Fatigue among anaesthesiologists in Europe: Findings from a joint EBA/NASC survey

BACKGROUND

Anaesthesiologists deliver an increasing amount of patient care and often work long hours in operating theatres and intensive care units, with frequent on-calls and insufficient rest in between. In the long term, this will negatively influence mental and physical health and well being. As fatigue becomes more prevalent, this has predictable implications for patient safety and clinical effectiveness. 1.

OBJECTIVE

This study aimed to evaluate the prevalence, severity, causes and implications of work-related fatigue amongst specialist anaesthesiologists.

DESIGN

An online survey of specialist anaesthesiologists.

PARTICIPANTS

The survey was sent to anaesthesiologists in 42 European countries by electronic mail.

MAIN OUTCOME MEASURES

Responses from a 36-item online survey assessed work-related fatigue and its impact on anaesthesiologists in European countries.

RESULTS

Work-related fatigue was experienced in 91.6% of the 1508 respondents from 32 European countries. Fatigue was caused by their working patterns, clinical and nonclinical workloads, staffing issues and excessive work hours. Over 70% reported that work-related fatigue negatively impacted on their physical and mental health, emotional well being and safe commuting. Most respondents did not feel supported by their organisation to maintain good health and well being.

CONCLUSION

Work-related fatigue is a significant and widespread problem amongst anaesthesiologists. More education and increased awareness of fatigue and its adverse effects on patient safety, staff well being and physical and mental health are needed. Departments should ensure that their rotas and job plans comply with the European Working Time Directive (EWTD) and introduce a fatigue risk management system to mitigate the effects of fatigue.

Multidisciplinary consensus guideline for the diagnosis and management of spontaneous intracranial hypotension

BACKGROUND

We aimed to create a multidisciplinary consensus clinical guideline for best practice in the diagnosis, investigation and management of spontaneous intracranial hypotension (SIH) due to cerebrospinal fluid leak based on current evidence and consensus from a multidisciplinary specialist interest group (SIG).

METHODS

A 29-member SIG was established, with members from neurology, neuroradiology, anaesthetics, neurosurgery and patient representatives. The scope and purpose of the guideline were agreed by the SIG by consensus. The SIG then developed guideline statements for a series of question topics using a modified Delphi process. This process was supported by a systematic literature review, surveys of patients and healthcare professionals and review by several international experts on SIH.

RESULTS

SIH and its differential diagnoses should be considered in any patient presenting with orthostatic headache. First-line imaging should be MRI of the brain with contrast and the whole spine. First-line treatment is non-targeted epidural blood patch (EBP), which should be performed as early as possible. We provide criteria for performing myelography depending on the spine MRI result and response to EBP, and we outline principles of treatments. Recommendations for conservative management, symptomatic treatment of headache and management of complications of SIH are also provided.

CONCLUSIONS

This multidisciplinary consensus clinical guideline has the potential to increase awareness of SIH among healthcare professionals, produce greater consistency in care, improve diagnostic accuracy, promote effective investigations and treatments and reduce disability attributable to SIH.

Fatigue amongst anaesthesiology and intensive care trainees in Europe: A matter of concern

BACKGROUND

There is a growing awareness of the effects of fatigue on trainee wellbeing and health. Trainees in anaesthesiology and intensive care work long hours, switching work schedules frequently with insufficient rest. This may have unwanted long-term effects on mental and physical health and emotional well being, resulting in burnout and affecting patient safety.

OBJECTIVE

The study aimed to evaluate the prevalence, severity, causes and effects of work-related fatigue in trainees in anaesthesiology and intensive care.

DESIGN

Online survey of trainees in anaesthesiology and intensive care.

SETTINGS

A total of 31 countries within Europe were included in the survey.

PARTICIPANTS

European anaesthesiology and intensive care trainees who responded to an invitation to take part by electronic mail or through social media.

MAIN OUTCOME MEASURES

Responses from a 29-item online survey to assess the realities within European countries with regards to work-related fatigue.

