The older surgical patient - to operate or not? A state of the art review.

The increasing age and subsequent medical complexity of patients presenting for surgery grants the opportunity to examine the processes and delivery of peri-operative care. There is a need to redesign peri-operative pathways allowing room for shared decision making and personalised, evidence-based care. In times of financial constraint, this is no easy task. However, neglecting to transform services now may lead to challenges in the sustainability of the provision of peri-operative care in the long-term. Challenges in redesigning peri-operative care pathways include identification and optimisation of those at highest peri-operative risk to inform the difficult conversations surrounding the appropriateness of surgery. The moral burden of these conversations on patient and professionals alike is increasingly recognised and managing this issue requires innovative models of collaborative, multidisciplinary and interprofessional working. To operate or not can be a challenging question to answer with a number of different perspectives to consider; not least that of the patient.

A comparison of two epidural catheter connectors.

BACKGROUND: Disconnection of the filter from its catheter is an established problem with epidural analgesia. Previously, it has been hypothesised that the screw cap connector is more prone to disconnection than the clamp connector design. The aim of this study was to test which of two mechanisms connecting the epidural catheter and filter was more prone to disconnection. METHODS: We recruited 20 consultant anaesthetists. First, each was asked to assemble an epidural set, either B Braun or Portex, in their normal way. Second, each anaesthetist assembled an epidural set, either B Braun or Portex, but was asked if they could improve the security of the connection, whilst avoiding catheter lumen occlusion. Each assembled set was then tested to determine adequacy of catheter connection using a standard protocol. Statistical analysis was performed using the Fisher's exact test. RESULTS: The strength of the connection of the B Braun epidural set was similar to the Portex set when assembled for everyday practice (mean 1100g; median 1100g; SD 249 vs. mean 920g; median 1050g; SD 603). However, the incidence of inadequate connection was 0 in the B Braun group vs. 5 (25%) in the Portex group (P=0.04). It was possible to improve the reliability of the Portex system, although episodes of weak connection were not eliminated. CONCLUSIONS: We conclude that the Portex connection system is more prone to disconnection and that connection design is an important consideration when trying to minimise catheter disconnection.

Safer arterial access.

Intra-arterial injection of drugs intended for intravenous delivery is a frequent and potentially devastating consequence of placing an arterial line in a patient. A system is described here that prevents this complication from occurring and its use is advocated in intensive care and operating theatre settings.