Lifebox pulse oximeter implementation in Malawi: evaluation of educational outcomes and impact on oxygen desaturation episodes during anaesthesia.

Pulse oximetry is an essential monitor for safe anaesthesia but is often not available in low-income countries. The aim of this study was to determine whether the introduction of pulse oximetry with training was feasible and could reduce the incidence of oxygen desaturation during anaesthesia in a low-income country. Pulse oximeters were donated, with training, to 83 non-physician anaesthetists in Malawi. Knowledge was tested immediately before and after training and at follow-up. Providers were asked to record the lowest peripheral oxygen saturation (SpO2 ) for the first 100 cases anaesthetised after training. The primary clinical outcome was the proportion of cases with an oxygen desaturation event (SpO2 < 90%). Seventy-seven of 83 (93%) participants completed all pre- and post-training tests. Pulse oximetry knowledge improved after training from a median (IQR [range]) score of 39 (37-42 [28-48]) to 44 (42-46 [35-50]) and this knowledge was maintained for 8 months (p < 0.001). Oxygen saturation data and provider responses were recorded for 4772 cases. The proportion of oxygen desaturation episodes decreased from 17.2% to 6.5%, representing a 36% reduction in the odds of an oxygen desaturation event in the second 50 cases compared with the first 50 (OR 0.64, 95%CI 0.50-0.82, p < 0.001). We conclude that donation of pulse oximeters, with training, in Malawi was feasible, improved knowledge and reduced the incidence of oxygen desaturation events.

Evaluation of a large-scale donation of Lifebox pulse oximeters to non-physician anaesthetists in Uganda.

Pulse oximetry is widely accepted as essential monitoring for safe anaesthesia, yet is frequently unavailable in resource-limited settings. The Lifebox pulse oximeter, and associated management training programme, was delivered to 79 non-physician anaesthetists attending the 2011 Uganda Society of Anaesthesia Annual Conference. Using a standardised assessment, recipients were tested for their knowledge of oximetry use and hypoxia management before, immediately following and 3-5 months after the training. Before the course, the median (IQR [range]) test score for the anaesthetists was 36 (34-39 [26-44]) out of a maximum of 50 points. Immediately following the course, the test score increased to 41 (38-43 [25-47]); p < 0.0001 and at the follow-up visit at 3-5 months it was 41 (39-44 [33-49]); p = 0.001 compared with immediate post-training test scores, and 75/79 (95%) oximeters were in routine clinical use. This method of introduction resulted in a high rate of uptake of oximeters into clinical practice and a demonstrable retention of knowledge in a resource-limited setting.

Surgical safety checklists: do they improve outcomes?

The concept of using a checklist in surgical and anaesthetic practice was energized by publication of the WHO Surgical Safety Checklist in 2008. It was believed that by routinely checking common safety issues, and by better team communication and dynamics, perioperative morbidity and mortality could be improved. The magnitude of improvement demonstrated by the WHO pilot studies was surprising. These initial results have been confirmed by further detailed work demonstrating that surgical checklists, when properly implemented, can make a substantial difference to patient safety. However, introducing surgical checklists is not as straightforward as it seems, and requires leadership, flexibility, and teamwork in a different way to that which is currently practiced. Future work should be aimed at ensuring effective implementation of the WHO Surgical Safety Checklist, which will benefit our patients on a global scale.

Oxygen is an essential medicine: a call for international action.

Hypoxaemia is commonly associated with mortality in developing countries, yet feasible and cost-effective ways to address hypoxaemia receive little or no attention in current global health strategies. Oxygen treatment has been used in medicine for almost 100 years, but in developing countries most seriously ill newborns, children and adults do not have access to oxygen or the simple test that can detect hypoxaemia. Improving access to oxygen and pulse oximetry has demonstrated a reduction in mortality from childhood pneumonia by up to 35% in high-burden child pneumonia settings. The cost-effectiveness of an oxygen systems strategy compares favourably with other higher profile child survival interventions, such as new vaccines. In addition to its use in treating acute respiratory illness, oxygen treatment is required for the optimal management of many other conditions in adults and children, and is essential for safe surgery, anaesthesia and obstetric care. Oxygen concentrators provide the most consistent and least expensive source of oxygen in health facilities where power supplies are reliable. Oxygen concentrators are sustainable in developing country settings if a systematic approach involving nurses, doctors, technicians and administrators is adopted. Improving oxygen systems is an entry point for improving the quality of care. For these broad reasons, and for its vital importance in reducing deaths due to lung disease in 2010: Year of the Lung, oxygen deserves a higher priority on the global health agenda.

Global oximetry: an international anaesthesia quality improvement project.