RESULTS

One thousand and two hundred trainees from 31 European countries answered the survey demonstrating that an alarming number of trainees were fatigued by their working patterns and night shifts. Trainees reported effects on personal well being, safe commuting and potential for clinical errors. Respondents described a lack of support from hospitals and management for recovery during and after night shifts.

CONCLUSION

Fatigue among trainees in anaesthesiology and intensive care has a significant impact on their well being and potentially, on the incidence of clinical errors. Current measures from authorities and hospital management are not sufficient to prevent serious fatigue, and therefore a fatigue risk management system should be considered. Failure to address this issue might lead to a further decline in trainees' wellbeing, their capacity to work in the speciality in the future, and potentially increase patient care errors.

Fatigue and its impact on performance and health

An increasing body of evidence suggests that fatigue among healthcare staff is widespread, owing to a combination of high work intensity, long daytime hours and night-shift working. This has been linked to poorer outcomes for patients and longer inpatient stays, and to increased risks of work-related accidents, errors and injuries for practitioners. These include needlestick injuries and motor vehicle accidents, and other impacts on practitioner health, ranging from cancer, mental health problems, metabolic disorders to coronary disease. Other 24-hour safety-critical industries have fatigue policies that acknowledge the risks of staff fatigue and provide a system to manage it and mitigate harm, but these are still lacking within healthcare. This review explains the basic physiology behind fatigue and outlines its impacts on healthcare practitioners' clinical practice and wellbeing. It proposes methods to minimise these effects for individuals, organisations and the wider UK health service.

Age and the anaesthetist: considerations for the individual anaesthetist and workforce planning: Guidelines about the ageing anaesthetic workforce from the Association of Anaesthetists: Guidelines for the ageing anaesthetic workforce from the Association of Anaesthetists

There is clear evidence of a growing workforce gap and this is compounded by demographic data that show the current workforce is ageing. Within the current workforce, more doctors are taking voluntary early retirement and the loss of these experienced clinicians from departments can have wide-ranging effects. Older doctors are at risk of age-related health problems (e.g. sight, musculoskeletal, menopause) and are more susceptible to the effects of fatigue, which may increase the risk of error and or complaint. The purpose of this working party and advocacy campaign was to address concerns over the number of consultants retiring at the earliest opportunity and whether a different approach could extend the working career of consultant anaesthetists and SAS doctors. This could be viewed as 'pacing your career'. The earlier this is considered in a clinician's career the greater the potential mitigation on individuals.

Survey of healthcare professionals’ knowledge, attitudes and practices regarding spontaneous intracranial hypotension

Objective

To assess the knowledge, attitudes and practices of healthcare professionals regarding the diagnosis and management of spontaneous intracranial hypotension (SIH).

Methods

We performed a cross-sectional, web-based survey of multiple healthcare professional groups in the UK from June to August 2021. There were 227 respondents to the survey, including 62 general practitioners, 39 emergency medicine physicians, 38 neurologists, 35 radiologists, 20 neurosurgeons, 18 anaesthetists and 15 headache nurse specialists. The majority of the respondents were at the consultant level and all worked in the UK National Health Service.

Results

Few general practitioners or emergency medicine physicians had ever been involved in the care of a patient with SIH or received teaching about SIH. Only 3 of 62 (4.8%) general practitioners and 1 of 39 (2.5%) emergency medicine physicians were confident in recognising the symptoms of SIH. Most neurologists were confident in recognising SIH and performed MRI of the brain as a first-line investigation, although there was variability in the urgency of the request, whether contrast was given or MRI of the spine organised at the same time. Most said they never or rarely performed lumbar puncture for diagnosis of SIH. Most neuroradiologists, but few general radiologists, were confident in interpreting imaging of patients with suspected SIH. Lack of access to epidural blood patching, personnel able to perform myelography, and established management pathways were identified by many respondents as barriers to the treatment of SIH.

Conclusions

We have identified a lack of awareness of SIH among non-specialists, several barriers to optimal treatment of SIH and a variation in current management pathways. The results highlight the need for education of healthcare professionals about SIH and the development of clinical practice guidelines to enable delivery of optimal and equitable care for patients with SIH.

