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CRGH

Anaesthesia and Pain Management

Ians Update Newsletter

February 2015

Technology: NTU Opthalmology Clinic


While in Taiwan over the festive season my wife needed to visit an opthalmologist, so an
appointment was booked online after looking to see which specialists were available in
which hospitals, and where there were vacancies. On the day of the appointment logging
on to the clinic appointments, while in transit, allowed us to see: who has already registered with the clerical staff (yellow); who is ready to be seen by the specialist (blue)
(actually they might be with a trainee or student); who is with the specialist now (red);
who is finished (green); and who has not registered (brown).
Since the per capita GDP of Taiwan is less than a third of Australia's I can only imagine
what amazing software our own IT department must be working on for our clinics!

Changes to MH Box
To improve and streamline our MH Box a few changes have been made:
Bags of 10% Dx have gone
Heparin and frusemide have gone
However, unfortunately , we could not source 250mL bags of sterile water from readily
available sources, consequently the 1L bags now have additional labelling to make it
clear that they are not for direct intravenous injection.
There are also some plastic bags, so it is possible to say to an orderly "go and fill these
with ice and bring them back straight away!" (as an alternative to using the task card).

Hosing In The News Again

The use of forced air warmers without the blanket attached, colloquially termed 'hosing',
seems to be gaining attention again. The practice involves inserting the hose between
sheet and blanket, or within a layer of blanket, and turning the device on. The purported
benefit of such use is that it is "more cost effective", however the FDA and American Patient Safety Foundation have been warning of the dangers for over a decade (citing
burns, including full thickness, and also a case requiring limb amputation for muscle necrosis). In 2013 an American Society of Anaesthetists examination of closed claims data
showed more than half of all warming equipment / heated material burns were caused by
this misuse of the device. I would encourage everyone to avoid this technique.
Image from www.geograph.org.uk

Common Sense Advice To Patients


It is pretty much standard to provide information to patients, however a look at this lists
shows what we miss, or are not prepared to say. You may have some issues with various
items, and some are not correct for our institution, however if our patients took these seriously I suspect there would be a general reduction in patient angst.
This advice is from www.doctorwakeup.com
The guide for patients having planned surgery in hospital to make it a stress-free experience

What you can do to reduce your chances of being cancelled on the day of surgery:
1. Be prompt. The surgeons and anaesthetists can only see you first thing in the morning or at lunch time, all
the rest of the time they are likely to be stuck in the operating theatre. So if you turn up late and they don't have a
chance to see you, you will automatically drop down the operating list in favour of patients who did turn up on
time and were seen.
2. Strictly adhere to the starvation guidelines. This may vary somewhat from hospital to hospital but it's
usually six hours for food and two hours for clear fluids (that's any drink you can read newspaper print through).
BEWARE! Milk counts as food and many people get caught out by having tea or coffee with milk. Juice with
bits in and sodas like coca cola are not considered clear fluids. I strongly advise you not to chew gum as it stimulates stomach acid production which affects the risks when giving general anaesthetics.
3. Have a very clear plan about which medications you can and can't take. Most patients having planned
surgery should have been seen in a pre-operative assessment clinic and it very important you know exactly
which of your regular medications you should be taking. Mostly we want you to take your regular medication
particularly if it's for asthma, acid indigestion and thyroid problems. However the ones to be careful about are
blood thinning tablets like warfarin, aspirin or clopidogrel, some blood pressure tablets and some diabetic medications. Patients have been cancelled for taking their medication incorrectly.
4. Call in advance and inform us if you've been unwell in the previous week with cold or flu-like symptoms such as fever, sore throat, coughing or diarrhoea and vomiting. It is definitely worth ringing up and asking
to be rescheduled. For non-emergency surgery we want you to be as well as possible, if you've been unwell your
immune system is compromised and there's an increased chance of post-operative complications like pneumonia.
Patients have been cancelled on the day of surgery for having a temperature and feeling unwell. Ideally we want
you to have been well for four to six weeks.
If you have had symptoms for a while of a potentially serious undiagnosed condition that have not been
investigated properly you may well be cancelled until this is looked into. Symptoms that are concerning are
chest pain, shortness of breath, palpitations or unexplained collapses. It is very important to get these symptoms
investigated and the results to be available at the hospital where you are having surgery. Often patients have had
investigations in one hospital and then have surgery in another. It is worth asking for a photocopy of the results
or a letter.
Understanding the operating list:
I think it would help patients to understand that there is often a reason why the operating list order is the way it
is. It is not random and done on a pot-luck basis.
If your operating list includes children on it they are usually done first with the youngest done first and then in
ascending order. The reason is that small children are less able to tolerate dehydration and starvation than adults.
Diabetic patients often have to be done earlier in the order, due to problems with controlling the blood sugars
and the effects of starvation and the need for insulin. Similarly if the patient is highly allergic to latex they are
often done earlier to reduce their exposure to latex which tends to increase throughout the day in hospitals.
The order of the list is often designed around the availability of special equipment. This includes laparoscopes
for key-hole surgery, x-ray machines for orthopaedic, plastics surgery and urology and special implants for joint
replacements in orthopaedics.
(Continued next page)

