Association of Cardiothoracic Anaesthetists 24th Autumn Meeting, The

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					                               ACTA News

                                                                                                                                                             No.27 June 2008

Association of Cardiothoracic Anaesthetists
24th Autumn Meeting, The City Hall, Cardiff
                                                                                                              H      ow whim comes to fruition. It seemed
                                                                                                                     to such a long time ago that I persuaded
                                                                                                              my colleagues that we should host the autumn
                                                                                                              ACTA meeting 2007 in Cardiff. It was even
                                                                                                              worse folly that following the Cambridge
                                                                                                              Spring ACTA meeting, I agreed that it would be
                                                                                                              even better if we hosted a Thoracic/Upper GI
                                                                                                              day before the Cardiac ACTA.

                                                                                                              I  n the planning, we had to overcome a few
                                                                                                                 hurdles including two of our speakers
                                                                                                              pulling out of the meeting for various reasons,
                                                                                                              our named contact for delegates’ registration
                                                                                                              etc leaving the anaesthetic department and
                                                                                                              then to top it off, the postal strike.Thus it was
                                                                                                              with a leap of faith and our fingers tightly
                                                                                                              crossed that we found ourselves hosting a
                                                                                                              two-day meeting in Cardiff City Hall.
                                         Cardiff City Hall. Entry to fair not included in registration fee.

  Upper Gastrointestinal & Thoracic Anaesthesia
                        Thursday 15th November 2007

M      y eternal gratitude goes to Dr Barbara
       Bahaman (our Upper GI Consultant
Anaesthetist Colleague) whose strength,
                                                    talk on cardiac output monitoring during one-
                                                    lung anaesthesia followed by the presentation
                                                    of the Japanese experience in lung isolation
enthusiasm and continued optimism ensured           techniques by Dr T Asai.
that we secured the appropriate speakers and
equipment for the first day.
                                                    T     hree upper GI surgeons Mr G Clark, Mr
                                                          W Lewis and Mr S Wajeed took up the                   Drs Martin Breutsche (left), Denny Levett (centre)
                                                                                                                                 and Barbara Bahlmann (right).
O      n the morning of the 15th, 141
       colleagues and I settled in for what were
hopefully informative presentations, workshops
                                                    early afternoon session giving us an insight into
                                                    their own practices and the implications for
                                                    their upper GI anaesthetic colleagues. The late           workshops (LIT). My colleagues Drs Rob Abel,
and good food. In the early morning session Dr      afternoon session had pain after thoracotomy              Barbara Bahlmann, S Balachandran, K
Denny Levett, of the University College             as the theme with very interesting                        Karthikeyan, Iliaz Hodzovic, D PLACE, Ash
London Hospitals recalled her experience of         presentations from Dr Ng from The Heart and               Wagle and Mike Gilbert effectively facilitated
Cardiopulmonary Exercise Testing at altitude        Lung Centre,Wolverhampton UK and our own                  the LIT workshop. I am grateful to Nick
on Everest and Dr M Brutsche of Basel               colleague Dr S Khot.                                      Chapman of Medical Graphics for providing the
provided a variety of informative details of                                                                  hardware for the CPX workshop and to Drs
cardiopulmonary exercise testing and its
clinical application Dr D Reuter from the
Ludwig Maximilians University Munich gave a
                                                    T     wo of the major successes of the day
                                                          were the Cardiopulmonary Exercise
                                                    Testing (CPX) and Lung Isolation Techniques
                                                                                                              Denny Levett and Martin Breutsche for
                                                                                                              interpreting the data and engaging the audience
                                                                                                              so effectively.

          Cardiac Anaesthesia / Cardiac Intensive Care
                                                      Friday 16th November 2007
                                                                                                            Dr Duncan Wyncoll of St. Thomas’ Hospital,
                                                                                                            London, in the early afternoon session gave us
                                                                                                            an insight in the use of levosmendan followed
                                                                                                            by an enlightening presentation from Dr
                                                                                                            Zaheer Yousef (UHW) into perioperative
                                                                                                            resynchronisation therapy.

                                                                                                            The meeting was finally coming to a close and
                                                                                                            it was with a huge sense of relief that I listened
                                                                                                            to the final presentation by Dr Albert T Cheung
                                                                                                            from the University of Pennsylvania,
                                                                                                            Philadelphia, on the management of
                                                                                                            postoperative hypertension. Though he had an
                                                                                                            unenviable task of delivering the final lecture to
                                                                                                            a flagging audience, he did it with the required
                                                                                                            enthusiastic panache. Dr Judith Hall presented
                                                                                                            the prizes for the best paper and poster. Finally
                                                                                                            having closed the meeting I looked forward to
                                                                                                            the dinner at the National Museum of Wales.
                                              Audience at the Cardiac Anaesthesia/Intensive Care meeting.
One hundred and fifty two attendees were to
have an early start on the Friday though all did
not pitch up at 08:30. Dr Judith Hall who kept
the seven presenters to time masterfully
chaired the first session, dedicated to the free
paper presentations. Concurrently there were
15 poster presentations, each of them manned
by the appropriate authors to answer any