Substance use disorder in the anaesthetist: Guidelines from the Association of Anaesthetists: Guidelines from the Association of Anaesthetists

Anaesthetists have a higher incidence of substance use disorder when compared with other doctors. This might be due to the ease of access to intravenous opioids, propofol, midazolam, inhalational agents and other anaesthetic drugs. Alcohol use disorder continues to be the most common problem. Unfortunately, the first sign that something is amiss might be the anaesthetist's death from an accidental or deliberate overdose. While there are few accurate data, suicide is presumed to be the cause of death in approximately 6-10% of all anaesthetists. If we are to prevent this, substance use disorder must be recognised early, we should ensure the anaesthetist is supported by their department and hospital management and that the anaesthetist engages fully with treatment. Over 75% of anaesthetists return to full practice if they co-operate fully with the required treatment and supervision.

Treatment of spontaneous intracranial hypotension: experiences in a UK regional neurosciences Centre

A robust treatment paradigm for spontaneous intracranial hypotension has yet to be agreed upon. We present retrospective data from the patient cohort at our UK regional neurosciences centre from 2010-2020 and describe our locally developed treatment pathway.Seventy-three patients were identified: 31 men and 42 women; mean age was 42 years. The majority presented with a headache of variable duration, and most had positive imaging. Very few patients (7%) responded to conservative treatment. Sixty-six underwent epidural blood patching, with 39 (59%) having a good response. Twenty-three patients underwent myelography and targeted treatment (injection of fibrin sealant at the leak site), with 13 (57%) showing a good response. One patient had successful surgery. The relapse rate after response to epidural blood patching was 10%, and after response to targeted treatment was 23%. Most patients who relapsed responded to repeated treatments.The outcome data for our diverse patient cohort shows the success of a staged approach to treatment. Relapse rates are low, and surgery is only rarely required. We use these data to inform our discussions with patients, and present them here to enable other centres to develop robust investigation and treatment paradigms of their own.

A national survey of out-of-hours working and fatigue in consultants in anaesthesia and paediatric intensive care in the UK and Ireland

The tragic death of an anaesthetic trainee driving home after a series of night shifts prompted a national survey of fatigue in trainee anaesthetists. This indicated that fatigue was widespread, with significant impact on trainees' health and well-being. Consultants deliver an increasing proportion of patient care resulting in long periods of continuous daytime duty and overnight on-call work, so we wished to investigate their experience of out-of-hours working and the causes and impact of work-related fatigue. We conducted a national survey of consultant anaesthetists and paediatric intensivists in the UK and Ireland between 25 June and 6 August 2018. The response rate was 46% (94% of hospitals were represented): 84% of respondents (95%CI 83.1-84.9%) contribute to a night on-call rota with 32% (30.9-33.1%) working 1:8 or more frequently. Sleep disturbance on-call is common: 47% (45.6-48.4%) typically receive two to three phone calls overnight, and 48% (46.6-49.4%) take 30 min or more to fall back to sleep. Only 15% (14.0-16.0%) reported always achieving 11 h of rest between their on-call and their next clinical duty, as stipulated by the European Working Time Directive. Moreover, 24% (22.8-25.2%) stated that there is no departmental arrangement for covering scheduled clinical duties following a night on-call if they have been in the hospital overnight. Overall, 91% (90.3-91.7%) reported work-related fatigue with over half reporting a moderate or significantly negative impact on health, well-being and home life. We discuss potential explanations for these results and ways to mitigate the effects of fatigue among consultants.

