Modeling daily veterinary anesthetist patient care hours and probabilities of exceeding critical thresholds.

OBJECTIVE: Use a referral dental clinic model to study how to calculate accurate 95% upper confidence limits for probabilities of workloads (total case duration, including turnover time) exceeding allocated times. ANIMALS: Dogs and cats undergoing dental treatments. METHODS: Managerial data (procedure date and duration) collected over 44 consecutive operative workdays were used to calculate the daily anesthetist workload. Workloads were compared with a normal distribution using the Shapiro-Wilk test, serial correlation was examined by runs test, and comparisons among weekdays were made using the Kruskal-Wallis test. The 95% confidence limits for normally distributed workloads exceeding allocated times were estimated with a generalized pivotal quantity. The impact of a number of procedures was assessed with scatterplots, Pearson linear correlation coefficients, and multivariable linear regression. RESULTS: Mean anesthetist's workload was normally distributed (Shapiro-Wilk P = .25), without serial correlation (P = .45), and without significant differences among weekdays (P = .52). Daily workload, mean 9.39 hours and SD 3.06 hours, had 95% upper confidence limit of 4.47% for the probability that exceeding 16 hours (ie, 8 hours per each of 2 tables). There was a strong positive correlation between daily workload and the end of the workday (r = .85), significantly larger than the correlation between the end of the workday and the number of procedures (r = .64, P < .0001). CLINICAL RELEVANCE: There are multiple managerial applications in veterinary anesthesia wherein the problem is to estimate risks of exceeding thresholds of workload, including the costs of hiring a locum, scheduling unplanned add-on cases, planning for late discharge of surgical patients to owners, and coordinating anesthetist breaks.

Accuracy of drawing up liquid medications by veterinary anaesthetists and nurses.

OBJECTIVE: To evaluate the accuracy with which veterinary anaesthetists and nurses of different experience draw up small volumes of liquid. STUDY DESIGN: Prospective blinded randomized study. METHODS: A group of seven European College of Veterinary Anaesthesia and Analgesia (ECVAA) diplomates, six ECVAA residents and six anaesthesia nurses participated in the study. For each participant, five target volumes between 0.01 and 1.0 mL were randomly allocated. They were drawn up 20 times in random order using a 1 mL syringe attached to a 23 gauge needle. A total of 1900 measurements were analysed. An investigator filled the syringe and needle dead space with water for injection before each experiment. The change in mass of the syringe once filled to the target volume was used to calculate the actual volume of liquid drawn up. RESULTS: Large errors were made with measurements < 0.04 mL, so they were excluded from the statistical analysis. There was a significant effect of the target volume (p < 0.001) and of the order (p < 0.01). For each mL increase in the target volume, the absolute error decreased by 4% and from the first to the hundredth withdrawal each participant's absolute error decreased by 1%. The target volume was underestimated in 52.3% of measurements, 42% were overestimated and 5.7% were on target. None of the between-subject predictor variables approached significance. CONCLUSIONS AND CLINICAL RELEVANCE: Accuracy of veterinary anaesthetists and nurses in drawing up medications decreases as the target volume becomes smaller. Small veterinary patients receive small volumes of anaesthetic drugs with higher risks of overdosing compared with larger dogs. Years of experience and staff grade are not associated with greater accuracy. Large percentage errors may be seen with target volumes less than 0.04 mL. Dilutions are recommended for volumes > 0.19 mL in 1 mL syringe.

DALES, Drug Allergy Labels in Elective Surgical patients: a prospective, multicentre cross-sectional study of prevalence, nature and anaesthetists' approach to management.

