Biomedical subjects
Publications and source records attributed to A J Byrne.
We describe a child who developed acidosis, hyperkalaemia and cyanosis while emerging from an otherwise uneventful anaesthetic. A diagnosis of tumour lysis syndrome was suspected and confirmed biochemically. Although this syndrome is usually associated with chemotherapy and has been described to occur spontaneously, it has not previously been reported as being associated with anaesthesia.
This review was undertaken to discover what assessment instruments have been used as measures of performance during anaesthesia simulation and whether their validity and reliability has been established. The literature describing the assessment of performance during simulated anaesthesia amounted to 13 reports published between 1980 and 2000. Only four of these were designed to investigate the validity or reliability of the assessment systems. We conclude that the efficacy of methodologies for assessment of performance during simulation is largely undetermined. The introduction of simulator-based tests for certification or re-certification of anaesthetists would be premature.
OBJECTIVE: To develop an effective and efficient method for basing nursing practice on research evidence. SETTING: The Royal Women's Hospital, Brisbane, Australia. METHOD: Nurses and midwives from various clinical areas were invited to participate in an evidence-based practice project. Standard procedures for retrieving relevant articles and evaluating their quality were observed. Where possible, raw data from studies with similar methods were summarised using appropriate statistical tests. FINDINGS: Several guidelines have been developed, staff involved with the project have become 'research literate' and the project is contributing to the hospital-wide quality improvement activities. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: It is possible to translate research findings into practice when small groups use systematic reviews to develop practice guidelines.
We have measured the performance of 10 trainee anaesthetists during a single simulated anaesthetic during which there was a complex critical incident. Errors in the recording on the anaesthetic charts of the "patient's" oxygen saturation, heart rate, systolic and diastolic arterial pressures and end-tidal carbon dioxide concentrations were used as a measure of mental workload and hence performance. The critical incident was designed to be stressful and contained, in sequence, episodes of hypotension, arrhythmia and bronchospasm. Chart recording errors increased markedly during the critical incident (P < 0.01) and decreased subsequently when the "patient" had stabilized. More than 22% of the values charted during the simulation were in error by more than 25% of the real value, and errors in excess of 100% of the actual value were recorded. There was no evidence of a tendency to consistently underestimate the magnitude of abnormal values. This method is appropriate for assessing the performance of groups of anaesthetists during simulated critical incidents. It also raises questions on the accuracy of anaesthetic record charts when recording critical incidents.
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We have compared the responses of four groups of anaesthetists, with different durations of clinical experience, to nine different simulated emergencies. Five anaesthetists in each group completed each of the nine simulated emergencies. Anaesthetists with less than 1 yr experience performed less well than the three other groups of anaesthetists (chi-square, P < 0.02). However, all groups made serious errors in both diagnosis and treatment, and accepted treatment guidelines were not followed. We have shown that a simple, inexpensive simulator can be used to evaluate the performance of anaesthetists of different durations of clinical experience.
Eleven anaesthetists completed a simulated anaesthetic which was deliberately complicated by a slow progressive bradycardia followed by an episode of severe bronchospasm. After the simulation, each anaesthetist was asked to complete an anaesthetic chart and a critical incident report. Considerable discrepancies were found between the anaesthetists' written accounts, a videotape of their performance and actual data from the simulator. During the simulations, all of the anaesthetists reacted appropriately and treated their "patient" successfully but their written accounts showed a tendency to record "typical" rather than actual events and to ignore events not consistent with their final diagnosis. Only four anaesthetists mentioned bradycardia in their written description and none accurately described the changes in arterial pressure during the episode of bronchospasm. The findings are in keeping with other studies which suggest that people record events as "schemata" rather than as collections of discrete facts. These results have significant implications for those involved in the teaching of anaesthesia and in the analysis of critical incidents.
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A new guar-containing wheatflake product was developed to assess its effect on carbohydrate tolerance in normal-weight, healthy subjects. The extruded wheatflake breakfast cereals containing 0 (control) or approximately 90 g guar gum/kg DM were fed to ten fasting, normal-weight, healthy subjects using a repeated measures design. The meals were similar in energy (approximately 1.8 MJ), available carbohydrate (78 g), protein (15 g) and fat (5.4 g) content. The guar gum content of the test meals was 6.3 g. Venous blood samples were taken fasting and at 15, 30, 45, 60, 90, 120, 150 and 240 min after commencing each breakfast and analysed for plasma glucose, insulin and C-peptide. The guar wheatflake meal produced a significant main effect for glucose and insulin at 0-60 min and 0-240 min time intervals respectively, but not for the C-peptide levels compared with the control meal. Significant reductions in postprandial glucose and insulin responses were seen following the guar wheatflake meal compared with the control meal at 15 and 60 min (glucose) and 15, 60, 90 and 120 min (insulin). The 60 and 120 min areas under the curve for glucose and insulin were significantly reduced by the guar gum meal, as was the 240 min area under the curve for insulin. Thus, it can be concluded that the use of a severe method of heat extrusion to produce guar wheatflakes does not diminish the physiological activity of the guar gum.
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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.
There must be a defined, predisposing condition to fulfil the criteria of brainstem death in the UK. A patient presented recently in coma and with absent brainstem reflexes, but no diagnosis was initially obvious. A subsequent diagnosis of Guillain-Barré syndrome was made, and the patient made a full recovery.
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The M1 air crash provided an enormous challenge to the anaesthetic and intensive care services of the hospitals which admitted the survivors, many of whom had serious injuries. This account describes some of the problems which were encountered in two of the hospitals, details the workload imposed on the anaesthetists and the staff of the Intensive Therapy Units and identifies factors which, if improved, might advance the management of multiple casualties admitted from the scene of a major disaster.
Stress ulcer is a dangerous complication for the critically ill patient. Prophylaxis with antacids can undoubtedly reduce this risk, if gastric pH is maintained above 3.5. Histamine receptor antagonists may achieve this more conveniently. We have studied the effects of ranitidine, given either as 50-mg boluses every 6 h or as one of two infusion regimes (125 or 250 micrograms/kg.h), in controlling pH in critically ill patients on a ventilator. The percentage of samples with a pH less than 4 fell in all groups during therapy; while there was no significant difference between groups, pH control was achieved more rapidly in the bolus group. Infusion therapy with ranitidine is an attractive concept but a loading dose must be used. The presence of occult blood in the gastric juice did not correlate with pH and was not affected by ranitidine therapy.