Incidence of severe critical events in paediatric anaesthesia in the United Kingdom: secondary analysis of the anaesthesia practice in children observational trial (APRICOT study).

The anaesthesia practice in children observational trial of 31,127 patients in 261 European hospitals revealed a high (5.2%) incidence of severe critical events in the peri-operative period and wide variability in practice. A sub-analysis of the UK data was undertaken to investigate differences compared with the non-UK cohort in the incidence and nature of peri-operative severe critical events and to attempt to identify areas for quality improvement. In the UK cohort of 7040 paediatric patients from 43 hospitals, the overall incidence of peri-operative severe critical events was lower than in the non-UK cohort (3.3%, 95%CI: 2.9-3.8 vs. 5.8%, 95%CI: 5.5-6.1, RR 0.57, p < 0.001). There was a lower rate of bronchospasm (RR 0.22, 95%CI: 0.14-0.33; p < 0.001), stridor (RR 0.42, 95%CI: 0.28-0.65; p < 0.001) and cardiovascular instability (RR 0.69, 95%CI: 0.55-0.86; p = 0.001) than in the non-UK cohort. The proportion of sicker patients where less experienced teams were managing care was lower in the UK than in the non-UK cohort (10.4% vs. 20.4% of the ASA physical status 3 and 9% vs. 12.9% of the ASA physical status 4 patients). Differences in work-load between centres did not affect the incidence and outcomes of severe critical events when stratified for age and ASA physical status. The lower incidence of cardiovascular and respiratory complications could be partly attributed to more experienced dedicated paediatric anaesthesia providers managing the higher risk patients in the UK. Areas for quality improvement include: standardisation of serious critical event definitions; increased reporting; development of evidence-based protocols for management of serious critical events; development and rational use of paediatric peri-operative risk assessment scores; implementation of current best practice in provision of competent paediatric anaesthesia services in Europe; development of specific training in the management of severe peri-operative critical events; and implementation of systems for ensuring maintenance of skills.

Monitoring teamwork: a narrative review.

A narrative review was carried out to identify articles on monitoring of teamwork, with particular relevance to anaesthetists. The papers reviewed showed that team monitoring takes place both implicitly and explicitly in the anaesthetic environment. No single optimal model of teamwork monitoring for all situations was identified. Most of the studies identified were of a pre-intervention, post-intervention design, without randomisation or control group. Information shared during a formal briefing is more likely to be recalled, and provides a basis for a shared team mental model. A number of studies appeared to show that targeted teamwork training has a positive impact on both teamwork and patient safety.

"They seem to be able to read your mind." An interview study to identify the cognitive non-technical skills of anaesthetic assistants.

The aim of this study was to identify the cognitive non-technical skills (i.e. situation awareness and decision making) used by anaesthetic assistants, as part of the development of a specialty-specific behavioural rating system for anaesthetic assistants. Semi-structured interviews were conducted with anaesthetic assistants (n=22), anaesthetic consultants (n=11) and trainee anaesthetists (n=12) in Scotland. The interviews were transcribed and thematically analysed. All 45 participants described the presence or failure of situation awareness (i.e. gathering information, its comprehension and anticipation) in 713 phrases. Decision making (i.e. considering options, selecting actions and reviewing decisions) by the anaesthetic assistants was reported much less frequently--only 34 participants described 89 phrases. Situation awareness is a key non-technical skill used by anaesthetic assistants, however decision making was less commonly described as required by anaesthetic assistants. This provides qualitative data to support the development of a non-technical skills taxonomy for anaesthetic assistants.

Evaluation of the prototype Anaesthetic Non-technical Skills for Anaesthetic Practitioners (ANTS-AP) system: a behavioural rating system to assess the non-technical skills used by staff assisting the anaesthetist.

This study tested the reliability, validity and usability of a prototype behavioural rating system for the non-technical skills of assistants working with the anaesthetist. Anaesthetic nurses and operating department practitioners (n = 48) used the prototype Anaesthetic Non-technical Skills for Anaesthetic Practitioners (ANTS-AP) system to rate the non-technical skills of anaesthetic assistants in 12 videos of simulated theatre work. Test-retest reliability was assessed with a sub-sample (n = 12). The skill categories assessed were 'situation awareness', 'teamwork and communication' and 'task management'. The internal consistency for the ratings of elements in categories was acceptable (Cronbach's α of 0.78, 0.77 and 0.69, respectively), with more modest inter-rater reliability (intraclass correlations for categories 0.54, 0.70, 0.86), test-retest reliability (intraclass correlations 0.68, 0.58, 0.38) and accuracy (weighted kappa 0.39). Most participants considered the system complete (n = 42, 87%), the wording clear (n = 48, 100%) and the system useful for structuring observation (n = 48, 100%).

The non-technical skills used by anaesthetic technicians in critical incidents reported to the Australian Incident Monitoring System between 2002 and 2008.