BACKGROUND: We sought to define the prevalence and nature of patient-reported drug allergies, determine their impact on prescribing, and explore drug allergy knowledge and attitudes amongst anaesthetists. METHODS: We performed a prospective cross-sectional study in 213 UK hospitals in 2018. Elective surgical patients were interviewed, with a detailed allergy history taken in those self-reporting drug allergy. Anaesthetists completed a questionnaire concerning perioperative drug allergy. RESULTS: Of 21 219 patients included, 6214 (29.3 %) (95% confidence interval [CI]: 28.7-29.9) reported drug allergy. Antibiotics, NSAIDs, and opioids were the most frequently implicated agents. Of a total of 8755 reactions, 2462 (28.1%) (95% CI: 29.2-31.1) were categorised as high risk for representing genuine allergy after risk stratification. A history suggestive of chronic spontaneous urticaria significantly increased the risk of reporting drug allergy (odds ratio 2.68; 95% CI: 2.4-3; P<0.01). Of 4756 anaesthetists completing the questionnaire, 1473 (31%) (95% CI: 29.7-32.3) routinely discuss perioperative allergy risk with patients. Prescribing habits in the presence of drug allergy labels differ depending on the implicated agent. Most anaesthetists (4678/4697; 99.6%) (95% CI: 99.4-99.8) prescribe opioids when reactions are consistent with side-effects, although 2269/4697 (48%) (95% CI: 46.9-49.7) would avoid the specific opioid reported. CONCLUSIONS: Almost 30% of UK elective surgical patients report a history of drug allergies, but the majority of reported reactions are likely to be non-allergic reactions. Allergy labels can impact on perioperative prescribing through avoidance of important drugs and use of less effective alternatives. We highlight important knowledge gaps about drug allergy amongst anaesthetists, and the need for improved education around allergy.

Suicide in anaesthetists: a systematic review.

Evidence suggests that healthcare professionals are at an increased risk of dying by suicide, with anaesthetists at particularly high risk. However, much of the data on which this is based are historical. With a focus on the epidemiology and methods used, we conducted a systematic review of evidence regarding suicide and suicidal behaviour among anaesthetists to provide a more contemporary summary. The systematic review process was adapted from a previous similar study in veterinary surgeons and was consistent with recommended guidance. We identified 54 articles published in or after 1990 that had anaesthetist-specific data and met the inclusion criteria. Seven of these reported epidemiological data, of which four were published after 2000. Although none of the more recent studies reported standardised mortality rates specific to suicide in anaesthetists, the proportion of anaesthetists dying by suicide was increased with respect to comparator groups, which is consistent with previous findings. Eleven studies that included information on suicidal behaviour reported suicidal ideation in 3.2-25% of individuals (six studies) and suicide attempts in 0.5-2% (four studies). Studies reporting methods of suicide highlighted the use of anaesthetic drugs, particularly propofol, supporting the suggestion that the increased risk of suicide in anaesthetists may be related to the availability of the means. We discuss our findings in relation to other recently published data and guidance concerning mental health problems in anaesthetists.

Perceptions of UK clinicians towards postoperative critical care.

Postoperative critical care is a finite resource that is recommended for high-risk patients. Despite national recommendations specifying that such patients should receive postoperative critical care, there is evidence that these recommendations are not universally followed. We performed a national survey aiming to better understand how patients are risk-stratified in practice; elucidate clinicians' opinions about how patients should be selected for critical care; and determine factors which affect the actual provision of postoperative critical care. As part of the second Sprint National Anaesthesia Project, epidemiology of critical care after surgery study, we distributed a paper survey to anaesthetists, surgeons and intensivists providing peri-operative care during a single week in March 2017. We collected data on respondent characteristics, and their opinions of postoperative critical care provision, potential benefits and real-world challenges. We undertook both quantitative and qualitative analyses to interpret the responses. We received 10,383 survey responses from 237 hospitals across the UK. Consultants used a lower threshold for critical care admission than other career grades, indicating potentially more risk-averse behaviour. The majority of respondents reported that critical care provision was inadequate, and cited the value of critical care as being predominantly due to higher nurse: patient ratios. Use of objective risk assessment tools was poor, and patients were commonly selected for critical care based on procedure-specific pathways rather than individualised risk assessment. Challenges were highlighted in the delivery of peri-operative critical care services, such as an overall lack of capacity, competition for beds with non-surgical cases and poor flow through the hospital leading to bed 'blockages'. Critical care is perceived to provide benefit to high-risk surgical patients, but there is variation in practice about the definition and determination of risk, how patients are referred and how to deal with the lack of critical care resources. Future work should focus on evaluating 'enhanced care' units for postoperative patients, how to better implement individualised risk assessment in practice, and how to improve patient flow through hospitals.

Anaesthetists' attitudes towards attending the funerals of their patients: A cross-sectional study among Australian and New Zealand anaesthetists.

