International Mine Countermeasures Exercise 2013: Role 2 Afloat.

In May 2013 a Role 2 Afloat team was deployed on board the Bay-class Landing Ship Dock (Auxiliary) RFA CARDIGAN BAY as part of the US-led Task Force involved in the International Mine Countermeasures Exercise 2013 (IMCMEX 13). This article introduces a series of papers from the various departments that make up the Role 2 Afloat team explaining the make-up of the team and also the overall capability of the team to deliver Role 2 care in the maritime environment.

Anaesthesia and critical care aspects of Role 2 Afloat.

The equipment and procedures for providing anaesthesia and critical care within the Role 2 Afloat team are described. In particular the lessons learned from a recent exercise onboard RFA CARDIGAN BAY are outlined with emphasis on the constraints of the unique maritime environment and the essential differences between the level of care at Role 2 and Role 3.

Hypophosphataemia causing profound cardiac failure after cardiac surgery.

We report the case of a patient who developed severe cardiac failure after cardiac surgery and required high-dose inotrope infusion. The patient was found to have significant hypophosphataemia and high insulin requirements immediately after surgery. On giving intravenous phosphate, there was a rapid decrease in inotrope requirement and improved glycaemic control. This occurrence raises questions about the cause of hypophosphataemia after cardiac surgery, the possible need for pre-operative plasma phosphate measurement and whether phosphate replacement should be part of the standard management of postoperative hypophosphataemia.

Measurement of carbon dioxide levels during use of ELSA and the effect of venting on these levels.

DESIGN: A prospective, objective assessment of ELSA use, in order to determine whether venting of the ELSA influences carbon dioxide (CO2) levels. PRIMARY ENDPOINT: Inspired and expired CO2 levels. SETTING: On board RFA ARGUS during Operation TELIC. METHODS: 10 volunteers had a baseline of inspired and expired CO2 levels taken. These levels were measured at one minute intervals during use of an ELSA in 3 conditions--sitting, jogging and jogging with venting. RESULTS: There was no difference in expired CO2 levels between baseline and use of ELSA whilst sitting. Periodic venting of the ELSA made no difference to inspired and expired CO2 levels. CONCLUSIONS: Venting of the ELSA during use makes no difference to CO2 levels whether inspired or expired. Therefore, venting is unnecessary and potentially wastes vital time during escape from a smoke-filled compartment and adds additional stress to the escapee.

Off-pump coronary artery surgery.

Cardiopulmonary bypass has several associated deleterious effects that include a systemic inflammatory response, coagulopathy, central nervous system complications and a variable degree of end-organ damage. The recent upsurge in interest in "beating-heart" surgery attempts to avoid these deleterious effects. Advances in surgical technique, such as the use of intracoronary shunts and the Octopus retractor, have made beating-heart surgery a reality. The challenges for the anaesthetist are greater than for coronary artery surgery using cardiopulmonary bypass, and whilst some advantages are proven, such as the lack of the inflammatory response and the decreased need for blood or blood products, others have yet to be proved and there is a need for further research. The advantages and disadvantages need to be evaluated in randomised studies in order to confirm the safety and efficacy of these new techniques in terms of long-term graft patency and decreased morbidity.