Abstract
These abstracts are published as supplied and have not been subject to editorial review or correction.
Plasma lidocaine concentrations following an intraoperative intravenous weight-based regimen in obese patients
1Department of Anaesthesia, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
2Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
3University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia
4Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Queensland, Australia
5Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
6Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellie, Nîmes, France
Intravenous lidocaine infusions may improve post-operative pain and nausea by minimising opioid consumption.1 Evidence to support dosing regimens in obesity is lacking, risking underdosing or toxicity in these patients. We aimed to measure the total and unbound plasma concentrations of lidocaine following a fixed weight-based bolus and infusion regimen of intravenous lidocaine in obese patients.
Methods
Ethics approval and informed consent was obtained (HREC/2018/QPCH/43981). Patients were included if they had a body mass index (BMI) > 30 kg/m2 and were undergoing elective laparoscopic abdominal surgery. Patients with the following were excluded: allergy to lidocaine, renal or liver disease, congestive cardiac failure, cardiac conduction abnormalities, seizure disorder, or pregnant. Based on lean body weight,2 a standardised intravenous lidocaine regimen was administered as follows: 1.5 mg/kg bolus over 10 minutes (maximum 100 mg) starting prior to skin incision, followed immediately by a continuous infusion of 1.5 mg/kg/h until the completion of surgery. No other local anaesthetic was administered. Arterial samples were obtained prior to bolus, then at 15, 30, 60, 90, 120, and 180 minutes. Post-infusion samples were obtained at infusion cessation, 5, 30 and 120 minutes. Plasma concentrations of total (bound and unbound) and unbound (pharmacologically active) lidocaine, were measured using liquid chromatography-mass spectrometry (LCMS), and compared against a target concentration of 2.5 to 3.5 µg/ml.3 Lidocaine metabolites, monoethylglycinexylidide (MEGX) and glycylxylidide (GX), were also measured. Patient characteristics, surgical procedure and baseline biochemistry data were collected.
Results
Thirty patients were included: 10 with Class I obesity (BMI 30–34.9 kg/m2), 10 with Class II obesity (BMI 35–39.5 kg/m2), and 10 with Class III obesity (BMI ≥ 40 kg/m2). The median (interquartile range (IQR)) age was 50.5 (43.5–60.8) years and 21 (70%) were female. The median (IQR, range) total body weight was 107 (91.8–132.5, 80.0–189.0) kg, and median (IQR, range) BMI was 37.7 (33.6–46.5, 30.2–58.4) kg/m2. Comorbidities included 13 (43%) patients with cardiovascular disease, 18 (60%) with respiratory disease, and 18 (60%) with diabetes. Median (IQR) serum albumin was 39 (36–42) g/l and creatinine 64.5 (58.3–84.0) µmol/l. Twenty-one (70%) patients underwent surgery for weight loss, and median (IQR) surgical time was 91.5 (75.3–116) minutes. Median (IQR) lidocaine bolus dose was 83.5 (72.0–99.5) mg, and infusion dose was 83.5 (72.0–101.75) mg/h. Total median (IQR) lidocaine dose delivered was 228.2 (198.8–280.7) mg.
The median (IQR) total lidocaine plasma concentration during the infusion was 1.6 (1.3–1.8) µg/ml. Twenty-two (73%) patients maintained total lidocaine plasma concentrations above 1 µg/ml for the duration of the infusion. Nine of those with BMI ≥ 40 kg/m2 (90%) achieved this concentration. Three of all patients (10%) reached a plasma concentration above 2.5 µg/ml. The maximum recorded lidocaine concentration was 2.6 µg/ml recorded in one patient at 90 minutes. The median (IQR) unbound lidocaine plasma concentration during the infusion was 0.3 (0.2–0.4) µg/ml. Median total and unbound MEGX plasma concentrations were 0.14 and 0.10 µg/ml, and 0.02 and 0.02 µg/ml for GX respectively. No arrhythmias or seizures were attributed to lidocaine.
Discussion
Plasma concentrations >1 µg/ml were maintained in most patients for the infusion duration. A much smaller proportion reached concentrations >2.5 µg/ml and none maintained this higher targeted concentration. Further research is required to establish the clinical benefit and risk of adverse events associated with higher plasma concentrations.
Acknowledgements
2019 and 2020 RBWH Research Postgraduate Scholarship.
2020 ANZCA Project Grant including Scholarship.
References
Evaluating the quality of opioid prescription amongst patients having outpatient surgery.
1Austin Health, Heidelberg, Victoria, Australia
Introduction
There is concern about opioid over-prescription after minor surgery and consequent unused opioids.1,2 In this Quality Assurance activity, we aimed to determine the quality of analgesia prescribed 24 hours after outpatient minor surgery. Good prescribing practice after minor surgery was defined as: ≥80% of patients prescribed opioids receiving quantity of ≤10 tablets; ≥80% of patients prescribed a multi-modal strategy; ≥80% patient rating satisfaction as ≥8 out of 10 on Likert scale; ≥80% patients using ≤25% of opioids dispensed within the first 24 hours; ≥80% of patients receiving information about excess opioids, provided a written plan for de-escalating analgesia and advice about managing pain if analgesia inadequate.
Methods
In this prospective Quality Assurance activity (Approval Number: 398768), outpatient surgery patients receiving an opioid on discharge between 5th October 2020 and 5th October 2021 were consented to be telephoned approximately 24 hours after surgery to answer a standardised series of questions. Data collected included demographic, surgical and medication details. A target of fifty patients was deemed as appropriate to answer the study aims. Opioids prescribed and consumed was converted to Oral Morphine Equivalent Daily Dose (OMEDD) to allow for comparison. Data was recorded and analysed using Microsoft Excel version 16.43.
Results
65 patients gave initial consent of which 50 participated. 56% of participants were female. Surgical location was the limb in 32% of patients, breast in 22% of patients and abdomen in 15% of patients, with other sites less frequent. Oxycodone was most commonly prescribed (37/50 patients) followed by paracetamol-codeine (6/50), tramadol (4/50), and tapentadol (3/50). Regarding number of tablets prescribed, oxycodone had a median (IQR) of 5 (5), paracetamol-codeine median (IQR) of 20 (0), tramadol median (IQR) of 10 (3.75), and tapentadol median (IQR) of 20 (5). Median (IQR) OMEDD prescribed was 75mg (39.75 mg); median (IQR) OMEDD used in the first 24 hours post-operatively was 4mg (15.75mg).
