All anaesthetists would agree in principle to aim to deliver volatile anaesthesia in a safe, cost-effective and environmentally responsible manner. However, it is commonplace to observe the employment of higher than necessary fresh gas flows via semi-closed circle breathing systems despite the availability of validated, pragmatic, optimal initial flow and vaporiser setting regimens [1, 2]. This results in widespread cost inefficiencies, excessive environmental pollution and poor breathing circuit conditioning [3]. Our department has benefitted from the introduction of a novel audit measure, the volatile consumption:uptake ratio (or volatile efficiency ratio; VER), which is determined by comparing the volumes of liquid volatile anaesthetic agent consumed per case with the calculated volume of liquid volatile uptake by each patient. These values are determined and displayed by a proprietary algorithm within the Dräger Primus anaesthetic machine (Drägerwerk AG & Co. KGaA, Lübeck, Germany) logbook (Software 4.0 update). The algorithm is in turn based upon comparing the differing concentrations of volatile within the breathing system throughout the respiratory cycle over time. Employment of the VER for adult patients as an audit standard over the last two years has produced a sustained reduction of hourly volatile costs in the operating theatre without any restriction on the availability of anaesthetic agents (Table 1). Total hospital volatile cost has reduced by a quarter secondary to significantly improved compliance within our department with the audit standards of a VER < 3 for short duration procedures and < 2 for anaesthesia lasting over one hour. We selected VER as the audit standard in preference to a simple measure of waste (i.e. consumption above uptake per case) to allow a degree of comparison between cases regardless of the volatile target concentration or patient weight. However, the VER is most useful when used by an individual anaesthetist to reflect upon, after each anaesthetic delivered. By tailoring fresh gas flows and vaporiser setting regimens over time, an anaesthetist can rapidly attain the most efficient combination of settings within each clinical context. Departmental aggregation of data merely tracks this improvement by individuals collectively. The VER also demonstrates the expertise and consistency with which an anaesthetist effectively applies the interaction of anaesthetic equipment with pharmacological and physiological variations. As delivery of anaesthesia is the exclusive domain of the anaesthetist (or a delegated physician’s assistant), the VER has the potential to be an excellent clinical performance indicator.

Background: Emergency abdominal aortic aneurysm (EmAAA) represents a spectrum of disease from symptomatic non-ruptured aneurysms to free intraperitoneal rupture, with significantly worse outcomes for patients in a haemodynamically shocked state before surgery. A study was undertaken to see if the preoperative journey and outcome were different in patients who deviated from the classic acutely shocked presentation.Methods: An observational database compiled from case notes of patients undergoing surgery for EmAAA at Sunderland Royal Hospital between April 2000 and October 2006 was interrogated to examine details of patient preoperative journey, physiological status and 30-day survival. Comparison between groups was performed using chi(2) analysis and the Mann-Whitney U test where appropriate.Results: Records for 98 patients were available for review. Overall 30-day mortality was 49%, and was significantly higher for patients in shock at induction of anaesthesia than in those who were haemodynamically stable (59.6% vs 34.1%, p = 0.01). At presentation, 56 patients were stable and misdiagnosis was significantly more common in these patients than in those who were in shock (58.9% vs 26.2%, p = 0.002), with a significantly increased median time delay from presentation to diagnosis (144 min (IQR 24-366) vs 12 min (IQR 0-42), p<0.0001). Median time from diagnosis to arrival in theatre was significantly longer in patients who were haemodynamically stable at presentation ( 90 min (IQR 60-150) vs 48 min (IQR 36-90), p = 0.02). Of the 56 patients who were haemodynamically stable at presentation, 19 underwent haemodynamic decompensation before surgery with a significantly increased mortality compared with those who remained stable (73.7% vs 37.8%, p = 0.02). Of these 19 patients, only 5 were correctly diagnosed at presentation.Conclusions: Diagnosis and treatment of EmAAA in haemodynamically stable patients is often delayed, with the risk of significant rupture and haemodynamic decompensation which is associated with poor outcome. Correct diagnosis and treatment before development of shock has the potential to reduce mortality.