After coffee Dr Yoanna Skrobik an intensivist
from Université de Montréal, Canada,
gave an excellent thought provoking
presentation on delirium in the ICU Patient
followed by Dr Harry Van Wezel and Dr
Dietrick Gommers both from the Netherlands
who spoke about metabolic modulation and
the open lung concept in cardiac surgical
patients, respectively.
                                                                            John Dunne relaxing at the reception before dinner in the National Museum of Wales.
After a lunch we had a very enthusiastic debate
on the motion; “Cardiac anaesthetists should          and Dr Chris Aps spoke against the motion             I am grateful to all my colleagues in organising
look after the cardiac surgical patient from          while Dr Julian Barker and yours truly spoke          such a successful meeting, Dr Christine Tan for
admission to discharge from the Intensive             for the motion. Dr Jack Parry Jones very ably         designing the flyers for the meeting, Dave Place
Care”. The debate, while offering little towards      defended his position though on occasions he          and Arun Kumar for ensuring their circulation,
inter-speciality harmony, was in equal measure        may have felt that he had entered a lions’ den.       Drs S Balachandran, C Tan, Rafail Baraz and K
entertaining, topical and well informed. Dr Jack      However in the end the majority of the                Karthikeyan       for    being    the     official
Parry Jones (our General Intensivist Colleague)       delegates voted in favour of the motion.              photographers. My thanks also to the Emma
                                                                                                            Davies and Juliet Lanchbury and Anne
                                                                                                            Leneghan for manning the registration desk. I
                                                                                                            would also like to acknowledge the individual
                                                                                                            contribution of Dr Rob Abel whose total
                                                                                                            attention to detail and military precision in the
                                                                                                            organisation of ACTA autumn meeting ensured
                                                                                                            its financial success.

                                                                                                            In conclusion I would like to thank the
                                                                                                            secretarial staff of the anaesthetic department
                                                                                                            for all their hard work, the exhibitors and
                                                                                                            sponsors who supported the meeting and
                                                                                                            finally the delegates for attending.

                                                                                                            John Dunne
  Drs Judith Hall and Justiaan Swanevelder judging             Dr Chris Aps speaking against the motion.
                                       the posters.
                         CHAIRMAN’S                                      Report                                      EACTA
                                                                                                                     Subscription Update