74% of patients were prescribed ≤10 tablets of opioids; 82% of patients were prescribed a multimodal strategy; 68% of patients rated their satisfaction with analgesia as ≥8/10. 82% of patients used ≤25% of opioids dispensed in first 24 hours; 10% received advice about how to manage excess opioids; 38% received written plan for pain management; and 74% were given advice to manage inadequate analgesia.
Discussion
Small quantities of opioids were prescribed for minor surgery and generally met predetermined measures of good prescribing practice. Areas for improvement in prescribing practice should focus on providing advice about managing excess opioids, and ensuring a written plan for pain management as these were well below targets. Satisfaction with analgesia prescribing could be improved and reasons for dissatisfaction should be explored.
Acknowledgements
The authors would like to acknowledge the staff at The Surgery Centre for their collaboration.
References
A retrospective audit of desaturation during ECT
1Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Victoria, Australia
Electroconvulsive therapy (ECT) is usually performed under general anaesthesia with a range of airway management techniques, most commonly bag-mask ventilation. There is limited evidence regarding the general incidence of desaturation (defined as SpO2 <90%) with results from prospective studies ranging from 17%1 to 29%.2
It is known that hypoxia is the commonest cause of airway-related deaths and can lead to significant morbidity. The primary aim of this audit was to identify the local incidence of desaturation during ECT, with an accepted standard of care for oxygenation defined as prevention of desaturation (SpO2<90%) during the procedure. The secondary aim was to collect information regarding current airway management.
Methods
The audit was conducted at Royal Melbourne Hospital, a tertiary teaching hospital which conducts approximately 400 ECT cases per year. This project was assessed by the local Office for Research Ethics & Governance team as an evaluation activity not requiring Human Research Ethics Committee (HREC) review (Project QA2021063). The audit included most recent first treatments of all ECT courses from 14/12/2016 to 22/05/2019. Only the first treatment of each ECT course was included to capture more titrations and minimise bias from repeat patients. Data was collected from scanned patient medical records and recorded into Excel spreadsheet. Data collected included: date of treatment, demographics (age, sex, height, weight, BMI), presence of OSA or underlying respiratory disease, baseline SpO2, duration of seizure, presence of titration, number of treatments during titration, lowest SpO2 during procedure, desaturation, documented difficult airway, use of airway adjuncts, and complications from procedure.
Results
The patients (n = 100) had a mean age of 32.3 years (SD 15.1), mean BMI 24.2 kg/m2 (SD 5.7). 2 patients had OSA and 9 had underlying respiratory disease. 4 patients had anticipated difficult airways. Mean baseline SpO2 was 98% (IQR 97–99). Mean duration of seizure was 51 seconds (IQR 33–82).
9 patients (9.2%) desaturated to SpO2 <90%, with a mean lowest SpO2 of 85% (IQR 80–86).
33.3% (n = 3) of patients who desaturated had difficult airways compared to 1.1% (n = 1) of those who did not desaturate. 44.4% (n = 4) had airway adjuncts compared to 13.5% (n = 12) of those who did not desaturate. Of the airway adjuncts used, 12 patients had oropharyngeal airways, 4 had laryngeal mask airways, 2 had endotracheal tubes (1 patient had both LMA and ETT).
There was no significant difference in the presence of OSA, baseline SpO2 or duration of seizure between patients who had desaturation and those who did not.
31 patients had cardiovascular complications (6 had bradycardia, 4 had hypertension, 2 had a junctional rhythm and 1 had tachycardia).
Discussion
The incidence of desaturation in the audit cohort was low (9%), suggesting that routine intervention for all patients is not required. Any proposed intervention to reduce the incidence of desaturation further should be targeted towards particularly high risk patients.
In current literature, BMI is shown to significantly correlate with post-ECT desaturation.
A recent study showed that Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) delayed desaturation in apnoeic obese patients undergoing ECT.3 THRIVE was not used in any of the patients in the audit. A possible intervention would be use of THRIVE for pre-oxygenation and maintenance of apnoeic oxygenation during ECT for obese patients, prior to repeat audit.
References
Postoperative sleep disturbance in children
1Department of Anaesthesia, Austin Health, Victoria, Australia
2Department of Anaesthesia, The Royal Children’s Hospital, Melbourne, Victoria, Australia
Negative behavioural change is a well-documented phenomenon in children after surgery and general anaesthesia.1,2 In particular, sleep disturbance is a recognised problem in the paediatric population which can cause distress to both patients and their families and significantly impact postoperative recovery. The primary aim of this audit was to determine the incidence of postoperative sleep disturbance in children between 2–6 years of age who had surgery at Austin Health over a six-month timeframe. The secondary aim was to identify any potential risk factors that may be associated with the problem.
Methods
After Human Research Ethics Committee approval (RiskmanQ number 41511), 56 children aged between 2–6 years of age who underwent surgery at Austin Health over a six-month timeframe (01/01/21–30/06/21) were included in this audit. A telephone survey was administered to primary carers of the children to identify the incidence of postoperative sleep disturbance. Questions were adapted from Vernon’s post-hospital behaviour questionnaire.3 Additional data such as patient demographics, type of surgery/procedure, nature of procedure (emergency vs elective), duration, history of behavioural issues, anaesthetic factors (use of premedication & type of induction) and presence of emergence delirium in recovery was collected from electronic medical records.
Results
The incidence of postoperative sleep disturbance was 16.1%, with up to 23.2% experiencing any form of postoperative behavioural change as recalled by the primary carer. Of those affected by postoperative sleep disturbance, the majority were pre-school aged (77.7%) and female (77.8%).
No sleep disturbance was reported for procedures that were less than 30 minutes. There was a significant association between children having emergence delirium in recovery and those who were reported to have sleep disturbance (p = 0.03; RR 3.71; 95% CI 1.12–12.31). There was no significant difference between the groups that were related to the type of surgery, elective versus emergency procedure, history of behavioural disturbance, type of anaesthetic induction or the use of premedication.
Discussion
One in six children in this audit were reported to have suffered from postoperative sleep disturbance. This highlights the importance of appropriate education and consent of caregivers for this potential risk as we routinely do so for other anaesthetic risks such as emergence delirium in the paediatric population. The suggestion that emergence delirium is associated with the occurrence of postoperative sleep disturbance has significant implications which warrants further research as it would be important to identify any modifiable risk factors to prevent or minimise the negative behavioural disturbances in children having general anaesthesia.
Acknowledgements
Dr Raymond Hu (Scholar Role Supervisor, Austin Health).
