Militia pharmacy officers' roles in the Swiss Armed Forces during the COVID-19 pandemic

Background: On March 2020, because of the COVID-19 pandemic, the Swiss Federal Council mobilised conscript formations of the Swiss Armed Forces. This was the largest military mobilisation since the Second World War. Purpose(s): To assess the roles of the militia pharmacy officers deployed throughout the country to assist the healthcare system. Method(s): All missions performed by militia pharmacy officers were systematically collected and evaluated. They were also compared to the official duties of pharmacists in the Swiss Armed Forces. Result(s): Ten pharmacy officers were enlisted in two out of four hospital battalions deployed, as well as in the medical logistic battalion and in the staff of the logistic brigade that embedded them. Their missions were mainly planning, conduct and control of medical logistics, as well as hygiene and drug manufacturing activities. In the hospital battalions, they especially managed: 1) supply of medical material dedicated to mission-related training, civilian health facilities assistance and medical transportation;2) establishment and application of hygiene procedures;3) provision of conscripts' own medication. In the medical logistic battalion, the support of both military and civilian pharmaceutical production facilities was the most important activity (e.g. disinfectants and anaesthetics manufacturing). Conclusion(s): Thanks to their civilian and military background, militia pharmacy officers have been quickly and effectively deployed throughout the country. The role of pharmacists within their respective battalions has emerged as especially crucial in the pandemic context and some of the performed missions were beyond their traditional duties. Their basic training has to be further developed accordingly.

Roles and challenges of a Swiss hospital pharmacy during the COVID-19 pandemic

Background: On March 16, 2020, because of the COVID-19 pandemic, the Swiss Federal Council declared an 'extraordinary situation' in terms of the Epidemics Act. Purpose(s): To assess the roles of an inter-hospital pharmacy in the fight against SARS-CoV-2. Method(s): All missions performed by our pharmacy were systematically collected and evaluated. They were also compared to its official duties. Result(s): Specific missions, which have been mainly managed by the crisis unit and the four departments of the pharmacy (Pharmaceutical Logistics, Drug Manufacturing, Clinical Pharmacy and Nursing Homes Supply), were: 1) human resources continuity;2) specific drug supply (for both hospitals and nursing homes;e.g. anaesthetics, sedatives, antiviral drugs, incl. for clinical trials);3) clinical assistance (especially in the ICU of the main acute hospital);4) individual drug manufacturing (e.g. hydroxychloroquine oral solution);5) on-site pharmacies management;6) own infrastructure securing (especially in term of hygiene);7) hand disinfectant production;and 8) hygienic masks supply for healthcare professionals in the area. The two last missions were out of the traditional duties of our pharmacy and have been achieved with the support of staff from the Swiss civil protection. A particular challenge was the management of the shortage of various products and the identification of alternative therapeutic options. Conclusion(s): Our pharmacy has faced various challenges during the acute pandemic situation. Some missions performed were even beyond our traditional ones. The disaster plan of our pharmacy has to be further developed, as well as the associated training of the staff, based on the lessons learned from this pandemic.

Regional anaesthesia for ambulatory surgery

Regional anaesthesia (RA) has an important and ever-expanding role in ambulatory surgery. Specific practices vary depending on the preferences and resources of the anaesthesia team and hospital setting. It is used for various purposes, including as primary anaesthetic technique for surgery but also as postoperative analgesic modality. The limited duration of action of currently available local anaesthetics limits their application in postoperative pain control and enhanced recovery. The search for the holy grail of regional anaesthetics continues. Current evidence suggests that a peripheral nerve block performed with long-acting local anaesthetics in combination with intravenous or perineural dexamethasone gives the longest and most optimal sensory block. In this review, we outline some possible blocks for ambulatory surgery and additives to perform RA. Moreover, we give an update on local anaesthesia drugs and adjuvants, paediatric RA in ambulatory care and discuss the impact of RA by COVID-19. Copyright © 2022 Elsevier Ltd