Whilst preparing to write this report I jotted       ACTA were pleased to receive a number of high            Message for ACTA members with a current
down on a piece of paper those areas of ACTA         quality applications for research monies for the         linked ACTA-EACTA subscription
activity I felt needed mentioning. Having got        2007 round of awards. Committee members
                                                                                                              Most ACTA members with linked EACTA
more than half way down the page with these          have scored the applications and will meet
                                                                                                              subscriptions will be aware that EACTA
notes, I realised what a busy six-months the         shortly to decide where the money will go.The
                                                                                                              changed to the North American Red
Association has had and the myriad of activities     difficulties in initiating and delivering high quality
                                                                                                              Elsevier ‘Journal of Cardiothoracic &
in which we are currently involved.                  local research projects have been identified in
                                                     many circles. The committee have received a              Vascular Anesthesia’ (JCVA) in 2008. In lieu
November 2007 saw the annual round of                proposal for establishing an ACTA research               of missing 18 months EJA, Marco Ranucci
committee changes. Sean Bennett and David            network – similar to that of the ICS- to                 (EACTA President) agreed to supply
Smith left after two terms on committee              facilitate        multi-centre        cardiothoracic     EACTA-ACTA members with the bimonthly
making way for Alistair MacFie from Glasgow          anaesthesia and ICU research projects across             JCVA until December 2008 without charge.
and Ravi Gill from Southampton. It goes without      the UK. At a higher level, the National Institute        In return, ACTA agreed to move the next
saying that both Sean and David have made            for Academic Anaesthesia which is a recently             collection date of both ACTA and EACTA
enormous contributions to ACTA during their          established joint venture between the Royal              subs back from May to November 2008 to
time in office and we wish them both well in         College of Anaesthetists and the AAGBI, has              synchronize subscription years and facilitate
their future roles with EACTA. We welcome            approached us to become involved in cross sub-           bulk ordering of JCVA on a calendar year
Alistair as Secretary with responsibilities for      specialty collaborative research.We are keen to          basis. The good news is that - as well as
thoracic issues and Ravi as Meetings Secretary       support any ventures that help in advancing the          getting a more relevant journal - your
with responsibilities for paediatric issues.         role of cardiothoracic academic anaesthesia and          EACTA subscription has been extended to
Alistair’s first major task has been to identify,    will be seeking to optimise and develop the              the end of 2008 without charge.
with our solicitors whether or not we are            research capabilities for all our members in
compliant with the regulations introduced                                                                     The bad news is that EACTA have
                                                     developing these initiatives.
under the Charities Act 2008/Companies Act                                                                    withdrawn the block discounted rate
2006 which come into law in April and if not         In conversation with an ACTA member at a                 formerly given to ACTA and increased the
what steps we need to take to ensure our             recent meeting I was asked whether ACTA                  linked annual subscription from 75 to 100
compliance.                                          could set up a page on the website which could           euros. Because the euro has also
                                                     form a portal for access to the plethora of              significantly strengthened against the pound
The committee year began with news of the            cardiothoracic guidelines currently available. I         in the past year, we will probably need to
suspension and subsequent withdrawal of              have asked Pete Alston to look into the                  collect £75-80 per linked EACTA
Aprotinin -aside from on a named patient basis       feasibility of setting up and maintaining this           subscription in November 2008. I will
- resulting from adverse outcome reports in the      facility and would welcome comment from                  email the exact amount in early autumn.
BART trial. The news was met with mixed              members on what content should be included.
feelings by ACTA members and we await                                                                         Even with the increase, the annual EACTA
further analysis before making any revised           Following on from the successful ACTA meeting            subscription represents excellent value and
position statement upon its use.                     in Cardiff last November- thanks to John Dunne           is still considerably cheaper than a ‘stand
                                                     and the organising Committee- many ACTA                  alone’ JCVA subscription. EACTA have
ACTA are presently involved with the                 members managed (selflessly) to make the long            also asked me to advertise that they still
Department of Health in a number of projects         journey to the ACTA/EACTA sponsored                      offer a discounted three year 250 Euro
and initiatives involving cardiothoracic practice.   Cardiovascular and Thoracic Anaesthesia                  subscription rate to individuals who pay
Donna Greenhalgh and David Smith represent           Seminar in South Africa. The South African               EACTA directly via
us on a working party advising on perfusionist       meeting - a satellite to the World Congress in
prescribing, following on from a recent highly                                                                All ACTA members who paid an additional
                                                     Cape Town - was largely organised by a UK
publicised adverse incident in this area. ACTA’s                                                              EACTA subscription last May, should already
                                                     contingent of expatriate South African cardiac
view – along with others- is that their needs to                                                              have received the February edition of JCVA.
                                                     anaesthetists ably led by Justiaan Swanevelder
be statutory legislation on this rather than local                                                            Please email me ASAP if you have not yet
                                                     and more than matched expectations in all
individual agreements, as currently proposed by                                                               received a copy of JCVA this year. Please
                                                     aspects of its delivery.
the Department of Health.                                                                                     also email me before October if you do not
                                                     ACTA now look forward to the Spring round of             wish to renew your linked EACTA
John McKay and I have joined the steering group      meetings that will be held in London. ACTA               subscription for 2009.
of the National Cardiothoracic Benchmarking          Echo 2008 hosted by St George’s Hospital and
Collaborative, this organisation which produced                                                               A message for ACTA members without a
                                                     organised by Nick Fletcher takes place on
its first report in 2007, aims to audit/benchmark                                                             2008-linked EACTA subscription. If you
                                                     Thursday June 5th followed on the Friday by the
national service delivery. Although the initial                                                               want to set up a 2009-linked EACTA
                                                     25th ACTA Spring Meeting hosted by the Heart
dataset is largely composed of demographic                                                                    subscription - that is prefer the
                                                     Hospital, organised by Mathew Barnard and
data the wider remit is to extend this over time                                                              convenience of ACTA collecting both
                                                     which continues the wild life theme of South
to quality of care data acquisition, by the                                                                   subscriptions together in November to
                                                     Africa in taking place at London Zoo.
incorporation of established audit activity from                                                              two separate direct payments - then
SCTS, BCIS etc. This initiative, which has been      Should you wish to comment upon any of the               please email me before October to allow
driven by a collaboration of specialty managers      topics or issues raised in this piece or any other       time for your direct debit instruction to be
is a potential portal for the collection of          ACTA related issues please e-mail your                   amended.
cardiothoracic anaesthetic related data. ACTA        comments to our ACTA administrator at the
are further involved with the DH Cardiac             RCoA. I look forward to seeing you in London.            Jon Mackay
Workforce Review Team the first meeting of                                                                    ACTA Membership Secretary
which is scheduled to take place in late spring.     J-P van Besouw, ACTA Chairman                  

       Training in TOE as an Anaesthetic Specialist Registrar
                                                     the 20 standard perioperative views and            study leave afternoon once a week to
                                                     started reading about the Doppler principle,       continue to attend the outpatient TOE clinics.
                                                     the continuity equation and how Bernouille         This enabled me to continue to build my
                                                     had been modified. My logbook of cases began       logbook numbers, whilst maintaining the skill
                                                     to grow at a rate of fifteen to twenty a           of performing TOE. Another six months and I
                                                     month. One afternoon a week, a TOE                 had completed 125 logbook cases. I was
                                                     outpatient clinic is run by a consultant cardiac   delighted to submit my logbook shortly after
                                                     anaesthetist so I was also able to learn the       that. Much to my surprise, the recent changes
                                                     technique on awake patients, using lidocaine       in the system for marking of logbooks meant
                                                     throat spray alone in most cases.                  that my completed logbook was returned to
                                                                                                        me just three months after submitting it. I was
                                                         realised that it would be in my own            very pleased to have passed.