References
Association between central venous catheter insertion depth and tip position
1Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
2Statistics Unit, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
3Royal Brisbane Clinical Unit, School of Medicine, University of Queensland, Herston, Queensland, Australia
The Royal Brisbane & Women’s Hospital (RBWH) anaesthetic department has a central venous catheter (CVC) checklist1 that suggests an insertion depth (ID) of 15–17 cm for right-sided CVCs and 18–20 cm for left-sided CVCs. These suggestions are based on Peres’ formula2 assuming an average adult height. The aim is to guide selection of an ID that places the CVC tip in the superior vena cava (SVC) or cavo-atrial junction. Tips in the brachiocephalic vein are “too high” and tips in the right atrium are “too low”. RBWH anaesthetists usually adhere to the suggested ID, although sometimes they deviate from it. We investigated which of these approaches were more likely to achieve an adequate tip position and also if any patient demographics were associated with tip position.
Methods
We conducted a retrospective observational study of jugular or subclavian CVC insertions in adult patients between January 2018 and October 2020. Patients were excluded if ID was not documented, there was no post-insertional chest X-ray, or if the CVC was malpositioned (e.g. jugular CVC deviating into the subclavian vein). A tip was considered adequate if it was reported as such on the radiology report; and met at least one of the following criteria: (A) the tip lay between 3cm above and 4cm below the carina;3 or (B) the tip was documented on the checklist as being in the SVC or cavo-atrial junction. Forty chest X-rays with indeterminate tip position were referred to a blinded radiologist for final determination. Statistical analysis was performed using bivariate tests of association where p < 0.05 was considered statistically significant.
Results
There were 484 CVC insertions meeting inclusion criteria; 458 (95%) were inserted via the right internal jugular vein. The suggested ID was adhered to in 430 CVCs (89%). Of the remaining 54 CVCs, 37 had an ID less than suggested (“too short”) and 17 had an ID greater than suggested (“too long”). Adherence to suggested ID resulted in adequate tip position more often than deviation from suggested ID (395/430 (92%) vs 44/54 (82%); p = 0.013). CVCs inserted “too short” had the lowest rate of adequate tip position (28/37 (76%)) whereas CVCs inserted “too long” had a higher rate (16/17 (94%)).
Height (p = 0.010), weight (p = 0.014) and sex (p < 0.001) were associated with tip position. Patients with adequate tip position had a median height of 172cm (interquartile range (IQR) 164–178 cm) and weight of 80 kg (IQR 69–93 kg). Patients whose tips that were “too low” were on average shorter (163 cm, IQR 158–171 cm) and lighter (72 kg, IQR 64–85 kg) whereas patients whose tips were “too high” were on average taller (176 cm, IQR 169–180 cm) and heavier (86kg, IQR 79–107 kg). Tips in men were more likely to be “too high” (9%) than “too low” (1%), whereas tips in women were more likely to be “too low” (6%) than “too high” (3%).
Discussion
Deviating from the ID suggested on the RBWH checklist reduces the likelihood of achieving an adequate CVC tip position. Adhering to the suggested ID results in a rate of adequate tip position comparable to published standards.2 Height is the most important variable that may warrant deviation from the suggested ID. Weight and sex may also warrant deviation but are most likely surrogate markers of height.
RBWH HREC: LNR/2020/QRBW/72138.
Acknowledgements
Dr Craig Hacking (RBWH Radiologist).
References
Analysis of Category 1 Emergency Caesarean sections performed under general anaesthesia in a Southeast Queensland hospital between 2020–2021
1Logan Hospital, Logan, Queensland, Australia
General anaesthesia (GA) is often performed for a Category one Caesarean section (C1CS). GA C1CS involves significant risks for the parturient including difficult airway, failed intubation and pulmonary aspiration.1 The United Kingdom Royal College of Anaesthetists (RCOA) suggests a rate of GA for a C1CS of <50%.2 For the anaesthetist, risks of GA must be balanced with the goal of providing timely anaesthesia, thereby minimising the decision-to-delivery time interval (DDI). For C1CS, an optimal DDI is widely accepted as <30 minutes.1 Currently there is no Australian standard and few studies to date evaluating rates of C1CS, rates of GA C1CS, DDI, frequent indications and adverse outcomes related to mode of anaesthesia for C1CS.
Methods
This was a retrospective audit based in a South East Queensland hospital hosting nearly 4000 births per year, with a known high rate of C1CS. The retrospective review was conducted between March 2020-September 2021 and aimed to reassess rates of C1CS, GA C1CS, mean DDI, indications and associated adverse outcomes and complications arising from GA C1CS. These findings were compared with previous outcomes for the hospital. It was anticipated that results would be unchanged and could provide insight for future improvement.
Deidentified patient electronic records were retrospectively analysed. Data collected included patient demographics, DDI, anaesthetic technique, maternal and foetal adverse events, and indication for C1CS. Women booked as C1CS were included. Continuous data were presented in the form of mean (standard deviation) or median (interquartile range) as appropriate. Count and percentage were used for categorical data. Statistical tests were two-tailed and a significance level of 0.05 was used.
Results
A total of 167 patients underwent C1CS in the time period, representing 20% of all emergency Caesareans. GA was performed in 44% of C1CS. The mean DDI for the re-audit period was 14.1 minutes (95% CI +/− 1.2 minutes), with 3 cases exceeding the recommended DDI of 30 minutes. Frequent indications for GA C1CS included fetal bradycardia/non-reassuring CTG (58%), cord prolapse (14%) and antepartum haemorrhage (12%). There were two intraoperative complications arising from GA LSCS, however both quickly resolved without further issue.
Discussion
The rates of C1CS and GA C1CS did not change significantly for this time period compared with previous rates for the hospital. Whilst the GA C1CS rate does fall within the recommendation by RCOA, there is still area for improvement. Proposed further actions include firstly initiating an institutional protocol to assist decision making for anaesthetic technique, including a rapid sequence spinal protocol. Also, findings of the audit will be presented to both anaesthetic and obstetric departments to provide education and invite further discussion on avenues for improvement.
Indications for GA C1CS were largely appropriate and provided insight into the range of presentations for C1CS. The mean DDI result is likely an underrepresentation, given multiple inaccuracies noted in documented times. There was no significant maternal morbidity or mortality associated with either GA or neuraxial technique for C1CS, however larger sample sizes may be required to adequately capture this.
The results of this audit add information to the literature on rates of C1CS, rates of GA C1CS and indications for C1CS, and may be used by other institutions for benchmarking and comparative information.