Occasionally we have to wait for the result of specific blood tests on the day of surgery and that means you are
far more likely to be done in the afternoon even if you arrive in the morning.
Another big issue is if you are having major surgery that means you are likely to need a high dependency or intensive care bed. The availability of these beds is often unpredictable as it is affected by unexpected, unplanned
emergency admissions. There are often problems moving patients out of ITU to a ward and making beds available and this may mean your operation is delayed or cannot proceed at all.
Strategies to reduce stress and frustration while waiting for your operation:

1. The truth is you may have to wait all day and there's always someone that's going end's up being last and
that may be you!. Disappointment and stress result from unmet expectations. So if you go with expectations that
you'll get done quickly you're far more likely to get worked up when this doesn't happen. Prepare yourself mentally for the possibilty that it could be a long wait and that you could be last.
2. Come prepared just as you would prepare for a long plane flight. Bring plenty of amusements and entertainment with you. You could bring books, magazines, movies on an ipad/smart phone although you do have to be
careful not to bring too may valuables that could be lost or stolen. I would definitely recommend bringing a device where you can listen to your favourite music, maybe even compile a special playlist of tunes. Also by far
the best is to have a companion who can keep you amused and help pass the time (although you need to check
the local hospital policy as not all hospitals are set up to allow someone to stay with you.
3. I stongly recommend you eat and drink until the last possible moment as recommended by the guidelines even if it means getting up in the middle of the night to eat and drink. I am always amazed when people turn up having not had anything to eat for twenty-four hours. I understand that you may be nervous before an
operation and so have lost your appetite but this can have major side-effects. When you're hungry you are more
prone to low mood or have a lower tolerance before becoming emotional due to your blood sugar dropping.
When you're thirsty you're more likely to develop headaches and it can be harder to find a vein when they need
to insert a drip. You need to factor in that you may go an additional twelve hours after arriving in hospital without eating and drinking.
4. Make sure you bring all your regular medications or a list with you, as it can be difficult to remember all the
names when asked. Also be very clear about what you're allergic to.
Another important issue for comfort is temperature. Hospital wards are not air conditioned and so it's hot in the
summer and cold in the winter. If you are poorly tolerant of temperature extremes you may wish to bring a handfan or extra layers of clothing. The cold makes it hard to find veins and so it is useful to stay as warm as you can
to make your veins prominent.
Bonus tips
6. If you are having your operation under a regional anaesthetic technique such as a nerve block or spinal or
epidural (i.e. you are staying awake throughout), I strongly recommend you bring an audio listening device
loaded with hypnosis or meditation tracks as it can be quite challenging to lie still and stare at the ceiling for a
prolonged period of time.
The hospitals will try to do everything they can to get you done on the day you're scheduled because they get
fined otherwise but bear in mind surgery is unpredictable. The patient on the list before you may suffer an unexpected complication this may result in prolonged surgery to fix the problem and delays to the rest of the list. If
that's the case you can try to practise gratitude that it was not you that suffered the complication. (I try using that
one whenever I get stuck in a traffic jam due to an accident or car breaking down!!!)

Pulmonary Hypertension and its Management


The image below raised my awareness of 2 recent publications in this area.

Image from: gas-and-air doc @mjslabbert via 'Twitter'


The Anaesthesia article by Pilkington is accompanied by an excellent editorial. Unfortunately I have no reference for the presentation in which the slide appears, and needed
to ponder putting a band through the third line of changes on the slide.
Transitions which may precipitate pulmonary hypertensive crisis are described:
spont resp to IPPV
addition of PEEP
positioning
pneumoperitoneum.
The following table for volatiles appears:

