The development of a nurse-led preoperative anaesthesia screening tool by Delphi consensus.

BACKGROUND: Low- and middle-income countries have a critical shortage of specialist anaesthetists. Most patients arriving for surgery are of low perioperative risk. Without immediate access to preoperative specialist care, an appropriate interim strategy may be to ensure that only high-risk patients are seen preoperatively by a specialist. Matching human resources to the burden of disease with a nurse-administered pre-operative screening tool to identify high-risk patients who might benefit from specialist review prior to the day of surgery may be an effective strategy. OBJECTIVE: To develop a nurse-administered preoperative anaesthesia screening tool to identify patients who would most likely benefit from a specialist review before the day of surgery, and those patients who could safely be seen by the anaesthetist on the day of surgery. This would ensure adequate time for optimisation of high-risk patients preoperatively and limit avoidable day-of-surgery cancellations. METHODS: A systematic review was conducted to identify preoperative screening questions for use in a three-round Delphi consensus process. A panel of 16 experienced full-time clinical anaesthetists representing all university-affiliated anaesthesia departments in South Africa participated to define a nurses' screening tool for preoperative assessment. RESULTS: Ninety-eight studies were identified, which generated 79 questions. An additional 14 items identified by the facilitators were added to create a list of 93 questions for the first round. The final screening tool consisted of 81 questions, of which 37 were deemed critical to identify patients who should be seen by a specialist prior to the day of surgery. CONCLUSION: A structured nurse-administered preoperative screening tool is proposed to identify high-risk patients who are likely to benefit from a timely preoperative specialist anaesthetist review to avoid cancellation on the day of surgery.

Establishing the Maximum Collectivity in Highly Deformed N=Z Nuclei.

The lifetimes of the first excited 2^{+} states in the N=Z nuclei ^{80}Zr, ^{78}Y, and ^{76}Sr have been measured using the γ-ray line shape method following population via nucleon-knockout reactions from intermediate-energy rare-isotope beams. The extracted reduced electromagnetic transition strengths yield new information on where the collectivity is maximized and provide evidence for a significant, and as yet unexplained, odd-odd vs even-even staggering in the observed values. The experimental results are analyzed in the context of state-of-the-art nuclear density-functional model calculations.

A report of the natural history of leptomeningeal gliomatosis.

Primary leptomeningeal gliomatosis (PLG) is a rare condition, with fewer than 50 patients reported. Our report illustrates the natural history of PLG in full, from the prodromal phase of subacute meningitis to the final stages characterised by extensive nerve root infiltration, cranial nerve palsies and widespread peripheral neurogenic muscle wasting. We provide correlative neuroimaging with serial MRI, and present the first published positron emission tomography imaging of this condition. We emphasise the importance of considering PLG in the differential diagnosis of chronic aseptic meningitis, the difficulties of making the diagnosis ante mortem, and the utility and potential limitations of early meningeal biopsy in this condition.

The effect of low molecular weight heparin (enoxaparin) on enhanced coagulation induced by crystalloid haemodilution.

The purpose of this study was to establish whether a low molecular weight heparin (enoxaparin) attenuated or abolished the enhanced coagulation induced by crystalloid fluid therapy. Twenty young, healthy male volunteers were injected subcutaneously with either enoxaparin 40 mg or saline on two separate occasions one week apart, in a randomised, blinded study. Twelve hours later, a blood sample was taken for thrombelastography analysis and haematocrit. Saline 14 ml.kg⁻¹ was then infused over thirty minutes and thrombelastography and haematocrit measurements repeated. There was a significant post-dilutional difference in the alpha angle (p = 0.002) and k-time (p = 0.001) between the two groups. There was a trend towards reduced shortening of r-time in the enoxaparin group compared to the saline control (p = 0.18). The findings suggest that enoxaparin diminished acceleration of clot formation due to haemodilution.

Drug administration errors: a prospective survey from three South African teaching hospitals.

This prospective study was undertaken to determine the incidence of drug administration errors by anaesthetists at three tertiary South African hospitals. Hospitals A and C treat adults predominantly, whereas Hospital B is a paediatric hospital. Anaesthetists completed an anonymous study form for every anaesthetic performed over a six-month period. They were asked to indicate whether or not an error or near-miss had occurred and if so, the details thereof. A total of 30,412 anaesthetics were administered during the study period. The response rate and combined incidence of errors and near-misses was as follows: Hospital A 48.8% (1:320), B 81.3% (1:252) and C 48.1% (1:250). The overall response rate was 53% and the combined incidence was 1:274. Neither the experience of the anaesthetist nor emergency surgery influenced whether an error occurred or not. Most errors occurred during the maintenance phase of anaesthesia. The most common errors were those of substitution. At the paediatric hospital, incorrect dose was as frequent an error as substitution. Of all errors, 36.9% were due to drug ampoule misidentification; of these the majority (64.4%) were due to similar looking ampoules. Another 21.3% were due to syringe identification errors. No major complication attributable to a drug administration error was reported. Despite an increasing awareness of the problem together with suggestions in the literature to reduce the incidence, drug administration errors remain fairly common in South Africa. Failure to institute suggested solutions will continue to compromise patient safety.