Pulse oximetry is mandatory during anaesthesia in many countries, a standard endorsed by the World Health Organization 'Safe Surgery Saves Lives' initiative. The Association of Anaesthetists of Great Britain and Ireland, the World Federation of Societies of Anaesthesiologists and GE Healthcare collaborated in a quality improvement project over a 15-month period to investigate pulse oximetry in four pilot sites in Uganda, Vietnam, India and the Philippines, using 84 donated pulse oximeters. A substantial gap in oximeter provision was demonstrated at the start of the project. Formal training was essential for oximeter-naïve practitioners. After introduction of oximeters, logbook data were collected from over 8000 anaesthetics, and responses to desaturation were judged appropriate. Anaesthesia providers believed pulse oximeters were essential for patient safety and defined characteristics of the ideal oximeter for their setting. Robust systems for supply and maintenance of low-cost oximeters are required for sustained uptake of pulse oximetry in low- and middle-income countries.

The World Health Organization and anaesthesia.

The World Health Organization has been involved in a wide range of global healthcare initiatives for many years. Recently an initiative 'Safe Surgery Saves Lives' has been launched to improve the safety of surgery throughout the world. Safe anaesthesia is a key component to achieving this aim.

The World Federation of Societies of Anaesthesiologists: supporting education in the developing world.

The World Federation of Societies of Anaesthesiologists (WFSA) was formed in 1955 and is currently composed of 120 national societies. The aims of WFSA are to improve the standards of anaesthesia worldwide, with a particular emphasis in developing countries. This article details the structure of the WFSA, the various activities carried out by the different committees, and our achievements in education and training.

Anaesthesia services in developing countries: defining the problems.

We describe the use of a questionnaire to define the difficulties in providing anaesthesia in Uganda. The results show that 23% of anaesthetists have the facilities to deliver safe anaesthesia to an adult, 13% to deliver safe anaesthesia to a child and 6% to deliver safe anaesthesia for a Caesarean section. The questionnaire identified shortages of personnel, drugs, equipment and training that have not been quantified or accurately described before. The method used provides an easy and effective way to gain essential data for any country or national anaesthesia society wishing to investigate anaesthesia services in its hospitals. Solutions require improvements in local management, finance and logistics, and action to ensure that the importance of anaesthesia within acute sector healthcare is fully recognised. Major investment in terms of personnel and equipment is required to modernise and improve the safety of anaesthesia for patients in Uganda.

Epidural infusion or combined femoral and sciatic nerve blocks as perioperative analgesia for knee arthroplasty.

BACKGROUND: Peripheral neural blockade appears to provide effective analgesia with potentially less morbidity than central neuraxial techniques. We compared the relative benefits of combined femoral (3-in-1) and sciatic nerve block with epidural blockade for postoperative knee arthroplasty analgesia. METHODS: Sixty patients, ASA I-III, undergoing unilateral knee replacement were prospectively randomized to receive either a lumbar epidural infusion or combined single-shot femoral (3-in-1) and sciatic blocks (combined blocks). All patients received standard general anaesthesia. Visual analogue pain scores and rescue opioid requirements were recorded at four time points postoperatively. Patient satisfaction, morbidity, block insertion time, perioperative blood loss and rehabilitation indices were also assessed. RESULTS: In both groups, pain on movement was well controlled at discharge from recovery and 6 h postoperatively but increased at 24 and 48 h. Median (95% CI) analogue scale scores were 0 (0-0), 15 (0-30), 55 (38-75) and 54 (30-67) mm for epidural block and 0.5 (0-22), 21.5 (10-28), 40 (20-50) and 34.5 (21-55) mm for combined block. VAS pain scores with the combined blocks were significantly lower at 24 h (P=0.004). Total morphine usage was low in both groups: median epidural group 17 mg (8-32) versus combined blocks 13 mg (7.8-27.5). Patient satisfaction was high in both groups with median (95% CI) scores of 100 (85-100), 83 (70-100) and 82 (57-90) mm for epidural and 90 (73-100), 100 (77-100) and 97 (80-100) mm for combined blocks (not significant). Perioperative blood loss and rehabilitation indices were also similar. CONCLUSIONS: Combined femoral (3-in-1) and sciatic blocks offer a practical alternative to epidural analgesia for unilateral knee replacements.

Comparison of articaine and bupivacaine/lidocaine for peribulbar anaesthesia by inferotemporal injection.

