The assessment and management of a patient who has an implanted cardiac device does require some special attention. Anticipation of behaviour, both of the patient and of the device, is the key to safe management and an uncomplicated procedure. When device interrogation facilities are not available locally, the most important information can be gained from careful history taking, inspection of the patient's device information card and by contacting the pacing clinic that the patient attends. Device manufacturers are also useful sources of information and support, and contact details are available on device identification cards.

BACKGROUND:There is increasing emphasis on performance-based assessment of clinical competence. The High Fidelity Patient Simulator (HPS) may be useful for assessment of clinical practice in anaesthesia, but needs formal evaluation of validity, reliability, feasibility and effect on learning. We set out to assess the reliability of a global rating scale for scoring simulator performance in crisis management.METHODS:Using a global rating scale, three judges independently rated videotapes of anaesthetists in simulated crises in the operating theatre. Five anaesthetists then independently rated subsets of these videotapes.RESULTS:There was good agreement between raters for medical management, behavioural attributes and overall performance. Agreement was high for both the initial judges and the five additional raters.CONCLUSIONS:Using a global scale to assess simulator performance, we found good inter-rater reliability for scoring performance in a crisis. We estimate that two judges should provide a reliable assessment. High fidelity simulation should be studied further for assessing clinical performance.

Fetal bradycardia leading to emergency caesarean section is a dramatic and memorable event. It may follow a procedure for regional analgesia in labour with disturbing consequences for the family. The temporal association between an important technical procedure such as insertion of an epidural catheter or a combined spinal-epidural (CSE) and a fetal bradycardia provides a strong suggestion of cause and effect. The resulting parental judgement is often impossible to reverse. But is the regional analgesia really to blame or is it just coincidental? Are there other possible causes?

Five patients with valvular or fixed subvalvular aortic stenosis presented to a high-risk obstetric anaesthetic clinic over a 3-year period. All five were assessed during pregnancy and admitted at full term. A low-dose lumbar epidural analgesia regimen was used during labour and delivery. The use of pre-assessment and planned admission, invasive monitoring, epidural analgesia and interventional assisted delivery is discussed with reference to this patient group, and other aspects of peripartum management of concern to the anaesthetist.

Background Marked cerebral swelling visible on magnetic resonance images has been found immediately after hypothermic (28 degrees C) cardiopulmonary bypass. The mechanism is unknown, but indices of cerebral ischemia are seen during rewarming from hypothermic bypass that are not present with normothermic bypass (37 degrees C). Methods T1-weighted and fluid-attenuated inversion recovery magnetic resonance images were taken of seven patients undergoing routine coronary artery bypass surgery before, 1 h, and 7 days after the operation using normothermic bypass. Results Marked cerebral swelling was seen in fluid-attenuated inversion recovery images in five of seven patients 1 h after bypass. Scans in four patients taken 7 days after bypass showed that the cerebral swelling had returned to normal. There was no change in cerebral ventricular size, and all patients had uncomplicated postoperative courses. Conclusions Normothermic bypass is followed by acute postoperative cerebral swelling. However, the amount of swelling was similar to that found in a previous study after hypothermic bypass. The mechanism of swelling is still obscure, and its relation to neurologic outcome is unknown.

The anaesthetic management of eight patients aged between 58 and 76 years undergoing laser prostatic surgery in a magnetic resonance imaging (MRI) scanner and the problems presented by the magnetic field and the working environment are discussed. The advantages of this type of surgery are better haemostasis and a reduction in the TURF syndrome. Two were managed with general anaesthesia and spontaneous respiration using a thiopentone N2O/O-2 isoflurane sequence. Six remained conscious during regional anaesthesia with combined spinal/epidural analgesia and oxygen therapy, and did not require sedation. The duration of anaesthesia varied between 85 and 165 min (mean 110 min) and three patients required an epidural top-up after 80-100 min. One patient with a history of angina developed chest pain and raised cardiac enzymes 5 h after the procedure which was otherwise uneventful. Monitoring the ST segment in a magnetic field is inaccurate, and the research protocol now excludes patients with significant ischaemic heart disease.

Cardiac pacemakers and implantable cardioverter-de®brillators have revolutionized the treatment of patients with cardiac arrhythmias. Since implantation of the ®rst pacemaker in 1958, cardiac device therapy has seen a steady expansion. This is mainly attributable to phenomenal progress in device technology and software sophistication. Recent data from landmark trials suggest that the indications for cardiac pacing and implantable de®brillators are set to expand further, to include, for example, heart failure, sleep disordered breathing and perhaps even routine de®brillator implantation in patients with myocardial infarction and poor ventricular function. This will inevitably result in more patients with cardiac devices being encountered by medical practitioners other than cardiologists. This article reviews the basic principles of device nomenclature, function and physiology for pacemakers and de®brillators commonly encountered in surgical patients who may require anaesthesia.