The slide suggested ketamine and etomidate were OK, whereas the Pilkington article
only points out that ketamine increases PVR in adults, and finds no comparative data for
etomidate. (From the table thiopentone doesn't look so bad!)
Central neuraxial blockade, by blocking cardiac sympathetic fibres is said to disrupt RV
homeometric autoregulation (which allows the RV to tolerate increased afterload, while
preserving coupling between RV and pulmonary circulation) and can lead to a critical reduction in afterload.
There is no evidence based guideline on the periop management of pts with pulmonary
hypertension.
While the article finds no strong evidence that any specific type of monitoring influences
outcome, the accompanying editorial views IABP as mandatory in the presence of suspected RV dysfunction or pulmonary HT.
The editorial also suggests:
consider echo
Pulmonary artery catheter "an option"
hypotension poorly tolerated
avoid bradycardia - RV may get overstretched (aim 70-100)
Use of inhaled prostacyclins is described, and one study is identified in which milrinone
was beneficial compared with conventional inotropic support. (Our pulmonary hypertension 'kit' has iloprost and milrinone, just ask the anaesthetic nurses to bring the kit and
drugs if you require them.)
A key issue from the editorial is that patients presenting for #NOF may have an increased
incidence of pulm HT, and for those having cemented hemiarthroplasties they are at increased risk for bone cement implantation syndrome (19% of cemented prosthetic replacements experience some level of this syndrome).
The difficulty of identifying undiagnosed pulmonary hypertension / RV dysfunction based
upon the non-specific symptoms is identified as a reason why we must raise our awareness and suspicion, especially in patients having cemented prosthesies.
Macdonald J, Klein AA, Ferguson K. (Editorial). (2015). Rumsfeld revisited: knowns and
unknowns affecting the right heart . . . Anaesthesia, 70, 1317. doi:10.1111/anae.12931
Pilkington S, Taboada, D., & Martinez, G. (2015). Pulmonary hypertension and its management in patients undergoing non-cardiac surgery. Anaesthesia, 70(1), 5670.
doi:10.1111/anae.12831
Fox, D. L., Stream, A. R., & Bull, T. (2014). Perioperative Management of the Patient
With Pulmonary Hypertension. Seminars in Cardiothoracic and Vascular Anesthesia, 18
(4), 310318. doi:10.1177/1089253214534780

Academic Journals, Their Cost, Open Access Initiatives


Ok, so I have an interest in this topic, and am returning to it (again).
Some may be aware of how Cambridge University mathematician Tim Gowers began a
discussion on the exploding costs of academic journals, as many universities have been
forced to limit their subscriptions, and how this turned in to a 'boycott' of publisher Elsevier. (See www.thecostofknowledge.com for a list of researchers who have signed up,
however there is a dearth of anaesthesia researchers there.)
The key gripe is that publishers get articles at no cost, which were conducted by (largely)
public or charity funded researchers, using (largely) public or charitable funding, get others to review them for free, then charge substantially to 'publish' them in journals, a process which is largely electronic, and which has seen dramatic reduction in costs over several decades.
The 23rd December 2014 education section of the 'news' source The Huffington Post
(http://www.huffingtonpost.com/education/) published an article titled "Academic Journals:
The Most Profitable Obsolete Technology In History", details how Elsevier posts profits
that are 39% of revenue, using a sales model in which universities must effectively subscribe to all the publishers journals, or face much higher costs for only a few journals.
The article looks at various alternatives, including the use of pre-print servers such as
arXiv.org, and the push by the National Institute of Health (US) and the Bill and Melinda
Gates Foundation to ensure any research they fund is open access. (In the case of the
NIH however, a period of one year is allowed before open access is required, effectively
denying open access until the material is far less relevant to other researchers, academics, or in the case of medicine, medical practitioners.)
A fascinating approach has been started by The Winnower (https://thewinnower.com/),
where would-be publishers do their work, seek reviews from peers, publish on the website, and open their publication to review by readers. This is reviewed on December 16
2014, by the International Clinician Educators Network (http://icenetblog.royalcollege.ca/),
associated with the Royal College of Physicians and Surgeons of Canada website. Highlighted advantages include the speed to publication, reviews which can be read by all
(along with the identity of the reviewer!), the opportunity to improve the article and update
it based upon reviews, and the manner in which data on the number of article reads and
downloads is in some cases supplanting the significance of the name of the journal in
which an article is published.
The two most amusing perspectives on this are for me:
(Reflecting on how universities in the US invest $100 billion of public funds on research
each year, researchers give the articles to the publisher, and the universities buy them
back for $10 billion.)
Imagine you are an obstetrician setting up a new practice. Your colleagues all make their
money by charging parents a fee for each baby they deliver. Its a good living. But you
have a better idea. In exchange for YOUR services you will demand that parents give
every baby you deliver over to you for adoption, in return for which you agree to lease
these babies back to their parents provided they pay your annual subscription fee.
(from http://www.michaeleisen.org)
(Continued over)

I'm opening an academic-publishing-themed restaurant. You bring the ingredients and


get volunteers to cook and serve. Now pay me $10,000.
(from Parker Higgins @xor on 'Twitter')