The approval number is HREC/2022/QMS/81906.
Acknowledgements
Logan Hospital Department of Anaesthesia.
References
Does propofol influence the protein binding and plasma concentrations of lidocaine? An in vitro study
1Department of Anaesthesia, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
2Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
3University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia
4Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Queensland, Australia
5Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
6Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
Intravenous lidocaine, a highly protein-bound drug (60–80%), is increasingly used as an anaesthesia adjunct.1, 2 It is unknown whether the co-administration of propofol influences the protein binding and unbound (pharmacologically active) proportion of lidocaine. We aimed to measure the effect of varying plasma concentrations of propofol and lidocaine on the protein binding and plasma concentration of lidocaine in vitro.
Methods
Ethics approval was obtained (UQ 2019003049). Known and varying concentrations of propofol and lidocaine, at predetermined commonly used and clinically relevant targeted plasma concentrations, were added to batches of de-identified drug-free human plasma: Propofol at 0, 2, 4 and 6 µg/ml, and lidocaine at 1, 3 and 5 µg/ml. Samples were prepared as triplicates in three different plasma batches. Samples were mixed, and the total and unbound plasma concentrations of lidocaine were measured by liquid chromatography-mass spectrometry (LCMS) to determine the percentage binding. Alpha-1 acid glycoprotein (AAG) is a main contributor to lidocaine protein binding and levels of AAG were measured in the drug-free plasma batches. Basic descriptive statistics were used to analyse the data.
Results
Mean (standard deviation (SD)) AAG levels were 0.9 (0.16) mg/ml and within the normal range (0.6–1.2 mg/ml). The mean (SD) percentage binding of lidocaine with a targeted propofol concentration of 0 µg/ml with 1 µg/ml lidocaine was 67.2 (9.0) %, 70.7 (6.9) % with lidocaine 3 µg/ml, and 70.0 (5.0) % with lidocaine at 5 µg/ml. The mean (SD) percentage binding of lidocaine with a targeted propofol concentration of 2 µg/ml was 70.7 (5.1) % with lidocaine at 1 µg/ml, 64.7 (1.9) % with lidocaine at 3 µg/ml, and 68.1 (2.7) % with lidocaine at 5 µg/ml. The mean (SD) percentage binding of lidocaine with a targeted propofol concentration of 4 µg/ml was 71.8 (8.0) % with lidocaine at 1 µg/ml, 69.5 (3.7) % with lidocaine at 3 µg/ml, and 67.8 (4.9) % with lidocaine at 5 µg/ml. The mean (SD) percentage binding of lidocaine with propofol targeted at 6 µg/ml with 1 µg/ml lidocaine was 70.0 (9.8) %, 68.8 (7.0) % with lidocaine at 3 µg/ml, and 67.4 (4.4) % with lidocaine at 5 µg/ml.
Discussion
The total mean percentage of lidocaine binding at clinically relevant and therapeutic plasma concentrations of propofol and lidocaine in vitro was 69.0%. Binding was not significantly altered by changes in the plasma concentration of propofol or lidocaine at clinically targeted plasma concentrations. Future work will evaluate if lidocaine protein binding is altered at higher concentrations of lidocaine or propofol.
References
An Eastern Health audit of elective day-of-surgery cancellations and the role of preadmission clinic in preventing DOS cancellation
1Department of Anaesthesia, Eastern Health, Victoria, Australia
2Eastern Health clinical school, Faculty of Medicine, nursing and Health Sciences, Monash University, Victoria, Australia
3Department of General Medicine, Eastern Health
4Centre for Healthy Brain Ageing (CHeBA), School of Psychiatry, University of New South Wales (UNSW), Australia
5Monash University, Melbourne, Victoria, Australia
Ethics approval:
QA21-042.
Day of surgery (DOS) cancellations cause distress for patients and carers, unsafe treatment delays and economic inefficiency. A systemic review and meta-analysis 1 reported an 18% cancellation rate, mainly due to logistics, failure to attend on the DOS, and unexpected medical conditions on presentation.
Preadmission clinics (PAC) were instituted two decades ago with the primary aim of reducing cancellations. Preliminary evidence does show that PAC reduces surgical cancellations.2 However, further clarification is needed to identify the specific PAC interventions that reduce these.
This audit at Box Hill Hospital (BHH) in metropolitan Melbourne, aims to document the rate and reasons for DOS cancellation, the impact of PAC attendance on risk and reason for cancellation, and inform on improvements to be implemented and re-audited.
Methods
With ethics approval, a retrospective analysis of DOS elective surgical cancellations at BHH was conducted from 01/06/19 to 31/12/19. Electronic medical records (EMR) were used to collect patient demographics, booking categories and dates, cancellation reasons, PAC attendance and reviewing clinician, investigations and referrals made after cancellation. EMR includes a flag for cancellation and its timing in relation to surgical booking time and date. Data were cross-checked by four investigators (CF, JB, SR, SL). Cancellation rate and reasons were noted for the subgroup of patients who attended PAC.
Results
There were 7, 142 planned elective procedures, of which 370 were DOS cancellations. After removal of duplicates, the cancellation rate was 5.2% (369 of 7142). Cancelled patients had a mean age of 58.1 years. 50% were female, 44% ASA 3 and 35% required category 1 surgery. The majority of cases in the PAC and non-PAC groups (62% and 50% respectively) were cancelled due to DOS logistical shortcomings, such as lack of theatre time or bed availability or unexpected medical condition on DOS (16% and 12% respectively).
Cancellations for the following reasons were fewer in the PAC group compared to the non-PAC group: medication and fasting advice not followed (5.7% versus 12%) and surgeon or patient requesting cancellation (5.7% versus 11% and 1.6% versus 7% respectively). Cancellations due to incorrect medication advice and incomplete medical workup were similar in PAC and non-PAC groups and resulted in referrals mostly to Cardiology (33%), Respiratory (33%), and the Perioperative Medicine Liaison Service (POMLS) (11%). The most common investigation ordered was a transthoracic echocardiogram.
Discussion
This audit highlights the complexity of the elective surgical bookings process from initial surgeon review to knife-to-skin, and several opportunities for improvement. DOS cancellation rate at BHH was less than published data. Nevertheless, significant proportions were for category 1 surgery and as a result of potentially preventable logistic reasons.