Mentoring for urologists

Trainee and established urologists are familiar with ‘generic mentoring’ as a potpourri of helping aids that include supervision, coaching, buddying, career advice, counselling and patronage to enable mentees to develop professionally. However, most are unfamiliar with ‘developmental mentoring’ as a highly specific learnt technique through which mentors help mentees, by interactive dialogue, to choose their own agendas and arrive at their own solutions to career/professional/personal opportunities or difficulties as distinct from the paternalistic mentor approach typified by the downward flow of information generated by ‘generic mentoring’. This paper is a systematic review of developmental mentoring as pertains to urologists in the UK, and reports outcomes of 1-hour taster sessions between Egan-trained mentors and urologists offered at British Association of Urological Surgeons (BAUS) annual general meetings since 2013. Both the General Medical Council and the Royal College of Surgeons of England imply that ‘mentoring’ is mandatory for both trainees and trained urologists, but fail to clarify what they mean by a ‘mentor’, which potentially creates a void in providing ‘developmental mentoring’ since the later requires specific training and is costly to provide. Currently, most ‘developmental mentoring’ is performed by trained staff in Local Education and Training Boards or National Health Service Trusts. BAUS has an opportunity to offer ‘developmental mentoring’ through a portal on its website to manage opportunities and difficulties experienced by its members.

Level of evidence: This paper is a systematic review as pertains to the place of mentoring in current urological practice. By its nature, it has reviewed previous narrative reviews and its highest level of evidence is a contemporary paper from 2016, which was a comparative cross-sectional study; other case series were reviewed. Overall, this amounts to level 4 with a recommendation of C as per the Oxford Centre for Evidence-based Medicine Levels of Evidence.

A national survey of the effects of fatigue on trainees in anaesthesia in the UK

Long daytime and overnight shifts remain a major feature of working life for trainees in anaesthesia. Over the past 10 years, there has been an increase in awareness and understanding of the potential effects of fatigue on both the doctor and the patient. The Working Time Regulations (1998) implemented the European Working Time Directive into UK law, and in August 2009 it was applied to junior doctors, reducing the maximum hours worked from an average of 56 per week to 48. Despite this, there is evidence that problems with inadequate rest and fatigue persist. There is no official guidance regarding provision of a minimum standard of rest facilities for doctors in the National Health Service, and the way in which rest is achieved by trainee anaesthetists during their on-call shift depends on rota staffing and workload. We conducted a national survey to assess the incidence and effects of fatigue among the 3772 anaesthetists in training within the UK. We achieved a response rate of 59% (2231/3772 responses), with data from 100% of NHS trusts. Fatigue remains prevalent among junior anaesthetists, with reports that it has effects on physical health (73.6% [95%CI 71.8-75.5]), psychological wellbeing (71.2% [69.2-73.1]) and personal relationships (67.9% [65.9-70.0]). The most problematic factor remains night shift work, with many respondents commenting on the absence of breaks, inadequate rest facilities and 57.0% (55.0-59.1) stating they had experienced an accident or near-miss when travelling home from night shifts. We discuss potential explanations for the results, and present a plan to address the issues raised by this survey, aiming to change the culture around fatigue for the better.

Exploring the relationship between mentoring and doctors' health and wellbeing: a narrative review

The health and wellbeing of doctors are crucial, both for the individuals themselves and their ability to deliver optimum patient care. With increased pressures on healthcare, support mechanisms that attend to doctors' health and wellbeing may require greater emphasis to safeguard those working in frontline services. To inform future developments, this systematic narrative review aimed to identify, explore and map empirical and anecdotal evidence indicating the relationships between mentoring activities and the health and wellbeing of doctors. Twelve databases were searched for publications printed between January 2006 and January 2016. Articles were included if they involved doctors' engagement in mentoring activities and, either health or wellbeing, or the benefits, barriers or impact of mentoring. The initial search returned 4669 papers, after exclusions a full-text analysis of 37 papers was conducted. Reference lists and citations of each retrieved paper were also searched. Thirteen papers were accepted for review. The Business in the Community model was used as a theoretical framework for analysis. Mentoring influenced collegiate relationships, networking and aspects of personal wellbeing, such as confidence and stress management, and was valued by doctors as a specialist support mechanism. This review contributes to the evidence base concerning mentoring and doctors' health and wellbeing. However, it highlights that focused research is required to explore the relationship between mentoring, and health and wellbeing.

Does specialty training prepare doctors for senior roles? A questionnaire study of new UK consultants

AIM

To measure new consultants' perceptions of their preparedness for different clinical and non-clinical aspects of the role of consultant.

