Methods of the 7th National Audit Project (NAP7) of the Royal College of Anaesthetists: peri-operative cardiac arrest.

Cardiac arrest in the peri-operative period is rare but associated with significant morbidity and mortality. Current reporting systems do not capture many such events, so there is an incomplete understanding of incidence and outcomes. As peri-operative cardiac arrest is rare, many hospitals may only see a small number of cases over long periods, and anaesthetists may not be involved in such cases for years. Therefore, a large-scale prospective cohort is needed to gain a deep understanding of events leading up to cardiac arrest, management of the arrest itself and patient outcomes. Consequently, the Royal College of Anaesthetists chose peri-operative cardiac arrest as the 7th National Audit Project topic. The study was open to all UK hospitals offering anaesthetic services and had a three-part design. First, baseline surveys of all anaesthetic departments and anaesthetists in the UK, examining respondents' prior peri-operative cardiac arrest experience, resuscitation training and local departmental preparedness. Second, an activity survey to record anonymised details of all anaesthetic activity in each site over 4 days, enabling national estimates of annual anaesthetic activity, complexity and complication rates. Third, a case registry of all instances of peri-operative cardiac arrest in the UK, reported confidentially and anonymously, over 1 year starting 16 June 2021, followed by expert review using a structured process to minimise bias. The definition of peri-operative cardiac arrest was the delivery of five or more chest compressions and/or defibrillation in a patient having a procedure under the care of an anaesthetist. The peri-operative period began with the World Health Organization 'sign-in' checklist or first hands-on contact with the patient and ended either 24 h after the patient handover (e.g. to the recovery room or intensive care unit) or at discharge if this occured earlier than 24 h. These components described the epidemiology of peri-operative cardiac arrest in the UK and provide a basis for developing guidelines and interventional studies.

Peri-operative trans-oesophageal echocardiography and nitric oxide during general anaesthesia in a patient with Eisenmenger's syndrome.

We describe the peri-operative care of a patient with Eisenmenger's syndrome presenting for laparotomy. These patients require techniques to prevent the potential increase in intracardiac shunt caused by anaesthesia, by minimising increases in pulmonary artery pressure and reductions in systemic vascular resistance. The successful use of combined epidural and general anaesthesia with elective use of inhaled nitric oxide as a pulmonary vasodilator, and intra-operative trans-oesophageal echocardiography is described.

The effects of temporal bone on transcranial Doppler ultrasound beam shape.

A knowledge of beam shape is desirable for many Doppler ultrasound applications, and is especially important for transcranial Doppler recordings where the beam may undergo significant distortion by the skull. Although it may not be possible to determine the precise beam shape for individual cases due to variations in the physical characteristics of the media in the beam path, information about the range of beam shapes that are likely to arise for in vivo recordings from the middle cerebral artery may in future allow limits of uncertainty to be derived, and may even allow partial correction in some cases. In order to assess the potential intersubject variation in beam sensitivity across the middle cerebral artery, the beam shapes generated by four commercial Transcranial Doppler transducers and the effects on beam shape of four different samples of temporal bone were investigated. The results demonstrate that there seems to be relatively little difference in the beam shapes of commercial transducers, but that the distortion effects of temporal bone are variable and unpredictable.

Fatal flecainide intoxication.

Flecainide acetate is a potent class 1C antiarrhythmic agent used mainly for the treatment of supraventricular arrhythmias. Acute overdose of this drug is rare but frequently fatal. The clinical course of a patient that ingested a large quantity of flecainide as a suicide attempt is described and current therapeutic strategies discussed.

Surgical complications of amyloid disease.

The case of a man with primary systemic amyloidosis without myelomatosis and long-term survival is described. The patient has had major surgical complications from large amyloid deposits in the colon, dorsal spine and peritoneal cavity. The patient remains well 14 years after diagnosis.

Necrotizing granulomatous splenitis complicating leukemia in childhood.

Two children are described with acute leukemia in remission who both developed a swinging pyrexia and pathologically identical splenic necrotizing granulomata. No organisms were seen in, or isolated from, either spleen. After splenectomy, systemic symptoms persisted and did not resolve until steroids were given. The etiology of this syndrome remains unknown.

Ependymal lined paraventricular cerebral cysts; a report of three cases.

Three cases are reported, each with a benign ependymal-lined cyst which produced clinical signs and symptoms simulating cerebrovascular disease or cerebral neoplasm. The pathological features are described and their histogenesis discussed.

Cardiac lesions in fatal cases of recent myocardial ischaemia from a coronary care unit.

In 100 consecutive deaths from a coronary care unit, the coronary arteries were examined microscopically in longitudinal sections (serial and semi-serial) so that the entire extramural part of each artery was scrutinized. Occluded coronary arteries were found in 88 cases, the occlusions being due to thrombi in 17, to the contents of soft atheromatous plaques in 22, and to a mixture of soft plaque content and thrombus in 49; thus in 71 cases the coronary occlusions are due basically to the rupture of soft plaques. After deep-freezing, the entire myocardium of each heart was examined naked eye in serial slices (using Nitro-BT) and selected areas microscopically. The findings allowed tentative groupings into single episode, double episode, and progressive lesions according to age structure. Correlation of the coronary and myocardial findings has been attempted.