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and activities, and called upon otherprofessional organisations to do thesame. The AAGBI called upon itsmembers to exert influence within their

own organisations to mitigate againstclimate change and environmental

degradation, and to lead by example.Finally, the AAGBI called uponGovernment to lead the transition to acarbon-neutral economy as soon aspossible. The AAGBIs statement is anattempt by the organisation to set out itsstall and focus our thoughts. None ofthese are new ideas and good businesspractice typically coincides with goodenvironmental practice, so we are doingsome of it already. Cutting back ontravel saves train fares, air fares and time,as well as carbon, and members expectus to do that, whatever the motivation.

Time is pressing, the failure ofCopenhagen lies immediately behindus and we face the abyss.

J. R. Sneyd

Professor of Anaesthesia & Vice-

President, AAGBI,

Peninsula College of Medicine and

Dentistry,

University of Plymouth,

Plymouth, UK

E-mail: [email protected]

H. Montgomery

Professor of Intensive Care Medicine &Director,

Institute for Human Health and

Performance,

University College London,

London, UK

D. Pencheon

Director,

NHS Sustainable Development Unit

for England,

Cambridge, UK

References1 Meinshausen M, Meinshausen N,

Hare W, et al. Greenhouse-gas

emission targets for limiting global

warming to 2 degrees C. Nature 2009;

458: 115862.

2 Allen MR, Frame DJ, Huntingford C,et al. Warming caused by cumulative

carbon emissions towards the trillionth

tonne. Nature 2009; 458: 11636.

3 Raupach MR, Marland G, Ciais P,

et al. Global and regional drivers of

accelerating CO2 emissions. Proceed-

ings of the National Academy of Sciences of

the United States of America 2007; 104:

1028893.

4 Canadell JG, Le Quere C, Raupach

MR, et al. Contributions to acceler-

ating atmospheric CO2 growth from

economic activity, carbon intensity,

and efficiency of natural sinks.

Proceedings of the National Academy of

Sciences of the United States of America

2007; 104: 1886670.

5 Betts R. http://www.metoffice.gov.

uk/climatechange/news/latest/four-

degrees.html (accessed 02 02 2010).

6 Soden BJ, Held IM. An assessment of

climate feedbacks in coupled ocean

atmosphere models. Journal of Climate

2006; 19: 335460.

7 Albritton DL, Allen MR, Baede

APM, et al. Climate Change 2001: The

Scientific Basis. Contributions of WorkingGroup I to the Third Assessment Report of

the Intergovernmental Panel on Climate

Change. Cambridge: Cambridge

University Press, 2001.

8 Zimov SA, Schuur EA, Chapin FS

3rd. Climate change. Permafrost and

the global carbon budget. Science

2006;312:16123.

9 Lynas M. Six Degrees Our Future on a

Hotter Planet. London: Fourth Estate,

2007.

10 Lim V, Stubbs JW, Nahar N, et al.

Politicians must heed health effects

of climate change. Lancet 2009; 374:

973.

11 Melzer D, Rice NE, Lewis C, Henley

WE, Galloway TS. Association of

urinary bisphenol a concentrationwith heart disease: evidence from

NHANES 2003 06. PLoS ONE

2010; 5:e8673.

12 Loff S, Kabs F, Subotic U, Schaible T,

Reinecke F, Langbein M. Kinetics of

diethylhexyl-phthalate extraction

From polyvinylchloride-infusion lines.

Journal of Parenteral and Enteral Nutrition

2002; 26: 3059.

13 Gray LE Jr, Ostby J, Furr J, Price M,

Veeramachaneni DN, Parks L. Peri-

natal exposure to the phthalates

DEHP, BBP, and DINP, but not

DEP, DMP, or DOTP, alters sexualdifferentiation of the male rat. The

Journal of Toxicological Sciences 2000; 58:

35065.

14 NHS England Carbon Footprinting

Report. Sustainable Development

Commission http://www.sd-com

mission.org.uk 2008 (accessed

02 02 2010).

15 Climate Change Act (2008). London:

HMSO, 2008.

16 Pencheon D. Saving Carbon,

Improving Health. The NHS carbon

reduction strategy for England. NHSSustainable Development Unit,

Cambridge 2009. http://

www.sdu.nhs.uk (accessed

02 02 2010).

17 Stevenson S. http://www.scottish.

parliament.uk/s3/committees/ticc/

inquiries/documents/Additional

InformationfromScottishGovernment.

pdf (accessed 02 02 2010).

doi:10.1111/j.1365-2044.2010.06332.x

Editorial

The hidden cost of neuraxialanaesthesia?

In this months Anaesthesia, Syzpula andcolleagues report on litigation related to

regional anaesthesia over the period

19952007 [1]. Their study indicatesthat there was a total cost from litigationto the National Health Service of just

over 1 million per year for the

twelve-year period up to 2007. This

may be compared with 62 claimsinvolving drug administration errorsover the same period that cost

4.3 million [2].

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Unfortunately, as the authors recog-nise, the relative safety of regionalanaesthesia cannot be determined fromreports of this type because we do not

know how many blocks were per-formed during the period examined,

or the total number of complicationsarising from those blocks; we knowonly the number of complications thatled to successful claims. Closed-claimanalysis will tend to underestimate thetrue incidence of complications becausenot all patients who suffer complicationswill sue [3]. Furthermore, we cannotaccurately establish the real severity ofthe complications, but must deal withonly the Courts assessment of thefinancial impact of injuries.

