BACKGROUND: Although most anesthesiologists will have 1 catastrophic perioperative event or more during their careers, there has been little research on their attitudes to assistive strategies after the event. There are wide-ranging emotional consequences for anesthesiologists involved in an unexpected intraoperative patient death, particularly if the anesthesiologist made an error. We used a between-groups survey study design to ask whether there are different attitudes to assistive strategies when a hypothetical patient death is caused by a drug error versus not caused by an error. First, we explored attitudes to generalized supportive strategies. Second, we examined our hypothesis that the presence of an error causing the hypothetical patient death would increase the perceived social stigma and self-stigma of help-seeking. Finally, we examined the strategies to assist help-seeking. METHODS: An anonymous, mailed, self-administered survey was conducted with 1600 consultant anesthesiologists in Australia on the mailing list of the Australian and New Zealand College of Anaesthetists. The participants were randomized into “error” versus “no-error” groups for the hypothetical scenario of patient death due to anaphylaxis. Nonparametric, descriptive, parametric, and inferential tests were used for data analysis. P′ is used where P values were corrected for multiple comparisons. RESULTS: There was a usable response rate of 48.9%. When an error had caused the hypothetical patient death, participants were more likely to agree with 4 of the 5 statements about support, including need for time off (P′ = 0.003), counseling (P′ < 0.001), a formal strategy for assistance (P′ < 0.001), and the anesthesiologist not performing further cases that day (P′ = 0.047). There were no differences between groups in perceived self-stigma (P = 0.98) or social stigma (P = 0.15) of seeking counseling, whether or not an error had caused the hypothetical patient death. Finally, when an error had caused the patient death, participants were more likely to agree with 2 of the 5 statements about help-seeking, including the need for a formal, hospital-based process that provides information on where to obtain professional counseling (P′ = 0.006) and the availability of after-hours counseling services (P′ = 0.035). CONCLUSIONS: Our participants were more likely to agree with assistive strategies such as not performing further work that day, time off, counseling, formal support strategies, and availability of after-hours counseling services, when the hypothetical patient death from anaphylaxis was due to an error. The perceived stigma toward attending counseling was not affected by the presence or absence of an error as the cause of the patient death, disproving our hypothesis.

Background: Ultrasound-guided techniques improve outcomes in regional anesthesia when compared with traditional techniques; however, this assertion has not been studied with novices. The primary objective of this study was to compare sensory and motor block after axillary brachial plexus block when performed by novice trainees allocated to an ultrasound- or nerve-stimulator-guided group. A secondary objective was to compare the rates of skill acquisition between the 2 groups.Methods: This study was a prospective, randomized, observer-blinded, 2-arm controlled trial. Anesthesia trainees participating in this trial were novices to axillary brachial plexus block and sonography. All trainee participants underwent a standardized training program. The primary outcome was combined sensory and motor block in the relevant territories 30 minutes after completion of block. A global rating scale was used to assess trainee block performance.Results: The study was ceased after 12 trainees completed 153 blocks. There was no difference between groups in combined motor/sensory score (P = 0.28) or as a function of block number (P = 0.38). There was no difference in onset between groups (P = 0.38). In both groups, there was an increase in the global rating scale score (P < 0.0001) and reduced preblock survey and block performance times (P = 0.001) with experience.Conclusions: We were unable to demonstrate a difference in the efficacy of axillary brachial plexus block performed by novices when ultrasound guidance was compared with a nerve stimulator technique. There was evidence of similarly improved clinical performance of novices in both groups.

BACKGROUND:Although anesthesiologists are leaders in patient safety, there has been little research on factors affecting their reporting of adverse events and errors. First, we explored the attitudinal/emotional factors influencing reporting of an unspecified adverse event caused by error. Second, we used a between-groups study design to ask whether there are different perceived barriers to reporting a case of anaphylaxis caused by an error compared with anaphylaxis not caused by error. Finally, we examined strategies that anesthesiologists believe would facilitate reporting. Where possible, we contrasted our results with published findings from other physician groups. METHODS:An anonymous, self-administered, mailed survey was conducted of 629 consultant anesthesiologists and 263 anesthesiology residents on the mailing list of the Australian and New Zealand College of Anaesthetists in Victoria, Australia. Participants were randomized into "Error" versus "No Error" groups for the specified anaphylaxis adverse event section of the survey. Data were analyzed using nonparametric descriptive and inferential tests. RESULTS:There were 433 usable returned surveys, a usable response rate of 49%. First, there was only 1 of 13 statements on attitudinal/emotional factors that influenced reporting of an unspecified adverse event caused by error with which more anesthesiologists agreed/strongly agreed than disagreed/strongly disagreed: "Doctors who make errors are blamed by their colleagues." Second, when an error rather than no error had caused anaphylaxis, participants were more likely to agree/strongly agree that 6 statements about litigation, getting into trouble, disciplinary action, being blamed, unsupportive colleagues, and not wanting the case discussed in meetings, were perceived as reporting barriers. Finally, the most favored assistive strategies for reporting were generalized deidentified feedback about adverse event and error reports, role models such as senior colleagues who openly encourage reporting, and legislated protection of reports from legal discoverability. CONCLUSION:The majority of anesthesiologists in our study did not agree that the attitudinal/emotional barriers surveyed would influence reporting of an unspecified adverse event caused by error, with the exception of the barrier of being concerned about blame by colleagues. The probable influence of 6 perceived barriers to reporting a specified adverse event of anaphylaxis differed with the presence or absence of error. Anesthesiologists in our study supported assistive reporting strategies. There seem to be some differences between our results and previously published research for other physician groups.

