Anaesthesia, 1992, Volume 47, pages 1 00&10 1 5

Basic life support training G.R. Lauder, FRCAnaes, P.J. McQuillan,

FRCAnaes and J . W . Sear, PhD, FFARCS Rebreathing and the Humphrey ADE breathing

system R. Ooi, FRCAnaes and N. Soni. FFARACS The ‘Whoosh’ test in children D. Bollinger, B. Med and P. Mayne, M B , BS When should blood pressure be measured before

A.C. Elston, FFARCSI and G.R. Park MD.

Arterial hypoxaemia and intrapulmonary shunt J.M. Handel. MRCP. FRCAnaes and N.J.H.

M.K. Sykes. FFARCS and J.L. Westbrook MRCP,

Laryngeal mask and bleeding diathesis J. Brimacombe, FRCAnaes Laryngeal mask airway and radiotherapy in the

M . Elias, FRCAnaes The laryngeal mask airway-suboptimal availability,

a cause for concern A.R. Williams, FFARCS and A. Cone, FRCAnaes Combined spinal-extradural anaesthesia for

M. Patel, FRCAnaes and A. Swami, FRCAnaes E. Roberts, FFARCS and D. Brighouse. FFARCS G. Lyons, R. Macdonald and B. Mikl Spinal anaesthesia for Caesarean section in an

M . Crawford, FFARCSI and D.A. Dutton, FFARCS Cerebrospinal fluid-a reliable guide to dural

puncture? Y. J. Nejad Alfentanil and raised intracranial pressure D.M. Hargreaves, FRCAnaes and J . Handel,

Patient-controlled analgesia-a serious incident W.G. Notcutt, FRCAnaes and R. Kaldas. MB. ChB Patient controlled analgesia in burn patients W.G. Notcutt. FRCAnaes

anaesthesia?

FRCAnaes

Davies, D M , MRCP, FRCAnaes

FRCAnaes

prone position

Caesarean section

achondroplastic dwarf

FRCAnaes

Correspondence

Basic life support training

1000

1001

1002

I003

1004

1004 1004

1005

1005

1005

1006 1006

1007

1007

I008

1008

1009

Fatal theophylline poisonig with rhabdomyolysis B.L. Taylor, FRCAnaes, G.B. Smith FRCAnaes and

S.M. Willatts, FRCP, FRCAnaes and M.J.A. Parr.

Pulse oximetry in pulseless patients N. Mackey. FRCAnaes. J . Plummer, PhD. A . Ilsley,

PhD and H. Owen, FRCAnaes Intra-aortic balloon pumps and the pulse oximeter T.C. Smith, FRCAnaes Obstruction due to wet soda lime granules P.S. Cossham Nil by mouth after midnight J.K. Moore, FRCAnaes Pipeline contamination and oxygen quality

P.G. Lawler. FRCP. FRCAnaes and

Propofol and abreaction M.T. Ali. M B , ChB Blood pressure measurements and intravenous

C.M. Wait, FFARCS An unusual case of postoperative hoarseness J.B. Mitchell, FRCAnaes Anaphylactoid reaction to topical chlorhexidine

J.M. Peutrell. MRCP, FRCAnaes The ‘hidden danger’ J.E. Hammond, FFARCS Hysteria: a cause for opisthotonous P.A. Stoddart, MRCP. FRCAnaes, R.S. Gill,

Hypocapnia and mental function D. Savva, FRCAnaes Throat packs and airway protection W . Ryder. FRCAnaes Two Boyle’s machines for inhalational induction of

A. Banerjee, M B , BS and A. Baranowski, FFARCS Patient misunderstanding J. Hickey, FRCAnaes

P.J. McQuillan. FRCAnaes,

M R C P , FRCAnaes

monitoring

P.T.N. Newman, FRCAnaes

infusions

during anaesthesia

FRCAnaes and M . Lim. M R C P , FRCAnaes

anaesthesia

1009

I009 1010

1010

101 1

101 1

101 1

101 1

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1014

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1015

1015

We share the disappointment of Dr Elias (Anaesthesia 1992; 47: 357), who demonstrated that 14 junior anaesthe- tists failed to meet the criteria set by the American Heart Association for successful cardiopulmonary resuscitation (CPR) and basic life support (BLS). Severe inadequacies in the CPR skills of nurses and house officers have also been reported [ I , 21. It is known that resuscitation experience without feedback increases confidence, not skill [3].

Recently, Morris et al. demonstrated improvements in theoretical knowledge with little improvement in skill of BLS in a 5-year follow-up of an original paper [4]. Why are current levels of teaching, assessment and retraining inade- quate? Is therefore the basic care of the sick or obtunded patient inadequate?

To address these questions we conducted a postal survey of 30 University Anaesthetic Departments to define current

All correspondence should be addressed to Dr M. Morgan, Editor of Anaesthesia, Department of Anaesthetics, Royal Postgraduate Medical School, Hammersmith Hospital, London W12 OHS, United Kingdom.

Letters (two copies) must be typewritten on one side of the paper only and double spaced with wide margins. Copy should be prepared in the usual style and format of the Correspondence section. Authors must follow the advice about references and other matters contained in the Notice to Contributors to Anaesthesia printed at the back of each issue. The degrees and diplomas of each author must be given in a covering letter personally signed by all the authors.

Correspondence presented in any other style or format may be the subject of considerable delay and may be returned to the author for revision. I f the letter comments on a published article in Anaesthesia. please send three copies; otherwise two copies of your letter will sufice.

Correspondence 100 1

Table 1. Teaching of BLS skills in University Hospitals.

