The following abstracts were presented at the Association of Anaesthetists of Great Britain & Ireland’s Group of Anaesthetists in Training (GAT)’s Annual Scientific Meeting in Cardiff, July 2010
Impact of gender, hand dominance and computer game experience on fibreoptic 'scope handling skills
M. Roberts, 1 E. Boucher, 2 A. R. Wilkes1 and I. Hodzovic1
1 Department of Anaesthetics and Intensive Care Medicine, School of Medicine, Cardiff University, Cardiff, UK
2 Department of Anaesthetics and Intensive Care Medicine, Royal Gwent Hospital, Newport, UK
Male gender, right hand dominance and computer game experience are associated with superior laparoscopic performance amongst surgeons . We could not find similar data related to fibreoptic 'scope handling skills amongst anaesthetists. We used two fibreoptic 'scope training models, the Oxford Box  and modified AirSim Multi manikin to assess impact of gender, hand dominance and computer game experience on fibreoptic manipulation performance.
Ethical approval was sought, but deemed not necessary for this volunteer study. Anaesthetists were asked to complete a standardised task on the Oxford Box and AirSim manikin in a randomised order. Task completion times and tip collision count were recorded. Tip collisions were independently counted from a video of the fibreoptic view, by two blinded instructors, three times each. Data obtained from 50 anaesthetists, with a wide range of experience, were used in this analysis. Mann-Whitney test was used for all analyses.
Data of twenty-four male and 26 female anaesthetists were analysed. The effect of gender on the task completion time and collision count is shown in Table 1.
Table 1. Task completion time and collision count for male and female anaesthetists. Values are median (range).
|Males||96 (35–267)||6 (1–30)||81 (35–144)||3 (0–8)|
|Females||154 (75–451)||10 (2–34)||90 (46–155)||3 (0–10)|
Hand dominance had no significant effect on the completion times or collision counts for either the Oxford Box (p = 0.25 and p = 0.37, respectively) or manikin (p = 0.25 and p = 0.67, respectively). Similarly, regular computer game use did not have a significant effect on performance (completion time or collision count) on either of the two fibreoptic 'scope trainers.
The superior performance of male anaesthetists on the Oxford Box trainer suggests better visuospatial and psychomotor skills. Task familiarity may even outweigh any inherent male advantage, as the difference was absent on the manikin, the task most similar to clinical practice. Uneven group sizes may explain the absence of effect of hand dominance and computer game use on the fibreoptic 'scope handling skills. Future studies should be performed to evaluate our findings further.
1 Grantcharov TP, Bardram L, Funch-Jensen J, Rosenberg J. Impact of hand dominance, gender and experience with computer games on performance in virtual reality laparoscopy. Surgical Endoscopy 2003; 17: 1082– 5.
2 Popat M, Benham SW, Kapila A, Addy V. Randomised controlled trial of learning fibreoptic skills on the ‘Oxford’ training box. Difficult Airway Society Abstract book 199: 61–2.
Time to oxygenation using the Quicktrach I emergency cricothyroidotomy device versus a choice of devices in a simulated ‘can’t intubate, can’t ventilate’ scenario
N. N. Tailor, 1 R. M. Knights, 1 A. Ingham, 2 J. Walker2 and D. Maloney2
1 Wales Deanery Anaesthetic Rotation, UK
2 Anaesthetic Department, Ysbyty Gwynedd, Betsi Cadwaladr University Health Board, Bangor, UK
Cricothyroidotomy is an emergency life-saving procedure used in a ‘can’t intubate, can’t ventilate’ situation . A simulator-based study was designed to compare how the Quicktrach I, a purpose-made emergency cricothyroidotomy device, would perform against existing equipment available for emergency cricothyroidotomy at Ysbyty Gwynedd.
Local research ethics committee approval was obtained for this randomised, crossover study. Twenty anaesthetists were asked to perform a cricothyroidotomy and oxygenate a modified Laerdel SimMan® in a simulated ‘can’t intubate, can’t ventilate’ scenario. Participants completed two simulations. In one, only the Quicktrach I was available. In the other, participants could use all available kit in the anaesthetic room and the cricothyroidotomy devices on the difficult intubation trolley (Cook Melker Emergency Cricothyroidotomy Catheter set, Portex Mini-trach II Seldinger kit and Cook emergency transtracheal airway catheter with Enk Oxygen Flow Modulator), but not Quicktrach I. The primary outcome was the time taken to achieve an oxygen concentration of 40%. Participants then ranked the devices in order of preference, and were questioned on their previous training and experience with the equipment. The differences in procedure times were analysed using the Wilcoxon rank-sum test.
The time to oxygenation with the Quicktrach I was significantly faster than with ‘all available kit’ (median 47.5 vs 134 s; p < 0.001), even in those participants who had no previous exposure to it, but had been trained in the use of their chosen device in the ‘all available kit’ group (55 vs 134 s; p = 0.005). The Quicktrach I was the most highly ranked device, with 15 out of 20 making it their first choice. These results are comparable to other studies .