                  Dr Alison Parnell in TOE action.
                                                     I   interests to sit the recently developed UK
                                                     BSE/ACTA TOE Accreditation examination as               am just coming to the end of another six-
    had decided that Cardiothoracic                  soon as possible, in the desire to never have      I    month post as a Senior Clinical Fellow in
I   Anaesthesia was my career intention by
the end of my first three-month module in
                                                     any more exams to sit! A consultant colleague
                                                     was also planning to sit the exam at the end
                                                                                                        Cardiothoracic Anaesthesia at the Glenfield
                                                                                                        Hospital in Leicester and have continued to
the speciality, during my second year as a           of October 2006, so we tested each other           maintain and improve my TOE skills. One of
Specialist Registrar on the Sheffield (North         regularly and benefited from the frequent TOE      the challenges of being a rotating Anaesthetic
Trent) Anaesthetic rotation. It rapidly became       meetings in the department. Our hard work          SpR is that maintaining and furthering ones
apparent to me that the role of                      paid off and we both passed the written            skills in TOE can be difficult whilst based in
transoesophageal echocardiography (TOE) in           examination.                                       district general hospitals, or whilst working in
cardiac theatres was permanent; therefore I                                                             specialities based in hospitals where there is
                                                        n the latter part of the six-month block in     no cardiac unit. However, I would strongly
needed to get going on learning the technique
as soon as possible if I wanted a consultant         I  cardiothoracic anaesthesia, I made a
                                                     conscious effort to concentrate on my
                                                                                                        encourage trainees interested in cardiac
                                                                                                        anaesthesia to start reading and learning
post in a few years time.
                                                     anaesthetic skills, beginning to perform cases     about TOE as soon as possible.Try not to be
    requested a six-month block at the               with more distant supervision and doing            put off by the fact that still rotating as a SpR
I   Northern General Hospital in
cardiothoracic anaesthesia in my third year as
                                                     thoracic lists more regularly. I managed to
                                                     maintain performing TOEs also, so that by the
                                                                                                        could make this difficult – there are ways and
                                                                                                        means! Proficiency in TOE will undoubtedly
a SpR. From day one, I was immersed into             time I finished the six-month block I had          play an important part of achieving a
TOE, both the practical and theoretical sides. I     performed and reported nearly 80 cases, well       consultant post in the future.
was fortunate to have intensive teaching from        over half of that required for the logbook
four of the cardiac anaesthetic consultants in       submission.                                        Dr Alison Parnell, FRCA
our department that perform TOE regularly. I                                                            SpR Anaesthesia, Sheffield.
                                                         then rotated out to a district general
am indebted to them for their time and
patience. I began by learning how to acquire         I   hospital for six months. I was granted a
                                                                                                         ACTA Echo 2008
                                                                                                         Thursday 4th June 2008
                                                                                                         Royal Society of Medicine, London.
                                                                                                         For more information, look-up
                                        Editorial                                               or contact Nick
                                                                                                         Fletcher at St Georges Hospital, London.
                   Editing this issue has been       given us an interesting account of                  Email:

    very gratifying for me as there has been a       experiences training in TOE. I am keen to           25th Spring Meeting - ACTA
    lot of copy to edit in addition to regular       read more accounts of trainees’                     London Heart Hospital
                                                                                                         Friday 5th June 2008,
    reports from the office bearers.We are           experiences so please encourage them to             London Zoo.
    have excellent report from John Dunne on         submit articles that are relevant to ACTA           For more details look-up
    ACTA’s Autumn meetings in Cardiff and            News. Sean Bennett has provided a report   or contact
                                                                                                         Dr Matthew Barnard
    well as meeting reports from a lot further       on the Educational Award from ACTA. Sadly,
                                                                                                         ACTA 2008, Department of Anaesthesia,
    away in South Africa.There is has been           Wynne Aveling has provided us with an               The Heart Hospital, 16 - 18 Westmoreland
    many photographs submitted for this issue        obituary for Bill Pallister - a well-known          Street, London.W1G 8PH
    and many of which have not been published        ACTA member. Please all continue to                 Tel: 0800 3213005, Fax: 020 87470995
    because of lack of space. In particular,         consider writing articles that you think
    Christine Tan did an excellent job recording     might be of interest to members for ACTA            25th Autumn Meeting of ACTA
                                                                                                         Friday 14th November
    the Cardiff meetings. Photographs greatly        News.
                                                                                                         Royal Hall, Harrogate.
    add to the written material so if you have                                                           For more details, contact Dr Michael
    any that you think might of interest to          R Peter Alston                                      Cross, Department of Anaesthesia, Leeds
                                                                                                         General Infirmary, Great George Street,
    members, please send them in with      
                                                                                                         Leeds. LS1 3EX. Email:
    appropriate captions. Dr Alison Parnell has                                                

