Factors associated with persistent opioid use 6-12 months after primary total knee arthroplasty.

Persistent pain following knee arthroplasty occurs in up to 20% of patients and may require ongoing analgesia, including extended opioid administration. A comprehensive secondary analysis was performed from results of a study that considered persistent postoperative pain in 242 patients who underwent unilateral knee arthroplasty using a standardised enhanced recovery programme. Opioid prescribing for 12 months before and 12 months after surgery was evaluated and converted to oral morphine equivalents. Demographic, functional, psychological and pain questionnaires were completed along with quantitative sensory testing and genetic analysis. Forty-nine percent of patients had at least one opioid prescription in the 12 months before surgery. Opioid prescriptions were filled in 93% of patients from discharge to 3 months and in 27% of patients ≥6 months after surgery. Persistent opioid use ≥6 months after surgery was strongly associated with pre-operative opioid use (RR 3.2, p < 0.001 (95%CI 1.9-5.4)). The median (IQR [range]) oral morphine equivalent daily dose was 3.6 (0.9-10.5 [0-100.0]) mg pre-operatively, 35.0 (22.5-52.5 [4.6-180.0]) mg in hospital, 12.8 (5.1-24.8 [0-57.9]) mg from discharge to 3 months and 5.9 (4.5-12.0 [0-44.5]) mg at ≥6 months following surgery. Predictors of increased daily oral morphine equivalent ≥6 months after surgery included increased average daily oral morphine equivalent dose compared with previous values (lag), increased body mass index and three or more comorbid pain sites. Persistent opioid use was not associated with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain (RR 1.003, p = 0.655, 95%CI 0.65-1.002) or WOMAC function (RR 1.001, p = 0.99, 95%CI 0.99-1.03) outcomes 6 months after surgery. There was no association between persistent opioid use and pre-operative quantitative sensory testing results or psychological distress. Pre-operatively, patients with a higher body mass index, more comorbid pain sites and those who had filled an opioid prescription in the last 12 months, were at increased risk of persistent opioid use and a higher oral morphine equivalent daily dose ≥ 6 months after surgery. Strategies need to be developed to limit dose and duration of persistent opioid use in patients following knee arthroplasty surgery.

The effect of intra-operative hypotension on acute kidney injury, postoperative mortality and length of stay following emergency hip fracture surgery.

The association between intra-operative hypotension and postoperative acute kidney injury, mortality and length of stay has not been comprehensively evaluated in a large single-centre hip fracture population. We analysed electronic anaesthesia records of 1063 patients undergoing unilateral hip fracture surgery, collected from 2015 to 2018. Acute kidney injury, 3-, 30- and 365-day mortality and length of stay were evaluated to assess the relationship between intra-operative hypotension absolute values (≤ 55, 60, 65, 70 and 75 mmHg) and duration of hypotension. The rate of acute kidney injury was 23.7%, mortality at 3-, 30- and 365 days was 3.7%, 8.0% and 25.3%, respectively, and median (IQR [range]) length of stay 8 (6-12 [0-99]) days. Median (IQR [range]) time ≤ MAP 55, 60, 65, 70 and 75 mmHg was 0 (0-0.5[0-72.1]); 0 (0-4.4 [0-104.9]); 2.2 (0-8.7 [0-144.2]); 6.6 (2.2-19.7 [0-198.8]); 17.5 (6.6-37.1 [0-216.3]) minutes, and percentage of surgery time below these thresholds was 1%, 2.5%, 7.9%, 12% and 21% respectively. There were some univariate associations between hypotension and mortality; however, these were no longer evident in multivariable analysis. Multivariable analysis found no association between hypotension and acute kidney injury. Acute kidney injury was associated with male sex, antihypertensive medications and cardiac/renal comorbidities. Three-day mortality was associated with delay to surgery ? 48 hours, whilst 30-day and 365-day mortality was associated with delay to surgery ≥ 48 hours, impaired cognition and cardiac/renal comorbidities. While the rate of acute kidney injury was similar to other studies, use of vasopressors and fluids to reduce the time spent at hypotensive levels failed to reduce this complication. Intra-operative hypotension at the levels observed in this cohort may not be an important determinant of acute kidney injury, postoperative mortality and length of stay.

Steroids to reduce the impact on delirium (STRIDE): a double-blind, randomised, placebo-controlled feasibility trial of pre-operative dexamethasone in people with hip fracture.

