The effects of fatigue on trainees in anaesthesia

McClelland, L. et al. | A national survey of the effects of fatigue on trainees in anaesthesia in the UK | Anaesthesia |2017; 72: 1069–77

Introduction

Long shifts remain a major feature of working life for trainees in anaesthesia. Over the past 10 years, there has been an increase in awareness and understanding of the potential effects of fatigue on both the doctor and the patient. Despite the introduction of the European Working Time Directive into UK law, reducing the maximum hours worked by junior doctors, there is evidence that problems with inadequate rest and fatigue persist.

Methods

These authors conducted a national survey to assess the incidence and effects of fatigue among the 3772 anaesthetists in training within the UK.

Results

A response rate of 59% was achieved, with data from 100% of NHS trusts. The results suggested that fatigue remains prevalent among junior anaesthetists, with 73.6% saying that it has effects on physical health, 71.2% that it affects psychological wellbeing and 67.9% that personal relationships are affected. The most problematic factor remains night shift work, with many respondents commenting on the absence of breaks, inadequate rest facilities and 57.0% stating that they had experienced an accident or near-miss when travelling home from night shifts.

Conclusions

The authors discuss potential explanations for the results, and present a plan to address the issues raised by their survey, aiming to change the culture around fatigue for the better.

Full article available via Wiley online Library

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A survey of acute pain services in the UK

The organisational state of inpatient pain management in UK hospitals is difficult to determine. We sent an electronic questionnaire to 209 acute pain service leads throughout the UK | Anaesthesia

Questions were about staffing and service provision. We received 141 responses (67%); 47% of all UK hospitals.

Each service was responsible for a median (IQR [range]) of 566 (400–839 [120–2800]) beds. Each acute pain specialist nurse was responsible for 299 (238–534 [70–1923]) beds. The mean (SD) number of consultant hours per week was 5.54 (4.62), delivered by a median of 1.0 (1.0–2.5 [0.2–7.0]) consultant. Overnight cover was provided by 20 (15%) acute pain services, and weekend cover by 39 (29%).

Acute pain services commonly (in 50 (35%) hospitals) had roles in addition to acute pain management. Most teams (105, (77%)) reviewed medical patients and patients with chronic pain (in 131, (96%) teams). Half of the services (56, (49%)), reported that they were part of an integrated acute and chronic pain service, however, 83 (59%) did not have any members who work in chronic pain clinics. The majority (79, (70%)) were able to access a nominated chronic pain consultant for advice.

Provision of acute pain services throughout the UK is highly variable. The majority do not meet core UK standards.

Full reference: Rockett, M. et al. (2017) A survey of acute pain services in the UK. Anaesthesia. Vol. 72 (Issue 10) pp. 1237–1242.

Information format and timing before scheduled adult surgery for peri-operative anxiety

A systematic review including 34 trials with 3742 participants, identified through 6 database and supplementary searches | Anaesthesia

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Image source: chico945 – Flickr // CC BY 2.0

A multimedia format, alone or in combination with text or verbal formats, was studied in 20/34 (59%) trials: pre-operative anxiety was unaffected in 10 out of 14 trials and reduced by the multimedia format in three; postoperative anxiety was unaffected in four out of five trials in which formats were compared. Multimedia formats increased knowledge more than text, which in turn increased knowledge more than verbal formats. Other outcomes were unaffected by information format.

The timing of information did not affect pre-operative anxiety, postoperative pain or length of stay.

In conclusion, the effects of pre-operative information on peri-operative anxiety and other outcomes were affected little by format or timing.

Full reference: Hounsome, J. et al. (2017) A systematic review of information format and timing before scheduled adult surgery for peri-operative anxiety. Anaesthesia. Vol. 72 (Issue 10) pp. 1265–1272

Guidelines for procedural sedation and analgesia in adults

Hinkelbein, J. et al. | European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults | European Journal of Anaesthesiology

Abstract

Procedural sedation and analgesia (PSA) has become a widespread practice given the increasing demand to relieve anxiety, discomfort and pain during invasive diagnostic and therapeutic procedures.

