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
- SOBA Guidelines available: http://www.sobauk.com
- 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!\
- Sux may increase desaturation in RSI as fasciculations use up your oxygen stores. Roc rocks, sux sucks (but have sugammadex handy!) http://www.ncbi.nlm.nih.gov/pubmed/21226862
- 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.
- Is chewing gum a solid? No; no need to cancel the patient if chewing gum http://www.ncbi.nlm.nih.gov/pubmed/25442242
- 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…
- Tea and coffee count as clear fluids so long as milk < 20% of total volume; so anything but a latte is fine! http://bja.oxfordjournals.org/content/early/2013/08/16/bja.aet261.short
- In fact a latte may be fine after all!! 500 ml of orange juice and 330 ml of non-human milk with 170 ml of water all leave the stomach at the same rate! http://bja.oxfordjournals.org/content/114/1/77.short
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!!
- RCoA form looks a lot better: http://www.rcoa.ac.uk/document-store/patient-feedback-questionnaire
- How measure the quality of an anaesthetic delivered from a patient’s perspective? Pain relief, compassion, avoiding PONV and good communication are the top patient priorities (plus not dying) http://bja.oxfordjournals.org/content/111/6/979.full?sid=7aefda90-62da-4826-b9eb-42f11aa5faa7