Neuro-inflammation may be important in the pathogenesis of postoperative delirium following hip fracture surgery. Studies have suggested a potential role for steroids in reducing postoperative delirium; however, the potential efficacy and safety of pre-operative high-dose dexamethasone in this specific population is largely unknown. Conducting such a study could be challenging, considering the multidisciplinary team involvement and the emergency nature of the surgery. The aim of this study was to assess feasibility and effectiveness of dexamethasone given as early as possible following hospital admission for hip fracture, to inform whether a full-scale trial is warranted. This single-centre, randomised, double-blind, placebo-controlled study randomly allocated 79 participants undergoing hip fracture surgery to dexamethasone 20 mg or placebo pre-operatively. Eligibility and recruitment rates, timing of the intervention and adverse events were recorded. Incidence and severity of postoperative delirium were assessed using the 4AT delirium screening tool and the Memorial Delirium Assessment Scale. Postoperative pain, length of stay and mortality were also assessed. The eligibility rate for inclusion was 178/527 (34%), and 57/178 (32%) of eligible patients presented to hospital when no researcher was available (e.g. after-hours, weekends, public holidays). Recruitment was limited mainly by ethical limitations (not including patients with impaired cognition) and lack of weekend staffing. Median (IQR [range]) time from emergency department admission to drug administration was 13.3 (5.9-17.6 [1.8-139.6]) hours. There was a significant difference in delirium severity scores, favouring the dexamethasone group: median (IQR [range]) 5 (3-6 [3-7]) vs. 9 (6-13 [5-14]) in the placebo group, with the probability of superiority effect size being 0.89, p = 0.010. Delirium incidence did not differ between groups: 6/40 (15%) in the dexamethasone group vs. 9/39 (23%) in the placebo group, relative risk (95%CI) 0.65 (0.22-1.65), p = 0.360). A larger randomised controlled trial is feasible and ideally this should include people with existing cognitive impairment, seven days-a-week cover and a multicentre design.

Persistent postoperative pain after total knee arthroplasty: a prospective cohort study of potential risk factors.

BACKGROUND: Persistent postoperative pain (PPP) is common after total knee arthroplasty (TKA). The primary aim of this prospective cohort study was to identify important predictors of moderate to severe PPP 6 and 12 months after TKA. METHODS: Consenting patients (n=300) undergoing primary unilateral TKA attended a preoperative session to collect clinical information (age, gender, BMI, preoperative knee pain, comorbid pain, likely neuropathic pain) and psychological variables (depression, anxiety, catastrophising, expected pain). Quantitative sensory testing (pressure pain thresholds, temporal summation, conditioned pain modulation) was performed, and blood samples were obtained for subsequent genotyping of OPRM1 and COMT. Acute postoperative pain was measured at rest and during movement. Surgical factors (surgery time, patella resurfacing, anaesthetic type) were collected after operation. Follow-up questionnaires were sent 6 and 12 months after surgery. Multivariate logistic regression was used to identify predictors of PPP. RESULTS: The prevalence of moderate to severe PPP was 21% (n=60) and 16% (n=45) 6 and 12 months after surgery, with 55% (n=33) and 60% (n=31) of PPP likely neuropathic in nature. At 6 months, a combination of preoperative pain intensity, expected pain, trait anxiety, and temporal summation (Akaike information criterion, 309.9; area under receiver operating characteristic (ROC) curve, 0.70) was able to correctly classify 66% of patients into moderate to severe PPP and no to mild PPP groups. At 12 months, preoperative pain intensity, expected pain, and trait anxiety (Akaike information criterion, 286.8; area under ROC curve, 0.66) correctly classified 66% of patients. CONCLUSIONS: Findings from this study highlight several factors that may be targeted in future intervention studies to reduce the development of PPP. TRIAL REGISTRY NUMBER: ACTRN12612001089820.

Job satisfaction, stress and burnout in anaesthetic technicians in New Zealand.

