Aneurysmal disease involving the origins of supra aortic vessels often requires complex open and/or endovascular repair that is not only associated with significant risk of mortality and morbidity but also often with perioperative blood loss requiring transfusion. We report a successful repair of a large thoracic aortic aneurysm (TAA) involving the aortic arch with a custom-made Bolton Relay 2-vessel branched thoracic aortic endograft in a 42-year-old Jehovah's Witness who would otherwise be very unlikely to survive an open repair. Branched thoracic aortic endografting offers a potentially safe, minimally invasive, and effective alternative for TAA disease involving the supra-aortic arteries, especially in patients who are at high risk of open surgery.

Introduction: The SAFE handover tool was developed to reduce critical omissions during handovers in obstetric anaesthesia. It comprises a simple proforma onto which the outgoing team documents patients who fall into one of four anaesthetically relevant categories: Sick patients; At-risk patients (of emergency caesarean section, major haemorrhage or anaesthetic problems); Followups; and Epidurals. We hypothesised that its use would reduce the number of critical omissions at handover.Methods: The efficacy of the SAFE handover tool was assessed through several audit cycles in a single maternity unit. The four SAFE categories were considered the gold standard, since they encompassed the consensus opinion of senior obstetric anaesthetists with respect to parturients they most wanted to know about at handover. Against these criteria it was possible to compare the number of cases that should have been handed-over against the number that were actually handed-over.Results: After implementation of the handover tool, patients were four times more likely to be handed-over than without the use of the tool: an increase from 49% to 79% of relevant cases (P < 0.0001, OR 4.1, 95% CI 2.19-7.6). The handover tool was particularly effective at increasing the handover rates of Sick and At-risk parturients, which increased from 21% to 67%(P < 0.0001, OR 7.7, 95% CI 2.7-21.7) and 25% to 78% (P < 0.01, OR 9.9, 95% CI 1.6-61.6), respectively.Conclusion: The SAFE handover tool significantly increased handover rates of anaesthetically relevant parturients. It is easy to remember and consistent with UK National Health Service Litigation Authority's guidance on risk management in maternity units. (C) 2013 Elsevier Ltd. All rights reserved.

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We would like to thank Dharmadasa et al. for their recent correspondence detailing plans for the introduction of a ‘SAFE’ handover (Sick patients, At risk, Follow-ups, Epidurals) in obstetric anaesthesia at Northwick Park Hospital. 1 Dharmadasa A. Dean M. Lucas D.N. et al. SAFE handovers in obstetric anaesthesia. Int J Obstet Anesth. 2011; 20: 192 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The group recognised informal verbal handovers between obstetric anaesthetists in their department had at times led to omission of important clinical information. This is not a concern confined to the north west of London. A national survey from 2006, as referenced in the correspondence, indicated 94% of handovers involved no documentation and a lack of formal structure had led to critical incidents. 2 Sabir N. Yentis S.M. Holdcroft A. A national survey of obstetric anaesthetic handovers. Anaesthesia. 2006; 61: 376-380 Crossref PubMed Scopus (38) Google Scholar In addition, documentation to ensure effective handovers would have significant beneficial cost implications for hospitals as indicated in the National Health Service Litigation Authority’s Clinical Negligence scheme guidelines. 3 NHS Litigation Authority. Clinical negligence scheme for trusts clinical risk management standards 2010/11. http://www.nhsla.com/publications [accessed December 2011]. Google Scholar Subsequent to the introduction of ‘SAFE’ handovers, the group at Northwick Park found that although the proforma tripled the time taken for handover, it increased the proportion of patients handed over from 49% to 79%, suggesting marked improvement in the quality of the handover process. 4 Bailes I.D.W. Dharmadasa A. Lucas D.N. et al. SAFE Handover: an audit of the efficacy of a structured handover tool. Int J Obstet Anesth. 2011; 20: S11 Google Scholar This work was warmly received by the obstetric anaesthetists at Chelsea and Westminster Hospital, and we would like to thank them for what is a simple, effective and very much needed tool on any labour ward.

Chlorohexidine/ethanol is commonly used for skin disinfection before neuraxial procedures. Two applications of this solution have been advocated but no evidence exists to support this. Our aim was to ascertain whether two applications of chlorohexidine/ethanol solution are more effective than one for skin disinfection before neuraxial anaesthesia. A 4-cm diameter soya agar contact plate was applied to the skin of the lumbar region of 309 healthy volunteers, followed by a single spray application of chlorhexidine gluconate 0.5% w/v in 70% v/v denatured ethanol. This was allowed to dry and a second contact plate applied. The disinfectant was re-applied and after drying, a third contact plate applied. Agar plates were incubated at 37°C for 24 h. No growth occurred in any plates after the first or second spray (p < 0.0001). We feel reassured that the current practice of using a single application of chlorhexidine/ethanol solution is sufficient to disinfect the skin before regional anaesthesia, particularly in the emergency situation when waiting for a second application to dry may add needless delay and risk translocation of excess chlorhexidine into the subarachnoid space.

INTRODUCTION:The objective was to assess the management, and short- and longer-term outcome of patients presenting with an acute blue finger.PATIENTS AND METHODS:This was a retrospective, case-note review and prospective follow-up by telephone and general practitioner enquiry. All patients who presented with sudden onset blue discolouration of a finger within the previous 72 h, with normal radial and ulnar pulses, were included.RESULTS:From 2000 to 2006, 22 patients, 15 female, 7 male, were reviewed. Median age was 56 years (range, 19-88 years). Median time from onset of blue finger was 6 days (range 1 day to 3 months). In most cases (17), no underlying cause was identified. Five patients had an underlying cause; two had symptoms compatible with Raynaud's phenomenon, one patient had signs (later confirmed on MRA) of arterial thoracic outlet syndrome and two had polycythaemia (haemoglobin > 17 g/dl). Otherwise, all laboratory investigations were normal. Upper limb duplex, echocardiogram and 24-h cardiac tapes were normal in all cases. Median follow-up was 19 months. Three patients had recurrent symptoms in the finger. No patient suffered tissue loss or loss of digit(s), and none had stroke or arterial embolisation.CONCLUSIONS:The acute blue finger is a benign condition not suggestive of arterial embolisation. Tissue or digit loss is not a threat and, in the longer term, there is no threat of embolisation to other vascular sites.