Editor—In 2007, our unit introduced a guideline to assist the staff in timing admission for daycase surgery and anaesthesia around routine childhood vaccinations. This measure was taken to reduce the disruption to the planned admission process. Before the implementation of this guideline, surgery was cancelled by some anaesthetists if the child had been recently exposed to a vaccine and conducted as scheduled by other anaesthetists. This led to a variable cancellation rate, inefficient use of theatre and day ward resources, dissatisfaction among staff caring for patients, and most importantly, a poorer experience for children and guardians attending the hospital. The guideline was formed after a review of the available literature on the subject and current practices in other children’s hospitals around the world. It was decided that surgery was to be scheduled at least 1 week after vaccination with an attenuated vaccine and at least 1 month after administration of a live attenuated viral vaccine. It was noted at that time that there was a paucity of strong evidence to inform clinicians on the effect of vaccinations on children undergoing general anaesthesia.1Siebert JN Posfay-Barbe KM Habre W Siegrist CA Influence of anesthesia on immune responses and its effect on vaccination in children: a review.Paediatr Anaesth. 2007; 17 (17474946): 410-420Crossref PubMed Scopus (41) Google Scholar 2Short JA van der Walt JH Zoanetti DC Immunisations and anesthesia—an international study.Paediatr Anaesth. 2006; 16: 514-522Crossref PubMed Scopus (38) Google Scholar Information given to parents verbally and in leaflet form was modified to reflect this change in practice, and the guideline was successfully introduced. There was an early and sustained decrease in cancellation on the morning of surgery for this reason. Using prospectively collected admission data from the past 2 yr (ongoing established audit in our department), we extracted information on the daycase cancellation rate for the period December–February in 2007–10 (Table 1). It was anticipated that this process would demonstrate an increase in our unit’s cancellation rate due to respiratory pathology secondary to H1N1 infection.3Rothberg MB Haessler SD Complications of seasonal and pandemic influenza.Crit Care Med. 2010; 38 (19935413): e91-e97Crossref PubMed Scopus (184) Google Scholar 4Patel M Dennis A Flutter C Khan Z Pandemic (H1N1) 2010 influenza.Br J Anaesth. 2009; 104: 128-142Abstract Full Text Full Text PDF Scopus (77) Google Scholar The results show that there was a modest increase in cancellations due to respiratory illness. However, there was a larger rise in cancelled surgery on the morning of admission due to recent H1N1 vaccination. We feel that there are a number of reasons to explain this occurrence. The vaccination programme included all children from 6 months to 16 yr, conducted on a phased basis by the Department of Health.5Swine Flu Vaccine www.hse.ie/eng/services/swineflu/vaccineGoogle Scholar Because of the large numbers of children receiving vaccination, it would have been more difficult to schedule surgery 1 week before or after exposure. The communication process where parents were given information about routine immunizations at the time of booking the procedure would have been superceded in the intervening weeks by the large amount of information on H1N1 available from heath-care workers, schools, and the media. Understandable parental concerns about viral infection may have influenced their decision to disregard the information previously furnished to them and attend the hospital for surgery in the days after their recommended vaccination. Over the winter months of 2009–10, our institution’s guideline was followed and this resulted in more children being sent home without their planned surgery. Protocol violation or deviation is used by some authorities as a measurable index of quality in clinical governance and overall health-care delivery. Indeed, our institution had previously observed the benefits of policy introduction on a range of issues, including childhood immunizations. However, this small audit illustrates the risks associated with guideline/policy implementation. The use of guidelines may produce rigid thinking and practice, which adapts poorly to a sudden change in circumstances. This may be deemed acceptable if there are well-documented adverse effects of a particular intervention, but is less acceptable when the weight of clinical or laboratory evidence is weak and the risk of proceeding with surgery is unknown. If we had not followed our recently introduced guideline during the period of H1N1 vaccine uptake by children, we would not have cancelled as many surgical procedures. This is a useful reminder that guidelines may require individualization as the clinical context changes, to prevent the tail from wagging the dog.Table 1Numbers and reasons for cancellation in children admitted to the day ward for elective surgeryMonthDec 2007Jan 2008Feb 2008Dec 2008Jan 2009Feb 2009Dec 2009Jan 2010Feb 2010Total no. of cases294305314322328352301289296Total no. of cases cancelled (%)5 (1.7)4 (1.3)5 (1.6)7 (2.2)4 (1.2)5 (1.4)9 (3.0)14 (4.8)16 (5.4)Booking error001101000Surgical reason101210100Respiratory illness212313355Diarrhoea/nausea/vomiting121011001Recent vaccination0100104910Other10100100 Open table in a new tab None declared.

Objective: Diagnosis of acute kidney injury (AKI) relies on measurement of serum creatinine concentration and urine flow, which change slowly and have low specificity and sensitivity. We investigated the potential of urinary levels of a-glutathione S-transferase (alpha-GST) and pi-GST - markers of proximal and distal renal tubule damage, respectively - to provide an earlier and more accurate indication of AKI in patients in the intensive care unit.Design, setting and participants: Urine samples were collected over the 48 hours after ICU admission from 40 consecutive patients who were admitted with a diagnosis of sepsis between October 2007 and May 2008. AKI was diagnosed during the 48 h after ICU admission with the criteria of the Acute Kidney Injury Network (AKIN). Urinary alpha-GST and pi-GST levels were measured with commercially available enzyme-linked immunosorbent assay (ELISA) kits. Serum creatinine concentration was also measured. Haemodynamic and resuscitation parameters were recorded, but managed independently by the ICU team.Results: Urine samples were analysed from 38 patients (21 men, 17 women) with a median age of 54 years (interquartile range [IQR], 41-69 years), median APACHE II score of 13.3 (IQR, 8-17), and median ICU length of stay of 9 days (IQR, 3-19 days). Hospital mortality was 24%, and ICU mortality was 13%. Nineteen patients (50%) developed AKI, all within 24h of ICU admission. Urinary alpha-GST level was not increased in patients who developed AKI versus non-AKI patients. Median (IQR) urinary pi-GST level (mu g/L) at ICU admission was 10.8 (4.7-22.65) in the non-AKI group, 19.3 (2.88-44) in those who developed Stage 1 AKI, and 27.4 (14.8-43.8) in those who developed Stage 3 AKI. Median urinary pi-GST level at ICU admission was higher in all groups than in healthy control subjects. The area under the receiver operating characteristics curve for urinary pi-GST level indicated that it was not a good predictor of AKI.Conclusions: Urinary pi-GST is elevated early in all patients with sepsis syndrome, but is not predictive of AKI as defined by AKIN. This may indicate sensitive detection of an earlier phase of kidney injury, and suggests that sepsis-related renal injury affects the distal tubules, giving new insights into the pathophysiology of AKI in sepsis.