South-East Scotland School of Anaesthesia

Ergonomics in relation to anaesthesia is the scientific study of the interaction between anaesthetists and their workspace environment in order to promote safety, performance and well-being. The foundation for avoiding pain or discomfort at work is to adopt and maintain a good posture, whether sitting or standing. Anaesthetists should aim to keep their posture as natural and neutral as possible. The successful practice of anaesthesia relies on optimisation of ergonomics and lack of attention to detail in this area is associated with impaired performance. The anaesthetic team should wear comfortable clothing, including appropriately-sized personal protective equipment where necessary. Temperature, humidity and light should be adequate at all times. The team should comply with infection prevention and control guidelines and monitoring as recommended by the Association of Anaesthetists. Any equipment or machinery that is mobile should be positioned where it is easy to view or reach without having to change the body or head position significantly when interacting with it. Patients who are supine should, whenever possible, be raised upwards to limit the need to lean towards them. Any item required during a procedure should be positioned on trays or trolleys that are close to the dominant hand. Pregnancy affects the requirements for standing, manually handling, applying force when operating equipment or moving machines and the period over which the individual might have to work without a break. Employers have a duty to make reasonable adjustments to accommodate disability in the workplace. Any member of staff with a physical impairment needs to be accommodated and this includes making provision for a wheelchair user who needs to enter the operating theatre and perform their work.

BACKGROUND AND AIMS: Advance warning of patients who are difficult to intubate may prevent an airway catastrophe but relies on effective communication between specialties. Anaesthetists aim to inform general practitioners whenever a difficult airway is encountered and expect general practitioners to include this information in subsequent referrals. We investigated how anaesthetists communicated with general practitioners, their knowledge of the Read Code (used by general practitioner computer systems) for difficult tracheal intubation, and how likely general practitioners were to pass the information on. METHODS AND RESULTS: We surveyed 631 consultant anaesthetists and 217 general practitioners. We found only 125 (20%) anaesthetists consistently wrote difficult airway letters to general practitioners. Only 20 (3%) knew the Read Code for difficult intubation (SP2y3), although 454 (72%) thought it to be useful. Most general practitioners (212, 98%) thought airway information to be important, but only half receiving a difficult airway communication forwarded it on. General practitioners recommended including the Read Code SP2y3 and labelling it 'high priority', ensuring that 'Difficult Tracheal Intubation' would be listed in the Emergency Care Summary generated for hospital referrals. CONCLUSION: Communication between anaesthetists and general practitioners is currently poor, but could be improved by simplifying difficult airway letters and including the SP2y3 code and a statement of priority.

*Department of Anaesthesia, Queen Margaret Hospital, Dunfermline, United Kingdom; †South East Scotland School of Anaesthesia; and ‡Departments of Anaesthesia and Critical Care, Royal Infirmary, Edinburgh, United Kingdom.

As clinicians working in critical care, it is our duty to provide all of our patients with the high-quality care they deserve, regardless of their gender identity. The transgender community continues to suffer discrimination from the media, politicians and general public. As healthcare workers we often pride ourselves on our ability to safely care for all patients. However, there remains a distinct lack of understanding surrounding the care of critically ill transgender patients. This is likely in part because the specific care of transgender patients is not included in the Faculty of Intensive Care Medicine's, Royal College of Anaesthetists', Royal College of Physician's, or Royal College of Emergency Medicine's curriculum. There are several important considerations relevant for transgender patients in critical care including anatomical changes to the airway, alterations to respiratory and cardiovascular physiology and management of hormone therapy. Alongside this, there are simple but important social factors that exist, such as the use of patient pronouns and ensuring admittance to correctly gendered wards. In this review we will address the key points relevant to the care of transgender patients in critical care and provide suggestions on how education on the subject may be improved.