The European Society of Anaesthesiology (ESA) and the European Board of Anaesthesiology have created a taskforce of experts that has been assigned to create an evidence-based guideline and, whenever the evidence was weak, a consensus amongst experts on: the evaluation of adult patients undergoing PSA, the role and competences required for the clinicians to safely perform PSA, the commonly used drugs for PSA, the adverse events that PSA can lead to, the minimum monitoring requirements and post-procedure discharge criteria.

A search of the literature from 2003 to 2016 was performed by a professional librarian and the retrieved articles were analysed to allow a critical appraisal according to the Grading of Recommendations Assessment, Development and Evaluation method.

These guidelines contain recommendations on PSA in the adult population. It does not address sedation performed in the ICU or in children and it does not aim to provide a legal statement on how PSA should be performed and by whom. The National Societies of Anaesthesiology and Ministries of Health should use this evidence-based document to help decision-making on how PSA should be performed in their countries.

Full document available here

Anaesthetic management of patients with myopathies

Schieren, M et al.  Anaesthetic management of patients with myopathies.  European Journal of Anaesthesiology | October 2017 | Volume 34 |Issue 10 | p 641–649

Abstract:

The anaesthetic management of patients with myopathies is challenging. Considering the low incidence and heterogeneity of these disorders, most anaesthetists are unfamiliar with key symptoms, associated co-morbidities and implications for anaesthesia.

The pre-anaesthetic assessment aims at the detection of potentially undiagnosed myopathic patients and, in case of known or suspected muscular disease, on the quantification of disease progression. Ancillary testing (e.g. echocardiography, ECG, lung function testing etc.) is frequently indicated, even at a young patient age.

One must differentiate between myopathies associated with malignant hyperthermia (MH) and those that are not, as this has significant impact on preoperative preparation of the anaesthesia workstation and pharmacologic management. Only few myopathies are clearly associated with MH.

If a regional anaesthetic technique is not possible, total intravenous anaesthesia is considered the safest approach for most patients with myopathies to avoid anaesthesia-associated rhabdomyolysis. However, the use of propofol in patients with mitochondrial myopathies may be problematic, considering the risk for propofol-infusion syndrome. Succinylcholine is contra-indicated in all patients with myopathies.

Following an individual risk/benefit evaluation, the use of volatile anaesthetics in several non-MH-linked myopathies (e.g. myotonic syndromes, mitochondrial myopathies) is considered to be well tolerated. Perioperative monitoring should specifically focus on the cardiopulmonary system, the level of muscular paralysis and core temperature. Given the high risk of respiratory compromise and other postoperative complications, patients need to be closely monitored postoperatively.

Full document available here

SafeguardingPlus – new information for anaesthetists

Protecting patients from harm and abuse is the responsibility of practitioners from all medical specialties. Anaesthetists play a particularly critical role in safeguarding due to their work across the perioperative pathway | RCoA

Today, the Royal College of Anaesthetists launches SafeguardingPlus – a new resource of peer-reviewed education and information to provide advice for anaesthetists on how to identify, manage and prevent harm in patients and improve understanding of consent and ethical issues.

We hope the new webpages will help support anaesthetists to deal with a safeguarding concern, or a consent or ethical issue in the perioperative setting, whether it relates to a child, young person or an adult, wherever they work in the UK.

The web pages contain key references, bespoke resources and materials and also provide links to shorter pieces on specific topic areas, including confidentiality, duty of candour, restraint, and DNACPR, with signposting to well-developed and up-to-date guidance.

Read the full overview here

Trauma Airway Management: Considerations and Techniques

It’s 2 am and you have just finished an emergency appendectomy when you get “that” call. Your friend down in the emergency department (ED) has a patient arriving in a few minutes who was assaulted in a local prison | Anesthesiology News

After asking for your potential assistance with his airway and mumbling something about a knife, he hangs up. You’ve been working nonstop since yesterday morning, so the only thing on your mind involves a pillow and the supine position. Nevertheless, you make your way down to the ED and arrive just as the medics roll in with their patient. He is awake and yelling as they roll him by you into the trauma bay. The emergency medical technician is applying pressure to the side of the patient’s neck and there is a large knife sticking out of the middle of the patient’s face (Figure 1). Your friend takes one look and asks you to help by managing the airway while he coordinates the rest of the trauma resuscitation. It looks like your night is about to get a lot more interesting!

Read the full article here