Summary

Background and objective: In the perivascular sheath of the brachial plexus, the volume of anaesthetic solution determines the quality of anaesthetic cover. Fibrous septa may divide the perivascular space into compartments, leading to inadequate diffusion of the anaesthetic solution. The aim of our study was to obtain good anaesthesia and less complications using high volume of low concentration anaesthetic solution, overcoming the obstacle of the septa with a double approach to the scalene sheath. Methods: Sixty patients scheduled for shoulder capsuloplasty received both Winnie interscalene brachial plexus block and Pippa proximal cranial needle approach. The patients were randomly assigned to two groups. A constant dose of local anaesthetic was administered to each group: Group I (30 patients) received high volume (60 mL of anaesthetic solution) and Group II (30 patients) received low volume of solution (30 mL of anaesthetic solution). Sensory and motor block in the upper limb and complications were evaluated. Results: In all the patients the quality of anaesthesia obtained at the surgical site was excellent. In Group I also the areas supplied by the medial cutaneous nerves of the arm and forearm, ulnar, median and radial nerves were blocked (P < 0.002). Complications were only observed in Group II and consisted of bradycardia and hypotension (66% of the patients) and phrenic nerve paresis (27% of the patients). Conclusions: The lower concentration of the anaesthetic solution avoids complications while increased volume provides good analgesic cover. The combination of the Winnie interscalene plexus block and the Pippa proximal cranial needle approach should contribute to fill up the scalene sheath overcoming the septa obstacles.

Summary

Background and objectives: Preoperative evaluation performed by anaesthesiologists primarily aims to estimate the risk of perioperative complications and to create opportunities to optimize the patients' condition before surgery. In this study an inventory was made of the current practice of preoperative evaluation in Dutch hospitals. It was estimated how many hospitals had implemented an outpatient preoperative evaluation clinic in 2004. Subsequently, current practice was compared with the results of a previous inventory (2000). It was also evaluated to what extent the guidelines of the Dutch Health Council and the Netherlands Society of Anaesthesiology were followed. Methods: The study consisted of two phases. First, a literature research was performed and pilot interviews were constructed. The interviews were conducted face-to-face with anaesthesiologists in a sample of Dutch hospitals. Based on the results, written questionnaires were constructed. In the second phase these questionnaires were sent to all general and academic hospitals in the Netherlands. Results: In 2004, 74% of the hospitals had an outpatient preoperative evaluation clinic, compared with 50% in 2000. The percentage of hospitals with an outpatient preoperative evaluation clinic available for all elective patients increased from 20% to 52%. Conclusions: The Dutch guidelines on preoperative evaluation seem to have influenced current practice. An increase in the number of outpatient preoperative evaluation clinics was seen after the guidelines were published. The implementation of an outpatient preoperative clinic seems to warrant that anaesthesiologists are carrying out the activities prescribed by the guidelines. Most hospitals without a clinic aim to implement one in the future.

Objective: Our aim was to determine the morbidity of patients awaiting tonsillectomy.

Design: The study comprised a questionnaire survey of 379 children and 278 adults waiting over 12 months for tonsillectomy.

Outcome measures: These comprised frequency of infection, sickness absence and continuing desire for surgery.

Results: Response rates were 70 per cent (children) and 60 per cent (adults). Morbidity was similar in adults and children, and in those waiting more or less than two years. In the six months prior to the study, 86 per cent of children and 83 per cent of adults had had tonsillitis. Sixty per cent of children and 50 per cent of adults had had three or more episodes. Sixty-two per cent of children and 59 per cent of adults had had at least one long episode of tonsillitis, and 29 per cent of children and 24 per cent of adults had had more than three long episodes. Eighty-nine per cent of children had missed school at least once, compared with 71 per cent of adults missing work at least once (p = 0.01). The frequency of infection was significantly associated with patients' desire for surgery (p < 0.001).

Conclusions: Patients awaiting tonsillectomy experience considerable morbidity. This study does not support the hypothesis that untreated patients will ‘outgrow’ their condition.

Objectives: Pre-admission clinics are traditionally run jointly by nurses and doctors. Within an adult ENT pre-admission clinic, we wished to assess what doctors added tonurses’ pre-clerking, to determine whether doctors were actually needed in the clinic.

Methods: Prospective study,looking at how often doctors, seeing patients after ward-based nurses, changed or added to clerking or tests as organized by nurses.

Results: Out of 184 patients, doctors changed or added to nurses’ clerking or planned investigations in 47 patients (26 per cent), making 64 different changes. The commonest reasonsfor changes were ordering blood tests (22 changes), chest X-rays (eight), cancelling due to hypertension (seven), altering drug history (five) and requesting electrocardiograms (five changes).

Conclusion: Most changes made by doctors could be eliminated by designing a pre-admission clinic protocol that could easily be used by nurses. We recommend that all ENT departments consider implementing nurse-led pre-admission clinics.

Estimation of haemoglobin is still undertaken routinely before ENT surgery in many centres despite evidence that it is unnecessary, traumatic and expensive. The haemoglobin was estimated of all 372 children about to undergo ENT surgery in a busy district general hospital over a one year period. No child was noted to be clinically anacmic, and no child had a haemoglobin of less than 9 g/dl. Of 18 children with a haemoglobin level of 10.5 or less, 10 had their operations postponed and eight did not. There were no complications in the latter group. We can find no published evidence that operating on children with mild anaemia is unsafe. Ceasing routine pre-operative haemoglobin estimation would safely save an estimated £9000 per year in our unit.