BACKGROUND: Articaine is a novel amide local anaesthetic with a shorter duration of action than prilocaine. METHODS: In a randomized, double-blind study we compared the efficacy of 2% articaine with epinephrine 1:200,000 with a mixture of 0.5% bupivacaine and 2% lidocaine with epinephrine 1:200,000 for peribulbar anaesthesia in cataract surgery using a single inferotemporal injection. Eighty-two patients were randomly allocated to one of two groups to receive peribulbar anaesthesia with 6-7 ml of articaine or a bupivacaine/lidocaine mixture. Both solutions contained hyaluronidase 30 iu ml(-1). Ocular movement was scored at 2 min intervals up to 10 min, at the end of surgery and at time of discharge from hospital. Time to readiness for surgery and any complications (proptosis, chemosis, pain) were recorded. RESULTS: The articaine group demonstrated a rapid onset of peribulbar block with mean time (SD) to readiness for surgery of 4.2 (4.5) min compared with 7.2 (5.7) min in the bupivacaine/lidocaine group (P=0.0095). The block obtained in the articaine group was dense with eye movement scores at 2, 4, 6, 8 and 10 min all significantly reduced (P<0.01 at each interval). There was also a faster offset of the block in the articaine group (P=0.0009). There was no difference in incidence of minor complications between the groups. CONCLUSIONS: Two per cent articaine is safe and effective for peribulbar anaesthesia by inferotemporal injection and is a suitable alternative to the traditional mixture of 0.5% bupivacaine and 2% lidocaine.

The use of the laryngeal mask airway and Combitube in cardiopulmonary resuscitation; a national survey.

The laryngeal mask airway (LMA) and Combitube have been recommended for use during cardiopulmonary resuscitation (CPR). An overview of current practice was sought by conducting a postal survey of 265 Resuscitation Training Departments, at different hospitals, throughout the UK. One hundred fifty-three (58%) completed questionnaires were returned. Only 38 (25%) hospitals which replied were currently using the LMA in resuscitation while seven (5%) were using the Combitube. The reasons for not using these airway adjuvants included concerns about airway protection, difficulties in training, cost, and the concept that when anaesthetists were available on cardiac arrest teams these devices were unnecessary.

Variable-temperature scanning tunneling microscopy and scanning tunneling spectroscopy study on copper phthalocyanine ultrathin films on a Au(111) surface.

Variable-temperature high-resolution scanning tunneling microscopy (STM) images reveal that well-ordered copper phthalocyanine (CuPc) strips can be self-assembled by depositing CuPc molecules on a Au(111) surface. The self-assembled strips are supposed to result from the balance of the intermolecular interaction and the interaction between the molecules and substrate during annealing. The energy band (approximately 1.9-2.1 eV) of CuPc, measured by scanning tunneling spectroscopy (STS), is comparable to the optical band gap (approximately 1.7 eV). Spectroscopic measurements confirm that a dipole layer and/or an effect of image force exist at the CuPc/Au(111) interface.

Comparison of articaine and bupivacaine/lidocaine for single medial canthus peribulbar anaesthesia.

In a single-centre, randomized, double-blind study, we compared the efficacy of 2% articaine with that of a mixture of 0.5% bupivacaine and 2% lidocaine for peribulbar anaesthesia in cataract surgery, using a single medial canthus injection technique. Eighty-two patients were allocated randomly to receive 7-9 ml of a mixture of 0.5% bupivacaine and 2% lidocaine or an equal volume of 2% articaine with 1:200,000 epinephrine. Hyaluronidase 30 iu ml(-1) was added to both solutions. The degree of akinesia was scored 1, 5 and 10 min after the block, at the end of surgery and at discharge from the day case unit. Primary outcome measures were the difference in ocular movement scores 5 min after block and the need for supplementary inferolateral injections. There was greater akinesia in the articaine group at 5 min (P=0.01). Ten patients (24%) in the articaine group and 21 patients (51%) in the bupivacaine/lidocaine group required a supplementary injection (P=0.02). The mean (SD) volume of local anaesthetic required to achieve adequate block for surgery was 9.7 (2.1) ml in the articaine group and 11.0 (2.2) ml in the bupivacaine/lidocaine group (P=0.01). There was a faster offset of akinesia after surgery in the articaine group (P=0.01). There were no differences between groups in the incidence of reported pain or of minor complications. In our study, 2% articaine with 1:200,000 epinephrine was safe and efficacious for single medial canthus peribulbar anaesthesia.

Bronchopleural fistula complicating group A beta-haemolytic streptococcal pneumonia. Use of a Fogarty embolectomy catheter for selective bronchial blockade.

A 36-year-old woman developed severe group A Streptococcal pneumonia, complicated by a bronchopleural fistula, ARDS and multi-organ failure. We describe the use of selective middle lobe bronchus blockade, with a Fogarty embolectomy catheter, to localise and control the air leak. This allowed effective mechanical ventilation and oxygenation on intensive care and during right middle lobectomy. The patient made a prolonged, but full recovery.