The outcome of critical incidents in the operating theatre has been shown to be influenced by the behaviour of anaesthetic technicians (ATs) assisting anaesthetists, but the specific non-technical skills involved have not been described. We performed a review of critical incidents (n=1433) reported to the Australian Incident Monitoring System between 2002 and 2008 to identify which non-technical skills were used by ATs. The reports were assessed if they mentioned anaesthetic assistance or had the boxes ticked to identify "inadequate assistance" or "absent supervision or assistance". A total of 90 critical incidents involving ATs were retrieved, 69 of which described their use of non-technical skills. In 20 reports, the ATs ameliorated the critical incident, whilst in 46 they exacerbated the critical incident, and three cases had both positive and negative non-technical skills described. Situation awareness was identified in 39 reports, task management in 23, teamwork in 21 and decision-making in two, but there were no descriptions of issues related to leadership, stress or fatigue management. Situation awareness, task management and teamwork appear to be important non-technical skills for ATs in the development or management of critical incidents in the operating theatre. This analysis has been used to support the development of a non-technical skills taxonomy for anaesthetic assistants.

Teamwork, communication, and anaesthetic assistance in Scotland.

Teamwork involves supporting others, solving conflicts, exchanging information, and co-ordinating activities. This article describes the results of interviews with anaesthetic assistants (n=22) and consultant anaesthetists (n=11), investigating the non-technical skills involved in the effective teamwork of the anaesthetic assistants in the operating theatre. Anaesthetic assistants most commonly saw themselves as either being part of a theatre team or an anaesthetic subgroup and most commonly described the senior theatre nurse as their team leader. Examples of supporting others included the following: checking equipment, providing equipment, being a second pair of eyes, providing emotional and decision support, and supporting trainee anaesthetists. Of the 19 anaesthetic assistants who were asked if they would speak up if they disagreed with a decision in theatre, only 14 said that they would voice their concerns, and the most common approach was to ask for the logic behind the decision. The WHO checklist was described as prompting some anaesthetists to describe their anaesthetic plan to the anaesthetic assistant, when previously the anaesthetist would have failed to communicate their intentions in time for equipment to be prepared. The prioritization of activities to achieve co-ordination and the anaesthetic assistants becoming familiar with the idiosyncrasies of their regular anaesthetists were also described by anaesthetic assistants.

Non-technical skills of anaesthetic assistants in the perioperative period: a literature review.

Non-technical skills (NTS), which include communication, teamwork, leadership, decision-making, and situation awareness, are important in the maintenance of patient safety. NTS frameworks have been developed for anaesthetists, surgeons, and scrub practitioners. Most studies of NTS in operating theatres to date have focused on anaesthetists and surgeons. We have attempted to identify the NTS used by anaesthetic assistants in the perioperative period. An electronic search of the NHS e-library, PubMed, BioMed Central, ScienceDirect, and Scopus databases was performed in December 2010. The abstracts of the papers identified were checked for relevance and the article examined. Out of 308 papers initially identified, there were only three papers describing the use of NTS by anaesthetic assistants. Communication and situation awareness were described in three papers, teamwork and decision-making in two, and leadership in one. This search did not reveal any comprehensive description of the NTS required by anaesthetic assistants. The benefits of developing an NTS taxonomy for anaesthetic assistants are discussed.

Use of a sentinel host system to study the questing behavior of Ixodes spinipalpis and its role in the transmission of Borrelia bissettii, human granulocytic ehrlichiosis, and Babesia microti.

Ixodes spinipalpis maintains Borrelia bissettii spirochetes in Colorado in a cycle involving wood rats and deer mice. This tick has been described as nidicolous, remaining either attached to its rodent hosts or in the rodent nest. Nidicolous ticks pose little risk of pathogen transmission to humans if they do not actively quest for hosts. To investigate the questing potential of I. spinipalpis, sentinel mice were placed in an area where I. spinipalpis had been commonly found on wood rats and deer mice. Concurrently, wild rodent populations were trapped and analyzed for Lyme disease spirochetes, the agent of human granulocytic ehrlichiosis (aoHGE), and Babesia microti. A total of 122 I. spinipalpis larvae and 10 nymphs were found on 19% of 244 sentinel mice. In addition, 4 sentinel mice became infested with Malaraeus telchinus or Orchopeas neotomae fleas. Questing I. spinipalpis were positively associated with woody shrubs and negatively associated with sunny and grassy areas. Four sentinel mice became infected with aoHGE after having been fed upon only by I. spinipalpis larvae. One sentinel mouse became infected with B. bissettii after having an I. spinipalpis nymph feed on it, and one sentinel mouse became coinfected with aoHGE and B. bissettii after it was fed upon by a single I. spinipalpis nymph. These sentinel mouse conversions suggest the possibility that the aoHGE is transovarially transmitted by I. spinipalpis, and that I. spinipalpis is capable of simultaneously transmitting B. bissettii and the aoHGE. The findings that I. spinipalpis quest away from rodent nests and will attach to and infect sentinel mice may be of public health importance. It suggests the potential transmission of the agents of human granulocytic ehrlichiosis and Lyme disease to other hosts by I. spinipalpis, in regions of the western United States where Ixodes pacificus is not found.