Nasal Humidified Oxygen


In December 2014 I mentioned an article on the use of high-flow humidified nasal oxygen
for difficult airway anaesthesia, and the role of the technique in emergency medicine.
More recently, an article in Critical Care Medicine describes use of the technique in an
ICU. The study was prospective, non-randomized. Patients were in either a 'before' or an
'after' group, preoxygenation moved from non-rebreathing bag with facemask to nasal
cannula oxygen. There were 50/51 patients in each arm. Improved oxygenation from the
technique, fewer episodes of severe desaturation were identified.
I'm sure there will be issues identified by some departmental members, and it will be interesting to follow developments in this area. Our ED and ICU have devices which can
deliver warmed, humidified nasal gases at flows of up to 60 and 70 Litres per minute respectively. I hope to see some of them soon.
Miguel-montanes, R., Hajage, D., Messika, J., Bertrand, F., Gaudry, S., Rafat, C., Ricard, J. (n.d.). Use of High-Flow Nasal Cannula Oxygen Therapy to Prevent Desaturation
During Tracheal Intubation of Intensive Care Patients With Mild-to-Moderate Hypoxemia.
Critical Care Medicine. doi:10.1097/CCM.0000000000000743

MRI Safety
You know all that stuff that keeps getting drummed into us about safety in the MRI Suite?
Turns out people do forget! This story from (I'm ashamed to admit it) The Daily Mail
(www.dailymail.co.uk) 30th December 2014:
Two hospital workers spent four hours pinned between a highly magnetic MRI machine
and a metal oxygen tank.
The 4ft tank was pulled across the room by the machine's magnetic field at Tata Memorial Hospital in New Delhi, India, leaving porter Sunil Jadhav and technician Swami Ramaiah seriously injured.
Hospital authorities launched an investigation into the incident, which was reportedly exacerbated when staff found they were unable to demagnetise the machine.
(Image over page)

Turned out the porter was asked to fetch an oxygen mask for the patient, and mistook the
request, bringing a whole tank of oxygen!

Extremely PoliticalRead At Your Own Risk!


Since the industrial revolution wealth has grown through waves of industrialisation,
mechanisation, automation, roboticisation, communication and computerisation. Unfortunately the world's best brains can currently think of no 'next' step beyond paying people
less to do the same job, often accompanied by laughable terms to justify such reductions.
In the UK the government has proposed changes to overtime pay for junior and senior
doctors at weekends. They have used the justification that doctors should "become more
professional, and move away from an 'hours counting culture'"!!!
Don't be surprised when some high-powered genius suggests the same here.
Source: BMJ 2015;350:h187

Closure on Incident Device Report


Those who work in the burns theatre will be aware that the 'Aestiva' anaesthetic machines have experienced serious intermittent problems, in which the ventilator has failed
to provide any pressure modes (pressure control, pressure support, PEEP) when
switched on (usually after induction and intubation!).
We are attempting to replace both machines, although a firm date for ceremonially pushing both of them into a garbage compactor has not been set.
The TGA has completed its investigation into the fault. Unfortunately the finding that the
"pneumatic sub-assembly caused incorrect feedback to the manifold pressure transducer" does not help at all, since "extensive testing" by the manufacturer could not duplicate the fault, or determine the root cause.
This fault has not been reported elsewhere apparently.

Side Items:
Ultrasound: Paravertebral block (LSORA)
https://www.youtube.com/watch?v=vSbhqR5oIAs
Tip: Wipe with a medical alcohol wipe over medical paper tape (the type that never
sticks to skin), it will stick really well! Source: gas-and-air doc @mjslabbert via 'Twitter'
The bravest man in the RAF never to have flown an aeroplane:
Professor of Anaesthesia Edgar Pask, anaesthetised, paralysed, intubated, then dropped
in a pool to test flotation vests for downed pilots during WWII (This would test your faith in
your colleagues!) http://vimeo.com/103762675
PiCCO in ICU: Zhang Z, Hongying N, Zhixian Q. Effectiveness of treatment based on
PiCCO parameters in critically ill patients with septic shock and / or acute respiratory distress syndrome: a randomized controlled trial. Intensive Care Medicine. doi:10.1007/
s00134-014-3638-4 (Online ahead of print)
PiCCO-based fluid management did not improve outcome compared to CVP-based management. The study was stopped early, after 350 patients were enrolled, due to futility.
Caregivers were not blinded to technique used, outcome assessors were.
Aspiration Deaths - Triennial Anaesthesia Mortality Report
5/22 deaths were due to aspiration, in 4/5 aspiration risk was high yet no airway protection was provided, 2 of these 4 cases involved anaesthetists. 4/5 aspiration deaths were
in the setting of endoscopy. My comment: balancing risks is complicated, assessment
and management of patients at high risk in an appropriate environment should be highlighted.
ANZCA Bulletin Dec 2014
Any comment or opinion is solely that of Dr Ian R Cox.