Oral paracetamol premedication: a proposal for increasing its use

Peri-operative intravenous paracetamol use has not been shown to be superior to oral administration in a randomised controlled trial looking at postoperative pain [1]. The use of intravenous paracetamol carries a wellrecognised increased financial and environmental cost compared to oral paracetamol. We audited the use of paracetamol in patients attending theatre at a district general hospital and propose a method to increase premedication with oral paracetamol. Methods We retrospectively audited the notes of all patients who underwent an elective surgical procedure in theatres, across a 5-day period at a district general hospital. Data regarding the use of paracetamol were collected. Patients who were already an inpatient and those having surgery under local anaesthetic alone were excluded. Results Forty-seven patients were included, five of whom had a spinal and 42 a general anaesthetic with representation from six different surgical specialities. Five of the patients included were under 18 years. Thirty-seven patients received paracetamol peri-operatively. Thirty-four patients received only intravenous paracetamol, two patients received oral paracetamol and one patient received both due to length of time between preoperative oral dose and surgery. Ten patients did not receive any paracetamol. No patients included had a documented allergy or contraindication to paracetamol. Discussion Our department recognised the financial and environmental benefits associated with oral pre-medication. Although many of these anaesthetists would prefer to prescribe pre-operative analgesia, the data indicate that there are barriers that prevent prescription and/or administration. As a result of the COVID-19 pandemic, elective orthopaedic surgery with an enhanced recovery protocol including the use of oral paracetamol premedication, was underrepresented in our data. Previous encouragement to prescribe oral premedication has produced good, short-term results but does not appear to provide long-lasting change. We propose a Patient Group Directive for the administration of pre-operative oral paracetamol by the admitting nurse on arrival to the pre-operative ward. We anticipate that this will both standardise and embed oral paracetamol premedication into the department and will therefore provide long-term change.

Anesthetic challenges in the management of Larsen syndrome: A rare congenital anomaly

Larsen syndrome is a rare inherited disease associated with dislocations of multiple joints, typical syndromic facies, and multiple spine abnormalities. They often required multiple corrective orthopedic surgeries to regain their functional ability, thus needing repeated anesthesia. Apart from skeletal deformities, they have predicted difficult airway and need extreme care during intubation and positing of the patient. Abnormal posturing due to spinal deformity and poor pulmonary reserve due to kyphoscoliosis creates an extremely challenging situation for the anesthetist to manage the case during the perioperative period. Here we are describing the perioperative anesthetic management of a patient with Larsen syndrome. Copyright © 2022 Saudi Journal of Anesthesia Published by Wolters Kluwer - Medknow.

Post-COVID-19 elective surgery and transformation: exploring the role of ambulatory spinals in the high-risk patient population

At Whipps Cross Hospital, multi-morbid (high-risk) patients undergoing urological surgery are routinely listed on the surgical inpatient pathway. The 'Getting it right first time' [1] review of anaesthesia recommended day-case surgery as the default for suitable procedures, to help with waiting lists as well as to provide patients with a safe environment. To improve patient choice and postoperative outcomes, an ambulatory spinal pathway was piloted. Methods An earlier scoping exercise identified a pool of urology high-risk patients who could potentially benefit from an ambulatory spinal pathway. Based on this, prilocaine use for ambulatory spinal anaesthetic was provisionally approved by the drugs and therapeutic committee. A pilot ambulatory pathway was put in place, which helped identify suitable patients. The pilot pathway was limited to a select group of anaesthetists to minimise variations. Postoperatively, patients were followed up at 3 and 24 h and assessed for postoperative nausea, vomiting, pain, mobilisation, neurological symptoms and cognitive impairment. Results The total number of patients was 19. Mean ASA was 2.9. Average age was 74 years. The mean dose of hyperbaric prilocaine 2% used was 2.9 ml, 21% of cases utilised additional intrathecal additives. Regarding intra-operative analgesia, only paracetamol was used in 15% of cases. There were no conversions to general anaesthetic. The most common procedure was a cystoscopy with or without biopsy (42%). With comorbidities, diabetes mellitus was the most common (58%), followed by cardiac disease (53%) and respiratory disease (42%). At 3 h, 100% of patients were eating and all sensation had returned, 0% had cognitive impairment, 47% were sitting out and 42% mobilising. Sixteen per cent had hypotension and 5% had pain at rest. At 24 h, 0% had cognitive impairment, 50% had required analgesia and 84% were mobilising. All patients reported they would have a spinal anaesthetic again in the future. Discussion With an ageing population, who have multiple comorbidities, there is huge benefit regarding providing the choice of a spinal anaesthetic rather than general anaesthetic, which allows patients to go home the same day. This will not only provide financial savings to the service provider but also help clear the backlog of surgeries due to the COVID-19 pandemic and enhance patient recovery.

