A comparison between thoracic epidural analgesia and rectus sheath catheter analgesia after open midline major abdominal surgery: randomized clinical trial
Author(s): Anton Krige, Sarah G. Brearley, Céu Mateus, Gordon L. Carlson, Steven Lane
Source: BJS Open, Volume 6, Issue 3, June 2022, zrac055,
Abstract: Rectus sheath catheter analgesia (RSCA) and thoracic epidural analgesia (TEA) are both used for analgesia following laparotomy. The aim was to compare the analgesic effectiveness of RSCA with TEA after laparotomy for elective colorectal and urological surgery. METHOD: Patients undergoing elective midline laparotomy were randomized in a non-blinded fashion to receive RSCA or TEA for postoperative analgesia at a single UK teaching hospital. The primary quantitative outcome measure was dynamic pain score at 24 h after surgery. A nested qualitative study (reported elsewhere) explored the dual primary outcome of patient experience and acceptability. Secondary outcome measures included rest and movement pain scores over 72 h, functional analgesia, analgesia satisfaction, opiate consumption, functional recovery, morbidity, safety, and cost-effectiveness. RESULTS: A total of 131 patients were randomized: 66 in the RSCA group and 65 in the TEA group. The median (interquartile range; i.q.r.) dynamic pain score at 24 h was significantly lower after TEA than RSCA (33 (11–60) versus 50.5 (24.50–77.25); P = 0.018). Resting pain score at 72 h was significantly lower after RSCA (4.5 (0.25–13.75) versus 12.5 (2–13); P = 0.019). Opiate consumption on postoperative day 3 (median (i.q.r.) morphine equivalent 17 (10–30) mg versus 40 (13.25–88.50) mg; P = 0.038), hypotension, or vasopressor dependency (29.7 versus 49.2 per cent; P = 0.023) and weight gain to day 3 (median (i.q.r.) 0 (−1–2) kg versus 1 (0–3) kg; P = 0.046) were all significantly greater after TEA, compared with RSCA. There were no significant differences between groups in other secondary outcomes, although more participants experienced serious adverse events after TEA compared with RSCA, which was also the more cost-effective. CONCLUSIONS: TEA provided superior initial postoperative analgesia but only for the first 24 h. By 72 hours RSCA provides superior analgesia, is associated with a lower incidence of unwanted effects, and may be more cost-effective.
Can surgical advanced care practitioners provide a cost effective local anaesthetic minor procedures service? Results from a 5-year retrospective study
Author(s) Taib A.; Hammill C.; Abraham A.; Subar D.; Fakim B.; Garstang P.
Institution(s) (Taib, Hammill, Abraham, Subar) Blackburn Research Innovation, Development Group in General Surgery (BRIDGES), Blackburn, United Kingdom
(Taib, Hammill, Abraham, Fakim, Subar) Department of General Surgery, East Lancashire Hospitals NHS Trusts, Blackburn, United Kingdom
(Garstang) Women's and Children's Division, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
Source British Journal of Surgery; Oct 2021; vol. 108
AbstractAims: Surgical Advanced Clinical Practitioners (SACP) form part of the extended surgical workforce and are drawn from allied health care backgrounds. The primary aim of this study was to determine if there is a financial benefit performing minor surgical procedures on dedicated SACP lists compared to consultant surgeon lists. Method(s): This was a retrospective cohort study including all patients who had a minor 'lumps and bumps' procedure undertaken between April 2014 and August 2019 at Anonymous Hospitals NHS Trust (AHT) under local anaesthetic by the general surgery team. Data such as lesion type, theatre staffing levels and operating time was collected. The cost of the procedure was calculated by operating time multiplied by cost of staff of per minute according to local banding. Result(s): A total of 1399 patients had a lesion excised; the majority were carried out by a doctor n=907, the rest independently by a SACP. The majority of lesions excised were lipomas and cysts. There was no difference in the median surgical time (20 minutes, IQR 14) taken to operate on each patient by SACPs and doctors. Minor procedures carried out on consultant surgeon lists cost 62.4% (21.72) more on average than those on SACP lists (56.55 vs 34.83 median respectively, p<0.001) due to excess staff for these cases. Conclusion(s): A dedicated and independent SACP 'lumps and bumps' list has shown to be a financially beneficial service. Operative times are similar to doctors. These lists free staff for consultant lists, potentially permitting more major cases.