Anaesthetic technicians play a key role in the operating room, yet little is known about their levels of job satisfaction or workplace stress. A blinded, confidential single mail-out survey was posted to anaesthetic technicians in New Zealand. The survey consisted of demographic information, a job satisfaction survey, the Maslach Burnout Inventory and the Short Form 12. At total of 154 forms were returned (51% response rate). Respondents worked predominantly in public hospitals and many had duties outside the operating room. Job satisfaction was related to teamwork, practical nature of work and patient contact, while dissatisfaction was related to lack of respect from nurses and limited career pathway. High to moderate levels of emotional exhaustion (48%), depersonalisation (39%) and low levels of personal accomplishment (58%) were indicators of burnout. The Short Form 12 revealed high levels of physical impairment in 24% and emotional impairment in 35% of respondents. These data suggest that work is needed to evaluate anaesthetic assistants' job structure and actively manage their important physical and emotional sequelae.

Crisis management during anaesthesia: the development of an anaesthetic crisis management manual.

BACKGROUND: All anaesthetists have to handle life threatening crises with little or no warning. However, some cognitive strategies and work practices that are appropriate for speed and efficiency under normal circumstances may become maladaptive in a crisis. It was judged in a previous study that the use of a structured "core" algorithm (based on the mnemonic COVER ABCD-A SWIFT CHECK) would diagnose and correct the problem in 60% of cases and provide a functional diagnosis in virtually all of the remaining 40%. It was recommended that specific sub-algorithms be developed for managing the problems underlying the remaining 40% of crises and assembled in an easy-to-use manual. Sub-algorithms were therefore developed for these problems so that they could be checked for applicability and validity against the first 4000 anaesthesia incidents reported to the Australian Incident Monitoring Study (AIMS). METHODS: The need for 24 specific sub-algorithms was identified. Teams of practising anaesthetists were assembled and sets of incidents relevant to each sub-algorithm were identified from the first 4000 reported to AIMS. Based largely on successful strategies identified in these reports, a set of 24 specific sub-algorithms was developed for trial against the 4000 AIMS reports and assembled into an easy-to-use manual. A process was developed for applying each component of the core algorithm COVER at one of four levels (scan-check-alert/ready-emergency) according to the degree of perceived urgency, and incorporated into the manual. The manual was disseminated at a World Congress and feedback was obtained. RESULTS: Each of the 24 specific crisis management sub-algorithms was tested against the relevant incidents among the first 4000 reported to AIMS and compared with the actual management by the anaesthetist at the time. It was judged that, if the core algorithm had been correctly applied, the appropriate sub-algorithm would have been resolved better and/or faster in one in eight of all incidents, and would have been unlikely to have caused harm to any patient. The descriptions of the validation of each of the 24 sub-algorithms constitute the remaining 24 papers in this set. Feedback from five meetings each attended by 60-100 anaesthetists was then collated and is included. CONCLUSION: The 24 sub-algorithms developed form the basis for developing a rational evidence-based approach to crisis management during anaesthesia. The COVER component has been found to be satisfactory in real life resuscitation situations and the sub-algorithms have been used successfully for several years. It would now be desirable for carefully designed simulator based studies, using naive trainees at the start of their training, to systematically examine the merits and demerits of various aspects of the sub-algorithms. It would seem prudent that these sub-algorithms be regarded, for the moment, as decision aids to support and back up clinicians' natural responses to a crisis when all is not progressing as expected.

Crisis management during anaesthesia: obstruction of the natural airway.

BACKGROUND: Obstruction of the natural airway, while usually easily recognised and managed, may present simply as desaturation, have an unexpected cause, be very difficult to manage, and have serious consequences for the patient. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for obstruction of the natural airway, in the management of acute airway obstruction occurring in association with anaesthesia. METHODS: The potential performance for this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. RESULTS: There were 62 relevant incidents among the first 4000 reports to the AIMS. It was considered that the correct use of the structured approach would have led to earlier recognition of the problem and/or better management in 11% of cases. CONCLUSION: Airway management is a fundamental anaesthetic responsibility and skill. Airway obstruction demands a rapid and organised approach to its diagnosis and management and undue delay usually results in desaturation and a potential threat to life. An uncomplicated pre-learned sequence of airway rescue instructions is an essential part of every anaesthetist's clinical practice requirements.

Crisis management during anaesthesia: water intoxication.