Development of a Novel Near-peer Surgical Simulation-based Teaching Programme for Intern Doctors

Background: Trends in healthcare have caused a shift in training towards more competency based programmes. The COVID-19 pandemic has reduced time available for direct exposure and clinical learning, necessitating incorporation of simulation in training. The objectives of this study were to develop, pilot and evaluate a four week simulation based surgical teaching programme. Method(s): Interns pursuing a career in Surgery joined a near-peer surgical training programme delivered by NCHDs. A survey established a baseline competency. Four skills workshops were delivered. Outcomes were measured using data from pre and post course surveys as well as a surgical skills competition. Result(s): Of The 12 trainees, 71% had scrubbed in theatre before. 50% were already confident to scrub independently, increased to 75% post training. 28% were confident gowning/gloving, increased to 75% post training. 28% were confident to place a Simple suture in theatre, this did not increase despite training. 42% were confident performing an instrument tie, increased to 75% post training. 14% were confident hand tying knots, this increased to 62%. 14% of participants were comfortable performing excisional biopsy in theatre, increased to 62% post training. Preparation and administration of local anaestetic could be performed confidently by 14% before training, this increased to 87%. on completion, a surgical skills competition showed that 100% were able to satisfactorily perform basic skills. Conclusion(s): Near-peer delivery of surgical training has enhanced The basic surgical skills of interns. Similar programmes in other sites would ensure that interns have The skills required to safely care for surgical patients.

MALIGNANT HYPERTHERMIA AND COVID-19: IS THERE A CORRELATION?

SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Malignant hyperthermia (MH) is a hypermetabolic crisis where an increase in carbon dioxide is seen despite an increased minute ventilation with a proposed mechanism as a disturbance in calcium homeostasis. Commonly seen in volatile anesthetic agents and depolarizing neuromuscular blockers, rarely with nondepolarizing agents. There has been one reported case of cisatracurium-induced MH in the setting of ARDS. There have been two cases reported of nondepolarizing neuromuscular agents causing MH in the setting of COVID-19. CASE PRESENTATION: A 34-year-old man with severe COVID-19 complicated by ARDS on ventilator day 16, due to refractory fevers, ventilatory dyssynchrony, high minute ventilation and auto-PEEP phenomena, the decision was made to attempt neuromuscular paralysis. After one dose of cisatracurium, the patient became hyperthermic and end-tidal carbon-dioxide increased from 58-98 with inability to oxygenate. The patient developed high peak pressures, bedside ultrasound revealed no evidence of pneumothorax also confirmed with chest x-ray. The patient then received a dose of dantrolene with end-tidal improving to 60 and tachycardia also resolved. A creatinine kinase level drawn was elevated at 571. DISCUSSION: A proposed mechanism of MH is calcium release from sarcoplasmic reticulum, a mutation in skeletal muscle ryanodine receptor calcium release channels that can release IL-6 when activated leading to excessive muscular contraction. Proinflammatory cytokine IL-6, dantrolene may block IL-6 release which results in its therapeutic effect in the treatment of MH. IL-6 has been used to predict deterioration from COVID-19. Dantrolene in this sense has been proposed as a potential therapeutic agent against COVID-19, inhibiting intracellular calcium influx thus preventing the pathological feedback of viral entry into cells via endocytosis, as this is a calcium dependent process. Given the possible link between IL-6 release, calcium and MH, SARS-CoV-2 viral entry into cells may place patients at higher risk of MH. Patients with COVID-19 may be at higher risk of MH, even in rare agents such as non-depolarizing agents as seen in this case. Awareness of this potentially increased complication from these agents in those patients with COVID-19 is key as we continue in the ongoing global pandemic. CONCLUSIONS: Given the possible link between IL-6 release, calcium and MH, SARS-CoV-2 viral entry into cells may place patients at higher risk of MH. Patients with COVID-19 may be at higher risk of malignant hyperthermia, even in rare agents such as non-depolarizing agents as seen in this case. Awareness of this potentially increased complication from these agents in those patients with COVID-19 is key as we continue in the ongoing global pandemic. Reference #1: Sathyanarayanan SP, Hamza M, Hamid K, Groskreutz D. Cisatracurium-Associated Malignant Hyperthermia During Severe Sars-CoV-2 Infection. Am J Ther. 2021 Aug 10;28(5):e590-e591. doi: 10.1097/MJT.0000000000001437. PMID: 34387563;PMCID: PMC8415506. Reference #2: Chiba N, Matsuzaki M, Mawatari T, Mizuochi M, Sakurai A, Kinoshita K. Beneficial effects of dantrolene in the treatment of rhabdomyolysis as a potential late complication associated with COVID-19: a case report. Eur J Med Res. 2021 Feb 8;26(1):18. doi: 10.1186/s40001-021-00489-8. PMID: 33557936;PMCID: PMC7868892. Reference #3: Han H, Ma Q, Li C, Liu R, Zhao L, Wang W, Zhang P, Liu X, Gao G, Liu F, Jiang Y, Cheng X, Zhu C, Xia Y. Profiling serum cytokines in COVID-19 patients reveals IL-6 and IL-10 are disease severity predictors. Emerg Microbes Infect. 2020 Dec;9(1):1123-1130. doi: 10.1080/22221751.2020.1770129. PMID: 32475230;PMCID: PMC7473317. DISCLOSURES: No relevant relationships by Hira Bakhtiar No relevant relationships by Timothy DAmico no disclosure on file for Sarah Margolskee;No relevant relationships by Carlos Merino No relevant relationships by Joanna Moore