Provision of a local anaesthetic minor procedures service by surgical advanced clinical practitioners: 5-year study.
Author(s) Taib, A; Hammill, C; Abraham, A; Fakim, B; Garstang, P; Carney, J; Natarajan, V; Subar, D
Institution(s) (Taib, A) Department of General Surgery, East Lancashire Hospitals NHS Trusts, Blackburn, UK.
(Hammill, C) Department of General Surgery, East Lancashire Hospitals NHS Trusts, Blackburn, UK.
(Abraham, A) Department of General Surgery, East Lancashire Hospitals NHS Trusts, Blackburn, UK.
(Fakim, B) Department of General Surgery, East Lancashire Hospitals NHS Trusts, Blackburn, UK.
(Garstang, P) Women's and Children's Division, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK.
(Carney, J) Department of General Surgery, East Lancashire Hospitals NHS Trusts, Blackburn, UK.
(Natarajan, V) Department of General Surgery, East Lancashire Hospitals NHS Trusts, Blackburn, UK.
(Subar, D) Department of General Surgery, East Lancashire Hospitals NHS Trusts, Blackburn, UK.
Source BJS open; Jul 2021; vol. 5 (no. 5)
AbstractBACKGROUNDSurgical advanced clinical practitioners (SACPs) form part of the extended surgical workforce drawn from a variety of allied healthcare backgrounds. The primary aim of this study was to determine whether there was a financial benefit in having minor surgical procedures undertaken by dedicated SACPs compared with operating lists assigned to consultant surgeons.METHODSThis was a retrospective cohort study including all patients who had minor 'lumps and bumps' procedures undertaken between April 2014 and August 2019 at East Lancashire Hospitals NHS Trust under local anaesthetic by the general surgery team. Clinical patient information, including lesion type, was collected along with operating room staffing levels and duration of operation. The cost of the procedure was calculated as operating time multiplied by cost of staff per minute according to local banding.RESULTSA total of 1399 patients had a lesion excised; 907 procedures were carried out by a doctor, and the rest independently by a SACP. The majority of lesions excised were lipomas and cysts. There was no difference in the median surgical time taken between SACPs and doctors (20 (i.q.r. 14-28) min). Minor procedures carried out on consultant surgeon lists cost 62.3 per cent (€25.33) more on average than those on SACP lists (median €65.96 versus 40.63 respectively; P < 0.001).CONCLUSIONA dedicated and independent SACP 'lumps and bumps' list was financially beneficial. Operating times were similar to those of doctors. These lists safely free trainee and consultant surgeons to undertake more complex work.
Author(s) Khan M.
Source Anaesthesia; Jul 2021; vol. 76 ; p. 49
In critical care, 80% of airway-related critical incidents occur post-intubation. There is also a high frequency of re-intubations in critical care patients within 48 h of extubation. Therefore, being able to anticipate a difficult airway holds value. Higgs et al.  recommend that identifying difficult airway can reduce adverse events and the critical care multidisciplinary team should be aware of patients with a difficult airway via effective documentation and handover, so that risks are mitigated.
The effect of COVID-19 on general anaesthesia rates for caesarean section. A cross-sectional analysis of six hospitals in the north-west of England
Author(s) Bhatia K.; Columb M.; Bewlay A.; Eccles J.; Hulgur M. et al.
