Quality issues in otorhinaryngology: Part I.
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Education, Medical, Graduate↗
Biomedical subjects
N Redfern
Publications and source records attributed to N Redfern.
Stress and trainees.
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Education, Medical, Graduate↗
Developing senior doctors as mentors: a form of continuing professional development. Report Of an initiative to develop a network of senior doctors as mentors: 1994-99.
BACKGROUND: Senior doctors report that mentoring skills are transferable to everyday medical practice and managing juniors. An analysis of views from consultants and general practitioners, who had trained together on a regional mentoring scheme, reveals significant potential for personal and professional development in such networks. CONTEXT: The Northern and Yorkshire Region Doctors' Development and Mentoring Network was set up in 1994. Since then there have been six programmes with 116 senior doctors participating. In 1997 there was an evaluation of the first four programmes. METHOD: Focus groups and postal questionnaire. RESULTS: There were responses from 71 senior doctors, giving a response rate of 86%, and responses from 78 professional stakeholders in 49 NHS organizations, a response rate of 54%. Results indicate that the programmes were highly valued by the participants, particularly with regard to: being part of a network of senior doctors; developing mentoring skills, and engaging in personal and professional development. The most difficult part of the programme was setting up mentoring networks for junior doctors, and reasons included: personal factors, such as levels of confidence in providing mentoring; cultural factors, such as juniors not wishing to be seen to need help, and organizational factors, such as lack of time allocated for mentoring. RECOMMENDATIONS AND ISSUES FOR FURTHER DEBATE: The positive benefits from the scheme raise questions about how to develop mentoring training for senior doctors. Issues include: developing mentors; who needs mentoring; mentoring and the organization; transferability of mentoring skills, and widening the network.
Clinical Competence↗
A study of junior doctors to investigate the factors that influence career decisions.
Both pre-registration house officers and general practitioner (GP) registrars agree on several desirable and undesirable factors that define their ideal career. These relate to fulfilling clinical work and preservation of a meaningful personal life. Many young doctors regret their choice of medicine as a career because of poor job conditions and stress and perceive career advice as inadequate. GP's influence over junior doctors at the time of their career decision making is very limited compared with that of consultants.
Career Choice↗
Why do women reject surgical careers?
UNLABELLED: The objective of this study was to identify some of the reasons why women reject surgical careers, and to suggest actions which might reverse that trend. The subjects were new entrants to medical school, third-year medical students and pre-registration house officers (PRHOs) at the Medical School of Newcastle-upon-Tyne. METHOD: A cross-sectional descriptive survey, using a self-administered questionnaire. RESULTS: Of 247 females surveyed, 99 (40%) had rejected surgical careers, mainly because of 'personal preference'. Women saw such careers as unfavourable to them, largely because of a perception of male bias. No more than 10% of females in each subject group had surgical role-models. The perceived quality of teaching and friendliness of consultants had a significant influence on career decisions. CONCLUSIONS: Women reject surgical careers because of perceptions of 'male bias' and 'negative attitudes'. An increase in the number of surgical role models among women could improve this situation, as could apparent enthusiasm for teaching and enjoyment of their specialty by consultants.
Career Choice↗
Anaesthetic management of Caesarean section in an elderly parturient with pre-eclampsia.
The number of women over 40 years of age becoming pregnant has increased over recent years. They suffer a high incidence of hypertensive complications, and require more frequent operative interventions. We present a case report of a 51-year-old woman having a Caesarean section for a twin pregnancy complicated by pre-eclampsia. We discuss the effects of age on pregnancy and the implications for anaesthetic management.
Anesthesia, Obstetrical↗
Exaggerated cardiovascular response to anaesthesia--a case for investigation.
We present a case of a 40-year-old woman who developed major cardiovascular complications during anaesthesia for an elective clipping of a cerebral arteriovenous malformation. Postoperative investigation confirmed the diagnosis of an adrenal phaeochromocytoma. In retrospect, it became apparent that she had experienced a series of potentially life-threatening events over a 20-year period all of which are known complications of phaeochromocytoma. This case highlights the importance of investigating young patients who have unexpected and unexplained cardiovascular events during anaesthesia and surgery.
Adrenal Gland Neoplasms↗
Low-dose clonidine infusion during labour.