The impact of COVID-19 on Intensive Care recruitment

Introduction: Recruitment in intensive care has long been discussed, with the pandemic bringing this into sharp focus. Most anaesthetists in training were fully redeployed into ICU rotas or provided technical expertise. As surge rotas settle and a 'new normal' is regained, the challenge of ICU consultant recruitment needs to be addressed. Historically, ICUs have been predominantly staffed by consultants trained in both anaesthetics and intensive care medicine (ICM), but the challenges of this career path have been augmented by COVID-19. Forecasts suggest a concerning supply shortage of both anaesthetic and ICM consultants.1 The latest recruitment round for ICM has been the most competitive year for applications (ratio 2.9:1 in 2021 compared to 1.49:1 in 2020).2 However, the anaesthetic/ICM dual-training contribution to this workforce has worryingly decreased from approximately twothirds to less than a half. But what factors are causing this and has COVID-19 redeployment worsened this? Objectives: As we emerge from the second wave of the pandemic, we assessed the attitudes of anaesthetists about future careers in intensive care. Methods: We performed a brief electronic survey of 100 dual-or single-specialty anaesthetists in training from four LETBs across England who were redeployed to ICU. Results: Our survey showed that 29% had a negative experience that dissuaded them from pursuing ICM careers or, in some circumstances, relinquish their ICM training number altogether. Promisingly, 64% had a positive experience, and of these 39% reaffirmed their desire to pursue a career in ICU and 13% developed a new interest in pursuing a career in ICU since their redeployment. Positive factors included, 'teamwork', 'complexity of patients' and 'adding variety to my anaesthetic practice'. Prominent negative factors were 'additional exams', 'two separate portfolios' and 'high risk of burnout'. Respondents suggested changes to attract more anaesthetists to dual-accredit with ICM. This included the removal of hurdles such as additional exams, separate portfolios, and duplicated assessments. The additional training time was also highlighted, particularly given that trainees already contribute significantly to ICM rotas. There was a need for more flexibility in training with dual trainees wanting to undertake advanced training modules like their anaesthetic counterparts. They also reported wanting more anaesthetic sessions in their future job plans possibly reflecting the desire for varied practice as a consultant. Conclusion: Although COVID-19 has had a positive effect by increasing ICM applications, this may be at the expense of dual-trained anaesthetic/ICM trainees. FFICM should consider the factors which dissuade these applicants and its future impact on skills available in ICU. Both the RCoA and the FFICM have recently announced changes to curricula and e-portfolio which may close some of these gaps. The pandemic has grabbed the attention of a few anaesthetists and presented an opportunity to work in a team that solves difficult physiological puzzles, rapidly escalates capacity, and increasingly focuses on staff wellbeing. We should capitalise on this and hope that COVID-19 will result in the conversion of some of our anaesthetic colleagues into dual-specialty ICM consultants.

