Tuesday 8am meetings May 2012

Tuesday 8 a.m. Meetings

 

Venue: ICU conference room 

May

1st

Thoracic anaesthesia

Dr Brian Harte

 

8th

The surgical patient with a pacemaker

Dr Leo Kevin

15th

Cardiac anaesthesia

Dr Paul Naughton

22nd

Oral opioids for acute pain: do you know your oxycontin from your oxynorm?

Dr Tadgh Lynch

29th

Pre-operative optimisation (Provisional title)

Dr Scully

 

WAS speakers at international events in 2012

WAS speakers will travel a little beyond Galway in 2012!  Here are some 2012 international events that feature lectures from WAS regulars:

Dr Brian Harte on advanced airway management

ESA Paris June 9 – 12

http://www.euroanesthesia.org/sitecore/Content/Congresses/Euroanaesthesia%202012.aspx

Dr Patrick Neligan on bariatric anaesthesia

World Congress of Anesthesia, Buenos Aires, Argentina, March 25 -30

http://www.wca2012.com/en/

Dr Leo Kevin on surgery for carotid endarterectomy

Society of Cardiovascular Anaesthesia (SCA), Boston ,USA April 28 – 31

http://www2.scahq.org/sca3/events/2012/annual/

Dr John McDonell on regional anesthesia

(ESRA), Bordeaux, France September 5 – 8

http://www2.kenes.com/esra/Pages/Home.aspx?gclid=COOc7oG65q4CFcZc3wodfiqnjg

If you are attending any of these meetings, why not drop by the ‘WAS International’ desk at the exhibit hall!

Ultrasound for central venous access

The ASA has published its guidelines for central venous access (see link below).  I am regularly amused by the slavish credence given by trainees to use of ultrasound as ‘mandatory’ for central  venous access.  Why I ask?  That ‘s what the NICE guideline says, they reply.  Do you work in the NHS I ask?

Yes ultrasound has undoubted utility for central venous access at times, and I have made good use of it.  But should it be a standard of care? Are landmark-based techniques worth learning in the modern age?  The ASA is much more luke-warm about ultrasound, as is the rest of the world! ‘Equivocal’ is the operative term throughout…

Studies show how useful US can be – but that is what the studies were meant to show!  They were performed by enthusiastic users of a new technology.

Maybe its our colonial heritage that makes us absorb NICE (and similar) admonitions as if they were coming from a high authority to which we owe allegiance.  Incidentally, the best informed UK anesthetists (several of whom with which I have worked) have many amusing things to say about the level of expertise that goes into NICE guidelines.  There has also been some thoughtful discussion in recent editions of anesthesia.

Here is the ASA link in Anesthesiology.

http://journals.lww.com/anesthesiology/Fulltext/2012/03000/Practice_Guidelines_for_Central_Venous_Access__A.13.aspx?WT.mc_id=HPxADx20100319xMP

Anaesthesia Trainees Reject Subconsultant Grade

Trainees in Anaesthesia in Ireland have given the thumbs down to the Minister of Health’s proposal for a “specialist” or “sub consultant grade”. These findings are contained in an impressive survey carried out by the group of anesthetists in training. What might be more worrying for Dr Reilly, is the sheer number of trainees planning on emigrating over the next few years. A major reason why over 80% of trainees may not return to the country is their rejection of contracts that they feel may not be equivalent to consultant colleagues. 91% would not envisage themselves employed in roles other that consultant, having finished their training. In other words – a big fat NO to the “sub consultant”, “specialist”, “associate specialist” grade (or whatever the Department of Health are calling it this week). Surprisingly, the majority of trainees would be happy to provide in house (1st call) cover as consultants and are happy to work alone (80.6%), without an NCHD (something they perceive to be different from current working practices). Perceptions indeed – 70.5% perceive that working conditions in Ireland are less attractive than abroad…..

The Western Anaesthesia Society has a policy on “subconsultants”: simply – a permanent job post CCST = consultant. The term “consultant” is emotional, of course and probably anachronistic. Elsewhere “attending physician” or “hospital specialist” is used, and these terms – although referring to consultants – conjure up different images. In some ways, from a sociopolitical perspective, it may be better to use the term “hospital specialist” as the current moniker has been severely soured by the media in recent years. But, whatever way you look at it – post CCST clinical specialist, with full autonomy, expected to teach trainees and medical students, participate in audit and research: sounds a lot like a consultant to us!

Perhaps the minister might take heed of these findings and engage the group of professionals whose future careers he seems intent on defining.

College Announces Run-Through Training

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.

Symposium 2013: What would you like to hear?

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

Ultrasound for Neuraxial Anaesthesia

Most of the time that we palpate the spine (70%) we are incorrect at assessing the level of the spine that we are palpating blindly. In the future ultrasound guidance will be standard of care for spinal anesthesia, according to Jose Carvlho, from Toronto at the Western Anaesthesia Symposium.

Does the line drawn across the iliac crests really cross the spine at L4? Actually it is usually at the level of L2,3 (or even higher). In addition, using the palpation technique usually results in a fishing expedition for the subarachnoid space, and the distance from skin to dura is much shorter than we think. Experienced operators state that they rarely have to reach for “the long needle” when using US for obese patients.

US is  very useful in patients that have had back surgery and have kyphoscoliosis – you can identify the the rods and spaces that have been spared. In addition, some patients have abnormal anatomy of the ligmentum flavum, and this might result you in using a different interspace or avoid, for example, placing an epidural. NICE, in the UK, first advocated the use of US in 2008; perhaps prematurely.

Spinal ultrasound is very easy – there are two patterns – the transverse approach that looks like the batman (or flying bat) sign. The saggital plane is used for identifying the sacrum – it looks like a saw (the teeth of the saw – peaks and troughs): you can then find the interspaces. A curvilinear probe is used – it is the same transducer that the obstetricians use – low frequency but high penetration.

The saggital view is used first – it is paramedic – this gives you the saw sign. The first trough seen is the L5,S1 interspace. This tells you where you are! You can place a mark adjacent to the level that you have chosen – and this is your horizontal level.

When you do the transverse scan – you see the sharp (paper cut) dural space – and you can measure, clearly, from the skin, the depth of the dura. Then you mark at the level that you had a great view of the space (vertically). You have now 2 marks on the skin – draw intersecting lines – and voila the point that you find is the needle insertion site!

Depth estimation is very accurate with ultrasound, but not as much with obese patients as you tend to compress fat – and underestimate the depth. Dr Carvalho is now using a paramedian approach to offset this problem.

A huge advantage of US is that you often find that some interspaces are very difficult to access (“bone, bone, bone”), some, in the same patient, are easy. Read here for more information.

Finally, Dr Carvalho is currently using ultrasound to look at stomach contents – whether the stomach of a laboring patient is full or empty. Two groups, one in France and one in Toronto are actively researching this field. Abstracts here and here. Food an air (full stomach) demonstrates a “frosted glass” sign.

Difficult Airway in the Obstetric Population

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”.