In this study, we have compared two different doses of clonidine (bolus of 25 micrograms and infusion of 19 micrograms h-1; bolus of 50 micrograms and infusion of 37 micrograms h-1, both added to 0.03% bupivacaine) with a control group of 0.03% bupivacaine alone. The study was performed in a randomized, double-blind manner, and a total of 45 patients were studied. Both clonidine regimens resulted in marked local anaesthetic sparing, with no change in the quality of analgesia. There was no difference in the severity of lower limb motor weakness and no difference in maternal sedation, although only a small number of patients were studied. No adverse maternal haemodynamic effects were observed. The newborn infants were not sedated on delivery. The number of fetal cardiotocographic traces judged to be of concern was higher in both clonidine groups. However, this just failed to reach statistical significance (P = 0.055).
Adolescent↗
Randomized trial of bolus phenylephrine or ephedrine for maintenance of arterial pressure during spinal anaesthesia for Caesarean section.
Thirty-eight healthy women undergoing elective Caesarean section under spinal anaesthesia at term were allocated randomly to receive boluses of either phenylephrine 100 micrograms or ephedrine 5 mg for maintenance of maternal arterial pressure. The indication for administration of vasopressor was a reduction in systolic pressure to < or = 90% of baseline values. Maternal arterial pressure (BP) and heart rate (HR) were measured every minute by automated oscillometry. Cardiac output (CO) was measured by cross-sectional and Doppler echocardiography before and after preloading with 1500 ml Ringer lactate solution and then every 2 min after administration of bupivacaine. Umbilical artery pulsatility index (PI) was measured using Doppler before and after spinal anaesthesia. The median (range) number of boluses of phenylephrine and ephedrine was similar; 6 (1-10) vs 4 (1-8) respectively. Maternal systolic BP and CO changes were similar in both groups, but the mean [95% CI] maximum percentage change in maternal HR was larger in the phenylephrine group (-28.5 [-24.2, -32.9]%) than in the ephedrine group (-14.4 [-10.6, -18.2]%). As a consequence atropine was required in 11/19 women in the phenylephrine group compared with 2/19 in the ephedrine group (P < 0.01). Mean umbilical artery pH [95% CI] was higher in the phenylephrine group (7.29 [7.28-7.30]) than in the ephedrine group (7.27 [7.25-7.28]). The results of the present study support the use of phenylephrine for maintenance of maternal arterial pressure during spinal anaesthesia for elective Caesarean section.
Adult↗
Influence of droperidol on nausea and vomiting during patient-controlled analgesia.
We have studied the addition of droperidol to morphine during patient-controlled analgesia (PCA) in 57 patients using PCA after abdominal hysterectomy. Patients in group 1 (control group) received placebo at induction of anaesthesia and a PCA containing morphine; those in group 2 received droperidol 1.25 mg and a PCA containing morphine and those in group 3 droperidol and a PCA containing droperidol 0.05 mg mg-1 of morphine. Patients in the control group suffered 51 episodes of nausea compared with 35 in the droperidol bolus group and 18 in the droperidol PCA group (P < 0.01). In the droperidol PCA group, only 10 doses of additional antiemetic therapy were required compared with 24 in the droperidol bolus group and 28 in the control group (P < 0.05). We did not observe side effects attributable to droperidol. We conclude that droperidol added to morphine in PCA reduces nausea and antiemetic requirements after abdominal hysterectomy.
Adult↗
Hydralazine boluses for the treatment of severe hypertension in pre-eclampsia.
OBJECTIVE: To audit the use of bolus hydralazine for control of severe hypertension within a protocol for the management of severe pre-eclampsia. DESIGN: A retrospective review. SETTING: Three UK teaching hospitals. SUBJECTS: Seventy consecutive women who received hydralazine for the treatment of sustained severe hypertension. Twenty-five women had more than one episode of hypertension amounting to a total of 109 treatment episodes. INTERVENTION: Intravenous bolus hydralazine 5 mg, repeated every 15 min to reduce the mean arterial pressure to < 125 mmHg. MAIN OUTCOME MEASURES: Change in mean arterial pressure in response to bolus hydralazine, fetal condition, as assessed by heart rate changes and umbilical arterial pH at delivery, and protocol violations were analysed. RESULTS: Mean arterial pressure fell by 12 mmHg (95% CI 10-14) after the first bolus, 9 mmHg (95% CI 6.5-12) after the second bolus and 5 mmHg (95% CI 1-10) after the third bolus. Eighty-two (75%) episodes were managed strictly according to the protocol; of these, blood pressure was controlled by bolus therapy alone in 89%. Of the 27 instances in which the protocol was not adhered to, blood pressure was not controlled in four. There were no significant differences in the incidence of cardiotocographic abnormalities or umbilical acidaemia in the women treated before delivery (n = 36) compared with those in whom treatment was first initiated afterwards (n = 34). CONCLUSIONS: Hydralazine given in 5 mg boluses is a safe and effective method of treating severe hypertension in pre-eclampsia. Despite clear management guidelines, protocol violations were common, and in 4% of treatment episodes these were potentially serious resulting in failure to control blood pressure.