The Use of Ketamine Sedation for the Treatment of Nail Bed Repairs in the Paediatric Emergency Department

Aim: To determine if ketamine sedation is a safe and cost-effective way of treating paediatric patients presenting with nail bed injuries to the emergency department. Method:Aretrospective cohort study was carried out over a nine-month period in children between ages 18 months and 16 years old, presenting to the paediatric emergency department (PED) at Chelsea and Westminster Hospital, London, with nail bed injuries requiring repair by the plastic surgery team. The primary outcome measures are complications at the time of sedation and at outpatient follow up including surgical site infection at seven days. A secondary outcome measure of parental satisfaction was collected at four months. A cost analysis comparison against procedures completed under general anaesthetic was also undertaken. Results: During the 9-month period, 10 nail bed repairs were performed under ketamine sedation in the PED. There were no serious adverse events recorded. No cases required further procedures and there were no cases of surgical site infections at 7 days. Parents reported favourable outcomes, with an average overall satisfaction score of 9.4 (where 10 is complete satisfaction). At follow up, there was one recorded complication which was successfully treated, with all patients being discharged from follow up within 3 months. Conclusion: This small study has shown ketamine procedural sedation in the paediatric population to be a safe and cost-effective method for the treatment of nail bed injuries in children presenting to PED. We believe that this management strategy, brought to the fore during the COVID-19 pandemic, should be considered as standard across all PEDs.

The Impact of 'Golden Local Anaesthetic (GLA)' Principal on Emergency Theatre Efficiency - Analysing 232 Hand and Plastic Trauma Operations

Aim: 'Golden local anaesthetic' (GLA) principals are known to improve theatre efficiency. This first GLA case should be suitable to be completed unsupervised by a registrar and confirmed 12 hours prior to the start of the list with a negative COVID PCR test. This allows for list to be started, whilst the consultant is able to see and consent the remainder of the patients for that list, maximising theatre efficiency. Method: Operative timings was gathered in real time in our electronic database (TIMS). Initially, retrospective analysis was performed for cases in November 2020, comparing lists whereby a potential GLA first case was present, versus lists that did not. After remodelling this process, lists in October 2021 were analysed. Statistical analysis was carried out using Mann Whitney U Test. Results: Initially (PDSA-1), 110 trauma cases (58% GA and 42% LA) were performed [3.67/day] whilst post refinement (PDSA-2) 122 cases (52% GA and 48% LA) were performed [3.94 /day]. In PDSA-2, there was a 29% (9/ 31) uptake of GLA list principals. The average GLA list start time was 09:27hrs in PDSA-1 and 09:08hrs in PDSA-2 [Δ 19 mins, p<0.05] whilst the average non-GLA list start time was worse (09:53hrs and 10:12hrs). By refining the GLA principal, £470.63 was 'saved' with a further £445.86 potentially able to be saved when starting at the earliest recorded start time (1) Conclusions: The GLA model is a simple and sustainable method to improve theatre efficiency which could be adopted by other units.

Difficult and failed intubation management in obstetrics

Failed intubation in obstetrics remains a topical issue, a rare but potentially devastating complication of obstetric general anaesthesia. The 2015 guidelines produced following several years of collaborative work between the Difficult Airway Society (DAS) and Obstetric Anaesthetists' Association (OAA) remain the definitive text. While deaths from failed intubation have declined significantly over 30 years, the incidence of failed intubation remains fairly constant at 1:300, with the latest studies showing a rate of 1:224. This reflects the significant decline in the use of general anaesthesia for caesarean section over the last three decades;however, it also highlights a decreased exposure for trainees to tracheal intubation in the obstetric population.

SASA 2022 Virtual Conference Abstracts

The proceedings contain 23 papers. The topics discussed include: petroleum jelly as an alternative coupling medium in focus assessed transthoracic echocardiography;perspectives on desflurane;use of high-flow nasal oxygenation outside COVID-19: a rural hospital experience;fitness for purpose of South African anesthesiologists;the effect of caregiver's recorded voice on emergence delirium in children undergoing dental surgery;perioperative outcomes of mitral valve surgery at Charlotte Maxeke Johannesburg Academic Hospital;comparison of a novel low-cost hyperangulated optic intubation stylet with the Bonfils fiberscope: a simulated difficult airway manikin study;the awareness of local anaesthetic systemic toxicity amongst registrars from surgical disciplines in a tertiary hospital, South Africa;and SARS-CoV-2 infection prevalence in healthcare workers, administrative and support staff: the first wave experience at three academic hospitals in the Tshwane District of Gauteng.

