The College of Anaesthetists of Ireland have announced the greatest shakeup in training structure ever. Anaesthesia will now become a 6 year categorical programme with semi-automatic progression from year to year. The final year is a fellowship year in Ireland or abroad. This is an effective 2-3 year reduction in training duration.
The Western Anaesthesia Society strongly supports this initiative.

There are some potential problems on the horizon that need to be aired:

1. Anaesthesia will become hyper-competitive for entry. It seems unlikely in the future that non EU medical graduates will be able to obtain places on the BST.
2. There will be, by necessity a reduction in BST numbers. What happens to all of the non training positions and the NCHDs filling them? Will there be a parallel programme for non-EU medical graduates?
3. Shorter training and the European Work Time Directive – will our trainees obtain sufficient experience to become consultants?
4. Will it be possible to enter mid-point on the scheme – for example trainees transferring from the USA or Australia/New Zealand?
5. Modular training will be essential to ensure competencies – how can this be achieved in the era of theatre closures and austerity?
6. Clearly shorter training means less time spent in community hospitals. How are these institutions going to cope with fewer NCHDs in the future? Is the College responsible for this?
7. What about MD and Phd programs – wherefore academic anesthesia?
8. It is time to reel back the academic and administrative day that the senior SPRs may or may not utilize effectively.
9. Most importantly – what about the service gap? Fewer trainees in shorter programmes is very attractive on the surface if you are a trainee. But there are dozens of maternity wards and ICUs across the country that need nocturnal anaesthesia cover. Who is going to provide this – now that 50% of NCHD positions are no longer “training” (in reality categorical) posts. Further, as non EU graduates are unlikely to be able to access training posts, why would they come to Ireland to fill non training positions? WIll our trainees, constrained by numbers and by EWTD, find themselves working more frequently at night in low impact positions: in other words – an hour at night does not equal an hour during the day in terms of training and experience. This is a problem.

The proposed date for the Western Anaesthesia Symposium 2013 is April 26/27.  Once more it will be held in the Radisson Blu Hotel Galway.  The program is already in evolution but we warmly invite submissions for suggested topics.  Are there areas of your anesthesia or intensive care practice that have intrigued, confused or challenged you?  Are there clinical controversies in your department or hospital that you believe would benefit from discussion and debate in an open forum such as WAS?    Contact any member of the committee (two suggested addresses below) by name or anonymously, and we will give enthusiastic consideration to your suggestions for WAS 2013 or future years.

leo.kevin@hse.ie

anaesthesiawest@gmail.com

Is there anything more scary than a difficult intubation in a patient undergoing emergency Caesarian delivery? The subject was discussed by Conan McCaul at the Western Anaesthesia Symposium.

The vast majority of women in the 3rd trimester have a Mallampati score of 3 or 4. The MP grade may actually become worse during the course of labour!

Predictive tests are for Macintosh intubation – they tell us nothing about LMA, fiber optics and rescue airways. The no1. risk factor is MP4, then short neck, receding mandible and then protruding incisors and MP3. But none of these alone are great predictors – MP4 only predicts difficult airway in 4%.

The published incidence of difficult airway is 4.2% (1.8 – 6%). Failed intubations – junior doctors, out of hours and may be related to inexperience rather than bad anatomy.

In the Brigham and Women’s hospital – over 5 years there were only 100 GAs for CS and 1 in 50,000 failed intubations. CMACE 2006-8 – 1 failed ETT resulting in death (the patient had a working epidural in situ).

In reality – there are very few intubations in obstetrics now; very few difficult intubations are encountered.

Every hospital should have a failed intubation protocol that includes supraglottic airways.

The major way of reducing failed intubation is to improve the system  – obstetricians flagging high risk patients are appropriate classification of C-sections. Prophylactic epidural

CS should be categorized. For example – Cat 1 – sustained fetal brady, hemorrhage.

In utero resuscitation: oxytocin off, full left lateral position, iv fluid, tocolysis.

“Patients do not die from failure to intubate – they die from failure to stop trying to intubate”.

