Advanced life support skills undertaken by nurses--UK survey.

Many nurses successfully complete the Resuscitation Council (UK), European Resuscitation Council, advanced life support (ALS) Provider Course. Acquiring ALS provider status is not necessarily a licence to practice and individual hospital policy determines which skills these nurses can then perform without direct medical supervision. This postal survey aimed to determine which ALS skills are utilised by nurse ALS providers working in a variety of clinical areas within acute hospitals in the UK. A questionnaire was sent to the Resuscitation Officer or Nursing Director of all acute hospital groups in the UK. Almost 261 (87%) of the questionnaires were completed and returned. Nurse ALS providers in 99% of coronary care units, 89% of intensive care units, and 88% of accident and emergency departments undertook manual defibrillation. The majority of hospitals ran compulsory in-house training sessions for intravenous cannulation. Laryngeal mask insertion by nurse ALS providers was permitted in 19% of coronary care units and in the wards of 16% of the responding hospitals. Tracheal intubation by nurse ALS providers working in coronary care units, intensive care units and emergency departments was permitted by 11% of the responding hospitals. This survey has demonstrated that many acute hospitals do not permit nurse ALS providers to use a number of the skills taught on the ALS provider course. General ward-based nurse ALS providers, in particular, are restricted in the ALS skills, they are permitted to use. It would be more efficient for nurses to be trained and assessed specifically in skills they are then permitted to use. Having been assessed in a given skill and achieved a nationally recognised standard, nurse ALS providers should be permitted to use it in clinical practice.

Supraventricular tachycardia complicating the use of prostaglandin vaginal gel for induction of labour.

We present a case of a 31-year-old female patient who developed a supraventricular tachycardia and haemodynamic instability secondary to the use of vaginal prostaglandin E(2)gel for induction of labour. This complication occurred despite the patient's young age, absence of pre-existing ischaemia or coronary artery spasm, and the use of vaginal, rather than intravenous or intramyometrial prostaglandin. Physicians should be aware that serious cardiovascular complications can occur with vaginal prostaglandin E(2)therapy even in the absence of pre-existing risk factors.

Thoracic epidural anaesthesia and analgesia: United Kingdom practice.

BACKGROUND: Thoracic epidural analgesia has become increasingly practised in recent years. Complications are rare but potentially serious and, consequently, careful evaluation is required before undertaking this technique. The practice surrounding this procedure varies widely amongst anaesthetists. METHODS: A postal survey to examine the practice of thoracic epidural analgesia was sent to all Royal College of Anaesthetists tutors in the United Kingdom. RESULTS: Responses were received from 240 tutors, representing a return rate of 83%. When obtaining consent for thoracic epidural cannulation, 42% of respondents mentioned risk of a dural tap complication and 11% mentioned neurological damage. Fifty percent of respondents performed epidural cannulation following induction of general anaesthesia. The practice of epidural insertion in patients with abnormal coagulation varied, although over 80% of respondents did not consider concurrent treatment with either aspirin or non-steroidal anti-inflammatory drugs a contraindication. Sterile precautions for epidural insertion also varied between anaesthetists. Postoperatively, 95% of respondents used an opioid-based bupivacaine solution for epidural infusions, and these were most commonly nursed on general surgical wards (63%). Seventy-eight percent of hospitals provided an acute pain team to review epidural analgesia. CONCLUSION: In the United Kingdom, there is little consensus in the practice of thoracic epidural analgesia relating to the issues of informed consent, epidural cannulation in patients with deranged clotting and the sterile precautions taken prior to performing epidural insertion. Most respondents use an opioid-based bupivacaine solution to provide postoperative epidural analgesia. Most hospitals in the UK now provide an acute pain service for thoracic epidural follow-up.

Patient-controlled intranasal diamorphine for postoperative pain: an acceptability study.

A patient acceptability study was conducted using patient-controlled intranasal diamorphine. Patients undergoing nonemergency orthopaedic or gynaecological surgery self-administered intranasal diamorphine for 24 h postoperatively. Pain, pain relief, sedation, respiratory rate, nausea and vomiting were assessed regularly. After 24 h, patients and their attending nurses completed a questionnaire assessing satisfaction and practical aspects of the technique. Satisfaction was reported as good or complete by 69% of patients and 69% of nurses. Pain relief was assessed as better than expected by 45% of patients and better than normal by 50% of nurses. Seventy-nine per cent of patients would be pleased to use patient-controlled intranasal diamorphine again and 89% of nurses would be happy for their patients to use it again. Sedation was uncommon and mild and there were no episodes of significant respiratory depression. Fifty-three per cent of patients reported no nausea and 74% did not vomit at any stage. There were seven withdrawals, four due to problems with the device and three due to therapeutic problems. The nasal spray may need modification to improve reliability. However, we found patient-controlled intranasal analgesia an effective technique, which was well tolerated by patients and nurses and was without unpleasant side-effects. Further work to determine how it performs compared with intramuscular or intravenous analgesia is now needed.

A neurogenic mechanism for symmetrical arthritis.

Human synovium is richly innervated by autonomic and sensory nerve fibres, many of which contain neuropeptides. The hypothesis is that, in addition to a sensory role, some of these fibres modulate the response of the synovial membrane to a variety of noxious stimuli by releasing these peptides. Synovial damage results in acute inflammation in the damaged joint and a neurogenically mediated infiltrate of inflammatory cells in the contralateral joint. These cells might protect the contralateral synovium from injury similar to that in the damaged joint. An increased response would lead to synovitis and symmetrical disease.