s and Programme: EUROANAESTHESIA 2011: The European Anaesthesiology Congress: ESA Best Abstract Prize Competition (BAPC)

Background and Objectives: Peripheral nerve blockade is associated with excellent patient outcomes after surgery; however, neurologic and other complications can be devastating for the patient. This article reports the development and preliminary results of a multicenter audit describing the quality and safety of peripheral nerve blockade.Methods: From January 2006 to May 2008, patients who received peripheral nerve blockade had data relating to efficacy and complications entered into databases. All patients who received nerve blocks performed by all anesthetists during each hospital's contributing period were included. Patients were followed up by phone to detect potential neurologic complications. The timing of follow-up was either at 7 to 10 days or 6 weeks postoperatively, depending on practice location and time period. Late neurologic deficits were defined as a new onset of sensory and/or motor deficit consistent with a nerve/plexus distribution without other identifiable cause, and one of the following: electrophysiologic evidence of nerve damage, new neurologic signs, new onset of neuropathic pain in a nerve distribution area, paresthesia in relevant nerve/plexus distribution area.Results: A total of 6950 patients received 8189 peripheral nerve or plexus blocks. Of the 6950 patients, 6069 patients were successfully followed up. In these 6069 patients, there were a total of 7156 blocks forming the denominator for late neurologic complications. Thirty patients (0.5%) had clinical features requiring referral for neurologic assessment. Three of the 30 patients had a block-related nerve injury, giving an incidence of 0.4 per 1000 blocks (95% confidence interval, 0.08-1.1:1000). The incidence of systemic local anesthetic toxicity was 0.98 per 1000 blocks (95% confidence interval, 0.42-1.9:1000).Conclusions: These results indicate that the incidence of serious complications after peripheral nerve blockade is uncommon and that the origin of neurologic symptoms/signs in the postoperative period is most likely to be unrelated to nerve blockade.

Background and Objectives: Visualization of the radial nerve can be a challenge during ultrasound-guided axillary blockade. The objective of this study was to plot the location and examine the sonographic appearance of the radial nerve in the axilla using both ultrasound visualization and nerve stimulator verification in patients undergoing axillary blockade. Methods: Fifty-one patients requiring an axillary block for surgery were enrolled. Sonograms of the radial nerve at the point of best nerve stimulator response were recorded. The needle tip and center of the radial nerve were both plotted on a 2-dimensional scattergram using coordinates relative to the center of the axillary artery. A video tracing the path of the radial nerve was also recorded. Results: The radial nerve location was confirmed with both ultrasound imaging and nerve stimulation in 46 patients (90%). Five nerves (11%) were immediately deep to the axillary artery (ie, at a 6-o'clock position), 6 (13%) were cephalad, and the remaining 35 (76%) were caudad to the axillary artery. The 2-dimensional (2D) scattergrams reveal the variability in radial nerve location and clarity, of which 14 (30%) of the 46 visible nerves were difficult to trace precisely. A fascial plane between the medial and long heads of the triceps containing the radial nerve could be imaged clearly in 41 (91%) of the videos. Conclusions: The radial nerve uncommonly lies immediately deep to the axillary artery. It is frequently located on the caudad side of the artery.

We thank Drs. Rao and Radhakrishnan for their interest in our survey determining the alteration in neuroanaesthetic practice in response to the IHAST II study.

Early and non-invasive evaluation of hydatid infestation of brain and spine is of paramount importance, especially in endemic areas. We present a spectrum of imaging findings in neurohydatidosis with a brief review of literature.

Deliberate mild hypothermia was first used in 1955 as an intraoperative technique to ameliorate new neurological deficits following cerebral aneursym clipping, and subsequently was also used following neonatal asphyxia, head trauma and cardiac arrest. The Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST II) randomized control trial was designed to determine the effectiveness of mild hypothermia to decrease neurological deficits following aneurysm surgery. No overall benefit was demonstrated in the hypothermic group versus normothermic group (67% versus 63% good outcome; p=0.32), with a higher rate of bacteraemia in the hypothermic group (5% versus 3%; p=0.05). We undertook a survey of Australasian and Asian neuroanaesthetists to determine whether their thermal management of patients undergoing cerebral aneursym clipping had changed in response to the IHAST II trial results.