Anaesthetic management of a parturient with Klippel-Trenaunay syndrome

Introduction: Klippel-Trenaunay syndrome (KTS) is a rare congenital vascular disease which is characterised by capillary, venous and lymphatic malformations. We describe the anaesthetic management of a 36 year old parturient with COVID-19 and KTS, who underwent an elective caesarean section. Very few such cases have been described and the multi-system nature of condition poses various challenges to both the obstetrician and the anaesthetist. Case Report: We had a 36-year-old woman who had experienced three previous normal vaginal deliveries and an elective caesarean section (CS) four years previously under general anaesthetic(GA) at 36 weeks gestation. She was told by a vascular surgeon that she was not suitable for regional anaesthesia. There was no recent imaging of her back to rule out arteriovenous(AV) malformations. Her past history included gastric bypass surgery under GA two years ago. She also had depression, varicose veins and three previous deep venous thrombosis andwas on prophylactic lowmolecularweight heparin. She had tested positive for COVID-19 4 days previously, and had mild symptoms of cough and sore throat. After a multi-disciplinary discussion involving an obstetrician, vascular surgeon, haematologist and anaesthetist, a decision was made to proceed with GA despite recent COVID-19, because of the possibility of AV malformations, in agreement with the patient. After securing two wide bore cannulae and adequate preoxygenation, a modified Rapid Sequence Induction was performed, and a tracheal tube was secured. Anaesthesia was maintained with oxygen, nitrous oxide and sevoflurane. After delivery of the baby, oxytocin 5U, followed by an infusion, midazolam, morphine, ondansetron and dexamethasone were administered. Extubation was performed when the patient was fully awake. In recovery, further opioids were given for pain. There were no concerns for the newborn. Estimated blood loss was 200 mL. Discussion: Gestation and its physiology may further exacerbate the manifestations of KTS, with increased obstetric risk. The success in the management of these patients requires the participation of a multidisciplinary team, consisting of obstetrician, anaesthetist, urologist, haematologist and vascular surgeon, with appropriate collaboration among the professionals involved. Periodic imaging and clotting tests are recommended to evaluate the evolution of vascular malformations in the pelvis, uterus and vagina, and identify neuraxial changes, to guide the safest way of delivery and anaesthesia.

Spinal anaesthesia for EXIT procedure

Introduction: The EXIT (ex-utero intrapartum treatment) procedure allows management of an abnormal fetal airway during operative delivery while they remain on utero-placental circulation. The vast majority of published cases were conducted under deep volatile anaesthesia [1] in order to provide uterine relaxation and a degree of fetal anaesthesia.10 cases have been reported under combined spinalepidural anaesthesia or intrathecal catheter, with supplemental GTN (glyceryl trinitrate) and remifentanil infusions. Recent research has improved the ability to predict the likelihood and complexity of surgical intervention. Regional anaesthesia cases all had a hysterotomy time of under 21 minutes. Here we present the first case report of an EXIT procedure conducted with simple spinal anaesthesia. Case Report: A 35-year-old woman with a BMI of 37 kg/m2, asthma and a recent COVID-19 pneumonia, had a history of post-dural puncture headache after a difficult epidural for labour, spinal anaesthetics requiring ultrasound and a lumbar puncture requiring x-ray guidance. Her fetal MRI had shown a 5.6 cm cystic neck mass, with a deviated but patent airway. The ENT team predicted surgical interventionwas unlikely or would be very short, but intubation likely. We advised a general anaesthetic as our centre did not yet have experience with EXIT under regional anaesthesia, but the patient adamantly wanted spinal anaesthesia until the baby was born, to be aware of their outcome on delivery. She preferred to avoid an epidural. An arterial line aided the challenging blood pressure management with intrathecal hyperbaric bupivacaine 13.5 mg and diamorphine 300 μg, remifentanil and GTN infusions. The uterus remained relaxed on 2.3 μg/kg/minute of GTN. Uterine tonewas later re-established with intravenous Syntocinon 10 U and intramuscular ergometrine 500 μg, with only 500 mL maternal blood loss. Despite remifentanil target controlled infusion (Minto model) at 3.5 ng/mL for 15 minutes before hysterotomy, the baby cried spontaneously. Hysterotomy timewas two minutes. Discussion: Our team were satisfied with this technique, allowing us to offer more choice to mothers with an expected short EXIT procedure. The utero-placental transfer of remifentanil has previously been found to be variable, but cases have described no fetal response to intubation from maternal remifentanil titrated to light sedation [2]. It is common for additional drugs to be given directly to the fetus even with volatile anaesthetic.