Transmission of the agent of human granulocytic ehrlichiosis by Ixodes spinipalpis ticks: evidence of an enzootic cycle of dual infection with Borrelia burgdorferi in Northern Colorado.

Previous work described an enzootic cycle of Borrelia burgdorferi sensu lato (hereafter referred to as B. burgdorferi) maintained by the rodent Neotoma mexicana and the tick Ixodes spinipalpis in northern Colorado. We investigated the incidence of coinfection among rodents with the agent of human granulocytic ehrlichiosis (aoHGE). aoHGE was detected in 23.5% of 119 rodent spleens examined. Biopsy results indicated that 78 (65.5%) of the 119 rodents were positive for B. burgdorferi, whereas 22 (78.5%) of the 28 animals that harbored aoHGE were also infected with B. burgdorferi. In 14 of 25 I. spinipalpis tick pools, aoHGE was detected by amplifying both the 16s rRNA and p44 gene of aoHGE. The ability of I. spinipalpis to transmit aoHGE was examined in C3H/HeJ mice. aoHGE was detected in their blood 5 days after I. spinipalpis infestation. This study confirms that both B. burgdorferi and aoHGE can be transmitted by I. spinipalpis ticks and that there is a high incidence of coinfection in rodents, predominantly Peromyscus maniculatus and N. mexicana, that inhabit the foothills of northern Colorado.

Babesia microti and Borrelia bissettii transmission by Ixodes spinipalpis ticks among prairie voles, Microtus ochrogaster, in Colorado.

An endemic transmission cycle of Babesia microti was discovered in Colorado in the foothills of the Rocky Mountains. B. microti were found by PCR in 4 of 25 Ixodes spinipalpis tick pools tested (a 3.2 % minimum infection rate) and in 87% (13 of 15) of Microtus ochrogaster (the prairie vole) spleen and blood samples. Using naturally infected I. spinipalpis collected from wild-caught M. ochrogaster as vectors, B. microti and Borrelia bissettii were successfully transmitted to laboratory-born M. ochrogaster. Neither I. spinipalpis, nor M. ochrogaster (the prairie vole) have been previously reported as a vector or a reservoir host of B. microti. Unlike the east coast of the United States where Peromyscus leucopus is an important reservoir for B. microti, evidence for Peromyscus spp. (neither P. maniculatus nor P. difficilis) as B. microti reservoirs was not found in this study.

The mechanism of blood flow in cardiopulmonary resuscitation--introducing the lung pump.

The mechanism of blood flow in cardiopulmonary resuscitation remains controversial. Inconsistencies in the cardiac pump model necessitated the development of the thoracic pump. Neither hypothesis alone can account for blood flow during external massage. Using the postulates that a cyclical pump has three components, an inlet valve, a compression chamber and an outlet valve, we propose the lung pump hypothesis where these components are represented by the pulmonary valve; the lung vasculature/left atrium/left ventricle; and the aortic valve. We explore the mechanism and effect of this hypothesis and match it to previous observations. The implications to cardiopulmonary resuscitation are addressed.

Changes in end-expiratory lung volume on induction of anaesthesia with thiopentone or propofol.

To determine the effects of induction agent and obesity on the change in functional residual capacity caused by induction of anaesthesia, we measured the change in end-expiratory respiratory volume (EERV) during induction of anaesthesia with either thiopentone or propofol. Female patients breathed via a face mask from a closed circle system connected to a water spirometer. The spirometer tracing was used to measure the decrease in EERV. The median decrease was 200 (95% confidence limits 90-280) ml after thiopentone and 285 (200-425) ml after propofol. The decrease in each group was significant (P < 0.01) but there was no difference between the two groups. The change in EERV, expressed as a proportion of the predicted functional residual capacity, was not related to obesity (estimated as the ratio of actual to predicted body weight).

Depth of central venous catheterization: an audit of practice in a cardiac surgical unit.

Central venous catheter (CVC) depth relative to the cephalic limit of the pericardial reflection (CLPR) was assessed retrospectively in 100 adult patients from chest radiographs taken after admission to the intensive care unit. A well known landmark proved to be considerably influenced by parallax; therefore we located the CLPR by a new landmark, the junction of the azygos vein and the superior vena cava, identified by the angle of the right main bronchus and the trachea. The majority (58) of CVC tips lay below the pericardial reflection on the first chest radiograph (CXR). Of these only two had been corrected by the time of the next routine CXR. No case of cardiac tamponade secondary to erosion by a CVC could be remembered, or identified from records of routine departmental audit meetings, for the last ten years. Nevertheless, reported incidents of this complication have often been fatal and vigilance is necessary in any patient with a CVC.