Oesophageal atresia with cleft lip and palate: a marker for associated lethal anomalies?

An adverse association between oesophageal atresia (OA) and cleft lip-palate (3% incidence) has been reported. The present study analyses outcomes of this rare association at a UK paediatric surgical centre. Hospital charts of newborns diagnosed with OA were reviewed. Demographics, associated anomalies and prognostic classification (after Spitz 1994) were recorded. Mortality rates and causes of death were examined in OA babies with cleft lip-palate. Of 152 patients treated for OA, five babies (3%) had cleft lip-palate. All of these newborns had common variant OA-TEF and were Spitz group II category. Deaths occurred in 3 of 5 patients (60%) in the OA-cleft group compared to only 8 of 147 patients (5%) without clefts (p < 0.005; Fisher's exact test). OA-cleft non-survivors succumbed to tetralogy of Fallot (n = 2) and trisomy 18 (n = 1; treatment withdrawn). Both survivors with cleft lip-palate had features of the VACTERL sequence: one baby also had Goldenhaar syndrome, the other aortic coarctation. These children now attend mainstream school. Although high-quality survival is possible in OA with cleft lip-palate, this rare phenotype is associated with a substantially decreased survival. Rather than causing death directly, the combination of OA and cleft lip-palate appears to be a marker for further lethal anomalies.

How good are the maternity services for 'drug misusers' in England and Wales? A national survey.

To assess the state of maternity services for pregnant drug misusers, a postal questionnaire-based survey was carried out in England and Wales in 2005. A total of 222 questionnaires were sent with a response rate of 80.63%, reporting a total of 5,324 births to drug-misusers. Data were collated and analysed using Microsoft Excel 2003. Despite improvement in the services provided to the pregnant drug-misusers, there is wide regional variation. Hepatitis-C screening is particularly under-offered. Pre-birth meetings appear to be the way forward to optimise overall outcome. Maternity-unit staff need appropriate training for providing sufficient knowledge of drug use and its consequences for the pregnancy.

Drug administration errors by South African anaesthetists--a survey.

OBJECTIVES: To investigate the incidence, nature of and factors contributing towards wrong drug administrations by South African anaesthetists. DESIGN: A confidential, self-reporting survey was sent out to the 720 anaesthetists on the database of the South African Society of Anaesthesiologists. RESULTS: A total of 133 questionnaires were returned for analysis (18.5% response rate). Of the respondents, 125 (94%) admitted to having inadvertently administered a wrong drug. Thirty respondents (22.6%) said they had made errors on at least four occasions. A total of 303 specific wrong drug administrations were described. Nearly 50% involved muscle relaxants. A further 43 incidents (14%) involved the erroneous administration of vasoactive drugs. Five deaths and 3 nonfatal cardiac arrests were reported. In 9.9% of incidents the anaesthetic time was prolonged by more than 30 minutes. Contributory causes identified included syringe swaps (40%), misidentification of drugs (27.1%), fatigue (14.1%), distractions (4.7%), and mislabelling of syringes (4.7%). Only 19% of respondents regularly use colour-coded syringe labels complying with the national standard. CONCLUSIONS: Most anaesthetists experienced at least one drug error. The incidence of wrong drug administrations by South African anaesthetists appears to be similar to that in Australasia and Canada. The commonest error was a 'syringe swap' involving muscle relaxants. Most drug errors are inconsequential. An important minority of incidents result in severe morbidity or death. The study supports efforts to improve ampoule labelling, to encourage the use of syringe labels based on the international colour code and to develop a national reporting system for such incidents.

The proseal laryngeal mask: results of a descriptive trial with experience of 300 cases.

BACKGROUND: The ProSeal laryngeal mask airway (PLMA) is a new laryngeal mask device with a modified cuff and a drainage tube. METHODS: We assessed the PLMA in 300 anaesthetized adults either paralysed or breathing spontaneously. We assessed insertion characteristics, airway seal pressures, haemodynamic response to insertion, ease of gastric tube placement, gastric insufflation, and postoperative sore throat. RESULTS: Insertion was successful in 294 patients (98%) and graded as easy in 274 patients (91%). We found no difference in ease of insertion or success rate with either the introducer or the finger insertion method, or in paralysed or non-paralysed patients. Mean airway seal pressure was 29 cm H2O, and 59 patients (20%) had seal pressures greater than 40 cm H2O. No gastric insufflation was detected. Gastric tube placement was successful in 290 of 294 patients (98.6%). There was no cardiovascular response to insertion, with a small reduction in heart rate 5 min after insertion and significant decreases in mean arterial pressure at 1 and 5 min after insertion. Sore throat was noted in 23% patients after operation and in 16% of patients after 24 h, with 90% of the sore throats described as mild. CONCLUSIONS: The PLMA is a reliable airway management device that can give an effective glottic seal in paralysed and non-paralysed patients. The device allows the easy passage of a gastric tube, causes a minimal haemodynamic response to insertion, and an acceptable incidence of sore throat.