A patient's death can pose significant stress on the family and the treating anaesthetist. Anaesthetists' attitudes about the benefits of and barriers to attending a patient's funeral are unknown. Therefore, we performed a prospective, cross-sectional study to ascertain the frequency of anaesthetists' attendance at a patient's funeral and their perceptions about the benefits and barriers. The primary aim was to investigate the attitudes of anaesthetists towards attending the funeral of a patient. The secondary aims were to examine the perceived benefits of and barriers to attending the funeral and to explore the rate of bonds being formed between anaesthetists, patients and families. Of the 424 anaesthetists who completed the survey (response rate 21.2%), 25 (5.9%) had attended a patient's funeral. Of the participants, 364 (85.9%) rarely formed special bonds with patients or their families; 233 (55%) believed that forming a special bond would increase the likelihood of their attendance. Showing respect to patients or their families was the most commonly perceived benefit of attending a funeral. Participants found expression of personal grief and caring for the patient at the end-of-life and beyond beneficial to themselves and the family. Fear of their attendance being misinterpreted or perceived as not warranted by the family as well as time restraints were barriers for their attendance. Most anaesthetists had never attended a patient's funeral. Few anaesthetists form close relationships with patients or their families. Respect, expression of grief and caring beyond life were perceived benefits of attendance. Families misinterpreting the purpose of attendance or not expecting their attendance and time restraints were commonly perceived barriers. Trial registration: ACTRN 12618000503224.

The flip side of speaking up: a new model to facilitate positive responses to speaking up in the operating theatre.

BACKGROUND: Speaking up is important for patient safety, but only if the concern raised is acknowledged and responded to appropriately. While the power to change the course of events rests with those in charge, research has focussed on supporting those in subordinate positions to speak up. We propose responsibility also rests with senior clinical staff to respond appropriately. We explored the perceptions of senior staff on being spoken up to in the operating theatre (OT), and factors moderating their response. METHODS: We undertook interviews and focus groups of fully qualified surgeons, anaesthetists, nurses, and anaesthetic technicians working in OTs across New Zealand. We used grounded theory to analyse and interpret the data. RESULTS: With data from 79 participants, we conceptualise three phases in the speaking up interaction: 1) the content of the speaker's message and the tone of delivery; 2) the message interpreted through the receiver's filters, including beliefs on personal fallibility and leadership, respect for the speaker, understanding the challenges of speaking up, and personal cultural and professional norms around communication; and 3) the receiver's subsequent response and its effects on the speaker, the observing OT staff, and patient care. CONCLUSIONS: The speaking up interaction can be high stakes for the whole OT team. The receiver response can strengthen team cohesion and function, or cause distress and tension. Our grounded theory uncovers multiple influences on this interaction, with potential for re-framing and optimising the speaker/receiver interaction to improve team function and patient safety.

A national survey of anaesthetists' preferences for their own end of life care.

OBJECTIVES: To describe individual views, wishes, and preferences for end of life care and to report UK anaesthetists' personal perspectives. METHODS: The 'bigconversations' questionnaire was developed by modifying an existing framework for end of life discussions. An online cross-sectional survey of UK anaesthetists was then conducted using the questionnaire in January 2019. RESULTS: The bigconversations questionnaire was validated as measuring the important aspects of end of life care by an expert panel and was found to have moderate test-retest reliability. Responses were received from 760/1913 (40%) of those invited to take part. Overall, 698/760 (92%) of respondents wished to be well informed about their condition and prognosis and 518/760 (68%) wanted to be heavily involved in decision-making about their health. Meanwhile, 639/760 (84%) of respondents would choose to forego treatment aimed at prolonging life should that life be of poor quality. The desire to spend time with family was a theme which arose from the qualitative analysis. CONCLUSION: This study provides the first systematic description of UK doctors', specifically anaesthetists', personal preferences for end of life care. Broad trends were identified: to be well informed; to avoid high-intensity medical treatments if terminally unwell; to spend remaining time with family and friends; and to be symptom-free and well cared for. However, a substantial minority expressed different, indeed opposite, opinions. This variation highlights that good quality end of life care must be driven by discussion of an individual's values, wishes, and preferences.

Barriers and aids to routine neuromuscular monitoring and consistent reversal practice-A qualitative study.