Post-operative caesarean section pain and analgesia following neuraxial anaesthesia

Introduction: Pain following caesarean section (CS) may hinder recovery and ability to care for the newborn. NICE [1] and PROSPECT [2] suggest analgesia be individualised. Regular paracetamol and NSAID should be co-prescribed. NICE advise adding regular dihydrocodeine where required. PROSPECT advise opioids for breakthrough where other techniques (e.g. regional) are contraindicated. Our protocol is PR diclofenac 100 mg in theatre, regular oral paracetamol 1 g + ibuprofen 400 mg, breakthrough dihydrocodeine 30 mg and oramorph 5 mg. The NHSL pain scale is a 0–4 numeric patientreported score, with >2 and <3 representing high and low scores. A CS audit in 2019–20 demonstrated 95% of patients being satisfied/very satisfied with pain relief, but 42% and 31% reported high pain scores on movement and rest, respectively. Only 28% received PR diclofenac, 85% paracetamol + ibuprofen, and 86% breakthrough dihydrocodeine. This re-audit assessed dynamic pain scores following introduction of regular dihydrocodeine 30 mg. Methods: After hospital clinical audit team approval, a prospective reaudit of postoperative CS pain and analgesia following neuraxial anaesthesiawas performed using a standardised patient questionnaire conducted on postoperative day 1 or 2 in Sep–Oct 2021. Participation was voluntary, occurring contemporaneously with routine postneuraxial anaesthesia follow-up. The NHSL pain scale was used. Elective and emergency patients were included. Cases under general anaesthetic were excluded. Results: The main outcomes are reported in the Table. (Table Presented) Discussion: Following introduction of regular dihydrocodeine, pain scores on movement did not improve. Use of breakthrough analgesia reduced. Time taken to receive breakthrough analgesia increased. The COVID-19 pandemic impacted staff absence rates. Telephone reviews post-discharge were not evaluated for the re-audit, which may skew results, with confounding factors contributing to pain. Future work will include midwife education, review opioid protocol prescribing and introduction of routine regional anaesthetic techniques (e.g. TAP block), followed by re-audit.

Experience of managing abnormally invasive placenta over an eight-year period in a UK centre

Introduction: Abnormally invasive placenta (AIP) has a significant risk of mortality and morbidity. International recommendations support management in specialist centres [1]. North Bristol Trust (NBT) is a large obstetric unit providing regional management since 2014 this service evaluation shows changing management over an eight year period, in line with local experience and published recommendations. Methods: Retrospective database analysis (with local audit approval) of AIP cases at NBT 2014–2021 were performed. Antenatal and perioperative management was reviewed via electronic patient records. Results: Sixty-one patients presented with AIP. Mean maternal age was 35.2 years and mean gestation at delivery was 34 + 2 weeks. Average paritywas 2.5 (range 0–7). No maternal deathswere recorded. Sixty women were identified pre-operatively and one unexpected intraoperatively. Postoperatively 60 cases were managed on our level- 2 obstetric critical care unit, one required level-3 critical care. Anaesthetic technique has evolved including: general anaesthetic (GA) plus low-dose spinal 36%;GA alone 36%;combined spinalepidural (CSE) 23%;CSE converted to GA 3%;epidurals 1.5%;and spinals 1.5%. Forty-five cases (72%) delivered via elective CS and 28% required urgent CS. Invasive arterial blood pressure monitoring was used in 84%. The hysterectomy rate was 67% (59% elective vs 100% urgent cases). Of 16 cases in the hybrid theatre, only four internal iliac artery balloons (IAB) were inflated (25%), for a mean of 62 min. One complication occurred, a femoral artery thrombus requiring embolectomy at the end of case. Mean estimated blood loss for all cases was 3.5 L (range 0.5–14 L). No statistical differencewas noted in blood loss with or without IAB (3.6 vs 3.1 L), nor planned vs urgent surgery. Intraoperative cell salvagewas used 97%;mean volume of cell salvaged blood (CSB) reinfused was 0.7 L (range 0–3.3 L). Packed red blood cells were transfused in 44%, fresh frozen plasma in 34%, platelets in 18%, and cryoprecipitate in 44%. ROTEM was utilised in 56% of cases and TXA given in 82%. Discussion: IAB have not been used in AIP management for 2 years in our institution. This does not appear to affect blood loss, transfusion rate, or requirement for critical care. Our GA rate has remained high compared to other centres [2], due to hybrid theatre ergonomics and Covid-19 PPE requirements. Use of autologous blood transfusion via cell salvage with rapid processing is central to our care.