                           ECHO NEWS                                                                      Prescribing by
Since the last newsletter there has been a          the Friday night and is well recommended to     As some of you are aware an unusual
couple of echo meetings.The first was the           members.                                        situation has arisen with the perfusionists. It
TOE Sub-committee where provision of                                                                has come to light following an incident with
courses was discussed. Although anaesthetists       Niall O’Keefe, Justiaan Swanevelder, Henry      too much calcium in the prime, that they, as a
still make the up the majority of course            Skinner and Mr Tom Spyt participated in a       profession are not legally allowed to
delegates, there are also around 20%                TOE workshop at the annual meeting of the       prescribe or give drugs. A working party has
intensivists, 7.6% cardiologists and 6.7%           Society of Cardiothoracic surgeons in           been set up by the Department of Health
surgeons. Consequently many courses are             Edinburgh, in March.This was well received      (DoH) to look into this issue and hopefully
altering their emphasis according to the mix        and a good session.The surgeons are keen to     prevent any further incidents.The working
of their delegates.There is a lot of discussion     have joint meetings with the cardiothoracic     party consists of DoH officials chaired by
about training of intensivists in Echo.             anaesthetists and in my opinion, a good         Professor Roger Boyle and Professor Sue
Echocardiography only being a part - all be it      direction to go.                                Hill, two surgeons, two perfusionists, two
an important part - of the general use of echo                                                      anaesthetists and NHS employment
in critical care as it is used for central lines,   One of the highlights this year was the World   representatives.
abdominal examinations etc. In Europe,              Congress of Anaesthesiology in Cape Town,       One way to overcome this problem is to
Dr Eric Sloth has shown that FATE (Focused          South Africa, which was preceded by the         regulate the perfusionists as a profession, for
Assessed Transthoracic Examinations) is a           satellite meeting in Kapama game reserve.       which they as a professional group have been
useful screening tool and easily applied with       As part of the World Congress there was an      lobbying since 2003.This would put them
minimal training. However, there is concern         Echo workshop, which ran for two days and       into a category along with nurses and ODP’s.
over conditions being missed, so it is              was then repeated on the following two days.    However, the DoH are reluctant to do this
important that a member of the team has             This was organised by Justiaan Swanevelder,     separately and wish to do this with the other
further training and accreditation to provide       Henry Skinner and Johan Bence, who all put      medical science groups; e.g. clinical
back up. Different levels of competency may         in an enormous amount of work to make this      physiologists. However, it is possible to
be the end result. It is important to note that     a successful part of the whole meeting. Apart   regulate professions separately, as they did
this is still under discussion and nothing has      from the UK speakers, which were myself,        with the ODP’s.The interim proposal is to
yet been decided.                                   Justiaan, Henry, Sean Bennett, David Duthie,    have Patient Specific Directive’s (PSD’s). A
                                                    Andy Roscoe, Gavin Wright and Sue Wright,       regulated professional signs for any drugs
Fifty-four took the perioperative exam - an         they had Jack Shanewise, Solomon Aronsen,       given and takes responsibility for this. (The
increase of ten from last year - and 72%            Jan Poelaert, Jan Hultman, Fabio Guarracino,    drugs Act states that drugs can then be given
passed, Anaesthetists made up the majority of       Dominique Bettex, Marco Ranucci to name a       with a verbal or written directive).This
candidates, 24 compared to 14 cardiologists.        few.There was a hands-on session at the end     would include the pump prime solution,
The top three candidates tied and were all          of the day, demonstrating the FATE views.       cardioplegia, heparin and any vasoactive
anaesthetists.The next exam will be in              Apart from an excellent day programme there     drugs.
Harrogate prior to the Autumn ACTA                  was a good social programme. One of the         The surgeons have said they can’t sign whilst
meeting on the 13th November 2008.                  events was an African experience at Mojo’s      operating and the DoH is pushing for the
                                                    where a number submitted to traditional face    anaesthetists to be responsible.We can
Regarding logbooks, there is improved turn          painting!                                       foresee problems with this.
around as the BSE Accreditation Association is
now managing TOE logbooks. A comment                The next main echo event will be the 3rd        ●   In some centres perfusion is managed by a
from the markers for those who have still to        Echo meeting in London on 5th June, prior to        firm contracted to provide perfusion
submit logbooks is that the tick box format         the ACTA Spring meeting and the venue is the        services and are not NHS employees.
                                                                                                    ●   In other centres perfusionists are under
doesn’t provide enough information and it is        Royal Society of Medicine. There is an
difficult to assess how the sonographer has         exciting programme on “New and Emerging             the surgical directorate.
                                                                                                    ●   We have no control over the management
assessed valves and reached conclusions. So         Technology” and trainee case presentations.
either a written report or one in addition to       Submissions for this please visit                   of cardiopulmonary bypass e.g. how long
the standard format is preferable.                   the pressure is down or what goes in the
                                                    There will be a prize for this.                     prime.
                                                                                                    ●   The composition of the cardioplegia is at
Unfortunately the BSE meeting, which is a
very good meeting and shows a different             Overall in the Echo world education is              the request of the surgeon, as is the
aspect of echocardiology, have changed their        progressing well. Until next time,                  frequency of administration.
format this year so there won’t be an ACTA                                                          PSDs have been implemented in some
session.This meeting is also in Harrogate on        Dr Donna Greenhalgh                             centres with varying success. At times, the
October 3rd / 4th with the dinner being on                                                          prescription is not signed until the end of the
                                                                                                    case.There is no provision as to what would
                                                                                                    happen if an untoward incident.
                                                                                                    As anaesthetists we have taken the fall in the
                                                                                                    past when providing a Good Samaritan
                          Educational Award                                                         service.
                                                                                                    By the time you read this, the Committee
                                                                                                    will have emailed the membership for their
    Dr Sunit Gosh form Papworth Hospital has won ACTA’s Educational Award for 2008.
                                                                                                    views as to whether they would be prepared
    He has been awarded £5000 for a study entitled ‘Pre-clinical evaluation of the ease of          to sign up for Patient Specific Directives or
    intubation and efficacy of securing lung isolation using a novel design of double lumen         not.These views will be submitted to the
                                                                                                    working party.
    endotracheal tube and bronchus blocker – the Papworth BiVent tube’.
                                                                                                    Donna Greenhalgh