BACKGROUND: Neuromuscular monitoring is recommended whenever a neuromuscular blocking agent is administered, but surveys have demonstrated inconsistent monitoring practices. Using qualitative methods, we aimed to explore barriers and aids to routine neuromuscular monitoring and consistent reversal practice. METHODS: Focus group interviews were conducted to obtain insights into the thoughts and attitudes of individual anaesthetists, as well as the influence of colleagues and department culture. Interviews were conducted at five Danish and one US hospital. Data were analysed using template analysis. RESULTS: Danish anaesthetists used objective neuromuscular monitoring when administering a non-depolarizing relaxant, but had challenges with calibrating the monitor and sometimes interpreting measurements. Residents from the US institution used subjective neuromuscular monitoring, objective neuromuscular monitoring was generally not available and most had not used it. Danish anaesthetists used neuromuscular monitoring to assess readiness for extubation, whereas US residents used subjective neuromuscular monitoring, clinical tests like 5-second head lift and ventilatory parameters. The residents described a lack of consensus between senior anaesthesiologists in reversal practice and monitoring use. Barriers to consistent and correct neuromuscular monitoring identified included unreliable equipment, time pressure, need for training, misconceptions about pharmacokinetics of neuromuscular blocking agents and residual block, lack of standards and guidelines and departmental culture. CONCLUSION: Using qualitative methods, we found that though Danish anaesthetists generally apply objective neuromuscular monitoring routinely and residents at the US institution often apply subjective neuromuscular monitoring, barriers to consistent and correct use still exist.

Appreciation of literature by the anaesthetist: A comparison of citations, downloads and Altmetric Attention Score.

BACKGROUND: Different metrics exist to evaluate the impact of a paper. Traditionally, scientific citations are leading, but nowadays new, internet-based, metrics like downloads or Altmetric Attention Score receive increasing attention. We hypothesised a gap between these metrics, reflected by a divergence between scientific and clinical appreciation of anaesthesia literature. METHODS: We collected the top 100 most cited and the top 100 most downloaded articles in Acta Anaesthesiologica Scandinavica (AAS) and Anesthesia & Analgesia (A&A) published between 2014 and 2018. We analysed the relationship between the average number of citations per year, downloads per year and Altmetric Attention Score. RESULTS: For both AAS and A&A, a significant correlation between the 100 most cited articles and their downloads (r = .573 and .603, respectively, P < .001) was found. However, only a poor correlation with Altmetric Attention Score was determined. For the 100 most downloaded articles, download frequency did not correlate with their number of citations (r = .035 and .139 respectively), but did correlate significantly with the Altmetric Attention Score (r = .458 and .354, P < .001). CONCLUSION: Highly cited articles are downloaded more frequently. The most downloaded articles, however, did not receive more citations. In contrast to the most cited articles, more frequently downloaded papers had a higher Altmetric Attention Score. Thus, a 'trending' anaesthesia paper is not a prerequisite for scientific appreciation, reflecting a gap between clinical and scientific appreciation of literature.

Guidelines on suicide amongst anaesthetists 2019.

Anaesthetists are thought to be at increased risk of suicide amongst the medical profession. The aims of the following guidelines are: increase awareness of suicide and associated vulnerabilities, risk factors and precipitants; to emphasise safe ways to respond to individuals in distress, both for them and for colleagues working alongside them; and to support individuals, departments and organisations in coping with a suicide.

The intraoperative use of non-opioid adjuvant analgesic agents: a survey of anaesthetists in Australia and New Zealand.

