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Enteral nutrition is currently the route of choice for feeding critically ill patients with a functioning gut but delivery is commonly associated with disruptions. Common reasons for interruptions to enteral nutrition are fasting for diagnostic procedures, surgery and airway management. These interruptions result in significant calorie deficits that are associated with increased complications. We aimed to describe the specific interruptions in our patient group and the impact they have on nutrition delivery before and after implementation of a fasting guideline.A service improvement project was undertaken over two different time points, 1 year apart, to evaluate the effectiveness of a fasting guideline in a general/trauma ICU in a London teaching hospital.There were 62 interruptions to enteral nutrition delivery with the first data collection and 64 in the second. Prolonged fasting before and after surgery and airway procedures were initially identified as the two most important causes of delays. Implementation of the fasting guideline resulted in statistical and clinical improvements in reducing fasting for airways procedures. The calorie deficit also statistically and clinically decreased as a result of the guideline.We conclude that the introduction of a simple guideline stipulating reduced fasting times before ICU procedures can result in less time lost in feed interruptions and improved enteral nutrition delivery.

Summary The 5th National Audit Project (NAP5) of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland into accidental awareness during general anaesthesia (AAGA) yielded data related to psychological aspects from the patient, and the anaesthetist, perspectives; patients' experiences ranged from isolated auditory or tactile sensations to complete awareness. A striking finding was that 75% of experiences were for

Government policy has been complicit in the increasing role of commercial companies in research, which in turn have little incentive to share the benefits of research. As a result, huge swathes of medical research rely on commercialisation and related patent protection in order to thrive. There is a distinct lack of evidence that commercialisation has led to an improvement in public health, the claim of increased innovation simply does not have empirical support. Commercialisation has led to skewed benefits in favour of companies, whereby industry is using the public’s resource without adequately paying for it, this imbalance may be seen as a form of exploitation. In this paper I argue that the skewed relationship between commercial and public interest needs to be addressed in order to ensure we meet healthcare needs of our patients in the future and ensuring the healthcare remains affordable.

Background Previous research indicates a much higher incidence of awareness during anaesthesia in children than in adults. The present study is the first large-scale, intraoperative assessment of awareness during paediatric anaesthesia using the isolated forearm technique, and the first large-scale study of memory function during paediatric anaesthesia. Methods One hundred and eighty-four children, 5–18 yr, underwent the isolated forearm technique during the first 17 min of surgery while receiving volatile anaesthesia. The isolated forearm technique was modified to accommodate brief or no paralysis. Bispectral index was monitored in a subset of 54 patients. Sixteen neutral words were played 20 times during surgery and, on recovery, implicit memory for these words was tested with a word identification task. Explicit memory for the surgical period was tested with a structured interview. Behavioural changes were assessed with age-appropriate questionnaires. Results No child had explicit recall of intraoperative events on recovery, and there was no evidence of implicit memory for words presented during anaesthesia. Two of 184 children made unambiguous and verified responses on the modified isolated forearm technique, an incidence of intraoperative awareness of 1.1%. One of these children reported that he was uncomfortable and not completely unconscious during surgery. Neither child had implicit memory for the neutral words, or adverse behaviour change. Conclusions The incidence of awareness during surgery in children is approximately eight times that measured in adults by postoperative recall. In contrast to adults, there is no evidence for preserved memory priming during anaesthesia.