         Erythropoietin (EPO) as part of a                                                                   O B I T U A RY
    multifaceted blood conservation programme                                                         William Knott Pallister (1926-2008)
       in cardiac surgery: an interim report

Introduction                                        Discussion
Previously we produce a significant reduction       Practical problems and efficacy of an EPO
in blood and blood product usage with the           programme
introduction of a conservation strategy             1) We could only access patients at our central
involving; reducing ordered blood, reducing            clinic and not at the 4 peripheral sites.
bypass prime, high dose aprotinin, cell savage      2) Only two of four surgeons agreed to
and new ‘blood transfusion triggers’. Our data         participate.
also demonstrated that the patients being           3) We were only allowed to screen patient                           Bill Pallister with Judith Hulf.
transfused tended to be in high risk groups            with a chronic disease.                        One of the founder members of ACTA Bill
that included pre-operative anaemia i.e.            4) We missed all urgent referrals.                Pallister, always known as ‘Uncle Bill’, has died
haemoglobin (Hb) <12.0 g/dl. About 40 of our        5) We missed all valve surgery (for the first     at the age of 81. Famous for his invention of
surgical patients per annum.                           six months).                                   the Brompton triple cuffed tube he was a
                                                    6) We could not give second and third doses       great practical anaesthetist who made several
We proposed to identify these patients,                of EPO if the Hb was >12.0g/dl thus            other notable contributions to the specialty.
screen for anaemia of chronic disease and              reducing the total possible red cell mass      Bill grew up in South Wales and at his local
treat consenting patients with EPO.Then                effect.                                        grammar school excelled both as a scholar
follow-up transfusion requirements.This was a       7) EPO is not licensed for this use.              and an all round games player. He studied
pilot study. Our aim was to identify the            8) During the programme there was an FDA          medicine at the Westminster, which he loved.
                                                                                                      However, after the port at ACTA spring
practical problems and efficacy of an EPO              warning on excessive deaths associated
                                                                                                      meetings he always confessed his regret at
programme.                                             with EPO, which temporarily halted the
                                                                                                      not having applied to Cambridge. He showed
                                                       programme.                                     an early interest in anaesthesia and after
Method                                                                                                national service in Aden took it up in
                                                    Recruitment has been very disappointing but
Patients for coronary surgery with chronic                                                            earnest.
                                                    we have learnt valuable lessons and plan to
disease other than cardiac had a full blood
                                                    screen at all cardiac clinics.The cost of the     Bill learned blind nasal intubation at the feet
count done at the first outpatient visit. If Hb
                                                    anaemia screen means that this is only done       of the master himself, Ivan Magill, and a skill
<12.0g/dl the patient had an anaemia screen
                                                    in patients with a low Hb.The dose and            that he later taught me. He loved his time at
performed; iron, ferritin, transferin saturation
                                                    frequency of EPO plus the use of oral iron is     the Brompton, later claiming that he only left
and reticulocyte He. Patients with low iron
                                                    restrictive. More flexibility and intravenous     the building for a haircut. It was to facilitate
stores had a course of oral iron, then checked
                                                    iron would increase the total red cell mass       bronchial sleeve resections that he invented
three weeks pre-operatively. If the Hb was still
                                                    achievable.                                       the tube that bears his name.The tube was a
<12.0g/dl they received EPO 150 U/kg by s.c.
                                                                                                      single lumen with a tracheal cuff and a
injection weekly for up to three weeks.             We would like to thank ACTA for the               bronchial double cuff - the second being a
Patients with normal iron returned at three         education award in support of our ongoing         spare in case the surgeon punctured the first
weeks pre-op for a course of EPO and oral           programme.                                        one. It largely fell out of use when double
iron. EPO patients were then tracked                                                                  lumen tubes came along but remained much
throughout their hospital stay for transfusion      Sean Bennett                                      beloved by final fellowship examiners.
requirements.                                       Cardiac Anaesthetist (
                                                    and                                               He was appointed consultant at the
                                                                                                      Middlesex Hospital at a time when
Results                                             Deborah Pinchon
                                                                                                      “hypotensive anaesthesia” was in its heyday.
Table 1. Patients that received EPO                 Transfusion Nurse Specialist                      Working with the gifted reconstructive
                                                                                                      urologist Richard Turner Warwick, Bill came
 Patient disease       Presenting Hb         Pre-op Hb           Units of red       Discharge Hb      to the conclusion that to reduce bleeding it
                       g/dl                                      cells                                was more important to reduce cardiac
                                                                                                      output (or blood flow to the operative field).
 Arthritis/diabetic    9.6                   10.4                2                  11.0              He called this rheostasis and gave a
 Diabetic              11.8                  12.2                0                  9.0               Hunterian lecture on the subject, backed up
 Heart failure         11.1                  12.9                0                  10.3              by his meticulous records held on punched
                                                                                                      cards. Relevant data could be fished out with
 Rheumatoid            10.9                  12.4                4 (post op         9.8               knitting needles. Sadly, he never condensed it
 arthritis, Lupus                                                bleed Hb _ 6.8)
                                                                                                      down to the 10000 words required by the
There were five patients whose Hb was >12.5g/dl                                                       editor for publication.
with iron alone and did receive EPO.
                                                                                                      After his retirement in 1991, Bill studied
                                                                                                      classical Greek and travelled widely in the
                                                                                                      Middle East until ill health got the better of
    Nomination for ACTA Honorary Membership                                                           him. He was proud of the honorary
                                                                                                      membership that ACTA awarded him at one
   His colleagues in Sheffield have nominated Dr Russ Powell for ACTA Honorary Membership.            of the Cambridge spring meetings. He was
   Honorary membership is awarded to full members who are judged by their peers to be                 predeceased by his wife and had no children.
   distinguished contributors to cardiothoracic anaesthesia. Russ was a founder member of
                                                                                                      William Pallister, anaesthetist, born 21 March
   ACTA and became one (the largest) of three ACTA Trustees when Derek Pearson
                                                                                                      1926, FFARCS 1955, died 8 Feb 2008.
   (Newcastle) retired. It is hoped that the membership will endorse this nomination at the
   Spring Business Meeting.                                                                           Wynne Aveling.