Reassuringly, there was a suggestion that PAC attendance reduced DOS cancellation due to surgeon or patient request, suggesting that the decision-to-operate process was nuanced with PAC review. Similarly, medication and fasting advice was more likely to be followed with attendance at PAC. However, PAC attendance did not entirely prevent cancellation due to incomplete work-up.
Firstly, early direct EMR referral from PAC to POMLS to facilitate specialist review and follow-up of investigations will be implemented. Secondly, implementation of a PAC pharmacy service to streamline perioperative medication management and instructions in tandem with fasting advice will be trialled. These incremental changes can be reaudited to assess improvements to DOS cancellations.
References
Variation in Patient Blood Management: A snapshot audit of 2730 patients undergoing major abdominal surgery in 56 Hospitals in Australia & New Zealand.
1Royal Adelaide Hospital, South Australia, Australia
2University of Western Australia, Perth, Western Australia, Australia
3University of Adelaide, Adelaide, South Australia, Australia
4University of Auckland, Auckland, New Zealand
5Fiona Stanley Hospital, Murdoch, Western Australia, Australia
6University of Otago, Otago, New Zealand
Introduction
Anaemia is common in patients undergoing surgery and negatively impacts perioperative morbidity. However, current management of perioperative anaemia is variable. We aim to assess compliance with Patient Blood Management (PBM) guidelines and the impact on patient outcomes after major abdominal surgery.
Methods
A prospective, multicentre, cohort study of patients was conducted over two fortnight periods in 2021 via a network of trainees, students, and consultants across 56 hospitals in Australia and New Zealand. National ethical approvals were obtained from the Western Australian South Metropolitan Health Service HREC (EC00265, RCG 4477), and the Auckland Health Research Ethics Committee (AH21859). Data collected on 2730 consecutive adult patients undergoing elective and emergency major abdominal surgery included: patient demographics, operation details and Hb levels (preoperatively and on discharge), any blood transfusion and follow up to 30 days. The audit standards were: 1. Preoperative anaemia management. 2. Operative Tranexamic acid. 3. Restrictive blood transfusion 4. Post-operative anaemia management.
Results
Complete datasets (>95%) were returned on 2730 patients, mean age 56.7 ± 17.3 years; 57.1% were female. Preoperative Hb was documented in 2461 (90.1%).
Preoperative anaemia was seen in 689 (28%), iron studies were performed in 244 (35.4%) and 128 (52.7%) had ferritin <100 µg/L. Intravenous iron was given to 41 patients (32.0% of 128). Audit compliance was associated with a lower risk of: blood transfusion (4.1% vs. 10.9%, p < 0.001), complications (5.9% vs. 9.0%, p = 0.01), and hospital stay (3 vs. 4 days, p = 0.005). Tranexamic acid was used in only 128 patients (4.7% of 2728), predominantly by gynaecology. Pretransfusion Hb averaged 73.9 (SD 11.6) g/L with audit compliance in 96 (57.5%) but no association with outcomes. Postoperative anaemia was common 59.3% (1227/2069). Oral and intravenous iron was received 9.9% (121/1227) and 11.1% (136/1227) respectively. Severe anaemia (Hb < 100 g/L in 15.6%; 322/2069) was associated with a higher 30-day readmissions (20.2% vs. 9.4%, p < 0.001).
Discussions
Adherence to PBM guidelines remain variable among a major proportion of hospitals across Australia and New Zealand. Attention to anaemia management remains a target for better patient outcomes.
Acknowledgements
We would like to thank the Royal Australasian College of Surgeons (RACS), Clinical Trials Network Australia New Zealand (CTANZ), and Michael Lawrence-Brown Trust, Chair of Surgery at University of Western Australia for their support funding the POST-operative Variability in anaemia TreatmenT and Transfusion (POSTVenTT) collaborative.
Using regularly scheduled pre-operative clear carbohydrate drinks to reduce excessive fasting times in emergency surgical patients
1Sunshine Coast Hospital & Health Service, Birtinya, Queensland, Australia
2Griffith University School of Medicine and Dentistry, Birtinya, Queensland, Australia
Current literature highlights the problem of prolonged clear fluid fasting durations for surgical patients despite guideline recommendations of 2 hours (h) for adults, and 1 h for children.1 Excessive fasting is associated with negative sequelae, including insulin resistance, patient discomfort and prolonged length of hospital stay.2 In response, the Pre-Operative Drink Schedule (PODS) was protocolled at the Sunshine Coast University Hospital in November 2020 for category C & D emergency surgical patients. Eligible adult patients were prescribed 200 mL carbohydrate drinks at specified time intervals while awaiting surgery. Children received 3ml/kg/h oral clear fluid until 1 h prior to surgery. Drinks were withheld if surgery was anticipated in the upcoming 2 h time frame for adults or 1 h for children. The primary objective was to assess whether the PODS reduced fasting durations for category C & D emergency surgical patients. Secondary objectives were to assess for any impact on number of aspiration events or surgical delays for the PODS cohort. It was hypothesised that the PODS would significantly reduce fasting durations without significantly increasing the frequency of aspiration events or surgical delays.
Methods
With approval (EX/2022/QPCH/83456), all adult and paediatric category C & D emergency surgical patients in March 2021 were retrospectively audited using the anaesthetic record and electronic medical record. The sample consisted of 355 patients, of whom 207 were prescribed the PODS, and 125 were not prescribed the PODS. Of the 355 patients, 289 were adults and 43 were children aged 17 years and below. Fasting duration was calculated from last documented clear fluid intake to anaesthetic airway establishment. Aspiration event data was collected as documented on the patient record. Surgical delay was defined as any documented delay of a surgical case directly due to the administration of a pre-operative drink. Data was analysed using the Mann-Whitney U test.
Results
The local health service had average fasting durations of 14 hours 8 minutes for adult patients and 11 hours for paediatric patients not prescribed the PODS. In comparison, the PODS group had significantly reduced clear fluid fasting durations in both the adult (mean reduction of 401 minutes, p < 0.001) and paediatric (mean reduction of 355 minutes, p = 0.018) patients, with no significant increase in aspiration events or documented surgical delay.
Discussion
The introduction of the PODS significantly reduced fasting durations for adult and paediatric Category C & D emergency surgical patients without an increased frequency of aspiration or surgical delays, therefore supporting the hypothesis. The data indicated that this cohort experienced excessive fasting when not prescribed the PODS, identifying a need to improve local standard of care. Future research could further optimise pre-operative oral hydration and explore the impact of reduced fasting on patient outcomes, particularly in the emergency surgery population, a cohort vulnerable to the logistics of surgical planning.