As the population ages, there is a higher prevalence of both dementia and conditions that require major surgery. However, patients with dementia undergoing surgery have poorer outcomes than surgical patients without dementia. This article explores new guidance about delivering perioperative care for patients with dementia presenting for surgery. Management of patients with cognitive changes begins with developing an understanding of the classifications and pathophysiology of these disease processes, and addressing any modifiable risk factors for developing dementia, postoperative cognitive decline and postoperative delirium. Thorough preoperative assessment provides the opportunity to identify patients with and at risk of these cognitive impairments and to involve the appropriate multidisciplinary team in care planning. Once patients are identified, an individualised perioperative management plan addressing any issues surrounding capacity and consent, conduct of anaesthesia, possible polypharmacy and potential drug interactions, and postoperative pain management can improve quality of care and outcomes for these patients.

Abstract The future and sustainability of the anaesthetic workforce is a growing concern with a projected shortfall of 11,000 anaesthetists by 2040. The supply of anaesthetists able to provide safe anaesthesia care does not meet the rising demand of surgical waiting lists. In recent years, changes to recruitment and curricula for anaesthetic specialty training have resulted in significant bottlenecks to training progression, further compounding the deficit in the numbers of fully trained anaesthetists. A rapid expansion the Anaesthesia Associate (AA) workforce has been proposed as one of the solutions to this worsening gap. However, no robust analysis of the impact of the expansion in AA numbers on anaesthetists in training has been conducted. There remain a number of concerns regarding access to training experience, scope of supervision, out of hours workload, equity of pay and cost of training, as well as the impact on future numbers of anaesthetists in training. In order to help shape the future integration of this workforce, we surveyed current anaesthetists in training, asking about their experiences of working with AAs, and their perceptions of the future expansion and regulation of these associate professionals. Through an online survey, we collected both quantitative and qualitative data to give a thorough representation of anaesthetists in training experience. Our results confirm that the impact of AAs on training remains a polarising topic. A third of anaesthetists in training with prior experience of working with AAs reported a negative impact on their training experience. Factors mentioned included lack of case numbers, lack of access to learning and performing regional anaesthesia, and lack of clarity in lines of supervision. Of those with no prior experience working with AAs, there was a strong negative perception towards expansion of the workforce. A small proportion described a positive experience, indicating that with clear role definition, careful implementation along with co-operation, a positive experience in all departments could be achievable. Our findings suggest a need for increased consultation and communication with stakeholders in the anaesthesia workforce, including anaesthetists in training, to ensure smooth and safe integration of the AA workforce.

Summary The most recent ST3 Anaesthetic recruitment for posts commencing in August 2021 saw larger numbers of applicants (n = 1,056) compared to previous years, with approximately 700 applicants failing to secure an ST3 post. We surveyed 536 anaesthetic junior doctors who applied for ST3 posts during this application round with the aim of investigating their experience of the recruitment process this year (response rate 536/1,056 = 51%). Approximately 61% were not offered ST3 posts (n = 326), a similar proportion to that previously reported. We asked all respondents what their potential career plans were for the next 12 to 24 months. The majority expressed intentions to take up either CT3 top-up posts or non-training fellow posts from August 2021 (79%). Other options considered by respondents included: pursuing work abroad (17%), embarking on a career break (16%), taking up an ST3 post in intensive care medicine instead of anaesthetics (15%) and permanently leaving the medical profession (9%). A number of respondents expressed a desire to pursue training in a different medical specialty (9%). Some respondents expressed an intention to pursue further education or research (10%). A large proportion of respondents (42%) expressed a lack of confidence in being able to achieve the necessary training requirements to later apply for ST4 in August 2023. The majority of respondents reported not feeling confident in achieving GMC Specialty Registration in Anaesthesia in the future without a training number (75%), and that their wider life plans have been disrupted due to the impending time out of training (78%). We received a total of 384 free-text responses to a question asking about general concerns regarding the ST3 applications process. Sentiment analysis of these free-text responses indicated that respondents felt generally negatively about the ST3 recruitment process. Some themes that were elicited from the responses included: respondents feeling the recruitment process lacked fairness, respondents suffering burnout and negative impacts on their wellbeing, difficulties in making plans for their personal lives, and feeling undervalued and abandoned despite having made personal sacrifices to support the health service during the COVID-19 pandemic. These results suggest that junior anaesthetic doctors in the UK currently have a negative perception towards postgraduate training structures, which has been exacerbated by the COVID-19 pandemic, changes to the postgraduate training curriculum and difficulties in securing higher training posts.