We present the main findings of the 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia (AAGA). Incidences were estimated using reports of accidental awareness as the numerator, and a parallel national anaesthetic activity survey to provide denominator data. The incidence of certain/probable and possible accidental awareness cases was ~1:19,600 anaesthetics (95% confidence interval 1:16,700-23,450). However, there was considerable variation across subtypes of techniques or subspecialities. The incidence with neuromuscular block (NMB) was ~1:8200 (1:7030-9700), and without, it was ~1:135,900 (1:78,600-299,000). The cases of AAGA reported to NAP5 were overwhelmingly cases of unintended awareness during NMB. The incidence of accidental awareness during Caesarean section was ~1:670 (1:380-1300). Two-thirds (82, 66%) of cases of accidental awareness experiences arose in the dynamic phases of anaesthesia, namely induction of and emergence from anaesthesia. During induction of anaesthesia, contributory factors included: use of thiopental, rapid sequence induction, obesity, difficult airway management, NMB, and interruptions of anaesthetic delivery during movement from anaesthetic room to theatre. During emergence from anaesthesia, residual paralysis was perceived by patients as accidental awareness, and commonly related to a failure to ensure full return of motor capacity. One-third (43, 33%) of accidental awareness events arose during the maintenance phase of anaesthesia, mostly due to problems at induction or towards the end of anaesthesia. Factors increasing the risk of accidental awareness included: female sex, age (younger adults, but not children), obesity, anaesthetist seniority (junior trainees), previous awareness, out-of-hours operating, emergencies, type of surgery (obstetric, cardiac, thoracic), and use of NMB. The following factors were not risk factors for accidental awareness: ASA physical status, race, and use or omission of nitrous oxide. We recommend that an anaesthetic checklist, to be an integral part of the World Health Organization Safer Surgery checklist, is introduced as an aid to preventing accidental awareness. This paper is a shortened version describing the main findings from NAP5--the full report can be found at http://www.nationalauditprojects.org.uk/NAP5_home.

Postoperative nausea and vomiting (PONV) frequently follows prominent ear correction under general anaesthesia in children. In a prospective, single-blind study, we compared the incidence of PONV after propofol infusion anaesthesia with that following thiopentone induction and isoflurane maintenance in 30 children aged from four to 14 years randomly allocated to one of two groups. All the children were mechanically ventilated. Anaesthesia was supplemented in both groups with nitrous oxide and infiltration of the ears using a mixture of bupivacaine, adrenaline, and hyaluronidase. One child receiving propofol (group P) complained of nausea, compared with eight receiving thiopentone/ isoflurane, (group T) (P = 0.005), while three children in group P and ten in group T vomited before hospital discharge, (P = 0.01). Eight children in group P were considered to be fit for discharge on the day of surgery as against four in group T, (not significant). Only four out of twelve children receiving opioid analgesia vomited.

We have performed a randomized, cross over study in 22 children suffering from acute leukaemia, who underwent repeated anaesthesia for bone marrow aspiration and lumbar puncture. For their first anaesthetic, the children (aged 3-10 years old) received, either a thiopentone/isoflurane anaesthetic or intravenous propofol, both supplemented with nitrous oxide. On a second occasion they received the alternative technique. Of those children receiving thiopentone/isoflurane, 32% had significant coughing during anaesthesia, two progressing to laryngospasm requiring 100% oxygen. None of the patients receiving propofol had a respiratory disturbance (P = 0.016). 68% of the children preferred the propofol anaesthetic. Only one child in the thiopentone/isoflurane group preferred this technique. Twenty-seven per cent had no preference. There was no significant difference in length of anaesthetic time (P = 0.07) or the time taken for recovery (P = 0.17) between the two groups. There was a large individual variation in propofol requirements and movement was common during stimulation of patients in this group, though this did not adversely affect the surgical procedure.

This report details the case of a 2-month-old baby boy with known cyanotic congenital heart disease (double outlet right ventricle with subpulmonary ventricular septal defect, VSD) in whom tracheal stenosis was undetected, being found later on failed intubation while undergoing anaesthesia for an arterial switch operation and VSD closure. As a result, the cardiac surgery was postponed. Such an association between congenital heart disease and tracheal stenosis has been reported but remains exceptionally rare. The baby subsequently underwent a slide tracheoplasty the next day and had major cardiac surgery a few days later. He was discharged approximately 3 weeks later after spending 8 days on the cardiac intensive care unit.

We have studied the pharmacokinetics of lignocaine in children after local infiltration for cleft palate surgery. After induction of anaesthesia, lignocaine 2.5 mg kg-1 with adrenaline 1:200,000 was injected into the palate. Blood samples were collected before and at 2, 5, 10, 15, 20, 30, 60 and 120 min after infiltration. Plasma concentrations of lignocaine were measured by a gas-liquid chromatographic technique. There were no signs of systemic toxicity on routine monitoring of the patients and the peak plasma concentrations were less than the accepted toxic values. Mean half-life was 72.9 (SEM 9.9) min, similar to that found previously in adults and children. However differences in mean clearance (24.6 (2.04) ml kg-1 min-1) and volume of distribution (0.80 (0.07) litre kg-1) were found between this and previous studies.