Competency based assessment relies on the definition of expected knowledge, skills and attitudes. The lack of adequately defined competencies in the workplace undermines the value of workplace assessment for both trainer and trainee. Rigorous academic methods exist, but are time consuming [1]. A comprehensive, yet practical alternative approach is presented. This two phase method combined semi-structured interviews (phase one) with a modified Delphi technique (phase two) to define competence in the provision of anaesthesia for vascular surgery. Ethical approval was not required for this service development project, although ethical principles were adhered to. Recently appointed consultant anaesthetists were interviewed in the first phase and a heterogeneous group of consultant anaesthetists took part in the Delphi process. The process produced list of competence targets and the objectives defining the performance required for their attainment. Phase one led to the production of four competences and 18 objectives. Sixteen of the 18 objectives were amended by the second phase and 10 additional objectives added. This gave an agreed final list of four competences and 28 objectives. The four defined competences that the trainee should be able to do were: (i) undertake thorough and effective pre-assessment; (ii) conduct safe anaesthesia; (iii) use knowledge, skills and attitudes gained elsewhere; and (iv) communicate effectively. The objectives reflected the changing nature of vascular surgery, addressed non-technical skills and placed added emphasis on pre- and postoperative management. For example, the trainee: should anticipate the likely level of care required postoperatively and communicate these needs with critical care colleagues as appropriate; must be aware of the organisational and managerial aspects of pre-assessment; should understand the role of a multidisciplinary team; and should be aware of models available to achieve high quality assessment, including the functions of a pre-assessment clinic. The competencies and objectives have been utilised by the Northern Schools of Anaesthesia in the production of a workplace assessment tool for post-fellowship trainees. The results demonstrate that the described method is effective in defining competence for workplace assessments. It represents a workable compromise between feasibility and stringent research methodology. It is straightforward to undertake and we believe the results are valid and fit for purpose. Wider implementation could enhance the validity and value of workplace assessments.

Pre-operative anxiety is common in adult patients attending for day case surgery. Increasing attention is being paid to a variety of non-pharmacological approaches to reduce anxiety and thus minimise associated adverse sequelae [1]. Our previous work demonstrated the potential for binaural beat audio to reduce preoperative anxiety [2] as measured by the State-Trait Anxiety Inventory. The primary aim of this study was to compare anxiety, as measured by a Visual Analogue Anxiety Scale (VAAS) [3], in participants listening to binaural beat audio and those listening to self-selected music in the preoperative period. Secondary aims were to ascertain whether the Bispectral Index (BIS) monitor was able to detect any differences within or between the two groups while listening to music, and to compare induction dose requirements between the two groups. Following Local Research Ethics Committee and Trust Research and Development approval, 20 consenting adult patients scheduled for day case surgery at Sunderland Royal Hospital were randomised to listen to either ‘Holosync’ audio (Centerpointe Research Institute, Beaverton, USA; Binaural Group) or music of their choice (Music Group) for 20–60 min in the hour preceding surgery. Visual Analogue Anxiety scores were sought before music, after listening to music and immediately before induction in the theatre environment, while BIS scores were recorded each minute during the music listening period. The dose of propofol required at induction to achieve a BIS score of 50 was also recorded. Data were compared using a one tailed unpaired t-test. Mean VAAS before listening to music was similar between the groups (Binaural: 49.7 mm and Music: 56.1 mm; p = 0.21). Anxiety scores were lowest immediately after listening to music in both groups (14.0 mm and 32.6 mm, respectively; p = 0.015). Mean VAAS before induction was 31.8 mm and 45.7 mm, respectively (p = 0.037). Bispectral index scores during listening did not account for changes in anxiety observed between the two groups. Induction doses of propofol were similar between groups. Binaural beat audio provides superior anxiolysis to patient-selected music in the pre-operative period as measured by VAAS. Changes in reported anxiety did not correlate with BIS scores nor induction dose requirements.

Patients undergoing abdominal aortic surgery have a high risk of peri-operative cardiac events. Modification of this risk with statins and β-blockers was adopted on the formation of a multidisciplinary pre-operative assessment team in April 2004. We wished to assess our unit's compliance with the introduction of β-blockers and statins in patients undergoing elective infra-renal abdominal aortic aneurysm repair, from pre-assessment through to discharge after surgery. The following data were extracted retrospectively from case records and a computer database over a two-year period: patients’ details; use of β-blockers and statins from pre-assessment through to hospital discharge; heart rate on the day of surgery (β-blockade surrogate); and morbidity and mortality rates. Serum troponin-T level and ECG on the first postoperative day were used to screen for cardiac events. Of the 46 cases, 42 notes were available for full analysis. The majority of patients received and tolerated β-blockade for at least two weeks pre-operatively (Table 1). This was successfully continued throughout the postoperative period. Five patients had no pre-operative β-blocker trial; four had no documented reason as to why. Heart rate < 60 bpm (< 100 for atrial fibrillation) on the day of surgery was achieved in only 38% of cases. Introduction of statins was less enthusiastically adopted, perhaps reflecting the level of evidence available in 2004 [1]. Nine patients experienced postoperative cardiac events (two myocardial infarctions, one isolated pulmonary oedema and six acute coronary syndromes). On the first postoperative day troponin-T was elevated in three patients (although erroneously omitted in 15 cases). Six patients had new ischaemic ECG changes on the first postoperative day. Thirty-day mortality was 4.3% (two deaths from 46 procedures). Our current protocol is to titrate up to 5 mg bisoprolol daily as tolerated which has been implemented successfully on an outpatient basis in over 90% of cases. As controlling heart rate for 48 h after surgery may reduce myocardial ischaemia in high-risk patients, some patients may not have been optimally β-blocked [2]. Based on this audit we will selectively introduce bisoprolol up to 10 mg daily pre-operatively and reiterate that all patients are to be considered for statins. Our method for cardiac event screening remains unchanged but will include additional testing on the third postoperative day.