A retrospective audit comparing peripheral nerve catheters to lidocaine patches for post-operative analgesia following ear reconstruction surgeryBackground and AimsEar reconstruction surgery involves harvesting rib cartilage to produce an ear-shaped structure. In our centre, post-operative pain had traditionally been managed with the use of peripheral nerve catheters or paravertebral block. Following a change of practice to post-operative lidocaine patches, anecdotal evidence showed a reduction in post-operative pain. We aimed to validate the analgesic superiority of lidocaine patches in this cohort of patients. MethodsA retrospective audit was performed to compare post-operative analgesic requirements for children who underwent ear reconstruction surgery at our centre between November 2015 and November 2017. Comparison was made between those who received peripheral nerve catheters (PNC), paravertebral blocks (PVB) or lidocaine patches.ResultsA total of 13 cases were performed u2013 notes were obtained for 11 cases. Four patients received PNC; 2 patients received PVB; and 5 patients received post-operative lidocaine 5% patches. Oral morphine solution was prescribed for breakthrough analgesia post-operatively for all patients. The average dose of oral morphine solution used in the first 48 hours post-operatively was 40.5mg with PNC; 34mg with PVB; and 22.8mg with lidocaine patch. When calculated as mg/kg, the average dose was 1.5mg/kg for PNC; 1.05mg/kg for PVB and 0.6mg/kg for lidocaine patch.ConclusionsResults would suggest that breakthrough analgesic requirements for children undergoing ear reconstruction surgery were reduced by 60% with lidocaine 5% patches compared with peripheral nerve catheters. Given the small annual number of cases, it has not been possible to perform statistical analysis. It should be noted that concurrent oral analgesia prescribed was variable between cases. We were unable to compare post-operative pain scores as documentation was inconsistent. The anecdotal evidence that lidocaine patches resulted in reduced post-operative analgesia requirements has been corroborated by the results of this audit. Ongoing data collection will be required to validate these results.

To the Editor: We thank da Costa et al.1 for their letter which makes some interesting observations. We agree that our study alone cannot be used to justify the use of extracorporeal membrane oxygenation (ECMO) as a strategy to protect the lungs in patients with moderate acute respiratory failure (ARF)—nor do we make a claim that it should. Severity of respiratory failure is not just defined by a single PaO2/FiO2 ratio value, but on a more complex clinical evaluation which must also take into account the duration of hypoxemia. We take this opportunity to stress that all patients in our study2 had ARF severe enough to receive ECMO based on the indications established by our national service. The “less severe” group had a median PaO2/FiO2 ratio of 105 mm Hg despite median FiO2 of 0.85, but fulfilled other criteria for ECMO. As this cohort was matched for PaCO2 with the “very severe” group, it is likely the price the patient has to pay for the PaO2/FiO2 ratio is injurious mechanical ventilation. Therefore, we would suggest that many of these patients would already meet criteria for ECMO in many systems, and that we are not advancing a “new” indication. There is now substantial evidence for the association between increased mechanical power, ventilator-induced lung injury and mortality in ARF,3 and in this context the use of ECMO allows the least damaging lung ventilation strategy4 and better outcomes.5 We would suggest, intuitively, that increased duration of high mechanical power to the lungs will thus increase mortality even if PaO2/FiO2 ratio is not yet “severe.” High mechanical power can—in the short term—increase PaO2/FiO2 masking the severity of disease, but ultimately increasing mortality. This was exactly what happened in the OSCILLATE Trial, where high-flow oscillatory ventilation resulted in better oxygenation but worse patient outcomes.6 The results of more recent studies are consistent with our findings: a large multinational cohort study of coronavirus patients suggested a survival benefit in those with PaO2/FiO2 ratio of 120–150 mm Hg.7 Da Costa et al. are correct also to identify the subset of ARF patients who experience acute right ventricular dysfunction, which is often exacerbated by “lung-protective” ventilation measures.8 Whether, or at what stage, such patients may benefit from ECMO support, is not a question our study can answer. The task then is how best to determine the answer to these questions? Do patients with “moderate-severe” respiratory failure benefit from ECMO? What about those with acute right ventricle (RV) dysfunction? Ultimately, we agree with da Costa et al. that in the absence of randomized controlled trials, the solution is in high-quality observational registries of ARF, not just of therapies such as ECMO, with advanced causal inference methods. For the individual patient, we suggest that the optimal strategy remains to identify the point at which the benefits of ECMO in preventing hypoxia and avoiding injurious lung ventilation outweigh its risks.