Adult↗
Phenytoin prophylaxis in severe pre-eclampsia and eclampsia.
OBJECTIVE: To determine plasma phenytoin levels and seizure outcome in women given phenytoin for seizure prophylaxis in severe pre-eclampsia and eclampsia. DESIGN: Prospective observational study comparing two phenytoin loading regimens. SETTING: Two UK teaching hospitals. SUBJECTS: Sixty-seven consecutive women with severe pre-eclampsia and five with eclampsia. INTERVENTIONS: The first 29 women were given a 15 mg/kg intravenous loading dose of phenytoin. The next 43 received 17.5 mg/kg. All were given 500 mg phenytoin 12 h after completion of the loading dose and then 250 mg every 12 h for four doses. MAIN OUTCOME MEASURES: Total plasma phenytoin levels at 30 min, 6 h and 12 h after loading dose, 6 h after first maintenance dose and on days 2 and 3 of maintenance therapy; eclamptic seizures after starting phenytoin. RESULTS: Mean plasma phenytoin levels were higher at 30 min and 6 h after the 17.5 mg/kg loading dose. Nine of 29 (31%) phenytoin levels 30 min after the loading dose were above the therapeutic range in the 15 mg/kg group compared with 26/38 (68%) in the 17.5 mg/kg group (P < 0.01). Six of 27 (22%) phenytoin levels 12 h after the loading dose were subtherapeutic in the 15 mg/kg group compared with 2/38 (5%) in the 17.5 mg/kg group (P < 0.05). Three women, two in the 17.5 mg/kg group, developed seizures after starting phenytoin. All three had plasma levels within the therapeutic range. CONCLUSIONS: Compared with a loading dose of 17.5 mg/kg, loading with 15 mg/kg phenytoin was associated with a lower incidence of high plasma levels at 30 min but a higher incidence of subtherapeutic levels at 12 h. Seizures occur in 2 to 3% of pre-eclamptics despite apparently therapeutic phenytoin levels.
Adult↗
A protocol for the intrapartum management of severe preeclampsia.
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Journal Article↗
Obstetric anaesthesia in dystrophia myotonica.
Two patients with dystrophia myotonica presented for urgent Caesarean section. Their per- and postoperative courses illustrate the anaesthetic problems posed by this disease. Respiratory difficulties are compounded by pregnancy and there is increased susceptibility to uterine haemorrhage. Choice of anaesthetic agent is discussed. Both had general anaesthetics; muscle relaxation was achieved with vecuronium.
Adult↗
Morbidity among anaesthetists.
Anaesthetists may be exposed to a number of occupational hazards. These include exposure to infections, environmental pollution with volatile anaesthetic agents and psychological and stress-related illness which may predispose to drug dependence or suicide.
Anesthesiology↗
The management of caesarean section in a patient with an intracranial arteriovenous malformation.
The anaesthetic management of elective Caesarean section in a 25-year-old woman with an inoperable intracranial arteriovenous malformation is described. The literature is reviewed.
Adult↗
Alfentanil for caesarean section complicated by severe aortic stenosis. A case report.
Alfentanil 35 micrograms kg-1, was used successfully in a patient with severe aortic stenosis, in order to minimize the haemodynamic responses to intubation and surgery during Caesarean section. The baby was delivered apnoeic, unresponsive and with poor muscle tone, but responded rapidly to naloxone. Plasma alfentanil concentrations and percentage binding to plasma proteins were measured in both maternal and neonatal blood. Free drug concentrations were similar in both mother and neonate, but maternal plasma proteins had a higher affinity for alfentanil. Only 67.26% of neonatal plasma alfentanil was bound to plasma protein. This value did not differ significantly from those estimated from the blood of a further 12 healthy neonates.
Adolescent↗
Anaesthesia for trans-sternal thymectomy in myasthenia gravis.
A retrospective review is presented of the thirty patients who underwent trans-sternal thymectomy for myasthenia gravis in our unit from 1980-85. The clinical status of these patients is contrasted to that of more severely debilitated patients described by other authors. The problems encountered by the anaesthetist in the perioperative care of patients with mild myasthenia gravis are discussed. Management of the perioperative anticholinesterase regime is described and a case presented for the use of suxamethonium for intubation. A less invasive postoperative regime is advocated in which tracheostomy and nasotracheal intubation are avoided, and anticholinesterase therapy is re-introduced orally as soon as possible after surgery.
Adolescent↗