Correspondence Anaesthesia, 2010, 65, pages 529–539 . ....................................................................................................................................................................................................................
guarantee against fixation, as the article and its accompanying editorial make clear [3]. The issue is whether the countermeasures to fixation, that proved largely ineffective in Fioratou’s study group, may actually have worked for a group of anaesthetists. This is important because our knowledge of what works and what does not with regards to overcoming fixation will influence our behaviour as anaesthetists, and will also influence anaesthetic training in the future. I would be interested to hear the authors’ views. J. Glen Southern General Hospital, Glasgow, UK E-mail:
[email protected]
References 1 Fioratou E, Flin R, Glavin R. No simple fix for fixation errors: cognitive processes and their clinical applications. Anaesthesia 2010; 65: 61–9. 2 Campbell MJ, Machin D. Medical Statistics, 2nd edn. Chichester: Wiley, 1993. 3 Yentis S. Of human factors, failings and fixations. Anaesthesia 2010; 65: 1–3. A reply
It was with great interest that we read Dr Glen’s letter. We commend the author for taking our work forward by testing consultant and trainee anaesthetists on the cheap necklace problem, thus showing how professionals rather than undergraduate and postgraduate students actually manage to solve this simple insight problem. The focus of Dr Glen’s small study is on the outcomes, i.e. problem solved or not solved, whereas the emphasis on our cheap necklace problem study was on the approaches and strategies that the participants used when attempting to solve the problem. The qualitative component of our original cheap necklace problem study did not feature in Dr Glen’s study and as this is the component in people’s performance that provides the most insight into fixation, we, as researchers, should place emphasis on investigating the strategies that lead to fixation and consequently discover effective countermeasures. 534
We welcome Dr Glen’s concerns about whether our countermeasures for the cheap necklace problem would work for the professional sample and we invite him to recognise these as speculation. Until his concerns are addressed empirically, no satisfactory answer can or should be given. We have attempted to provide an account of fixation in the lab; fixation ‘in the wild’ is still at large waiting to be empirically explored. We look forward to further attempts to test fixation and its countermeasures in future simulation work. E. Fioratou R. Flin R. Glavin Industrial Psychology Research Centre, University of Aberdeen, Aberdeen, UK Victoria Infirmary, Glasgow, UK E-mail:
[email protected] doi: 10.1111/j.1365-2044.2010.06317.x
Is cell salvage safe in transnasal surgery?
Cowlishaw and Belavy [1] raised concerns in their correspondence regarding the sterility and safety of cell salvage in transnasal surgery. Cell salvage has been shown to be safe in a 5-year retrospective review of adverse events associated with blood transfusion. This review examined over 27 000 cases where salvaged, predonated autologous or allogeneic blood was transfused, and found the incidence of adverse events with autotransfusion to be 0.027% compared to 0.14% with allogeneic blood transfusion [2]. In 1986 the American Medical Councils report on autologous blood transfusions stated that cell salvage was contra-indicated where the blood has come into contact with bacteria [3]. Since that date many studies have investigated the incidence and clinical effects of microbiological contamination of salvaged blood. During ‘sterile’ procedures the incidence ranges from 12.7% [4] to 33.3% [5]. The most common source of contamination is thought to be skin and environmental contamination. The relationship between the transfusion of contami-
nated cell salvaged blood and adverse clinical outcomes is not clear, but there have been a number of studies that have investigated this aspect. A prospective observational study of 38 patients undergoing orthotopic liver transplantation investigated microbiological contamination of salvaged blood. Samples of processed salvaged blood were positive for micro-organisms in 68.4% of cases. A variety of micro-organisms were cultured; staphylococcus (73%), Escherichia coli (4%), propionibacter (4%) and candida (8%). Blood cultures were taken on postoperative days 1 and 3, and none of these were positive for the organisms previously cultured from the salvaged blood [6]. A randomised controlled trial of 44 patients with penetrating abdominal trauma demonstrated that salvaged blood was positive for micro-organisms in 91.7%. They found no association between positive microbiology of the cell saved blood and postoperative infectious episodes [7]. As these studies have demonstrated no relationship between the transfusion of contaminated cell salvaged blood and adverse clinical outcomes, we suggest that cell salvage in transnasal surgery is safe. Indeed, reduction in transfusion of allogeneic blood in this setting may lead to decreased morbidity and cost. Therefore cell salvage should be considered whenever surgery is undertaken that may lead to significant blood loss. A. Ashworth J. Hanison A. A. Klein North Manchester General Hospital, Manchester, UK E-mail:
[email protected]
References 1 Cowlishaw PJ, Belavy D. Is cell salvage safe in transnasal surgery? Anaesthesia 2010; 65: 209. 2 Domen RE. Adverse reactions associated with autologous blood transfusion: evaluation and incidence at a large academic hospital. Transfusion 1998; 38: 296–300. 3 Council of Scientific Affairs. Autologous blood transfusions. Journal of the