When interpreted correctly, waveform capnography can prevent morbidity and mortality during airway management. However, misidentification of capnography as other waveforms (e.g. pressure or flow) continues to cause preventable deaths [1] and has been implicated in a Coroner's Regulation 28 report [2]. Non-standardised monitor displays increase the risk of human error, leading to clinical delays or misjudgements [3]. Despite the capnography recommendations from the Association of Anaesthetists [4], Project for Universal Management of Airways and capnography safety campaigns, preventable deaths persist [5]. System design (removing the possibility of error) is the most effective form of error prevention [6]. In recognition of this, the Safe Anaesthesia Liaison Group (SALG) recommends standardising waveform capnography as a white solid filled-in graph at the bottom of the monitor display [7]. It is not known how widely this recommendation has been adopted. We aimed to establish the extent of variation in waveform capnography across the UK and assess compliance with the SALG standard. We devised a survey to collect capnography waveform and equipment data from participating hospitals (online Supporting Information Appendix S1). A website (https://cavastudy.co.uk) was established for hospital registration and respondent survey access. Participation was voluntary and open to all 420 NHS hospitals that provide anaesthesia services [1]. Survey respondents were asked to identify distinct clinical areas in their hospital where waveform capnography was used, establish the number of different waveforms in each area, and categorise them according to 11 colours, two waveform types and three screen locations. These variants were chosen from a pilot survey in south-east Scotland. Departmental clinical directors of participating hospitals were asked to agree to their hospital's participation and state their personal awareness of the SALG standard. The survey was not anonymised. Research Ethics Committee and Caldicott Guardian approval were not required. Investigators registered the project via their local governance teams. Survey responses were collected from 9 September 2024 to 31 October 2024 using Microsoft Forms (Microsoft, Redmond, WA, USA). Analysis was conducted in R Studio (R version 4.4.1; R Foundation, Vienna, Austria). Data were received from 138/420 (33%) eligible hospitals (which were part of 65 NHS Trusts/health boards). We analysed 9052 individual capnography waveforms and identified 36 variants across nine colours, two morphologies (line and filled in) and three monitor locations (top, middle and bottom). The most common waveform was a white line at the bottom of the screen, followed by the SALG standard and then a white line in the middle. The remaining capnographs varied considerably in morphology (Table 1 and Fig. 1). Colour: White Type: Line Location: Bottom of screen Colour: White Type: Filled In Location: Bottom of screen Colour: White Type: Line Location: Middle of screen Colour: Yellow Type: Line Location: Bottom of screen Colour: Yellow Type: Filled in Location: Top of screen In 585/1816 (32%) clinical areas, monitors displayed other waveforms (e.g. pressure or flow), with identical morphology to capnography. The median (IQR [range]) of waveform variants per hospital was 4 (2–5.25 [1–13]). Across Trusts/health boards with multiple hospital sites, variants increased to 6 (4–8 [1–15]). Monitoring equipment service manuals were examined for customisation options to meet the SALG standard: 5008/9143 (54.5%) machines were user-modifiable to the standard; 4054/9143 (44.5%) required manufacturer modification; and 81/9143 (1%) were unmodifiable due to hardware limitations. The SALG standard was known to 77/102 (75%) of clinical directors. This survey highlights potential patient safety risks relating to variability in waveform capnography across UK hospitals. Both capnography waveform heterogeneity and ambiguity of non-capnography waveforms increase the risk of misinterpretation, potentially leading to errors in situational awareness. Such misinterpretations contribute to over 80% of anaesthesia-related adverse events, primarily due to failures in perceiving and comprehending critical information [8]. The risk is particularly high for clinicians moving between different hospital areas and rotating within Trusts/heath boards. Despite a low response rate (33%) from eligible hospitals, 36 variants of capnograph is concerning. A higher rate of participation may have identified even greater variation. We did not assess the impact of variation on clinical performance or error rates, and we did not explore the practical or financial implications of national capnography waveform standardisation. Despite publication of a Regulation 28 Coroner's report and the Royal College of Anaesthetists' national response, patients have continued to die due to unrecognised oesophageal intubation in the UK [5]. Although 54.5% of monitoring machines were user-modifiable and 75% of clinical leads were aware of the SALG standard, only 15.3% of waveforms conformed to it. System-level design limitations also contribute to the problem, with 44.5% of machines requiring manufacturer modification (online Supporting Information Table S1). This substantiates the Coroner's concern and suggests that clinicians and individual Trusts/health boards cannot be relied upon alone to implement the necessary standardisation. Our findings provide a snapshot of the extent of waveform capnography variation in the UK. Mandated change via regulatory intervention (as was performed for gas cylinder colours) is necessary to achieve national standardisation, whilst specialist airway societies and safety groups should continue to work collaboratively with machine manufacturers to facilitate this process and strive to achieve the SALG national standard for waveform capnography. The authors wish to thank all CAVA collaborators across the UK for their work and dedication to complete the survey. The authors with to thank Dr Mathew Lyons for website hosting and domain name provision. No external funding or competing interests declared. Appendix S1. Survey forms as text taken from Microsoft Forms. Appendix S2. The CaVa UK collaborators. Table S1. Device manufacturers encountered and their proportion of use. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Background Managing Emergencies in Paediatric Anaesthesia for Trainees (MEPAT) is an internationally recognised, peer reviewed and literature based simulation course which aims to give anaesthesia trainees the opportunity to develop skills in the management of paediatric anaesthetic emergencies.1 Anaesthetic training in the UK is competency based with a minimum of 60 individual assessments and 20 ‘Units of Training’ required to be signed off for completion of Intermediate training alone.2 Previous work has mapped the MEPAT course to the Royal College of Anaesthetists UK (RCoA) coded competencies to create a curriculum map.3 Following positive feedback from trainees using this curriculum map we had requests to embed Work Place Based Assessments into the MEPAT course – we piloted the use of standardised Case Based Discussion (CBD) templates. Methodology We reviewed learning objectives (LO’s) within the MEPAT scenarios alongside our local MEPAT database of ‘Take Home Messages’ (THM’s) – reported learning outcomes from course participants following each structured debrief. THM’s matched the LO’s set out for each scenario and were consistent across all courses. Following this analysis we felt confident that our MEPAT debriefs or ‘simulated case based discussions’ were standardised – allowing us to create a CBD Template for each scenario using the THM’s as core themes for discussion. The template could then be easily transferred to the RCoA electronic portfolio. Results Feedback from trainees and specialist paediatric anaesthetists has been extremely positive. It has allowed trainees to sign off several different competencies within one MEPAT scenario and has provided the assessor with a template to work from therefore minimising the substantial workload required to complete each CBD. Potential impact We hope that our work in both curriculum mapping and CBD templates can be used by the RCoA as a model for embedding simulation into the anaesthetic training curriculum. References 1. [www.mepa.org.uk][1] 2. 2010 Curriculum for a CCT in Anaesthetics, Edition 2 Version 1.6. A publication by the Royal College of Anaesthetists UK, August 2010, Annex C 3. Winton P, Armstrong L. Mapping ‘MEPAT’ Paediatric Anaesthesia Simulation Course to the RCoA (UK) Curriculum. Poster Presentation – Association of Paediatric Anaesthetists of Great Britain and Ireland Annual Scientific Meeting, Aberdeen, May 2015 [1]: http://www.mepa.org.uk