Acknowledgements
None of the authors declare any conflicts of interest.
References
Analgesia and adverse effects of intrathecal buprenorphine: a meta-analysis
1Sunshine Coast University Hospital Department of Anaesthetics and Pain Medicine, Birtinya, Queensland, Australia
2Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
Buprenorphine has a long duration of action and an analgesic profile equivalent to morphine, suggesting the potential for it to be a highly efficacious adjunct to neuraxial anaesthesia.1,2 As it was traditionally viewed as having limited use in the context of acute pain there is little evidence regarding the efficacy and adverse event profile of buprenorphine when used for spinal anaesthesia. The aim of this systematic review and meta-analysis is to evaluate the use of intrathecal buprenorphine in patients undergoing spinal anaesthesia for elective non-cardiac surgery and caesarean sections.
Methods
A systematic search of databases including Medline, Embase and Central was performed. Primary research studies examining the use of intrathecal buprenorphine against a control were eligible for inclusion. Studies including epidural or combined spinal-epidural techniques were excluded. The primary outcomes assessed included time to rescue analgesia and composite outcome of adverse events. Adverse events were defined as respiratory depression, sedation, nausea, vomiting, hypotension, bradycardia, pruritus, shivering, headache and urinary retention. Dichotomous data was analysed using an Odds Ratio (95% CI), and The Mantel-Haenszel (M-H) random effects model was applied to continuous outcomes.
Results
The initial search yielded 584 publications, from which 33 articles met inclusion criteria. Compared to placebo there was a significant increase in time to rescue analgesia by 302.56 minutes (95%CI = 233.98 to 371.13 minutes; I2 = 100%; p < 0.00001). For the composite outcome of any adverse event, there was a significant increase in adverse events (OR = 2.64; 95%CI = 1.53 to 4.55; I2 = 61%; p = 0.0005). Buprenorphine significantly increased the incidence of nausea (OR = 2.96; 95%CI = 1.94 to 4.59; I2 = 0%; p < 0.00001; n = 1,280), vomiting (OR = 2.19; 95%CI = 1.02 to 4.72; I2 = 0%; p = 0.045; n = 590) and sedation (OR = 5.23; 95%CI = 1.96 to 13.93; I2 = 2%; p = 0.001).
Discussion
Buprenorphine demonstrated increased time to rescue analgesia compared to placebo. However, the prolonged time to rescue analgesia was associated with an increased rate of adverse events when compared to placebo. Further studies are needed to differentiate the clinical effect of buprenorphine compared with other intrathecal additives, including morphine.
References
Impact of frailty on inpatient outcomes in older patients with isolated rib fractures: a retrospective study
1Department of Anaesthesia and Perioperative Medicine Westmead Hospital, Sydney, New South Wales, Australia
ETHICS Approval Code
QA 5720 (Ethics approval was gained from the Western Sydney Local Health District Ethics Committee)
Introduction
Rib fractures in geriatric trauma patients is associated with poor outcomes1. Frailty has also been shown to be a predictor of worse outcomes in geriatric trauma.2,3 However, it is unclear if this is also true for older patients with isolated rib injuries.
The objective of this study was to assess the impact of frailty on inpatient outcomes in older patients with isolated rib fractures.
Methods
A retrospective review of patient medical records aged ≥65 years old presenting to Westmead Hospital (a major trauma centre) with isolated rib fractures over a one-year period (2016) was carried out. Frailty was defined as a score ≥5 as per the Clinical Frailty Scale (CFS)2.
21% of all patients had documented baseline cognitive impairment.
Cognitive impairment was considered present if documented by the geriatric team or if patients had neurocognitive testing scores which met criteria.
All baseline differences were statistically significant (p≤0.05) apart from anticoagulation status.
Using multiple variable logistic regression analysis, frail patients were more likely to be discharged to higher level care (11% vs 35%; OR 3.1 95%CI 1.2–7.8; p = 0.02). Frail patients were also more likely to suffer respiratory failure (16% vs 4%; OR 4.5 95%CI 1.1–18.8; p = 0.04).
Frailty was not an independent risk factor for delirium after multiple logistic regression(OR 1.6 95%CI 0.6–4.4; p = 0.37), pneumonia (OR 0.5 95%CI 0.2–1.3; p = 0.15) or ICU admission (OR 0.3 95%CI 0.04–3.1; p = 0.34). However, patients with baseline cognitive impairment were more likely to suffer from inpatient delirium (OR 5.5 95% CI2.0–15.7; p = 0.001).
Frail patients received oral analgesia mainly (33% vs 26% in non-frail patients). More non-frail patients received PCA (53% vs 43%) and regional analgesia (14% vs 2%). These findings were all statistically significant reaching p ≤ 0.05.
Conclusions
Our study demonstrated that frail older patients with isolated rib fractures are a more vulnerable group compared to non-frail patients. They are at significantly higher risk of inpatient complications which is in keeping with the literature in geriatric trauma.1–3 Frailty should therefore potentially be part of routine risk stratification in these patients and the CFS may be a suitable tool.
There is scope for evidence-based bundles of care for these patients similar to hip fracture care. Prospective studies are needed to evaluate multidisciplinary bundles of care targeting frail older patients with rib fractures to improve outcomes.
References
Clinical audit of the electronic MedAlert status in patients who have been diagnosed as susceptible to Malignant Hyperthermia in Western Australia
1Royal Perth Hospital, Perth, Western Australia, Australia
2The Malignant Hyperthermia Investigation Unit, Perth, Western Australia, Australia
Introduction
Malignant Hyperthermia (MH) is a pharmacogenetic clinical syndrome that occurs after exposure to Volatile Anaesthetics or to the depolarizing muscle relaxant Succinylcholine.1 MH is a life-threatening reaction which requires prompt diagnosis and initiation of treatment, as well as rigorous follow up for the patient and their family.2 In Australian and New Zealand, approximately one in five thousand people in the population are susceptible to MH, and approximately one in every ten thousand general anaesthetics will result in a MH reaction.2 Furthermore, unlike other neuromuscular disorders MHS has no characteristic phenotype.1 This excludes rare neuromuscular conditions associated with MH such as central core disease, King-Denborough syndrome or those that experience exertional heat illness or exercise induced rhabdomyolysis. Therefore, a patient’s MH status is regarded as vital information for the Anaesthetist prior to administering an anaesthetic.