BACKGROUND: Opioids have long been the mainstay of drugs used for intra-operative analgesia. Due to their well-known short and long term side effects, the use of non-opioid analgesics has often been encouraged to decrease the dose of opioid required and minimise these side effects. The trends in using non-opioid adjuvants among Australian Anaesthetists have not been examined before. This study has attempted to determine the use of non-opioid analgesics as part of an opioid sparing practice among anaesthetists across Australia and New Zealand. METHODS: A survey was distributed to 985 anaesthetists in Australia and New Zealand. The questions focused on frequency of use of different adjuvants and any reasons for not using individual agents. The agents surveyed were paracetamol, dexamethasone, non-steroidal anti-inflammatory agents (NSAIDs), tramadol, ketamine, anticonvulsants, intravenous lidocaine, systemic alpha 2 agonists, magnesium sulphate, and beta blockers. Descriptive statistics were used and data are expressed as a percentage of response for each drug. RESULTS: The response rate was 33.4%. Paracetamol was the most frequently used; with 72% of the respondents describing frequent usage (defined as usage above 70% of the time); followed by parecoxib (42% reported frequent usage) and dexamethasone (35% reported frequent usage). Other adjuvants were used much less commonly, with anaesthetists reporting their frequent usage at less than 10%. The majority of respondents suggested that they would never consider dexmedetomidine, magnesium, esmolol, pregabalin or gabapentin. Perceived disincentives for the use of analgesic adjuvants varied. The main concerns were side effects, lack of evidence for benefit, and anaesthetists' experience. The latter two were the major factors for magnesium, dexmedetomidine and esmolol. CONCLUSION: The uptake of tramadol, lidocaine and magnesium amongst respondents from anaesthetists in Australia and New Zealand was poor. Gabapentin, pregabalin, dexmedetomidine and esmolol use was relatively rare. Most anaesthetists need substantial evidence before introducing a non-opioid adjuvant into their routine practice. Future trials should focus on assessing the opioid sparing benefits and relative risk of using individual non-opioid adjuvants in the perioperative period for specific procedures and patient populations.

A survey of cricoid pressure application in a single institution in Ethiopia.

OBJECTIVE: The aim of this survey is to determine the standard of practice of cricoid pressure application on rapid sequence induction in Ayder comprehensive specialized hospital from April 3 to May 3, 2019. RESULTS: A total of 30 anesthetists were involved in the study with a response rate of 87%. Ninety percent of the respondents do not mask ventilate during rapid sequence induction and they do aspirate the naso-gastric tube if present. Almost half of the respondents have witnessed regurgitation during application of cricoid pressure and 93% do not remove the naso-gastric tube before rapid sequence induction. Seventy percent had experienced difficulty of endotracheal intubation during application of cricoid pressure. All of the respondents had less than 10 years of working experience as anesthetist.

Difficult airway management for the anaesthetist.

This article reviews the key considerations when managing a patient with a difficult airway. The difficult airway may be anticipated from preassessment allowing time for investigations and preparation. Alternatively, the unanticipated difficult airway can present in an emergency situation, or unexpectedly during a routine anaesthetic. The main airway management techniques are discussed with a description of their advantages and limitations. Current guidelines are included that demonstrate how the techniques are incorporated into an overall strategy with a plan A-D when failure occurs. It is critical to progress through such an algorithm in a timely manner to prevent the onset of hypoxia.

Suicide amongst anaesthetists - an Association of Anaesthetists survey.

Following a 2-3-month period of publicity, anaesthetists were invited to participate in an online survey that was administered by a third party company on behalf of the Association of Anaesthetists and ran between 3 September and 31 October 2018. Anaesthetists working in the UK or Ireland were asked about the presence or absence of welfare/support structures or resources in their workplace in the case of mental illness, addiction and/or suicide. Anaesthetists working anywhere in the world were also asked for their experiences of a colleague's suicide, defined as a colleague's taking his or her own life - whether intentional or not - while practising as an anaesthetist in the UK or Ireland, in the same department and at the same time as the respondent. Respondents were also asked about experiences of other suicides not meeting this definition. A total of 3638 responses were received. Most respondents were unaware of the existence of policies/guidance on mental illness, addiction or suicide, or of welfare leads, within their Trust or department. A total of 1916 cases of suicide meeting the survey's definition were reported by 1397 respondents, although the actual number of discrete cases is unknown because of likely multiple reporting of the same cases. A third of respondents who reported a suicide had experience of more than one case. Most reports were of suicide in the last 10 years, and most reported cases involved anaesthetic drugs. Deficiencies were noted in the support available and in the way the deaths were handled, although examples of good support were also described. A further 1715 respondents reported suicides that did not meet the primary definition. Overall, 92% of respondents reporting suicide experienced it through work, and 41% outside of work (total > 100% as some reported both). Although unable to provide estimates of suicide rates, or numerical associations between the features of the deaths, this survey highlights the considerable emotional and mental burden of suicide on anaesthetists.

Comment on: Unusual mechanical complications of central venous catheterization.

[No Abstract Available].