British Journal of Anaesthesia: Volume 103 Number 4 October 2009
By addebook • Oct 14th, 2009 • Category: Medicine
British Journal of Anaesthesia: Volume 103 Number 4 October 2009
by: Charles S. Reilly
en | Oxford University Press
Training and assessment in anaesthesia
The recent implementation of the Working Time Directive (WTD) has raised awareness of the constraints placed on time for training. In the BJA this month there are a number of timely articles that help to define the problems and to provide solutions. Two articles compare the ‘before and after’ effect of the WTD on training. Underwood and McIndoe (pages 518–23) compared training data from 1997 and 2008 in a large teaching hospital and found that case numbers and supervision for trainees had been maintained over that period. In contrast, Fernandez and Williams (pages 566–9), comparing log-book data from 2000 and 2007 for trainees in a large paediatric hospital, found a decrease in the case-load of specialist trainees. The changes in training time means that improved methods of assessment of trainees are required. The methods of assessing procedural skills in trainees are covered in a thorough review of the subject by Bould et al. (pages 472–83). A method of workplace-based assessment (mini-Clinical Evaluation Exercise) (Weller et al., pages 524–30) was found to be of use in improving skills, allowing assessment and promoting trainee/supervisor interaction. The use of simulators for teaching and assessment is increasing and two articles address these different aspects. Grottke et al. (pages 594–600) describe an MRI-based virtual reality simulator for teaching of regional block techniques. Finally, the addition of a formal debriefing session to simulation scenarios was shown to improve performance (Morgan et al., pages 531–7).
Magnesium and anaesthesia
The potentially beneficial applications of magnesium as a drug are increasing. The perioperative effects of magnesium are assessed in two studies. In a comparison of remifentanil infusion or magnesium (bolus dose, 50 mg kg21 followed by infusion, 15 mg kg21 h21) for controlled hypotension for middle ear surgery, Ryu et al. (pages 490–5) found similar intraoperative conditions between the two groups but improved postoperative pain scores and less PONV in the magnesium group. In a RCT comparing magnesium (50 mg kg21) or placebo, Jee et al. (pages 484–9) found attenuation of arterial pressure increases during laparoscopic cholecystectomy, with reduction in catecholamine response. The pharmacology of magnesium and its emerging applications in anaesthesia and intensive care are addressed in an excellent editorial by James (pages 465–467).
Ultrasound-guided blocks
The use of ultrasound guidance for the placement of nerve blocks is increasing and has been described in previous issues of the BJA. Two new studies provide further useful data on these techniques. The topography of the brachial plexus in the axilla and upper arm is described using detailed ultrasonography (Christophe et al., pages 606–12). This shows that while the order of nerves around the axillary artery is constant, there are frequent variations in their arrangement. The use of ultrasound-guided TAP block for analgesia after open appendicectomy was found to decrease postoperative morphine requirements and pain scores (Niraj et al., pages 601–5). In an accompanying editorial (Bonnet et al., pages 468–70) the current role of TAP block is evaluated.
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