BACKGROUND: Irrigation of closed body spaces may lead to substantial perioperative fluid and electrolyte shifts. A syndrome occurring during transurethral resection of prostate (TURP), and a similar syndrome described in women undergoing transcervical endometrial ablation (TCEA) are both characterised by a spectrum of symptoms which may range from asymptomatic hyponatraemia to convulsions, coma, and death. Such potentially serious consequences require prompt recognition and appropriate management of this "water intoxication" syndrome. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for water intoxication, in the management of this syndrome occurring in association with anaesthesia. METHODS: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. RESULTS: From the first 4000 incidents reported to AIMS, 10 reports of water intoxication were identified, two from endometrial ablations under general anaesthesia and eight from male urological procedures under spinal anaesthesia. The "core" crisis management algorithm detected a problem in seven cases; however, it was deficient in dealing with neurological presentations. Diagnosis of the cause of the incident would have required a specific water intoxication sub-algorithm in eight cases and a hypotension algorithm in a further two cases. Corrective strategies also required a specific sub-algorithm in eight cases, while the hypotension and cardiac arrest sub-algorithms were required in conjunction with the water intoxication sub-algorithm in the remaining two. CONCLUSION: This relatively uncommon problem is managed poorly using the "core" crisis management sub-algorithm and requires a simple specific sub-algorithm for water intoxication.

Crisis management during anaesthesia: laryngospasm.

BACKGROUND: Laryngospasm is usually easily detected and managed, but may present atypically and/or be precipitated by factors which are not immediately recognised. If poorly managed, it has the potential to cause morbidity and mortality such as severe hypoxaemia, pulmonary aspiration, and post-obstructive pulmonary oedema. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for laryngospasm, in the management of laryngospasm occurring in association with anaesthesia. METHODS: The potential performance of this structured approach for the relevant incidents amongst the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. RESULTS: There were 189 reports of laryngospasm among the first 4000 incidents reported to AIMS. These were extracted and analysed. In 77% of cases laryngospasm was clinically obvious, but 14% presented as airway obstruction, 5% as regurgitation or vomiting, and 4% as desaturation. Most were precipitated by direct airway stimulation (airway manipulation, regurgitation, vomiting, or blood or secretions in the pharynx), but patient movement, surgical stimulus, irritant volatile agents, and failure to deliver the anaesthetic were also precipitating factors. Desaturation occurred in over 60% of cases, bradycardia in 6% (23% in patients aged <1 year), pulmonary oedema in 4%, and pulmonary aspiration in 3%. It was considered that, correctly applied, the combined core algorithm and sub-algorithm recommended for the diagnosis and management of laryngospasm would have led to earlier recognition of the problem and/or better management in 16% of cases. CONCLUSION: Laryngospasm may present atypically and, if not promptly managed effectively, may lead to morbidity and mortality. Although usually promptly recognised and appropriately managed, the use of a structured approach is recommended. If such an approach had been used in the 189 reported incidents, earlier recognition and/or better management may have occurred in 16% of cases.

Crisis management during anaesthesia: regurgitation, vomiting, and aspiration.

BACKGROUND: Regurgitation, vomiting and aspiration may occur unexpectedly in association with anaesthesia. "Aspiration/regurgitation" was ranked fifth in a large collection of previously reported incidents that arose during general anaesthesia. These problems are encountered by all practising anaesthetists and require instant recognition and a rapid, appropriate response. However, the diagnosis may not be immediately apparent as the initial presentation may vary from laryngospasm, desaturation, bronchospasm or hypoventilation to cardiac arrest. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for regurgitation, vomiting and aspiration, in the management of these complications occurring in association with anaesthesia. METHODS: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. RESULTS: There were 183 relevant incidents of regurgitation, vomiting and aspiration among the first 4000 reports to the AIMS. Aspiration was documented in 96, was excluded in 69, and in 18 it could not be determined whether or not aspiration had occurred. It was considered that the correct use of an explicit algorithm would have led to earlier recognition and/or better management of the problem in 10% of all cases of regurgitation and vomiting and in 19% of those in which aspiration occurred. CONCLUSION: Regurgitation and/or aspiration should always be considered immediately in any spontaneously breathing patient who suffers desaturation, laryngospasm, airway obstruction, bronchospasm, bradycardia, or cardiac arrest. Any patient in whom aspiration is suspected must be closely monitored in an appropriate perioperative facility, the acuity of which will depend on local staffing and workload. If clinical instability is likely to persist or if there are concerns by attending staff, the patient should be admitted to a high dependency unit or intensive care unit.

Crisis management during anaesthesia: pulmonary oedema.

