The history and achievements of the National Confidential Enquiry into Perioperative Deaths.

The National Confidential Enquiry into Perioperative Deaths started in 1989 as a direct development of a Confidential Enquiry in the United Kingdom in 1984. Different samples from the 20,000 deaths in hospital within 30 days of a surgical operation are selected each year. Questionnaires about these are examined by groups of anaesthetists and surgeons, and lessons about the quality of perioperative care are derived. Causation is not emphasized but examples of potential for improvement are sought. Changes of consultant practice, increase in medical audit, improvement in physiological monitoring, appropriate matching of specialist experience to patients' medical conditions and increased awareness of the need for critical care areas are believed to have been influenced by this unique enquiry.

Basic simulations for anaesthetists. A pilot study of the ACCESS system.

This paper describes the design and initial testing of the ACCESS (Anaesthetic Computer Controlled Emergency Situation Simulator) system, which has been designed to simulate anaesthetic emergencies with the aim of providing training for junior doctors. The simulations require little or no capital expenditure with minimal use of time by staff or trainees. They are based on standard anaesthetic equipment, with a microcomputer providing an image of commonly used instruments. Problems are presented as scenarios administered by the teacher, and test the skills of the pupil. During 64 scenarios, five trainees caused two 'deaths' and solved the problems in a median time of 2.5 min, while an experienced group of anaesthetists caused one 'death' and took 1.8 min. The simulation was rated by the pupils as easy to use, realistic and a valuable educational tool.

A comparison between mivacurium and suxamethonium in children.

The neuromuscular effects of mivacurium were compared with those of suxamethonium in 69 children (aged 2-12 years), during nitrous oxide, oxygen and halothane anaesthesia in a randomised open study. Neuromuscular block was monitored by measuring the acceleration of the thumb caused by contraction of the adductor pollicis muscle after supramaximal stimulation of the ulnar nerve at the wrist using an Accelograph. End-tidal carbon dioxide was maintained at about 4 kPa in both groups. The mean times (95% confidence intervals) for T1:T0 ratio to decrease to 75%, 50%, 25% and 5% of control values were 50 (42-59), 62 (52-74), 83 (68-100) and 93 (46-108) s respectively for mivacurium and 18 (15-22), 26 (22-30), 32 (28-37) and 43 (38-49) s respectively for suxamethonium. The times for T1:T0 ratio to recover to 25%, 50% and 70% of control values were 615 (542-698), 769 (687-859) and 901 (820-993) s respectively for mivacurium and 196 (179-214), 216 (201-234) and 242 (216-259) s respectively for suxamethonium. The range of maximum block was similar for both drugs. The average time to reach maximum block was 143 s for mivacurium and 56 s for suxamethonium. Intubating conditions were similar in the two groups.

Policy for controlling pain after surgery: effect of sequential changes in management.

OBJECTIVE: To observe the effects of introducing an acute pain service to the general surgical wards of a large teaching hospital. DESIGN: A study in seven stages: (1) an audit of current hospital practice succeeded by the sequential introduction to the general surgical wards of (2) pain assessment charts; (3) an algorithm to allow more frequent use of intramuscular analgesia; (4) increased use of local anaesthetic techniques of wound infiltration and nerve blocks; (5) an information sheet for patients about postoperative pain; (6) the introduction of patient controlled analgesia; (7) a repeat audit of hospital practice. Data were collected on each patient 24 hours after operation. SETTING: University Hospital of Wales, which has both district general and tertiary referral functions. PATIENTS: 2035 patients over nine months from all surgical specialties (excluding cardiac) at the hospital. General surgical operations were studied in detail and separated into major, intermediate, and minor for data collection. MAIN OUTCOME MEASURES: A change in the median visual analogue pain scores 24 hours after surgery for pain during relaxation, pain on movement, and pain on deep inspiration at each stage of the study. RESULTS: There was a reduction in median visual analogue scores during the study. The median (95% confidence interval) scores for pain during relaxation decreased from 45 (34 to 53) in stage 1 to 16 (10 to 20) in stage 7 for major surgical procedures. Pain on movement decreased from 78 (66 to 80) to 46 (38 to 48), and pain on deep inspiration decreased from 64 (48 to 78) to 36 (31 to 38). The reductions in median scores for intermediate and minor operative procedures showed similar patterns. CONCLUSIONS: The introduction of an acute pain service to the general surgical wards led to considerable improvement in the level of postoperative pain as assessed by visual analogue scores. Simple techniques of regular pain assessment and the more frequent use of intramuscular analgesia as a result of using an algorithm were particularly effective.