Jose Carvalho discussed pain following Caesarian Delivery at the Western Anaesthesia Symposium.

12-15% of patients have chronic pain 10 months following Caesarian section. This is not related to previous surgery, vertical incision, obesity or infection. The more pain a patient has postpartum, the more likely they are to have chronic pain and it is associated with postpartum depression.

The standard practice in his institution is multimodal – neuraxial opioid plus ketoralac (NSAID)  plus paracetamol. Patients can be given morphine or hydromorphone. No codeine based analgesics are given.

Certain patients are at high risk for postoperative pain. Temporal summation appears to be an effective tool for screening high risk patients.

Continuous wound infiltration with ropivicaine and diclofenac for 48 hours significantly reduces post operative pain, and may be associated with fewer side effects and length of stay versus spinal morphine (Click here for the paper – O’Neill et al).

The TAP block may be an effective method for reducing post operative pain (in the absence of neuraxial opioids), but it adds little when patients are treated with intrathecal morphine. Which is better – TAP or spinal morphine: spinal morphine.

Intravenous ketamine has been extensively studied in preventing postoperative pain. Patients that are temporal summation positive appear to benefit from ketamine.

Gabapentin appears to be quite promising for post C-Section analgesia: 600mg 1 hour before C-Section reduces postoperative pain. Click here for paper

John Laffey has presented Critical Illness in Pregnancy at the Western Anaesthesia Symposium Today. Critical illness is an uncommon but potentially devastating complication of pregnancy. The majority of pregnancy-related critical care admissions occur postpartum.

Antenatally, the pregnant patient is more likely to be admitted with diseases non-specific to pregnancy, such as pneumonia. Pregnancy-specific diseases resulting in ICU admission include obstetric hemorrhage, pre-eclampsia/eclampsia, HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, amniotic fluid embolus syndrome, acute fatty liver of pregnancy, and peripartum cardiomyopathy.

Alternatively, critical illness may result from pregnancy-induced worsening of pre-existing diseases (for example, valvular heart disease, myasthenia gravis, and kidney disease).

Pregnancy can also predispose women to diseases seen in the non-pregnant population, such as acute respiratory distress syndrome (for example, pneumonia and aspiration), sepsis (for example, chorioamnionitis and pyelonephritis) or pulmonary embolism. The pregnant patient may also develop conditions co-incidental to pregnancy such as trauma or appendicitis. Hemorrhage, particularly postpartum, and hypertensive disorders of pregnancy remain the most frequent indications for ICU admission.

Management of the critically ill mother poses special challenges. The physiologic changes in pregnancy and the presence of a second, dependent, patient may necessitate adjustments to therapeutic and supportive strategies.

The fetus is generally robust despite maternal illness, and therapeutically what is good for the mother is generally good for the fetus. For pregnancy-induced critical illnesses, delivery of the fetus helps resolve the disease process. Prognosis following pregnancy-related critical illness is generally better than for age-matched non-pregnant critically ill patients

To read a full review by this speaker on this topic click here (subscription required)

At today’s Western Anaesthesia Symposium, Joey Costello presented the latest data on post-dural puncture headache. This occurs with 1-3% of epidurals. Unfortunately, the majority of interventions that have been proposed are largely ineffective: caffeine, coca-cola, epidural saline, lying supine etc. There are promising data for co-syntropin and epidural morphine. The epidural blood patch remains the standard of care. The success rate of blood patch is 60-70%. It is 90% for a second patch. The larger the hole in the dura – the greater the likelihood that the blood patch will fail. The longer you wait to do the blood patch, the more likely it is to be successful. Best wait 2 or more days. How much blood to inject? It is unclear – certainly no more than 20ml.

This year’s Western Anaesthesia Symposium (the “Galway Meeting”) will be held in the Radission Hotel in Galway on March 2nd and 3rd. This year most of the sessions will be interactive – using audience response systems. In addition you will be able to text in questions for the experts on the panels. There will also be a special party for Anaesthetists in Training. We are looking forward to seeing you in the West.