We have shown that Quicktrach I allows rapid oxygenation and does so faster than the anaesthetist’s alternative chosen device. This is true even when the operator has never encountered the Quicktrach I before. We propose that all areas where patients undergo tracheal intubation should have immediate access to the Quicktrach I.
1 Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult airway society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59: 675– 94.
2 Dimitriadis JC, Paoloni R. Emergency cricothyroidotomy: a randomised crossover study of four methods. Anaesthesia 2008; 63: 1204–8.
The use of procalcitonin in sepsis: a district general intensive care unit experience
M. Huntley, J. Schutzer-Weissmann and A. Knight-George
Intensive Care Unit, Hillingdon Hospital, London, UK
Monitoring procalcitonin in patients with sepsis has been shown to reduce the length of antibiotic therapy and the intensive care unit (ICU) admission [1–3]. We investigated whether routine monitoring of procalcitonin on a typical nine-bedded district general ICU was practical and cost-effective.
Over an 8-week period, we identified all new ICU patients with a diagnosed or suspected infection. We made a structured clinical assessment and measured procalcitonin, white cell count (WCC) and C-reactive protein (CRP) each morning of their admission. The WCC and CRP result was revealed to the consultant on the midday ward round. Subsequent decisions regarding antibiotic management and suitability for ward discharge were recorded. The procalcitonin result was revealed on the afternoon ward round and the consultant was asked what changes they would now make to their earlier management decisions.
Twenty-six patients were included in the study. The procalcitonin level corresponded with the consultant’s assessment of patient progress and septic status more commonly than did WCC or CRP. On the basis of procalcitonin, escalation of antibiotic therapy was avoided in seven (27%) patients and discontinued sooner in five (19%) patients. This resulted in an estimated cost saving of £3095.
This study provides a useful insight into monitoring procalcitonin on a district general ICU. From our experience, procalcitonin promoted earlier discontinuation of antibiotics; prevented escalation to second- or third-line agents; more readily supported the consultant’s clinical assessment and facilitated decision-making. Our estimates of cost savings as a result of improved antibiotic management more than justify the cost of monitoring procalcitonin.
1 Bouadma L, Luyt CE, Tubach F, et al. Use of procalcitonin to reduce patients’ exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial. Lancet 2010; 375: 463–74.
2 Christ-Crain M, Jaccard-Stolz D, Bingisser R, et al. Effect of procalcitonin-guided treatment on antibiotic use and outcome in lower respiratory tract infections: cluster-randomised, single-blinded intervention trial. Lancet 2004; 363: 600–7.
3 Tang H, Huang T, Jing J, et al. Effect of procalcitonin-guided treatment in patients with infections: a systematic review and meta-analysis. Infection 2009; 37: 497–507.
Mitochondrial uncoupling proteins and energetics in human heart and skeletal muscle
A. Johnson, 1 C. Holloway, 1 L. Edwards, 1 L. Heather, 1 L. Cochlin, 1 D. Taggart, 2 C. Ratnatunga, 2 R. Pillai, 2 R. Evans1 and K. Clarke1
1 Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
2 Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford, UK
Heart failure is a progressive disease with a high mortality, suggesting that the fundamental cellular mechanisms leading to failure are not being addressed. In heart failure, the ratio of phosphocreatine to adenosine triphosphate (PCr:ATP) in the myocardium is decreased, and PCr re-synthesis times following exercise in skeletal muscle are increased, both of which suggest mitochondrial dysfunction, but the cause remains unknown. We postulate that increased expression of mitochondrial uncoupling protein 3 (UCP3) in cardiac and skeletal muscle underlies the mitochondrial dysfunction in heart failure.
With ethics committee approval and after informed consent, 47 patients having cardiac surgery underwent pre-operative 31P magnetic resonance spectroscopy of cardiac and skeletal muscle and measurement of fasting plasma free fatty acids. Intra-operatively, ventricular and skeletal muscle biopsies were taken for measurement of UCP3 expression.
Plasma free fatty acids increased (rs = .28; p = .04), myocardial PCr:ATP decreased (rs = −.42; p < .01) and skeletal muscle Qmax decreased (rs = −.33; p = .03) with increasing heart failure severity. Ventricular UCP3 increased with severity of heart failure (rs = .32; p = .03) and correlated negatively with myocardial PCr:ATP (r = −.33; p = .03). Skeletal muscle UCP3 expression correlated negatively with Qmax (r = −.33; p = .02), but not with heart failure severity. UCP3 expression did not correlate with plasma free fatty acid concentration.
UCP3 expression is associated with energetic dysfunction in cardiac and skeletal muscle and is increased in the failing ventricle, which could partially explain the decreased myocardial PCr:ATP in heart failure.