Cardiopulmonary resusciation course Duration of cardiopulmonary

Refresher course Assessment-written

resuscitation course

-viva -practical -none

Staff/pupil ratio (range) Number of manequins (range) Tracheal intubation taught Compulsory course

Students

95% 2-6 h

50% 25% 20% 60 Yo 40 yo

5.8 (2-10)

80% 3.7 (1-12)

60 Yo

House staff

80% 1-2 h

20% 0 0

40 ?‘o

i;o Yo 8.4 (2-20) 2.5 (0-6)

35% 60 Yo

practice in the teaching of resuscitation and anaesthesia skills. The 22 completed questionnaires, a response of 73%, were evaluated and the results are summarised in Table 1. All hospitals run recuscitation courses for undergraduate medical studies, but only 80% for housemen. Refresher courses were run by only 33% and 20% for students and house staff respectively. No formal assessment of BLS skills was conducted by 40% of hospitals for students and 60% of hospitals for house staff. Tracheal intubation was taught on a course by 80% for students and only 60% for house staff. Only 25% of hospitals provided a resuscitation course for senior doctors and only 50% provided a resuscitation officer.

Airway management is basic in the care of the anaesthe- tised patient and important in the teaching of BLS. The anaesthesia component of the undergraduate curriculum varied frdm 1 to 4 weeks. The ideal duration of under- graduate anaesthesia attachment, including exposure to ITU, was universally quoted as 2-3 weeks out of a total of 6 years’ training. Unfortunately, 30% of anaesthetists in some teaching centres refused students ‘access’ to anaesthe- tised patients. Teaching of the compromised airway took place as a formal lecture in 85% of hospitals; with encouragement to attend Accident and Emergency depart- ments, emergency operating theatres and recovery areas emphasised in 55%.

As part of the questionnaire we made a suggestion that 2-3 months of the house year should be spent in a ‘resusci-

tation’ house job involving supervised periods in anaes- thesia, intensive care, coronary care and accident and emergency, familiarising the prospective senior house officer with airway, breathing and circulation problems and their management. This was considered a good idea for all, or at least some, house staff by 5% and 55% of respon- dents respectively. It was considred a bad idea by 40% of respondents.

We need to d o more than comment on the inadequacies of CPR skills. Audit of resuscitation skills is essential. Training must be compulsory, assessed, a component of final examinations and re-assessed throughout a doctor’s career. Resuscitation officers should be part of every department and supplied with sufficient time and resources to train and retrain members of the department. If anaes- thetists consider the above level of training to be adequate it seems hardly surprising that junior doctors (and by inference senior doctors) of all specialties perform badly in BLS. It is as a consequence of the inadequate level of understanding of the physiology and practice of ABC that our intensive care units continue to accept a stream of patients whose basic management has been substandard causing significant morbidity, mortality and cost.

Shackleton Department of Anaesthetics, G.R. LAUDER Southampton General Hospital, P.J. MCQUILLAN Southampton SO9 4XY, J.W. SEAR Nufleld Department of Anaesthetics, John Radcliye Hospital, Oxford OX3 9DU

References [ I ] WYNNE G , MARTEAU TM, JOHNSTONE M, WHITELEY CA,

EVANS TR. Inability of trained nurses to perform basic life support. British Medical Journal 1987; 294 1198-9.

[2] SKINNER DV, CAMM AJ, MILES S. Cardiopulmonary resuscitation skills of preregistration house officers. British Medical Journal 1985; 290: 1549-50.

[3] MARTEAU TM, WYNNE G , KAYE W, EVANS TR. Resuscitation: experience without feedback increases confidence but not skill. British Medical Journal 1990; 300: 849-50.

[4] MORRIS F, TORDOFF SG, WALLIS D, SKINNER DV. Cardio- pulmonary resuscitation skills of preregistration house officers: five years on. British Medical Journal 1991; 302: 626-7.

Rebreathing and the Humphrey ADE breathing system

It is interesting to read the comments by Dr Humphrey (Anaesthesia 1992; 47: 625) on the Humphrey ADE system. His previous findings [I], that this anaesthetic system is more effective than the conventional Magill during manual ventilation, have since been corroborated by other workers [2]. However, his statements about the greater efficiency of the ADE relative to the Magill attachment during spontaneous ventilation is open to question. The studies [3,4] reporting on the more favourable fresh gas economics of the ADE system, were all based on the use of minimum inspired carbon dioxide tension (Flco,min) as an indicator of rebreathing. Whilst Flco,min is easily accessible, given the advent of capnography, many investigators have raised doubts about the reliability of this clinical measurement in detecting the onset of rebreathing [5-81.

Kain and Nunn defined rebreathing to be present when the mixed inspired gas reaching the alveoli contains a concentration of CO,,greater than could be accounted for by the alveolar gas re-inhaled from the patient’s anatomical

deadspace [5]. Consequently, they implied that the measurement of mean inspired CO, concentration (with respect to volume inspired) would be appropriate but difficult to apply with semi-closed systems. It would require measurement of inspiratory flows in addition to CO, concentration, and an on-line microprocessor which integrates the signals from these analysers similar to that used by Noe [9] and Byrick and Janssen [lo]. Kain and Nunn also noticed that the inspired COz is raised above zero during rebreathing, but recognised the flaws of interpreting such changes in relation to the mean CO, of the inspired gas. These reservations were reiterated by Conway in his review of breathing systems [ I I]. Conway commented that rebreathing cannot always be recognised by monitoring inspired CO, concentration, for this may be increased during parts of inspiration and decrease to zero during other parts of the inspiratory period. Similar concerns about this measurement point were also voiced by Sykes [6] and Miller [7]. The latter pointed out that a raised minimum inspired CO, is a late sign of rebreathing because