Obstetric Anaesthetists' Association

Summary Sickle cell disease is a multisystem disease characterised by chronic haemolytic anaemia, painful vaso‐occlusive crises and acute and chronic end‐organ damage. It is one of the most common serious inherited single gene conditions worldwide and has a major impact on the health of affected individuals. Peri‐operative complications are higher in patients with sickle cell disease compared with the general population and may be sickle or non‐sickle‐related. Complications may be reduced by meticulous peri‐operative care and transfusion, but unnecessary transfusion should be avoided, particularly to reduce the risk of allo‐immunisation. Planned surgery and anaesthesia for patients with sickle cell disease should ideally be undertaken in centres with experience in caring for these patients. In an emergency, advice should be sought from specialists with experience in sickle cell disease through the haemoglobinopathy network arrangements. Emerging data suggest that patients with sickle cell disease are at increased risk of COVID‐19 infection but may have a relatively mild clinical course. Outcomes are determined by pre‐existing comorbidities, as for the general population.

The Royal College of Anaesthetists 6th National Audit Project examined Grade 3-5 perioperative anaphylaxis for 1year in the UK. To describe the causes and investigation of anaphylaxis in the NAP6cohort, in relation to published guidance and previous baseline survey results. We used a secure registry to gather details of Grade 3-5 perioperative anaphylaxis. Anonymous reports were aggregated for analysis and reviewed in detail. Panelconsensus diagnosis, reaction grade, review of investigations and clinic assessment are reported and compared to the prior NAP6 baseline clinic survey. A total of 266 cases met inclusion criteria between November 2015 and 2016, detailing reactions and investigations. One hundred and ninety-two of 266 (72%) had anaphylaxis with a trigger identified, of which 140/192 (75%) met NAP6 criteria for IgE-mediated allergic anaphylaxis, 13% lacking evidence of positive IgE tests were labelled "non-allergic anaphylaxis". 3% were non-IgE-mediated anaphylaxis. Adherence to guidance was similar to the baseline survey for waiting time for clinic assessment. However, lack of testing for chlorhexidine and latex, non-harmonized testing practices and poor coverage of all possible culprits was confirmed. Challenge testing may be underused and many have unacceptably delayed assessments, even in urgent cases. Communication or information provision for patients was insufficient, especially for avoidance advice and communication of test results. Insufficient detail regarding skin test methods was available to draw conclusions regarding techniques. Current clinical assessment in the UK is effective but harmonization of approach to testing, access to services and MHRA reporting is needed. Expert anaesthetist involvement should increase to optimize diagnostic yield and advice for future anaesthesia. Dynamic tryptase evaluation improves detection of tryptase release where peak tryptase is <14μg/L and should be adopted. Standardized clinic reports containing appropriate details of tests, conclusions, avoidance, cross-reactivity and suitable alternatives are required to ensure effective, safe future management options.

To the Editor: We read the editorial by Birnbach et al1 with interest and echo their sentiment about the importance of the issues. Connector interconnectivity and the associated misadventures are indeed a major risk to patients. However, we believe that in their enthusiasm they have misstated some important aspects of the problem. Implied, but not stated by Birnbach et al, is that this is a global problem requiring a global solution, which necessitates a completely new set of international standards (ISO 80369), and the adoption of these standards by industry across the global neuraxial medical device arena. The accusation that the entire anesthesia community has turned a blind eye is wrong. Clinicians are cautious about design change to devices they rely on because these may have unintended consequences for patient safety. It is also possible that some national anesthesia societies may not have been engaged in the process because they were unaware of the standardization efforts. However, The World Federation of Societies of Anaesthesiologists (WFSA), a global anesthesia alliance representing over 140 countries, has chosen to participate directly in this process. Other participants have included many manufacturers, the Food and Drug Administration, Association for Advancement of Medical Instrumentation (AAMI), and the CHPSO Patient Safety Organization, representing over 350 hospitals and other providers in the Western United States. These truly international discussions have been amicable, constructive, and focused on improving patient safety while also cognizant of the logistical realities of managing a significant design change and global deployment. Efforts to resolve this problem were initiated in Europe by The European Committee for Standardization (CEN) in 1999, but the development of a solution has been surprisingly difficult. Attempts in the UK between 2009 and 2015 to deploy non-Luer equipment largely failed because of concerns about proprietary designs, poor clinical acceptability of epidural devices, and knowledge of the impending publication of ISO 80369 series. In 2008, California hospitals, in the interests of patient safety, successfully advocated for a legal requirement for nonconnectivity by January 1, 2011, for enteral, epidural, and intravenous connectors. This deadline had been extended several times with the recognition that without standardization and well-tested replacements for Luer, patient risk could increase. Now the standards have been developed and tested. The new enteral connectors are already rolling out, and nonmisconnecting neuraxial medical devices will be appearing late 2016, in time for the latest California deadline of January 1, 2017, then spreading worldwide in 2017. Given the difficulty of designing nonmisconnecting connectors in the restricted dimensional space available for small-bore medical devices, enormous progress has been made since 1999. Major unanswered questions remain: will national anesthesia organizations participate as this process unfolds with the necessary education, alerts, and management of resistance to change to safer but less convenient products, or will they leave it to manufacturers and regulatory agencies alone? Adrian W. Gelb, MBChBWorld Federation of Societies of Anaesthesiologists Safetyand Quality of Practice CommitteeDepartment of AnesthesiaUniversity of California San FranciscoSan Francisco, California[email protected] Phoebe Mainland, MBBSWorld Federation of Societies of Anaesthesiologists Safetyand Quality of Practice CommitteeISO/TC210/JWG4 Small Bore Connectors Workgroup Peter Phillips, MRPharmSWelsh Non-Luer Connectors Reference GroupDirector, Surgical Materials Testing Lab,Abertawe Bro Morgannwg University Health BoardUnited Kingdom Paul Sharpe, MBChBNHS England Small Bore Connector Advisory Group Stephen Michael Kinsella, MBBSObstetric Anaesthetists’ Association Representative on theNHS England Small Bore Connector Advisory Group Anne-Laure Bailly, MD, PhDConvener of CEN/CLC TC3 WG2 Small Bore Connectors Rory Jaffe, MDCHPSO Patient Safety Organization AAMI (USA) Small BoreConnectors Workgroup

Thromboelastography is an in vitro, point-of-care monitor of whole blood coagulation. Thromboelastography studies have demonstrated a hypercoagulable state during pregnancy. Perhaps the hypercoagulability is attributable to female sex hormones. The aim of the study was to determine if sex, in addition to pregnancy, affected thromboelastography variables by studying male and female (pregnant and nonpregnant) volunteers. Thromboelastography showed significant (P <0.01) differences in sex, with a significant (P < 0.0001) trend of increasing whole blood coagulability from men through nonpregnant to pregnant women. The thromboelastograph, used as a diagnostic tool, shows that women have more whole blood coagulability than men. Implications The thromboelastograph, used as a diagnostic tool, shows that women have more whole blood coagulability than men.

Editorial 150 years of ether anaesthesia and what is next?History i s more or less hunk.It's tradition.We don't want tradition.We want to live in the present and the onlv histor!. rhat is worth a tinker's damn is the history we make t o d q .Henry Ford, 1916Progress, ,far jirom consisting in change, depends