Source Anaesthesia; 2020
Publication Date 2020
At the onset of the global pandemic of COVID-19 (SARS-CoV-2), guidelines recommended using regional anaesthesia for caesarean section in preference to general anaesthesia. National figures from the UK suggest that 8.75% of over 170,000 caesarean sections are performed under general anaesthetic. We explored whether general anaesthesia rates for caesarean section changed during the peak of the pandemic across six maternity units in the north-west of England. We analysed anaesthetic information for 2480 caesarean sections across six maternity units from 1 April to 1 July 2020 (during the pandemic) and compared this information with data from 2555 caesarean sections performed at the same hospitals over a similar period in 2019. Primary outcome was change in general anaesthesia rate for caesarean section. Secondary outcomes included overall caesarean section rates, obstetric indications for caesarean section and regional to general anaesthesia conversion rates. A significant reduction (7.7 to 3.7%, p < 0.0001) in general anaesthetic rates, risk ratio (95%CI) 0.50 (0.39-0.93), was noted across hospitals during the pandemic. Regional to general anaesthesia conversion rates reduced (1.7 to 0.8%, p = 0.012), risk ratio (95%CI) 0.50 (0.29-0.86). Obstetric indications for caesarean sections did not change (p = 0.17) while the overall caesarean section rate increased (28.3 to 29.7%), risk ratio (95%CI) 1.02 (1.00-1.04), p = 0.052. Our analysis shows that general anaesthesia rates for caesarean section declined during the peak of the pandemic. Anaesthetic decision-making, recommendations from anaesthetic guidelines and presence of an on-site anaesthetic consultant in the delivery suite seem to be the key factors that influenced this decline.Copyright © 2020 Association of Anaesthetists
The Cappuccini test
Author(s) Wilson A.; Lie J.
Source Anaesthesia; Jan 2020; vol. 75 ; p. 66
Following the recommendations of the Francis report, it has been NHS policy that all hospital patients have a named consultant responsible for their care to ensure patient safety. Many theatre lists are run by non-autonomous SAS grades (NASG) who, although they are the lead anaesthetist for their list, have a designed consultant supervisor .
At East Lancashire Hospitals NHS Trust (ELHT), there is a designated duty anaesthetist at both Royal Blackburn Teaching Hospital (RBTH) and Burnley General Teaching Hospital (BGTH).
Methods The audit was conducted as per the Cappuccini test guidance produced by the Royal College of Anaesthetists . Twenty elective lists conducted by NASG over 2 weeks were identified at ELHT. The NASG was asked who is supervising you and how would you get hold of them if you needed them now? I then checked that I was able to contact the consultant myself and then asked the consultant the following four questions: which lists are you currently supervising, in which surgical specialty are they working currently, do you know of any issues that the NASG are concerned about and if they required your help would be able to attend?
Results The NASG knew 19/20 of the names of the duty anaesthetists and all of them knew how to get in contact with the consultant if required, which was by a designated deck phone. I was able to get in contact with all the duty anaesthetists. The duty anaesthetist was aware of 15/20 lists and knew the specialities for 14/ 15 of the lists they were aware of. There were no issues reported and all duty anaesthetists said they were able to attend if required for the lists they were aware of (15/15); however, for two of the lists (same supervisor/session), the duty anaesthetist was carrying the registrar bleep due to sickness so would have been less available than usual. Discussion The results show that the NASG knew who the duty anaesthetist was and how to contact them. This is most likely due to the fact that there is a designated duty anaesthetist at both RBTH and BGTH, who is not attached to a specific theatre list, but has the responsibility of supervising all theatres including the NASG and giving assistance when required. The knowledge of the duty anaesthetist of the lists they were supervising was lower, RBTH and BGTH are large departments with 11 and 14 theatres, respectively, which likely factors into this score. All duty anaesthetists said they would be able to attend if required with the one example of slight difficulty due to carrying the registrar's bleep due to sickness.
The following databases were searched:
EMBASE, MEDLINE, PsycINFO, BNI, CINAHL,
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