This audit aims to identify those patients who are MHS who have not been assigned a MedAlert on i.Clinical Manager (i.CM), an electronic program housing patient data in public hospitals in Western Australia (WA). Our hypothesis predicted this would identify only a small number of patients given the vigorous follow-up processes in place within the MH Investigation Unit at Royal Perth Hospital (RPH). However, given there have been numerous written and electronic databases of medical alert patient information, the impact of this was unmeasured until now.
Methods
Approval to undertake this quality improvement project was gained by the Royal Perth Hospital Audit and quality framework in November 2021, approval number 42617. Following this, the MH Investigation Unit’s database was used to identify all patients in WA with a diagnosis of MHS. The diagnosis was confirmed by sighting the In Vitro Contracture Test or the blood DNA test results. The MedAlert status was subsequently checked in i.CM. 3-point-identification was used to confirm the identity of each patient. Two investigators performed the search separately, and any discrepancies regarding the results of the search were resolved by consensus.
Results
The total number of patient identified as having a diagnosis of MHS was 474. Of these, 425 (90%) had a correctly assigned medical alert on i.CM, 49 (10%) did not. Those with MHS, who did not have a medical alert in i.CM were categorised into five groups; no medical record number, lost to follow up, deceased, alert not clear and unspecified.
Discussion
The medical alert system used in WA public hospitals is a tool to aid clinicians manage their patients safely. This audit showed a 10% non-compliance rate with correct assignment of a medical alert for MHS patients. The reasons for this are multifactorial and include both human and systems errors. The adequacy of a MedAlert for a serious, life-threatening condition needs to be considered given the poorly visible nature of the text. Lastly, i.CM is only available to public hospitals in WA, this highlights the challenges of information sharing across the public-private health interface.
References
Understanding the impact of involvement in Trainee-led Research And Audit in Anaesthesia for Sustainable Healthcare (TRA2SH) activities on anaesthetic doctors in Australia and New Zealand
1University of Melbourne, Melbourne, Victoria, Australia
2Austin Hospital, Melbourne, Victoria, Australia
3Royal Melbourne Hospital, Melbourne, Victoria, Australia
In light of the current climate crisis, a growing body of research has examined the environmental impact of peri-operative healthcare. However, few studies have examined how involvement in sustainability activities impacts the participant.1 This study is the first to explore how involvement in Trainee-led Research And Audit in Anaesthesia for Sustainability in Healthcare (TRA2SH) activities has personally and professionally impacted anaesthetic doctors.
Results
A total of 17 anaesthetic doctors of all grades were interviewed. The 3 primary themes that emerged were; the development of professional skills, multi-disciplinary collaboration and the factors that impact sustainability activities. Professionally, participants described learning skills in leading multi-disciplinary teams, logistical problem-solving and diplomatic communication. The majority noted an increased understanding of clinical governance and public healthcare provision. Participants reported acquiring skills in audit and research and the all stated they would continue contributing their time to quality improvement. Two consultants felt their participation and leadership in sustainability as fellows was advantageous in securing consultant positions. Most participants described feeling rewarded by sharing a values-based project with other hospital staff leading to a stronger sense of purpose, belonging and community. Some registrars reported their integration into new departments was expedited by completing sustainability audits and presenting at staff meetings. Clinicians in rural and metropolitan hospitals described an expansion of professional networks while two participants described new international connections. Many felt that working with a multi-disciplinary team to complete a sustainability activity encouraged a flattening of the hospital hierarchy. Consultants and fellows described having a stronger personal connection to registrars involved in TRA2SH activities. This led them to feel a sense of learning and inspiration from junior trainees.
Conclusion
Increasing involvement of anaesthetic doctors in sustainability activities can benefit the patient, the clinician, the multi-disciplinary team and the wider community. This study highlighted that doctors involved in sustainability activities acquire a skill-set that can directly benefit patient safety. Acquiring broad knowledge of healthcare provision places participants in a position of leading hospital-wide quality improvement and research. This professional development comes as a by-product of decreasing the environmental impact of anaesthesia which ultimately improves the environmental health of the community.
Reference
An audit of prescription and management practice for intrathecal catheters during labour at KEMH
1KEMH, Perth, Western Australia, Australia
Intrathecal catheters (ITC) are an uncommon high risk labour analgesia technique.1 The placement of a catheter intrathecally following an inadvertent dural puncture allows for the intrathecal administration of medications; this can rapidly provide labour analgesia and be converted to surgical anaesthesia for caesarean section.1 Despite the reported advantages, there are significant risks to consider when using local anaesthetic and opioid solutions via an ITC.1–3
The safety of this technique requires appropriate measures being implemented at the initiation of the ITC set up. This audit aims to assess compliance of this technique against the Women and Newborn Health Service Clinical Practice Guidelines, including adherence to prescription guidelines, incidence of complications associated with the ITC technique, and identify barriers to compliance and potential safety issues to improve upon.
Methods
This project is a retrospective audit of all patients admitted to KEMH between Jan 2018 to Oct 2021. An inclusion criteria of patients having had an ITC sited for the purposes of labour analgesia was applied. These patients were identified from the RedCAPS pain service electronic database.
This audit collected basic insertion and removal data, adherence to prescription recommendation, mode of delivery, and documented complications. Data was extracted from the anaesthetic documentation on the epidural/spinal chart and inpatient notes, recorded using a prespecified data collection form and analysed using a secure Microsoft Excel database.
Results
19 women received labour analgesia from an ITC during the audit period. 70% of ITC insertions and prescriptions were by junior registrars; 84% were conducted after hours.
32% prescribed a patient controlled intrathecal anaesthetic (PCSA) regimen; 68% prescribed clinician only boluses. 50%of PSCA prescriptions adhered exactly to the KEMH guidelines for bolus and dosing regimens.
Of note, there was 100% compliance of supplementary boluses given by the anaesthetist, informing midwifery staff, and APS documentation. Other guideline points were variably followed, for instance clearly documented regular monitoring of maternal block height and vital sign monitoring occurred in 5% and 26% of cases respectively. Clear labelling of ‘intrathecal catheter’ occurred in 74% of all cases. The first on call anaesthetist was informed in 63% of overall cases. There was a documented PDPH in 89% of cases.
Discussion
The results of this audit suggest wide variability in prescribing practice for ITC analgesia during labour, and variability in compliance in documentation of the additional precautions required to safety delivery labour analgesia via the intrathecal route.
This baseline audit has provided a platform for assessment of current clinical practice. Potential improvements have been suggested and is in the process of being actioned; this includes the development of a single dedicated ‘checklist’ document for initiation and monitoring of a patient controlled spinal analgesia regimen, a prospective education program for rotating ANZCA trainees and midwifery staff, development of a specific intrathecal prescription sticker and resources to aid decision . There will be a plan to reaudit over a period after this education.