An eight-year-old boy with a Burkitt's lymphoma of the upper airway is described. The use of sevoflurane for induction of anaesthesia in patients with airway obstruction is discussed. The logistical problems of upper airway surgery and anaesthesia in this type of patient are considered.

Ed Julian F Bion BMJ Books, £45, pp 456 ISBN 0 7279 1076 0 ——————— Rating: ★★★ Anaesthesia has its roots in the basic sciences and interfaces with every branch of medical practice. The specialty thus seems particularly suited to the publication of series of books that are more than journals but, individually, are not comprehensive textbooks. Intensive Care Medicine is the latest in the BMJ’s series Anaesthesia and Acute Medicine. The editor is a recognised authority in the specialty, the book consists of 32 monographs by 52 authors, mostly from Britain but including some from continental Europe, Australia, and north America. It is refreshing that some of the contributors are trainees; the book cannot be regarded as merely the idiosyncratic musings of a self selected group of crusty old consultants. The book is divided into three sections, the first being a historical introduction, necessarily brief because intensive care has only been around for four decades. Secondly, four essays on the pathogenesis of critical illness set the scientific scene. Thirdly, the main body of the book comprises 25 chapters covering many clinical problems as they manifest in intensive care. Each chapter is some 12 pages long, easy to read, and well referenced. The highlights are the chapters on acute lung injury and ventilatory failure, which should be compulsory reading for all who work in an intensive care unit, even the cleaner. They present well referenced, clearly summarised advice on some of the commonest problems presenting in every intensive care. Three other chapters are particularly worthy of attention. “Ethical Legal Issues” provides an authoritative review of consent in the management of adults and children, withholding and withdrawing intensive care, and the ethics surrounding research in the specialty. Its author, described modestly as “barrister at law,” was, in a previous career, one of the country’s foremost authorities on cardiothoracic intensive care and anaesthesia. “Tissue Hypoxia and Ischaemia—Reperfusion Injury” is the uninspiring title of a clearly explained, logical discussion of the mechanisms underlying cell damage during and after shock. It emphasises the role of free radicals and the place of antioxidants. These mechanisms are relevant to so many disease processes that all of us should have an appreciation of this science. “Obstetric Critical Illness” describes, in some detail, the presentation and current management of uncommon but potentially disastrous complications of pregnancy—HELLP syndrome, eclampsia, amniotic fluid embolism, and acute fatty liver of pregnancy. There is also a down side to the book. I was baffled by abbreviations in the chapter on cytokines: in one sentence the letters “TNF” appear six times. The chapter on the surgical abdomen summarises itself towards the end with the phrase “request a surgical consultation,” reminding me of a now retired colleague who gave a lecture to the FRCS course on anaesthesia by saying “Leave it to the experts” and departing the room. The chapter on the critically ill child paints a picture using the only photographs of patients in the book, but it is overshadowed by the book Paediatric Intensive Care in the same series. I was disappointed by the omissions. Perhaps budget holders will be pleased that protein C managed only one line. I could find little practical advice the on the rational choice of inotropes and vasoactive drugs. Most worrying of all, there was nothing on septic shock in spite of recent outbreaks of meningococcaemia in teenage and student populations. Anyone who reads this book cannot fail to appreciate the growth of intensive care from the “iron lung” ventilator to the scientifically based multidisciplinary management of some of our sickest patients. Who knows what the next 40 years will bring.

EDITOR,—R H Davies is to be praised for the sensitive approach taken in striving to obtain the most appropriate care for a ventilated patient.1 Undoubtedly those readers who have been in a similar situation will have been reminded of their own experiences and the seemingly endless round of meetings that took place. In 1993 I undertook a postal survey of members of the Paediatric Intensive Care Society asking about children ventilated at home in Britain. I hoped, forlornly, to organise a …