AAGBI WSM 2015

Summary of the first day at the 2015 Winter Scientific Meeting. The full programme of the meeting can be found here.

This is a summary (with references) of the talks I was able to attend.

LV Assessment and its Pitfalls. Dr Jim Newton, Oxford

  • EF correlates with postoperative mortality; < 35% sees big increases in mortality.
  • Best assessment of EF is radionuclide assessment but toxic. 2D assessment not very accurate. 3D volumetric echo or cross-sectional methods (e.g. MRI) much better.
  • TTE 2D via M-mode assessment basically hopeless and only measures a fraction of the whole cardiac cycle.
  • Large intraobserver variation with all methods of EF measurement – often up to 16% variation in EF!
  • 3D Echo is much better and correlates with cardiac MRI.
  • What we really need is a global measure of cardiac function. Myocardial performance index (MPI) via Doppler measures global ventricular function: abnormal if >0.4. Independent of HR, valvular disease, preload and afterload.
  • Almost impossible to assess EF in the presence of AF; might as well pluck a number at random!!
  • Take home message; beware the EF numbers and review the qualitative assessment (ie what the operators impression of the ventricular function was).

The Very Obese Patient. Dr Martin Dresner, Leeds

  • Pre-op screen for OSA via STOP-BANG (high-risk 5-8); often not possible to optimise with CPAP etc due to urgency of surgery.
  • Forearm cuff for DINAMAP helpful with bingo-wings, but tends to overread.
  • Ramping for pre-O2 either with Oxford pillow or lots of pillows! Ensure ear level with sternum.
  • Obesity not a predictor in itself for difficult intubation. Look at the patient’s head; don’t get distracted by the adiposity!\
  • Start to gently bag ASAP; if easy, relax. If difficult BVM then start intubation ASAP. You have no FRC so time is short…
  • Use lean body weight for everything apart from sux & reversal (90 kg for men, 70 kg for women)
  • SAB Issues: start feeling at the thoracic spine (which is always palpable) and work down.

Preoperative fasting – What’s the issue? Dr Ian Smith, Stoke-on-Trent

  • Many guidelines on the fasting but all agree that 6 h for solids and 2 h for clear fluids, but lots of grey areas.
  • Drinking fluids 2 h prior to anaesthesia actually decreases gastric volumes but anaesthetic departments still being conservative i.e. NBM from midnight.
  • Most patients are actually NMB for longer than 2 h (8-21 h). Due to lack of instructions, lack of understanding or the fact that all instructions are based on the start of the list time (not individual time of surgery).
  • Patients who drink 2 h pre-op are less thirsty, less anxious, reduced PONV, and have improved recovery…

Getting patient feedback for your appraisal. Dr Liz McGrady, Glasgow

  • GMC do not specify a minimum number of patient feedback returns, but expect 15-30 to be achievable.
  • Patient feedback assesses communication skills, ability to inspire trust and inclusion of patient in decision-making process. Not a measure of patient satisfaction.
  • Form must be GMC approved. Should be a random selection of patients, should be distributed by a third party and collected anonymously and collated by a third party. Should reflect your whole practice.
  • Optimum time to collect feedback is after pre-operative consultation. Make sure the patients know who there anaesthetist was! Perhaps we need a photograph on the form to make sure that the patient isn’t given feedback about the porter!!
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