Mallampati score in predicting difficult airway management in the paediatric population has been questioned and some clinicians prefer the Colorado Pediatric Airway Score (COPUR), since it uses a detailed scoring system and is therefore possibly more reliable. 2 Cooperation for airway assessment in children is not always easy and the availability of a score which accounts for a number of different aspects of the airway is more thorough. (See Table 1 for details.) Data pertaining to the real incidence of difficult airway management in children are sparse, but they are thought to be lower than in the adult population. Certain features predicting potential difficulties with airway management are often present in a number of syndromic children seen in paediatric anaesthesia practice. Predictors of difficult intubation include the presence of dysmorphic features, limited neck extension due to fusion of cervical vertebrae as found in Klippel‐ Feil syndrome, limited mouth opening, and restricted mobility of temporo-mandibular joints, a large tongue (macroglossia) such as found in Beckwith‐Wiedemann syndrome, limited submandibular space (retrognathia, micrognathia, mandibular hypoplasia or dysplasia) as found in Pierre Robin syndrome and Treacher Collins syndrome, and the presence of structural abnormalities in the laryngo-tracheal passage. Other predictors include soft tissue tumours, storage diseases such as mucopolysaccharidoses, and arteriovenous or lymphatic malformations involving the airway. In neonates and infants, the lateral profile may be more useful in eliciting the subtle signs of mandibular hypoplasia which are easily missed. (Refer to Table 2 for the anatomical site predominantly causing the airway problem in these syndromes.) This review focuses on some common syndromes predominantly seen in paediatric anaesthesia practice that are associated with potentially difficult airway management and highlights the related relevant features. A broader discussion of difficult intubation in the paediatric population has been published elsewhere and is beyond the scope of this review. 34
Haemophilia can be classified as haemophilia A, B, or C depending on the deficiency of the coagulation factors VIII, IX, or XI respectively. Haemophilia A and B are inherited as X-linked recessive (XLR) disorders due to mutation in the long arm of chromosome X at F8 and F9 genes, respectively. As with any XLR disorder, males are affected and females are carriers. One-third of the patients presenting with haemophilia have no family history. Factors VIII and IX mainly play an important role in the intrinsic pathway of the clotting cascade. These factors are required for thrombin generation and fibrin formation. The plasma concentration of factors VIII and IX can be expressed in IU ml or as percentages of normal pooled plasma. 1 IU is the concentration of coagulation factor in 1 ml of normal pooled plasma. The normal value is 0.5–1.5 IU ml or 50–150%. Diagnosis of haemophilia is usually suspected when bleeding symptoms occur spontaneously or after trauma. The risk of bleeding increases as the factor levels decrease (Table 2). Patients usually present with bleeding into the weight-bearing joints (knees, ankles and elbows), muscles and rarely the genitourinary system. The most common cause of death is intracranial bleed. The routine clotting screen may be normal and the only abnormality may be a prolonged activated partial thromboplastin time. The definitive diagnosis is made only by a factor level assay.
Obstetric anaesthetists’ primary role in the maternity unit is the provision of anaesthesia and analgesia to women in labour and who require Caesarean delivery. In addition, they are essential members of the multidisciplinary team who will assist with the management of the various types of emergency that can arise in the maternity unit. Emergencies in the maternity unit may arise as a result of obstetric, anaesthetic, or general medical problems and there is no widely recognized classification or definition for these situations. Emergency problems in obstetric patients pose a unique set of challenges: these situations are generally rare, so even experienced clinicians may only have limited experience; obstetric units are frequently geographically remote, so clinicians may be working in unfamiliar surroundings and lastly obstetric patients are generally fit and healthy, so, faced with a physiological insult, will initially compensate, before deteriorating precipitously, prompting an urgent call for help. The emergencies that may lead to an urgent call to labour ward are summarized in Figure 1. Maternal collapse is the generic term that may be used to describe the endpoint of a variety of clinical problems. It is defined as ‘an acute event involving the cardiorespiratory systems and/or brain resulting in a reduced or absent conscious level (and potentially death), at any stage in pregnancy and up to 6 weeks postdelivery’. Maternal collapse may arise as a result of pregnancy-related conditions, pre-existing disease, or co-incidentally during pregnancy. As with all patients, the aide memoire four Hs and four Ts (Hypoxia, Hypovolaemia, Hypothermia, Hypoor hyper-kalaemia/-magnesaemia/-calcaemia, Thromboembolism, Toxins, Tamponade, Tensionpneumothorax) can be used to classify common causes of collapse in pregnancy, with the addition of eclampsia and intracranial haemorrhage (Fig. 2).
Pain is commonly classified into acute and chronic. Acute pain implies a painful condition with a rapid onset or of a short course whereas chronic pain is referred to as a painful condition persisting beyond the normal time of healing. Transition of acute pain to chronic pain is an observed entity associated with enormous burden on the healthcare system. Minimization of this transition has been a challenge for decades. Numerous studies have investigated different factors that increase susceptibility in transition of acute to chronic pain. This article focuses on the basic science and pathophysiological changes during pain processing and clinical modalities aiming to minimize the risk of transition from acute to chronic pain.
Chronic abdominal pain is a frequently presenting condition in the pain clinics. Patients have often undergone a plethora of investigations, including diagnostic surgery and psychiatric review, before referral to Pain Management Services. Ongoing pain leads to development of central sensitization, which is heightened sensitivity to pain and touch, because of the effect of persistent pain on the neuroplasticity of the central nervous system. It can result in significant anxiety, distress, and loss of work days for the patient. Up to 30% of patients with chronic abdominal pain have pain originating in the abdominal wall 1,2 and abdominal cutaneous nerve entrapment syndrome (ACNES) is the most frequent cause of pain in these cases. 3 This diagnosis can be established from the patient’s history, physical examination, and positive response to local anaesthetic injection. 4 More awareness among clinicians of the abdominal cutaneous nerve entrapment syndrome could lead to earlier diagnosis and prevent the consequences of prolonged investigation and pain.
Pain control in cancer patients reduces suffering and improves the quality of life. The classic World Health Organization (WHO) analgesic ladder may be effective in controlling cancer pain in 80–90% of patients. In the UK, current application of the principles embodied in the WHO ladder follows a modified algorithm by which interventional techniques should be considered as adjuvant therapy alongside all steps of the analgesic ladder. Recent UK experience suggests that, despite optimization of systemic analgesia, 11% patients in a hospice setting were considered for interventional therapy. The scope of advanced pain management techniques in adult palliative care is contained within the Specialised Services National Definition Set and the full range of interventions has been reviewed elsewhere. This article describes the technique and application of percutaneous cervical cordotomy (PCC) in the management of intractable unilateral cancer pain. Experience of the neurological deficit resulting from tuberculous lesions of the spinal cord caused Spiller to conclude that pain could be relieved by cutting the pain pathway in the spinal cord, leading to the first open surgical cordotomy in 1905. Reports of open cordotomy via thoracic and cervical laminectomy continued until percutaneous techniques were described in the 1960s, initially using a radioactive needle and subsequently with radiofrequency (RF) thermocoagulation. A computed tomography (CT)guided technique has been described, but the vast majority of cordotomies performed in the UK are by percutaneous RF under fluoroscopic guidance.