Uranium decay products found on Mir space blanket mitt.

The space blanket mitt which covered the Trek detector on Mir during four years of orbital flight has been measured for gamma radiation with HPGe and multidimensional spectrometers. Difference spectra from very-long-period spectrometer runs on the mitt and on a similar non-deployed mitt from the same manufacturer show that the mitt has acquired small but significant amounts of gamma radioactivity during orbital flight. Twelve gamma-ray peaks have been measured in the difference spectra, including peaks identified as due to 214Bi and 214Pb from the uranium-radium alpha decay series, and others possibly due to the uranium-actinium series. This implies the presence of a sparse population of uranium decay products in lower orbital space which can only have come from nuclear explosions, burned-up satellite nuclear batteries, the solar wind, or supernova fragments in the local interstellar medium.

The effect of eltanolone on pulmonary vascular resistance in landrace swine.

This paper reports on the haemodynamic effects of eltanolone observed in Landrace swine during the investigation of the drug with respect to safety in malignant hyperthermia-susceptible individuals. Pigs were sedated with intramuscular ketamine, followed by induction of anaesthesia employing thiopentone administered via an ear-vein. After intubation, anaesthesia was maintained using nitrous oxide in oxygen. A total of eight pigs were then further anaesthetised on two separate occasions using one of two dose schedules. A bolus of 1.5 mg kg(-1) of eltanolone was administered, followed by a continuous infusion at either 2 or 10 mg kg(-1) h(-1). There were no significant changes in heart rate, mean arterial pressure, cardiac output or systemic vascular resistance following eltanolone. In all cases eltanolone induced marked rises in pulmonary artery pressure and pulmonary vascular resistance (P<0.01) at all measuring points and in right ventricular stroke work at 6-10 min after drug exposure. We conclude that the selective influence of eltanolone on the pulmonary vasculature is probably species-specific, but may have clinical significance in patients with pulmonary hypertension.

Eltanolone (5-beta-pregnanolone) does not trigger, and attenuates halothane triggering of, malignant hyperthermia in malignant hyperthermia susceptible swine.

Eltanolone is the lipid emulsion formulation, for intravenous use, of the steroid anaesthetic 5-beta-pregnanolone. We have screened this agent in malignant hyperthermia susceptible (MHS) Landrace swine to assess its potential to trigger the Malignant Hyperthermia (MH) syndrome in MHS subjects or to influence halothane triggering of MH in such patients. Administered in anaesthetic concentration, eltanolone did not trigger the MH syndrome in MHS swine. When co-administered in low dosage with halothane, the drug prevented initiation of the MH syndrome in four of eight pigs and attenuated its progress in the remainder.

Total i.v. anaesthesia with propofol and the laryngeal mask for orthopaedic surgery.

One hundred ASA I orthopaedic surgical patients (four randomized groups) were anaesthetized using continuous propofol and intermittent fentanyl (TIVA), with controlled ventilation via a tracheal tube in groups 1 and 2, and a laryngeal mask airway (LMA) in groups 3 and 4. Neuromuscular blockers were used in groups 1 and 3 only. There were no significant differences between groups in total anaesthetic requirements, as assessed by cardiovascular variables and movement. Coughing interfered with surgery and made controlled ventilation difficult to manage. In contrast, movement not associated with coughing did not impair surgery or ventilation. Patients in group 2 (tracheal tube, no neuromuscular blocker) required more interventions for coughing than the other groups, while patients in group 4 (LMA, no neuromuscular blocker) needed more boluses for movement than groups 1 and 3. Groups 1 and 2 (tracheal tube) had significantly higher heart rates and mean arterial pressures than groups 3 and 4 for varying periods up to 5 min after insertion of the airway management device. There was no correlation between mean arterial pressure and plasma concentrations of catecholamines related to insertion of either the tracheal tube or LMA. The LMA was found to be a highly effective device for controlled ventilation in TIVA and easier to manage than the tracheal tube in the absence of neuromuscular blockers.

Future health services--a challenge for disabled people.

Living as a disabled person in our society raises many challenges--physical, economic, political. The struggle by disabled people to escape the medical model and enter the paths of integration have not been easy. This paper explores options for participation and consumer impact.

Cerebellar pacemaker patients: an update.

Of the initial group of 38 patients in whom we have used cerebellar stimulation for treatment of intractable behavioral pathology, 25 continue to have beneficial effects. However, there have been significant technical problems due to failure of the equipment. While impairing treatment, these complications have provided inadvertent controls. The procedure must still be considered developmental at this time, despite promising therapeutic efficacy.