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Back in April of this year, just around the time of the SAQ, those pleasant people at NICE published new guidance on Perioperative Hypothermia (Inadvertent).  It didn’t make it into the last exam, because it was published too late, but it strikes me that because maintaining a patient’s temperature during anaesthesia and surgery is a fairly straightforward thing to do, is relatively inexpensive in the grand scheme of things, and has so many potential benefits, that it has a high chance of coming up in the exam this time around.

There is also an article in this month’s Anesthesiology about Temperature Monitoring and Perioperative Thermoregulation by Daniel Sessler from the USA, who has a special interest in perioperative thermoregulation and has been studying it for about 22 years.

CEACCP published Thermoregulation and mild peri-operative hypothermia, an article about mild perioperative hypothermia and its effects, in 2003.

Remember also, that you may be asked in viva voce about methods of temperature monitoring and how the devices used work, and that HME filters are also a possible topic for questioning.

If you have a topic or concept you want to know more about, or are struggling to understand, or simply want another explanation of, please get in touch by email to help-me@examintelligence.com, or use the Contact Us page.

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What are the properties of the ideal intravenous/inhalational anaesthetic agent?

We’re not sure whether this is a popular question, in and of itself anymore, but we certainly advise you to be wary of the question which goes along these lines:

What’s your favourite inhalation agent/intravenous induction agent?

And how does that compare with the qualities you’d like to see in an ideal anaesthetic agent?

OR

And how does that compare with X (being another agent of the same class)?

Now, obviously you should pick your favourite agent very carefully, and make sure you know plenty about it.

For example, if you choose propofol you must know it’s physical properties, mode of presentation, administration, doses for adults and paediatric patients, effects and side-effects, probable mechanism of action, pharmacokinetics, pharmacodynamics and its use in TIVA.  For this kind of information we’d refer you to this book: Pharmacology for Anaesthesia and Intensive Care by Tom Peck and Sue Hill.

However, we did come across this little article about Ideal Agents, written by a couple of FRCAs back in 2003 in the Royal Pharmaceutical Society’s Journal.  Interestingly, even the Surgical-Tutor website has something to say about the Ideal inhalational anaesthetic agent in an article on Anaesthesia and Relaxation!

As PassingTheFinal pointed out, one of the questions done badly in the April 2008 paper was one of the questions the college felt was answered badly.  The question was:

A 4 year old (20 kg) is admitted with acute appendicitis and is scheduled for urgent surgery. She has
been vomiting for 2 days, is pyrexial, has a tachycardia of 170 bpm and prolonged capillary refill.
a) Describe the perioperative fluid management of this case using intravenous crystalloids. (60%)
b) Outline the complications that can occur with inappropriate intravenous crystalloid therapy. (30%)

There were several publications last year which prompted that particular question, we suspect.  The first of these was the National Patient Safety Agency report into use of intravenous fluids in paediatric practice, specifically it was Reducing the risk of hyponatraemia when administering intravenous infusions to children.

Their advice essentially boils down to NOT using 0.18% NaCl with 4% glucose except in specialist areas, using 0.9% NaCl for resuscitation, and maintenance with 0.45% NaCl + 5% glucose or 0.45% NaCl + 2.5% glucose, bearing in mind these are hypotonic solutions.  Hypotonic solutions should definitely not be used in children at risk of developing hyponatraemia.  More info in the link above!

Another publication that will have prompted this is the Association of Paediatric Anaesthetists of Great Britatin and Ireland’s Consensus Guideline on Perioperative Fluid Management in Children from September last year.  These are worth reading, if only to realise that consensus is not always easy to reach, and for some of the insights it offers!

Anaesthesia journal published an editorial in Volume 62 Issue 4 , Pages 322 - 324 (April 2007) about the guidelines.

An older article can be found in the CEACCP from the British Journal of Anaesthesia: Cunliffe M. Fluid and Electrolyte Management in Children. 2003; 3:1-4. (You will need a password for this, which you can arrange through the Royal College if you don’t already have one.  To do this, email your college reference number and your name to subs@rcoa.ac.uk with a request to get access to CEACCP and BJA online.)

Hope that is useful….

Rumours have reached our ears that there are some trainees looking around for a book to help them through the first few months of anaesthetic training.

Well, we have just the thing: How to Survive in Anaesthesia: A Guide for Trainees

This is the latest edition of a popular novice anaesthetists’ guide book to be published. It contains three sections, titled Nuts and Bolts, Crises and Complications and Passing the Gas.  Each of these contains a number of chapters, some of which outline, amongst other things, the basics of evaluation, control and management of the airway, venous access, ventilators, monitoring, cardiac arrest, anaphylaxis, anaesthetic mishaps, anaesthesia for different types of procedure, and post-op analgesia.

For someone starting from scratch, this is the ideal book.

Click on the link above, or the image below to be taken to Amazon.

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In case you missed it, Sugammadex (a reversal agent molecularly designed to reverse Rocuronium) got it’s license approved in the EU last week…but not in the USA!

See MedicalNewsToday’s article.

So what does that mean?

Well apart from making anaesthetics very interesting in the very near future, it means that the question about reversal agents which was done badly in the April exam has a high probability of showing up again.

So here are a few links to information about it, and references to articles which you ought to read:

Safety and tolerability of single intravenous doses of sugammadex administered simultaneously with rocuronium or vecuronium in healthy volunteers
Cammu et al. Br. J. Anaesth..2008; 100: 373-379

Neuromuscular monitoring and postoperative residual curarisation: a meta-analysis
M. Naguib, A. F. Kopman, and J. E. Ensor
Br. J. Anaesth., March 2007; 98: 302 - 316.

COMMITTEE FOR MEDICINAL PRODUCTS FOR HUMAN USE SUMMARY OF POSITIVE OPINION* for BRIDION [The EU Regulatory Authority's Report]

Wikipedia Article on Sugammadex

Remember that one of the main parts of the question centred on side-effects of reversal agents, so make sure you are aware of the side effects of Glycopyrrolate-Neostigmine as well!