A digital future in antenatal education-unintentional benefits from a pandemic

Introduction: EROS (Enhanced Recovery after Obstetric Surgery) protocols have become a mainstay in many UK obstetric units since 2015 [1]. As part of our local EROS pathway we had awell-established face-to-face caesarean delivery preparation class for mothers and birthing partners. It utilised an MDT approach involving midwifery, physiotherapy and anaesthetics to share information that embeds EROS principles and empowers mothers with confidence and knowledge about delivery and recovery. The COVID-19 pandemic challenged us to find new ways to deliver this information safely. The class was relaunched on a digital platform. We assessed whether we could achieve the same standard and patient satisfaction with this online format. Methods: We collated feedback from 40 mothers and birthing partners attending the online class and compared it to those who attended face-to-face classes before the pandemic. Data were descriptive free-text answers to questions and a 10-point rating scale measuring confidence pre and post class attendance. A further 25 responses evaluating the online class were obtained following improvements suggested by the first online cohort. Results: A total of 90 patients provided feedback. For the face-to-face class, median confidence score increased from 7 pre-class to 9 after the class, and for the digital class it increased from 6 to 9 (P = 0.0005). 67% of mothers felt more confident about their delivery after the face-toface class and 92% after the digital one. (Figure Presented) Discussion: Both face-to-face and digital classes are effective at increasing confidence in delivery and recovery from caesarean delivery, with data suggesting that online sessions were able to do this more effectively. The most commonly reported strengths of digital sessions were that they provided comprehensive information in an easy-to-understand format, particularly around recovery and mobilisation, and that the relaxed nature encouraged questions. Initially, we experienced some technical difficulties with the digital platform and this was noted as an area of improvement from the first round of feedback. Several respondents noted missing the in-person element and opportunity to meet other expectant mothers. We are now assessing the feasibility of a hybrid class.

Does mouth opening in patients with dental infections improve after induction of anaesthesia? A prospective observational study

Dental infection can cause reduced mouth opening which may make tracheal intubation after induction of general anaesthesia difficult. Although it is widely quoted in the literature that reduced mouth opening secondary to dental infection might not improve post-induction of anaesthesia,1 the evidence base for this is limited. The 4th National Audit Project in Anaesthesia highlighted that airway complications often resulted from poor assessment, inadequate planning of management, and a reluctance to use advanced airway techniques.2 An improved understanding and awareness of the effect of dental infection on mouth opening could help highlight potential airway difficulty, improving planning of airway management and the use of appropriate techniques to do this. We conducted a prospective observational study at the Royal Hallamshire Hospital, Sheffield. After study approvals (REC ref: 18/LO/1134, IRAS ID: 264468) were obtained, 11 patients presenting with dental infection requiring surgical management under general anaesthetic were recruited between December 2018 and January 2020. Maximal mouth opening was measured immediately before and after the induction of general anaesthesia using a TheraBite® ROM scale.3 The presence of a number of parameters associated with the severity of dental infection was also recorded. The mean pre-induction maximal mouth opening of the study participants was 18 mm (standard deviation [SD], 5.16 mm) whereas the mean post-induction maximal mouth opening was 22.3 (5.56) mm. Although the maximal mouth opening of 3 (17%) patients improved by more than 10 mm after induction of anaesthesia, the other 8 (73%) patient’s maximal mouth opening improved by less than 2 mm. Unfortunately, there was a large under-recruitment to the study in part owing to difficulties resulting from the COVID-19 pandemic. The study was therefore underpowered to perform further statistical analysis of the influence of induction of anaesthesia on a patient’s maximal mouth opening or to examine the influence of the presence of parameters associated with the severity of dental infection on maximal mouth opening. To our knowledge, this is the first study to look at the change in maximal mouth opening after induction of anaesthesia as a primary endpoint in patients with dental infection. Even in the context of the small sample size, the finding that 73% of the patients in the study had a less than 2 mm improvement in maximal mouth opening after induction is clinically highly relevant. A lack of improvement in reduced mouth opening has significant implications on airway management. This study clearly shows there is a reasonable prospect of this scenario in patients with dental infection and supports the practice of assuming mouth opening will not improve after induction of anaesthesia when planning airway management in these patients. References 1. Morosan M, Parbhoo A, Curry N. Continuing Education in Anaesthesia Critical Care & Pain 2012;12: 257–62 2. Cook TM, Woodall N, Frerk C. On behalf of the Fourth National Audit Project. Br J Anaesth 2011;106: 617–31 3. TheraBite® Range of Motion Scale. Available from: accessed date as: 5th November 2021