     Seminar - Kapama Game Reserve - South Africa
                                                        24-28 February 2008
                                                                                                           Ravi Mahajan and Jonathan Thompson brought
                                                                                                           proceeding to a close with a stimulating session
                                                                                                           on protective strategies for the kidneys and

                                                                                                           T      he lectures were exceptionally well
                                                                                                                  attended and feedback from delegates
                                                                                                           was very positive. The vast majority of
                                                                                                           delegates rated the scientific value,
                                                                                                           organisation, venue, and social aspect of the
                                                                                                           seminar as excellent or good. Constructive
                                                                                                           criticism centred on the audiovisual difficulties.
                                                                                                           The staff at Kapama has been extremely
                                                                                                           helpful, flexible and professional throughout
                                                                                                           our stay. A number of delegates felt the
                                                                                                           programme was rather full and left too little
                                                                                                           time for relaxation. However, our primary aim
                                                                                                           was for the seminar to stand independently as
                                                                                       Kapama Lodge.       a scientific endeavour and to that end we
A      CTA and EACTA co-sponsored a
       Cardiovascular       and      Thoracic
Anaesthesia Seminar hosted by the University
                                                   breakfast, Prof Deepak Tempe updated us on
                                                   the state of off-pump surgery and Marco
                                                   Ranucci explained the intricacies of
of Stellenbosch in Kapama Game Reserve -           inflammation. Jack Shanewise delivered the first
South Africa, 24-28 February 2008.                 of two excellent presentations on
One hundred and fifteen delegates, many of         transoesophageal echocardiography, Stefan de
whom are ACTA members, including 21                Hert gave an overview on myocardial
speakers from 14 countries, attended a hugely      protection and Peter Slinger kept the non-
successful meeting at this fantastic venue. In     cardiac anaesthetists entertained with a great
addition to delegates and speakers, there were     talk on advances in thoracic anaesthesia. The
65 accompanying persons.                           evening feast in the Kapama River Lodge boma
                                                   was accompanied by a local choir and later the

D      ue to overwhelming interest, the
       accommodation at Kapama were rapidly
filled and the adjacent Hongonyi and Matumi
                                                   game rangers started jamming on guitars and
                                                   sang around the campfire.
                                                                                                               It’s not often at meeting that one gets to see two
Game Lodges put up additional delegates. This
ensured a good turnout at the seminar but          A      fter another late night and early morning
                                                          game drive, David Duthie and Peter
                                                                                                                                      lions, up a tree, very close!

created minor logistical difficulties with
transferring delegates to and from the
                                                   Slinger got the final day started with good talks
                                                   on lung isolation and lung injury after                 D      ue to an awe-inspiring Bushveld
                                                                                                                  thunderstorm, the barbeque on the last
                                                                                                           evening was strategically relocated to the
conference centre.                                 resection. Prof David Rowbotham then
                                                   addressed novel strategies in post-operative            conference hall but the African theme retained.

A      high calibre faculty provided 5 hours of
       medical education each day for three
days. ACTA were strongly represented on the
                                                   pain management. Prof Andre Coetzee, Prof               Most folk still got up in time for the final game
                                                                                                           drive. By know many visitors had already ticked
                                                                                                           off all animals on the “big five” list before
faculty list. Highlights on day one was John                                                               setting off for the World Congress of
Murkin’s insightful talk on cerebral monitoring,                                                           Anaesthesia in Cape Town or back to Europe,
Ravi Gill’s synopsis of coagulation and Eric                                                               Australia, America and Asia.
Sloth’s proposal to use echocardiography as an
extension to clinical examination on ICU. Sean
Bennett told us eloquently how not to give                                                                 A      ll participants and stakeholders have
                                                                                                                  benefited from this concerted effort.
                                                                                                           ACTA have supported this venture from the
blood.After a memorable game drive delegates
and guests were served mouth-watering                                                                      start and can rightly feel proud about raising
African cuisine in a dry riverbed.The songs and                                                            the profile and enthusiasm for cardiovascular
movement of the Marimba dancers was                                                                        and thoracic anaesthesia. We thank ACTA for
something to behold.                                                                                       the support.