There has been a definite increase in the popularity and use of complementary and alternative medicines, including herbal medicines, in the last ten years. The aim of this study was to determine the prevalence and patterns of use of herbal medicines and vitamin supplements by patients in the preoperative period. A questionnaire was offered to all patients attending the pre-admission clinics at St. Vincent's Hospital and Box Hill Hospital, Melbourne, over an eight-month period in 2002. In all, 1102 questionnaires were completed (91.8% response rate). The prevalence of herbal medicine use was 14.3%, with an average user age of 54.0 years and 61.4% female predominance. The five most popular herbs were Garlic, Evening Primrose, Gingko, St. John's Wort and Echinacea. The commonest reasons for herbal medicine use were acute and chronic medical conditions. 63.2% of patients had self-prescribed. 27.8% of herbal remedy users had informed the hospital doctors and 41.8% had notified their general practitioner The prevalence of vitamin supplement use was 20.4%, with an average user age of 54.8 years and 66.2% female predominance. The five most popular vitamins were multivitamins, followed by vitamin B, C, E and D. The commonest reasons for vitamin use were maintenance of general well-being and health. The use of herbal medicines and vitamin supplements preoperatively by patients is common. Clinicians should endeavour to familiarize themselves with the more popular and significant herbal medications and, as part of the routine preoperative assessment, ask all their patients about their consumption of herbal remedies.

In this study we investigated the effect of topical application of cool irrigation fluid on brain tissue temperature during craniotomy. Eight patients were given a standard general anaesthetic for craniotomy. Distal oesophageal and nasopharyngeal temperatures were measured continuously and systemic normothermia was maintained. A sterile needle temperature probe was inserted 18 mm into the cerebrum to measure brain temperature. Brain temperatures were recorded for five minutes while the brain was irrigated with 1000 ml of normal saline at a temperature of 30 degrees C. Measurement continued until the brain temperature returned to baseline. The mean maximum decrease in cerebralparenchymal temperaturefollowing irrigation was 1.6 +/- 0.5 degrees C (P<0.01). The average time to return to baseline temperature after cessation of irrigation was 5.3 +/- 1.5 minutes. Cooling the brain has a marked protective effect after brain injury, but systemic hypothermia can produce significant harmful effects. This study demonstrates that the use of cool irrigation fluid during neurosurgery is a simple and effective method of cooling the brain whilst minimizing the use of systemic hypothermia.

Mediastinal lymphadenopathy is commonly detected on CT. It is a non-specific finding, but because of its significance in the treatment in lung carcinoma it is important to know with which other disease states it is associated. We present a series of 42 patients in whom CT of the chest was used to confirm a clinical diagnosis of bronchiectasis. The size, number and distribution of mediastinal lymph nodes is documented. Lymph nodes were visible in 81% of patients. Nodes larger than 10 mm, the recognised maximum size for normal nodes in the U. K., were detected in 29%. In the absence of other recognised causes of lymphadenopathy in these patients, these findings confirm “reactive” mediastinal lymph node enlargement in bronchiectasis.

Improved technology enables better visualization of normal anatomical structures. The rete testis is now visible as an ill-defined echo-poor region at the testicular hilum, sometimes with arboriform projections into the parenchyma. In a retrospective review of 100 cases of non-inflamed testes, the rete testis was seen in 18%. The anatomy was confirmed by scanning post-mortem specimens in a waterbath, marking the echo-poor region and then studying the histology. The spectrum of ultrasound appearances of the normal rete testis is presented. The rete testis can be distinguished easily from pathology because the parenchyma remains otherwise homogeneous and normal in appearance.

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Weight-loss, total body-potassium, and total body-nitrogen were measured in 12 men and 15 women with severe chronic heart-disease. Compared with age-matched healthy controls, the men had lost an average of 13 kg in weight, 915 mmol of potassium, and 354 g of nitrogen, whereas the women had lost 5·6 kg of weight, 327 mmol of potassium, and 66 g of nitrogen. Although the potassium/nitrogen ratio in the lost tissue is not precisely known, the loss of nitrogen indicates that most of the potassium loss in men is due to tissue loss and that there is little fall in the intracellular concentration of potassium in either the men or the women.

Arteriography in two patients with renovascular hypertension suggested fibromuscular hyperplasia, mainly affecting the right renal artery. When saralasin was infused intravenously there was no fall in blood-pressure in either patient. However, both had a raised renal-vein plasma-renin activity on the affected side, relative to the unaffected kidney. Auto-transplantation resulted in a sustained reduction in arterial pressure in both patients. A negative saralasin test should not necessarily exclude further investigation of young patients with severe hypertension.