Improving fluid prescription in trauma patients
S. J. Cross and L. S. McLaughlan
Department of Anaesthesia, Queen Margaret Hospital, Dunfermline, UK
Studies show that new doctors have inadequate knowledge and sub-optimal fluid prescribing skills . The Scottish Audit of Surgical Mortality states that problems with fluid management are thought to contribute to poor outcomes . The recent publication of a British consensus guideline on intravenous fluid for surgical patients, GIFTASUP , has brought this controversial issue back into the limelight. Anecdotal evidence suggested that fluid prescribing for peri-operative trauma patients locally was poor.
We audited the prescription of maintenance fluids to adult patients on the trauma list for 20 days. A tutorial on fluid management was conducted for foundation doctors and the audit subsequently repeated. Key teaching points included assessing fluid status and ensuring appropriate replacement of water, sodium and potassium in maintenance fluid. Data collected included the rate, type and volume of intravenous fluid prescribed, age, American Society of Anesthesiology (ASA) grade and operation. Graphpad Prism was used for data analysis.
There were 85 patients in the first group and 86 in the second. Two patients in the critical care unit pre-operatively were not studied as were three patients who were prescribed less than 12 h of fluid. There was no significant difference between the two groups in age (p = 0.37), category of surgery (p = 0.26), or ASA grade (p = 0.68). More patients in the second group received fluids (51 (61%) vs 27 (33%); p = 0.0004), but the duration of intravenous fluids was no different (16.5 h vs 16.8 h; p = 0.87). The volume of fluids prescribed reduced from a mean (SD) of 1917 (1039) ml to 1408 (317) ml (p = 0.002). The type of fluid changed to include more Hartmann’s solution instead of saline (21% vs 83%; p < 0.0001). The potassium prescribed increased from a mean (SD) of 10 (17) mmol to 23 (17) mmol (p = 0.002), while the sodium was reduced from a mean (SD) of 250 (102) mmol to 102 (44) mmol (p < 0.0001).
Following an education session, Foundation Doctors prescribed fluids much more closely to the recommended daily requirements, with a reduction in sodium load, an increased prescription of potassium and the introduction of balanced salt solutions. We hope this will contribute to reducing morbidity and mortality. A regular teaching session and e-learning package are being introduced to ensure that these changes are maintained.
1 Lobo DN, Dube MG, Neal KR, et al. Problems with solutions: drowning in the brine of an inadequate knowledge base. Clinical Nutrition 2001; 20: 125–30.
2 The Scottish Audit Of Surgical Mortality Summary Report 2009 (2008 Data). Edinburgh: ISD Publications Scotland, 2009.
3 Powell-Tuck J, Gosling P, Lobo DN, et al.. British consensus guidelines on intravenous fluid therapy for adult surgical patients GIFTASUP. http://www.bapen.org.uk/pdfs/bapen_pubs/giftasup.pdf (accessed 08/09/10).
Frequency of British publications in five high impact factor anaesthetic journals
F. M. Morell-Ducos1 and R. Haniffa2
1 Department of Anaesthesia, Chase Farm Hospital, London, UK
2 Department of Anaesthesia, University College London Hospital, London, UK
A decreasing quantity of published original research from the UK in recent years has been described , and it has been suggested that this indicates a decrease in British anaesthetic academic activity. We undertook a review of five high impact factor anaesthetic journals (Anaesthesia, British Journal of Anaesthesia [BJA], Anesthesiology, Anesthesia and Analgesia, and Acta Anaesthesiologica Scandinavica) during the period from January 2006 to December 2009. Our aim was to document and assess any change in the previously reported trend in academic output from the UK.
The electronic archives of the journals in question for the defined period were accessed. We included all types of articles apart from letters and editorials, and subdivided these into original (experimental research, randomised controlled trials, observational studies, equipment assessment) and non-original research (the remainder).
Table 2 shows the trend in the number of original articles surveyed over the period 2006–2009.
Table 2. Original articles published in the five journals surveyed over the period 2006-2009. Values are number or proportion.
|British Journal of Anaesthesia||28||35||30||30|
|Anesthesia and Analgesia||4||7||12||6|
|Acta Anaesthesiologica Scandinavica||1||3||1||1|
|Original publications as a percentage of all types of publications||40.1%||41.7%||40.7%||38.3%|
The predominance of Anaesthesia, followed by the BJA, in the publication of all types of articles in anaesthetic literature originating from the UK can be appreciated. The previously described downward trend in the period 1997–2006 in original British literature  is not evident in our survey of the period 2006–2009, showing year-on-year increases in the journals Anaesthesia for 2007–2008; the BJA for 2006–2007; Anesthesia and Analgesia for 2007–2008; and Anesthesiology for 2008–2009. The proportion of original research as a percentage of the total published output appears stable at around 40% throughout the 4-year period.
1 Feneck R, Natarajan N, Sebastian R, Naughton C. Decline in research publications from the United Kingdom in anaesthesia journals from 1997 to 2006. Anaesthesia 2008; 63: 270–5.