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American Medical Association 1986; 256: 2378–80. Ezzedine H, Baele P, Robert A. Bacteriologic quality of intraoperative autotransfusion. Surgery 1991; 109: 259–64. Sugai Y, Sugai K, Fuse A. Current status of bacterial contamination of autologous blood for transfusion. Transfusion and Apheresis Science 2001; 24: 255–9. Feltracco P, Michieletto E, Barbieri S, et al. Microbiologic contamination of intraoperative blood salvaged during liver transplantation. Transplantation Proceedings 2007; 39: 1889–91. Bowley DM, Barker P, Boffard KD. Intraoperative blood salvage in penetrating abdominal trauma: a randomized, controlled trial. World Journal of Surgery 2006; 30: 1074–80. doi: 10.1111/j.1365-2044.2010.06318.x
Links to the organ donation register: a survey of hospital websites
The Organ Donation Taskforce [1] highlighted the need to identify the most effective methods through which organ donation could be promoted to the general public. One way of promoting the organ donation register (ODR) is to advertise on websites and we therefore decided to investigate how often links to the organ donation register could be found on hospital websites. In October 2009 we looked at the websites of NHS hospitals in the UK. We inspected each site to see if there was a link to the ODR on the homepage or on the patients’ page. When there was no link on either of these webpages, we used the website search facility to see if this provided a link to the ODR. When more than one hospital was represented by the same NHS Trust or NHS Board website, the website was only assessed once to prevent duplication. We looked at 199 websites. Overall 75 websites (38%) had any type of link to the ODR. Only 45 (23%) had a link on the homepage. When there was no link on the homepage, a link could be found on the patients’ webpage in a further six
websites (3%). Another 24 websites (12%) had links to the ODR that could only be found using the website search facility or via the useful links page. It took a median of three clicks to find a link after using the search facility. Links to the ODR were found on the homepage or patients’ page on 67% of Scottish websites, 24% of English websites and none of the Welsh or Northern Irish websites. UK transplant units had a link to the ODR on the homepage or patients’ page on 67% of websites. Of the 51 links on the homepage or the patients’ page, 44 (86%) used a recognised organ donor logo. The remaining seven consisted of simple text links. Over 16 million people are on the ODR and the government has set a target of 22.5 million by 2016. The most popular ways of joining the register are via The Driver and Vehicle Licensing Agency and GP registration forms [2]. We were surprised that so few websites had a link to the ODR. Although 67% of UK transplant units had links to the ODR, we think that this should be higher. Hospital websites are a cheap and easy method of promoting the ODR. Even if these links do not result in significant ODR registrations, they may help demonstrate a hospital’s support for organ donation. J. Harkins P. Jefferson D. R. Ball Dumfries and Galloway Royal Infirmary, Dumfries, UK E-mail:
[email protected]
References 1 Organ Donation Taskforce. Organs for Transplants: A Report from the Organ Donation Taskforce. London: Department of Health, 2008. 2 http://www.uktransplant.org.uk/ukt/ newsroom/fact_sheets/nhs_organ_ donor_register_a_history.jsp (accessed 08 ⁄ 01 ⁄ 2010). doi: 10.1111/j.1365-2044.2010.06319.x
Lipid emulsion: is there sufficient knowledge among hospital staff?
We believe, like other enthusiasts [1, 2], that lipid emulsion therapy for the treat-
2010 The Association of Anaesthetists of Great Britain and Ireland
ment of local anaesthetic toxicity should be familiar not only to anaesthetists within the operating theatre environment but also to any practitioner who administers these agents. We believe that it is our responsibility to educate and lead on this aspect of patient care and safety. Physicians, surgeons and nurse practitioners administer local anaesthetics; examples include orthopaedic surgeons manipulating forearm fractures, cardiologists implanting pacemakers, and nurses caring for patients receiving local anaesthetic infusions. We feel little is known regarding the knowledge of the treatment of local anaesthetic toxicity amongst health professionals. With this in mind, we undertook a small survey in our hospital. Anaesthetists and non-anaesthetists (cardiologists, cardiothoracic surgeons, operating department assistants, senior nursing staff and hospital coordinators) were asked whether they knew of the use of lipid emulsion as specific treatment for local anaesthetic toxicity and also whether they were aware of the Resuscitation Council (UK) [3] policy for local anaesthetic toxicity that endorses lipid emulsion therapy. All 10 anaesthetists had knowledge of lipid emulsion use and the guidelines for its use but only 5 of the 25 non-anaesthetic staff knew about lipid emulsion, with none knowing of structured guidelines for its use. Our small survey reinforced our belief that there is good dissemination of the AAGBI guidelines [4] amongst anaesthetists, but that there is poor knowledge about lipid emulsion therapy in other disciplines. Most of the people we surveyed are current Adult Life Support providers or instructors and active members of our hospital’s cardiac arrest team. It is concerning that they have not received education about the management of local anaesthetic toxicity as part of their Adult Life Support training. We believe that Adult Life Support courses are an ideal forum for education on the management of local anaesthetic toxicity. In conclusion, we urge wider dissemination of the AAGBI guidelines to non-anaesthetists and we encourage anaesthetists to take on this patient safety
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