The impact of trained assistance on error rates in anaesthesia: a simulation-based randomised controlled trial.

Trained assistance for the anaesthetist appears likely to improve safety in anaesthesia. However, there are few objective data to support this assumption, and the requirement for a trained assistant is not universally enforced. We applied a simulation-based model developed in previous work to test the hypothesis that the presence of a trained assistant reduces error in anaesthesia. Ten randomly selected anaesthetists, five trained anaesthetic technicians and five theatre nurses without training in anaesthesia participated in two simulated emergencies, with anaesthetists working alternately with a technician or a nurse. The mean (SD) error rate per scenario was 4.75 (2.9). There were significantly fewer errors in the technician group than the nurse group (33 vs 62, p = 0.01) and this difference remained significant when errors were weighted for severity. This provides objective evidence supporting the requirement for trained assistance to the anaesthetist, and furthermore, demonstrates that a simulation-based model can provide rigorous evidence on safety interventions in anaesthesia.

A simulation design for research evaluating safety innovations in anaesthesia*.

SUMMARY: It is notoriously difficult to obtain evidence from clinical randomised controlled trials for safety innovations in healthcare. We have developed a research design using simulation for the evaluation of safety initiatives in anaesthesia. We used a standard and a modified scenario in a human-patient simulator, involving a potentially life-threatening problem requiring prompt attention--either a cardiac arrest or a failure in oxygen supply. The modified scenarios involved distractions such as loud music, a demanding and uncooperative surgeon, telephone calls and frequent questions from a medical student. Twenty anaesthetics were administered by 10 anaesthetists. A mean (SD) of 11.3 (2.8) errors per anaesthetic were identified in the oxygen failure scenarios, compared with 8.0 (3.4) in the cardiac arrest scenarios (ANOVA: p = 0.04). The difference between the combined standard scenarios and the combined modified scenarios was not significant. The mean rate of errors overall was 9.7 per simulation, with a pooled SD of 4.46, so in future studies 21 subjects would provide 80% statistical power to show a reduction in error rate of 30% from baseline with p

The effect of time of day on the duration of neuromuscular blockade elicited by rocuronium.

In a prospective, observational trial, we investigated the influence of time of day on the duration of neuromuscular blockade (NMB) elicited by rocuronium. Forty-nine patients scheduled for surgery between 08:00 and 02:00 were enrolled after giving written informed consent. Time to neuromuscular recovery was measured following three doses: (1) a fat-free-mass (FFM) related induction dose (0.6 mg x kg(-1): n = 47); (2) a maintenance dose (20% of the induction dose: n = 42); and (3) a standard 10-mg dose (n = 35). The extent of NMB was dependent on the time of administration (p = 0.038 General Linear Model Analysis). The maximum effect of 50 min (95% CI 41-59 min) was elicited between 08:00 and 11:00 and the minimum duration of 29 min (95% CI 23-35 min) between 14:00 and 17:00 (p = 0.005). A similar pattern was observed for the maintenance dose. The duration of action of rocuronium is influenced by time of day and this effect is of potential clinical significance and practical relevance to research.

Circadian neuroendocrine physiology and electromagnetic field studies: precautions and complexities.

The suppression of melatonin by exposure to low frequency electromagnetic fields (EMFs) 'the melatonin hypothesis'. has been invoked as a possible mechanism through which exposure to these fields may result in an increased incidence of cancer. While the effect of light on melatonin is well established, data showing a similar effect due to EMF exposure are sparse and, where present, are often poorly controlled. The current review focuses on the complexities associated with using melatonin as a marker and the dynamic nature of normal melatonin regulation by the circadian neuroendocrine axis. These are issues which the authors believe contribute significantly to the lack of consistency of results in the current literature. Recommendations on protocol design are also made which, if followed, should enable researchers to eliminate or control for many of the confounding factors associated with melatonin being an output from the circadian clock.

Acute exposure to circularly polarized 50-Hz magnetic fields of 200-300 microT does not affect the pattern of melatonin secretion in young men.

Environmental exposure to time-varying (alternating current) magnetic fields (MFs) produced by electrical current flow is a perceived public health risk. Several epidemiological studies report correlations between MF exposure and carcinogenesis. It has been hypothesized that MF-induced suppression of melatonin could provide the mechanism by which this effect is mediated. Here, we describe results from a controlled laboratory-based study designed to detect changes in human melatonin secretion after a 2-h exposure to 200-300 microTesla, 50 Hz circularly polarized MF. Exposure was timed to occur before or during the nightly melatonin rise, and levels administered were some 4-6 times higher than the commonly encountered maximum levels. Results from 19 male subjects aged between 18 and 35 yr indicate that acute exposure to 50 Hz MFs of this nature does not result in significant suppression, alteration of peak levels, or a change in timing of the nighttime melatonin rise. We conclude that acute exposure to 50 Hz MFs does not have a significant effect on the normal nighttime production of melatonin in young men.