Quality Activity 42438
Acknowledgements
Thanks to Dr Chloe Heath (fellow) and Dr Jodie Jamieson (FANZCA) for conceiving the idea for the audit topic and for significant contributions. Thanks to the KEMH anaesthetic department and APS team for supporting the audit.
References
Exploring barriers to discontinuing desflurane use
1Department of Anaesthesia and Acute Pain Management, Peninsula Health, Frankston, Victoria, Australia
2Department of Anaesthesia and Perioperative Medicine, Monash Health, Clayton, Victoria, Australia
3Department of Anaesthesia and Perioperative Medicine, Monash University, Clayton, Victoria, Australia
4Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
Background
Desflurane has a high environmental impact compared to alternative agents. ANZCA encourages the use of ‘agents that have a lower impact on the environment’1 and many anaesthetic departments have removed desflurane from their operating theatres. These approaches have been ‘top down’ rather than following a traditional change management approach.
We undertook a mixed method study using a survey and focus groups to determine how desflurane is used and barriers to removal of the agent. Specifically:
How often and why desflurane is used If it would be missed if no longer supplied Why users are resistant to change
Methods
Following local ethics committee approval (QA/80514/PH-2021/285952(v1)), an online survey was sent to consultants and trainees. Questions related to use of desflurane including frequency and indication, knowledge of the environmental impact of desflurane, compared other agents and asked for opinions on how desflurane should be used within the department.
Following completion, the survey was discussed at a departmental meeting, followed by a further discussion with just trainees. Independent thematic analysis by the two researchers established topics raised and discussed by group members relating to ceasing desflurane use.
Results
Response rate was 46/66 (70%) and reflected the composition of the department. Over half the respondents (25/46, 54%) used desflurane with 7 (15%) using daily or weekly. Most trainees (72%) were non-users.
Users chose the agent for rapid awakening. Commonly for patient obesity, carotid endarterectomy, and long surgical duration. Non-users cited environmental concerns as their reason for avoiding the agent (20/21, 95%).
Only 7 respondents (15%) were unaware that propofol total intravenous anaesthesia (TIVA) had a lower environmental impact than desflurane, of whom 86% (6/7) were daily or weekly desflurane users. Most people (36/46, 78%) stated that desflurane removal would not affect their practice. Only 8 respondents (17%) believed that desflurane should be available on every anaesthetic machine.
Themes identified in discussions supporting desflurane availability were anaesthetist independence, patient safety and registrar teaching. Opposing themes were environmental concerns and availability of TIVA as an alternative.
Discussion
Many hospitals have removed or restricted desflurane availability by edict, but there is limited literature for a consensus-based approach. This mixed-method study is limited by examination of a single site, but has a high response rate that allows the identification of several enablers and barriers to change.
Despite a majority of anaesthetists using desflurane in our department, there is a willingness to change. Both survey and focus group results indicate the main barrier to change is a small, older group who believe it is superior in some circumstances and cannot be replaced. Reducing agent availability to small number of vaporisers with availability on request was supported by most respondents and doesn’t restrict autonomy.
Frequent users of desflurane indicated a relatively poor understanding of its environmental impact. Improved awareness may result in reduced usage in this group, even in their private practice. Education on TIVA use may also increase confidence in this technique as an alternative.
References
Audit cycle of prescription and initiation practices for remifentanil PCIA in labour
1King Edward Memorial Hospital, Perth, Western Australia, Australia
Remifentanil patient controlled intravenous analgesia (PCIA) is an efficacious alternative to epidural, the gold standard of labour analgesia.1 Safe use is dependent on appropriate prescription and initiation practices.2 Unfamiliarity and concern around potential side effects of remifentanil PCIA are likely barriers to utility at King Edward Memorial Hospital.2 Audits were undertaken to assess initiation and prescription practices and reassess outcomes of implemented changes to improve safety and standard of care.
Methods
Retrospective audits were conducted with institutional approval. Baseline audit (WA Health approval: GEKO 31456. Re-audit (GEKO 42099). Labour remifentanil PCIA cases were identified from department REDCAP databases and Schedule 8 Drugs of Addiction Register books. Prescription details, PCIA indication and prescription protocol compliance data was collected. Audit 42099 collected additional data on protocolised changes (checklist) implemented after audit 31456. Data was analysed using Microsoft Excel.
Results
Activity 31456 audited 29 remifentanil PCIA cases over 27 months. Remifentanil PCIA is infrequently used during labour at KEMH. Compliance was 90% for initial prescription guidelines. Additional precautions for safe use were frequently not documented (7%-24% compliance). Education sessions, a checklist to assist in consistent and complete documentation and resources in a dedicated location were implemented. In the 24-month period for audit 42099, 17 remifentanil PCIA were prescribed for labour analgesia. Compliance was 100% for initial prescription guidelines. The protocolised checklist was present in 76% of cases. Documentation of mandatory requirements was poor for cases with no checklist (0% for 7 of 11 requirements)
Discussion
Remifentanil PCIA is infrequently used for labour analgesia at KEMH. Unfamiliarity increases clinical risk and reinforces need for good communication and documentation of safety procedures to deliver this high potency opioid. Based on audit 31456 investigators prioritised improved understanding and communication of the safety requirements for administering remifentanil PCIA. Recommendations were implemented by education sessions and development of a checklist to be placed in patient notes at time of PCIA prescription for accurate and complete documentation. The checklist was placed in a dedicated marked folder with guidelines and equipment including drug delivery pumps.
Re-audit found remifentanil PCIA use remains infrequent at KEMH with lack of familiarity likely still an issue, reinforcing the need for comprehensive education and communication for remifentanil PCIA prescriptions. Encouragingly, there is improved compliance with documentation of both the initial drug delivery protocol and the initiation and monitoring requirements. The latter increase from 7–24% at baseline to 76–100% on re-audit is a significant improvement. It can be deduced that ease of access to guidelines and education sessions have improved the prescription of remifentanil PCIAs and use of the checklist shows an evident improvement in compliance with safety documentation. In the 4 cases where there was no checklist, the mandatory requirements were infrequently documented.
This audit cycle reinforces that introduction of simple initiatives can improve the safety and standard of care, with infrequent high-risk procedures being important targets.
Acknowledgements
KEMH anaesthetic department for supporting the audit.