Pre-operative anxiety is common and often significant. Ambulatory surgery challenges our pre-operative goal of an anxiety-free patient by requiring people to be 'street ready' within a brief period of time after surgery. Recently, it has been demonstrated that music can be used successfully to relieve patient anxiety before operations, and that audio embedded with tones that create binaural beats within the brain of the listener decreases subjective levels of anxiety in patients with chronic anxiety states. We measured anxiety with the State-Trait Anxiety Inventory questionnaire and compared binaural beat audio (Binaural Group) with an identical soundtrack but without these added tones (Audio Group) and with a third group who received no specific intervention (No Intervention Group). Mean [95% confidence intervals] decreases in anxiety scores were 26.3%[19-33%] in the Binaural Group (p = 0.001 vs. Audio Group, p < 0.0001 vs. No Intervention Group), 11.1%[6-16%] in the Audio Group (p = 0.15 vs. No Intervention Group) and 3.8%[0-7%] in the No Intervention Group. Binaural beat audio has the potential to decrease acute pre-operative anxiety significantly.

We investigated whether positioning patients undergoing general anaesthesia for cholecystectomy in a 20 degrees head-up position, as opposed to supine, improved the efficacy of 3 min of standard pre-oxygenation via a circle breathing system. Following pre-oxygenation, patients received a standard induction of anaesthesia and the apnoea time (from administration of rocuronium to the arterial oxygen saturation to fall to 95%) was recorded. Mean (95% CI) apnoea time was 386 (343-429) s in the 20 degrees head-up position (n = 17) vs 283 (243-322) s in the supine position (n = 18; p = 0.002). Pre-oxygenation is significantly more efficacious and by inference more efficient in the 20 degrees head-up position than in the supine position.

A British ®eld hospital, under canvas, providing up to 200 beds, six operating tables and an eight-bed ITU (four ventilated, four HDU beds) with 650 triservice staff was established near the Kuwait/Iraq border as part of the medical provision for casualties during the Gulf War 2. This was planned to provide role 3 medical support: that is initial stabilizing surgery, with de®nitive care provided in the UK within the NHS. In addition, there were specialist burns, head and neck and neuro teams. Apart from battle casualties, patients as a result of accidents during troop movements along with routine medical and surgical illness were anticipated, and injured prisoners of war (POW). The hospital treated its ®rst case on March 7. The main campaign started on March 20. The greatest number of theatre cases on battle casualties occurred on day 2 of the action. Thereafter, theatre cases included civilians and patients returning to theatre for a further procedure. In all but three patients these returns were POWs or local civilians, as coalition casualties were repatriated home as soon as stable. A total of 352 theatre cases (189 patients) were treated by the time the hospital closed before relocation at the end of effective war activity (May 8), of whom 77 were coalition, 145 civilians (including 49 paediatric cases aged 6 months to 15 yr) and 130 POWs (Fig. 1). The maximum number of theatres in use simultaneously was three. Anaesthetic techniques were mostly using the Triservice drawover OMV vaporizers with iso ̄urane, propofol, morphine, and vecuronium, although in a number of cases remifentanil, ketamine, and TIVA was used as appropriate for the type of case. A few cases were given regional techniques. The Intensive Care Unit was used for postoperative ventilation and as an HDU. The busiest UK ®eld hospital during Gulf War 1 (1991) operated on a total of 102 cases in a 2-month period, but that campaign was remarkable for the low casualty rate. During this con ̄ict, we exceeded their caseload within 10 days of the main campaign commencing. At no time however, did the theatre workload ever approach the maximum capacity of the hospital, although discharging of Iraqi nationals from the wards posed a problem.