BACKGROUND: Pulmonary oedema may complicate the perioperative period and the aetiology may be different from non-operative patients. Diagnosis may be difficult during anaesthesia and consequently management may be delayed. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for pulmonary oedema, in its management occurring in association with anaesthesia. METHODS: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. RESULTS: Pulmonary oedema was identified in 35 (<1%) of the first 4000 reports to AIMS. The most frequent presenting sign was hypoxia (46%) and the most specific sign was the presence of frothy sputum (23%). The core algorithm, although successful in the management of the initial physiological upset, was found to be inadequate for the ongoing management of pulmonary oedema. A specific sub-algorithm for the management of perioperative pulmonary oedema was devised, tested against the reports and would have been effective, if properly applied, in the management of all but one of the reported cases. CONCLUSION: Successful recognition and management of perioperative pulmonary oedema is likely with the application of the structured algorithm and specific sub-algorithm approach outlined in this study.

Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database.

Eight hundred and ninety-six incidents relating to drug error were reported to the Australian Incident Monitoring Study. Syringe and drug preparation errors accounted for 452 (50.4%) incidents, including 169 (18.9%) involving syringe swaps where the drug was correctly labelled but given in error, and 187 (20.8%) due to selection of the wrong ampoule or drug labelling errors. The drugs most commonly involved were neuromuscular blocking agents, followed by opioids. Equipment misuse or malfunction accounted for a further 234 (26.1%) incidents; incorrect route of administration 126 (14.1%) incidents; and communication error 35 (3.9%) incidents. The outcomes of these events included minor morbidity in 105 (11.7%), major morbidity in 42 (4.7%), death in three (0.3%) and awareness under anaesthesia in 40 (4.4%) incidents. Contributing factors included inattention, haste, drug labelling error, communication failure and fatigue. Factors minimising the events were prior experience and training, rechecking equipment and monitors capable of detecting the incident. The information gained suggests areas where improved guidelines are required to reduce the incidence of drug error. Further research is required into the effectiveness of preventive strategies.

The management of patients with ischaemic heart disease undergoing non-cardiac elective surgery: a survey of Australian and New Zealand clinical practice.

Improvements in patient risk stratification and peri-operative beta-blockade have been suggested as methods which can reduce cardiovascular risk in patients with known cardiac risk factors. A postal questionnaire was sent to all Australian and New Zealand teaching hospitals to identify patterns of pre-operative cardiac risk evaluation and methods of peri-operative beta-blocker use. In all, 67 replies were evaluated (64% response rate). Specialist anaesthetists are present in the majority of pre-admission clinics (78%), with a designated peri-operative physician in 9%. Further cardiological referral was possible in almost all institutions (96%), and specific peri-operative physician referral in 54%. Waiting times for specialist consultation were < 7 days in the majority of cases. Whilst 79% of institutions used peri-operative beta-blockade, specific protocols were available in only 10%. In 60% of institutions, beta-blockers were administered to high-risk patients, and in 25% they were given to intermediate risk group patients. There was a wide range in the duration of pre- and postoperative beta-blocker administration. Whilst peri-operative risk assessment appears to be consistent, the pattern of beta-blockade, a known beneficial intervention, is variable. Reasons need to be identified, protocols developed and consistent administration targeted for further improvements to be made.

Incident reporting in anaesthesia: a survey of practice in New Zealand.

A postal survey of anaesthetists practising in New Zealand assessed their practice and attitudes to anaesthetic incident reporting. 136 replies were received (57% response rate). Respondents indicated a high awareness of the Anaesthetic Incident Monitoring Study (AIMS) based incident monitoring yet individual utilization may be declining due to a perception that this system is ineffective. Seventy-five per cent of respondents used AIMS forms in their current institute, whilst 87% had at some time completed an AIMS form. Two-thirds of respondents used the forms for morbidity and mortality audit activities. Support for the continuing practice of incident reporting was high, yet opinion suggested that the present system was not being used productively. Almost half the anaesthetists felt that the AIMS reporting system had changed their practice. Common concerns with the system included a need to simplify the reporting process and to ensure that information is managed to provide a useful outcome. This study suggests that incident reporting in its present form needs to be re-evaluated in light of changing priorities in anaesthesia quality improvement activities.

Job satisfaction, stress and burnout in Australian specialist anaesthetists.