DESIGN

A cross-specialty questionnaire was developed and validated, containing items asking how well specialty training had prepared respondents for the role of consultant in a number of clinical and non-clinical areas. Responses were on a five-point Likert scale with a 'Not relevant/no opinion' box, and one free text section. Analysis was carried out on 10 scales derived from the questionnaire items through exploratory factor analysis.

PARTICIPANTS

Consultants who had completed their specialty training in the north of England between 2004 and 2009 and had held a substantive consultant post in the region for <5 years were sent questionnaires in late 2009.

RESULTS

The effective response rate was 70.6% (211/299). Ten factors reflecting areas including clinical skills, communication skills, team and resource management were identified. Overall, higher scores were observed on factors relating to 'providing care for individual patients' rather than 'having responsibility for the system of care'. The lowest scoring factors related to resource management and supervision, with mean scores falling below the scale midpoint. There were no significant differences between specialty groups, or on any demographic variables.

CONCLUSIONS

A questionnaire to measure new consultants' perceptions of how well their specialty training had prepared them for practice was developed and validated. Findings were similar across specialties, suggesting that training programmes in all areas need to integrate higher-level management skills into their curricula, alongside the development of clinical expertise.

Counting the cost of surgical training: perspective from a school of surgery

It has long been acknowledged that hospital doctors train their juniors with only limited extra time or support and little formal training for their role. The introduction of job planning was intended to recognise formally the additional time needed for this and other activities and the new Postgraduate Medical Education and Training Board (PMETB) standards for trainers are intended to address the need for faculty development. If these Standards for trainers are to be achieved, regulators may need to provide clearer guidance to trusts about the time required in job plans to deliver the expected standard of educational and clinical supervision and other deanery and royal college educational roles.

Trainee and training issues

This chapter deals with the obligations of trainers and trainees to each other, the responsibilities of the programme and the conflicts of providing a service while training. Management of trainees with differing needs, such as those working part-time or returning to training after sickness, is reviewed. Assessment of performance and the obligation of consultants to identify, manage and support struggling trainees are discussed. Ethical discussion is based on the principles of autonomy, non-maleficence, beneficence, and justice to which fidelity is added. Case studies illustrating the application of ethical principles to work and decision-making are presented to stimulate debate. Opinions vary as to which principle carries more weight in individual cases, and how best to balance the conflicting requirements of the parties involved (patient, trainee,.trainer, employer, society). For all healthcare practitioners, the needs of patients remain our first concern. Acting in a consequentialist way, we must "maximise the good" and minimise the attendant harms in training. However, deontology states that certain sacrosanct rules and principles should never be breached. Doctors must abide by the duties of a doctor described in Good Medical Practice, maintaining standards in a way that ensures professional qualifications are respected. For the patient, there are advantages and disadvantages to receiving care in an educational setting. A 'teaching environment' tends to encourage and maintain high standards of practice from senior clinicians, but it also exposes patients to new learners, who are less efficient and polished and perhaps more prone to make errors. Learning has to fit round and complement the clinical and emotional needs of patients.

Why do women reject surgical careers?

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.

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.

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.

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.

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.

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).

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.

Women's experiences of repetitively contracting sexually transmitted diseases

Our purpose in conducting this qualitative, descriptive research was to explore and describe women's experiences of repetitively contracting sexually transmitted diseases (STDs). Ten open-ended, semistructured, in-depth interviews with 8 women, along with stories and anecdotes from one author's clinical practice, provided data. Thematic analysis was used to generate themes important to the women. Themes included the power and significance of heterosexual relationships, female powerlessness, the sense that STDs are an inevitable part of a woman's life, stigma, and victimization. The women's explanatory models for the STDs were quite different from those of health care providers evidenced in the professional literature. The findings from this research support the following suggestions for practice: (a) Practitioners and clients should share their explanatory models to work toward safe sexual behavior, and (b) practitioners need to scrutinize their practices to make sure they are not minimizing the risks of STDs.

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.

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.

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.

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.

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.