The Critical Care Canada Forum was held in Toronto, Canada from October 25-28 2009. The conference, which focuses on the care of critically ill patients wherever the patients are located, was attended by 879 delegates and featured 197 separate presentations, including several as yet unpublished trials. The hot topic this year was planning for the impact of a worldwide outbreak of H1N1 influenza on critical care systems, but the conference also covered a broad range of critical care interventions including mechanical ventilation, sedation and analgesia, renal replacement therapy, and extracorporeal membrane oxygenation. Herein we summarize just a few of the many exciting clinical trials and plenary topics presented at the conference.

Recent world events have further highlighted the social and legal disparities suffered by the LGBTQ+ community.Transgender people have been at the very centre of this discrimination, with their personal lives regularly thrust to forefront of public discussion.Being transgender is criminalised in 37 countries, only 97 countries allow people to legally change gender, and the UK government continues to ignore calls to ban so-called conversion therapy. 1 Regardless of your personal views, it is vital that medical professionals continue to deliver the best care possible to all patients, irrespective of gender identity.Indeed, the General Medical Council mandates that all doctors must not unfairly discriminate patients by allowing personal views to affect the treatment we provide. 2 The Royal College of Anaesthetists has joined the Royal College of Physicians' 'Inequalities in Health Alliance' aiming to tackle some of the health inequalities that certain patient cohorts experience when they require healthcare. 3espite campaigns like this, 61% of transgender patients feel their specific healthcare needs are not understood. 4Our recent survey on UK anaesthetists suggested it may be even more than this, with the median confidence regarding the perioperative care of transgender patients being 3/10. 5As discussed in our recent review article in the journal, 6 many of the specific considerations for transgender patients are relevant to critical care (alterations to airway anatomy, cardiovascular and respiratory changes, the management of hormone therapy etc.), and it would therefore be logical to extrapolate that a similar knowledge gap exists in this domain.One of the most surprising findings from the survey were some of the responses from senior doctors, including: 'I believe in biology not ideology', 'How would I opt out of treating a transgender patient', and 'I would refuse to treat a transgender patient undergoing elective surgery'. 5Such discrimination is illegal under the Equality Act 2010. 7hese comments may represent the tip of a transphobic iceberg and highlight just how important it is to energise education for change.Estimates of the number of openly transgender patients in the UK vary from 200,000 to 600,000, with numbers increasing year on year. 4,8Whilst anaesthetising for gender-affirming surgery may remain largely the domain of specialist tertiary centres, the care of acutely

This is a single-centre, prospective, observational study that aimed to establish the incidence of airway events and the interventions required to manage these events in a 9-bedded general intensive care unit. During the 30-day study period there were 278 significant airway events requiring 332 interventions. Forty-six (16.5%) events were associated with hypoxia, and medical intervention was required for 25 events (9%) with the remainder managed by trained nurses or physiotherapists. The most frequent events were tube blockage due to secretions (47.8%) and circuit disconnection (14.3%). Events occurred more frequently in those ventilated with tracheostomy compared to endotracheal tube (event rate per ventilator day 1.76 vs 1), but these were less likely to lead to hypoxia (OR 2.93). We have found a rate of airway events of 1.22 per ventilator day and conclude that access to appropriately skilled and trained staff is required to manage these intensive care airway problems.