A postal survey was sent to specialist anaesthetists in Australia looking at aspects of job satisfaction, dissatisfaction and stress. Burnout was measured using the Maslach Burnout Inventory. The response rate was 60% (422/700) with the majority of respondents being male (83%). Stressful aspects of anaesthesia included time constraints and interference with home life. Experienced assistants and improved work organisation helped to reduce stress. The high standard of practice and practical aspects of the job were deemed satisfying, whereas poor recognition and long hours were the major dissatisfying aspects of the job. With respect to burnout, high emotional exhaustion, high levels of depersonalisation and low levels of personal achievement were seen in 20, 20 and 36% of respondents, respectively. Female anaesthetists reported higher stress levels than males (p = 0.006), but tended to prioritise home/work commitments better than males (p = 0.05). Private practitioners rated time issues of high importance compared with public hospital doctors, whereas public hospital doctors rated communication problems as being more significant than with private specialists. Although burnout levels are high in anaesthetists, they compare favourably with other medical groups. There are, however, aspects of the anaesthetist's job that warrant further attention to improve job satisfaction and stress.

Recovery room incidents: a review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS).

Four hundred and nineteen incidents that occurred in the recovery room were extracted from the Anaesthetic Incident Monitoring Study database, representing 5% of the total database of 8372 reports. Incidents were reported mainly in daylight hours, with over 50% occurring in ASA 1-2 patients. The most common presenting problems related to respiratory/airway issues (183; 43%), cardiovascular problems (99; 24%) and drug errors (44; 11%). One hundred and twenty-two events (29%) led to a major physiological disturbance and required management in the High Dependency Unit or Intensive Care Unit. Contributing factors cited included error of judgement (77; 18%), communication failure (57; 14%) and inadequate pre-operative preparation (29; 7%), whilst factors minimising the incident included previous experience (97; 23%), detection by monitoring (72; 17%) and skilled assistance (54; 13%). Staffing and infrastructure of the recovery room needs to be supported, with ongoing education and quality assurance programmes developed to ensure that such events can be reduced in the future.

Awareness during general anaesthesia: a review of 81 cases from the Anaesthetic Incident Monitoring Study.

Because of recent studies suggesting that awareness is still a major issue in anaesthetic practice, we reviewed 8372 incidents reported to the Anaesthetic Incident Monitoring Study. There were 81 cases in which peri-operative recall was consistent with awareness. There were 50 cases of definite awareness and 31 cases with a high probability of awareness. In 13 of the 81 incidents, the patients appeared to receive adequate doses of anaesthetic drugs. Where the cause could be determined, awareness was mainly due to drug error resulting in inadvertent paralysis of an awake patient (n = 32) and failure of delivery of volatile anaesthetic (n = 16). Less common causes included prolonged attempts at intubation of the trachea (n = 5), deliberate withdrawal of volatile anaesthetic (n = 4) or muscle relaxant apnoea with inadequate administration of hypnotic (n = 3). An objective central nervous system depth of anaesthesia monitor may have prevented 42 of these incidents and an improved drug administration system may have prevented 32. On the basis of these reports, we have developed guidelines that may have prevented the majority of these incidents.

Personality testing and profiling for anaesthetic job recruitment: attitudes of anaesthetic specialists/consultants in New Zealand and Scotland.

Specialist/consultant anaesthetists based in New Zealand and Scotland were sent a reply paid postal questionnaire asking about their attitudes to personality testing and personality types in the recruitment process for registrars and specialists. The questionnaire consisted of nine Likert-style questions and 14 visual analogue questions. The overall response rate was 65% (523/808). The responses to all the questions were broadly similar in the two countries. Personality testing was deemed of use in recruiting trainees and specialists, with a slightly greater proportion considering personality traits more important than academic achievement. An overwhelming majority believed the presence of an adverse personality trait would influence an appointment process, but few believed that the personality makeup of anaesthetists influenced the way in which they react to stressful situations. A slight majority considered the interview process a poor predictor of personality. New Zealand anaesthetists rated independence, orderliness, compassion, empathy, reflectiveness and patience higher than did anaesthetists in Scotland. In contrast, anaesthetists in Scotland rated pragmatism, as opposed to perfection, as a more important characteristic than did the New Zealand specialists. Personality assessment, although not effective as the sole tool for candidate selection, may have a role in the process of anaesthetic job recruitment and warrants further investigation.