                                                                                                           Justiaan Swanevelder
S   leep was not high on the agenda and a few
    hours later some folk were privileged to
see leopard on the morning game drive. After
                                                    Eating area at River Lodge. No, its not on fire just   Henry Skinner
                                                                                                           Johan Bence
                                                                      water mist to keep the area cool!
             The 14th World Congress of Anaesthesia
                                       Cape Town, South Africa, March 2-7, 2008
     he     14th     World      Congress       of
T    Anaesthesiologists was held in March this
year in Cape Town, South Africa. The venue
was the International Conference Centre at
the foot of Table Mountain, close to the Cape
Town Waterfront. Around six thousand
delegates attended this 4-yearly event to meet
international friends, share information, learn,
and also enjoy the best hospitality that the host
country could offer.

    everal ACTA members were involved in the
S   organisation and faculty of the
Perioperative Echocardiography Workshops
during this memorable event.         These
interactive, hands-on, 2-day workshops ran

                                                         View out over Cape Bay from the editor’s hotel room.The hotel was also the venue for the Association of
                                                                                                                                       Anaesthetists reception.
                                                     points. The short lecture sessions contained          Peninsula, up Table Mountain, and the
                                                     ‘pearls of wisdom’ with clear take home               Stellenbosch wine region, the echo workshops
                                                     messages. The case based discussions involved         were exceptionally well attended and feedback
                                                     expert panels and stimulated audience                 from      delegates    was     very     positive.
                                                     participation. The high quality contributions         At completion of the workshops the delegates
                                                     from younger ACTA members like Andy                   had an appreciation of the significant impact of
                                                     Roscoe (Wythenshawe) and Justin Williams              echocardiography on perioperative decision
                                                     (Glenfield) were particularly refreshing,             making in different clinical scenarios.
                                                     demonstrating that ACTA has actually                  Everybody involved in this project gained a lot
                                                     succeeded over the past 15 years in developing        of experience and information, and many new
                                                     and raising echocardiography standards in the         friends were made. ACTA can rightly feel
                                                     UK to a world class level.                            proud about the involvement of their members
                                                                                                           raising ACTA’s profile at international level in
                                                           uring the afternoon sessions there was          the field of perioperative echocardiography.
                                                     D     plenty of opportunity to perform and
                                                     practice hands-on ‘focussed assessed trans-
One of the more exotic delegates - Jackass or Cape                                                         Justiaan Swanevelder
penguin, Boulder Beach, Jonestown, Cape Peninsula.   thoracic examinations (FATE)’. The organisers
                                                     are very grateful to GE, Philips, Siemens and
                                                     Sonosite (in alphabetical order!) for supplying
parallel to six other simultaneous academic
                                                     their state of the art equipment. At one stage
sessions.      The       strong      international
                                                     there were 14 stations with ultrasound
echocardiography faculty contained 30
                                                     machines running simultaneously! Each of the
speakers from 13 countries all over the world.
                                                     echo stations had a model and supervising
Of these 10 were ACTA members.
                                                     teacher for real-time trans-thoracic scanning
The workshops were limited to 50 participants
                                                     to maximise educational value. Johan Bence
per day and designed for anaesthetists,
                                                     (Glenfield) co-ordinated these sessions with
intensivists, cardiologists, cardiac surgeons and
                                                     precision, and Eric Sloth (Copenhagen) and
echocardiographers involved with the
                                                     Sean Bennett (Castle Hill) led the teaching.
perioperative care of the cardiac, and critically
                                                     Add to that the experience of David Duthie
ill patient.
                                                     (Leeds), Donna Greenhalgh (Wythenshawe),
                                                     and the combination of Wrights (Gavin-
     here was not enough time in the
T    programme to cover a comprehensive
course on echocardiography, but the objective
                                                     Harefield and Sue-Heart Hospital), nothing
                                                     could go wrong!             The 25 digital
                                                     echocardiography laboratory workstations
was to improve the foundation of the
                                                     kindly supplied by GE were also very well
perioperative echocardiography practitioners
                                                     received. Henry Skinner (Nottingham) and
that attended. It covered more advanced
                                                     Heinz Tschernich (Vienna) led these sessions
topics of difficult decision-making, interesting
                                                     and elegantly guided the participants to report
examples and rare pathology. Each lecture
                                                     pre-recorded patient studies.
consisted of a brief summary of the topic                                                                    Cape-Dutch style outbuilding at Groot Constantia
information, together with plenty of echo                                                                   estate and vineyard, Cape Town that was established
                                                           lthough competing with official World
examples to demonstrate important learning
                                                     A     Congress day-trips around the Cape                                         in the early 18th century.