The costs awarded for obstetricregional anaesthesia claims (median

5 678) were higher thanthose awardedfor non-obstetric regional anaesthesiaclaims (median 3 337). Neuraxialblock accounted for all of the obstetricclaims and 82% of the non-obstetricclaims. The interpretation of these fig-ures must be in the light of how theCourts determine the amount of moneyawarded in damages. Sums are awardedto compensate loss of earnings and

requirement for ongoing care; thus,complications resulting in the death of apatient may not receive as great an award

as those causing issuesrequiring ongoing,expensive care. However, the eightdeaths that were recorded were awarded

a median award of 42 000 (with alargest payment of 178 000), whereasthe 68 severe complications receivedonly 6 000 (but with a largest pay-

ment of 2 070 000); this may havebeen influenced by care needs for achild who may also have been injured.Interestingly, it may be observed thatthe severity of non-fatal complicationdid not correlate well with theamounts awarded, with the cost per

case greater for moderate complicationsthan for moderate severe ones asassessed by the authors.

Whenone turns to the typeof regionalanaesthesia performed, the results may beinterpreted as sobering or encouraging,depending on which type of anaesthesiaone practises. The total cost of damagesfollowing complications of neuraxialregional anaesthesia was 12 million,

the cost for ophthalmic regional anaes-thesia claims was 0.36 million and thecost for all other peripheral blocksexcluding unspecified was 0.12

million. This is partly related (see Table3 in the authors manuscript) to the

catastrophic complications that mayoccur following neuraxial anaesthesia.Perhaps surprisingly, damages awardedfollowing lower limb blocks (116 000)far exceeded those awarded followingupper limb blocks (1 000).

The cost of awards related to centralneuraxial blockade amounted to 89% ofall regional anaesthesia claims. Of these,81% were for complications related toepidurals (72% of all claims). One canonly speculate on the reasons for thesefindings; perhaps, a greater number ofepidurals are performed, complications

occur more frequently and or are morelikely to be successfully settled follow-ing neuraxial blockade, or more simply,complications are less frequent follow-ing peripheral nerve blockade. Theworrying possibility is that epidural

anaesthesia is not as safe as we oncethought. The Third National AuditProject of the Royal College of Anaes-thetists on major complications follow-

ing neuraxial block estimated theincidence of adverse sequelae followingperi-operative epidural block at

between 1 in 6000 and 1 in 12 000and the incidence of paraplegia or deathat approximately 1 in 100 000, whichthe authors of the report found reassur-ing [4]. The size of the awards presentedby Szypula et al. serve as a reminder thatalthough severe complications afterneuraxial block are rare, when they dooccur they have a major impact onpatients lives.

Brull and colleagues reviewed 32studies primarily investigating neuro-logical complications of regional anaes-thesia [5]. The rate of both temporary

and permanent neuropathy after spinaland epidural anaesthesia was 3.78:10000 (95% CI 1.0613.50:10 000) and2.19:10 000 (95% CI 0.885.44:10 000), respectively. For peripheralnerve blocks, the rate of neuropathyafter interscalene brachial plexusblock, axillary brachial plexus block,and femoral nerve block was 2.84:100(95% CI 1.335.98:100), 1.48:100 (95%

CI 0.524.11:100), and 0.34:100 (95%CI 0.042.81:100), respectively. Thismight suggest that there is less risk ofneurological complications followingcentral neuraxial than peripheral blocks.However, they also stated that the rates

of permanent neurological injury afterspinal and epidural anaesthesia were04.2:10 000 and 07.6:10 000, respec-tively, with only one case of permanentneuropathy reported in 16 studies ofneurological complications after periph-eral nerve blockade. This second state-ment probably reflects both the rare butserious sequelae following central neur-axial blockade and a high incidence oftemporary neurological symptoms withvery rare permanent neurological dam-age following peripheral block. Thismay have more relevance to patients

and also in relation to successful damageclaims.

What conclusions should we draw

from Szypula and colleagues report?Caution is certainly advisable, given theafore-mentioned lack of a denominator

to lend context to the numerator pro-vided. Caution is also advisable giventhat the real severity of claims is skewedto the Courts view of financial impact.

However, we feel that it is wise tobear in mind the potentially majorimpact on patients lives of the compli-

cations related to regional, and inparticular, epidural, anaesthesia. A largemulti-centre Australian study of epiduralanalgesia following major surgery didnot show the 20% reduction in mortalityand morbidity it was powered to find,and patients in both the treatment and

control (non-epidural) groups demon-strated low pain scores [6]. This mayhave influenced a reduction in epiduralusage in Australia and New Zealand [7].One cannot dispute the excellentdynamic analgesia that regional analgesiacan provide postoperatively. However,

now that epidural analgesia is routinelyadministered on the open ward, hypo-tension and failure are frequentlyencountered and its success relies onthe presence of an efficient, on-siteacute pain service to deal swiftlywith these problems and other compli-cations that occur. The paucity of clearevidence of benefit and risk relatingto the use of peri-operative epidural

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438 Journal compilation 2010 The Association of Anaesthetists of Great Britain and Ireland


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analgesia means that anaesthetists shouldstill make risk-benefit calculations foreach patient.

We should also perhaps be

encouraged that the amount of damagesawarded following peripheral regional

anaesthetic blockade was so small. Theevidence is limited here in much thesame way as was discussed regardingepidurals: the lack of a denominatormakes firm conclusions inadvisable.However, this evidence may providefurther encouragement that peripheralnerve blocks result in few significantinjuries.

Finally, we would also emphasisethe importance of informed consentbefore the performance of regionalanaesthetic techniques and the record-ing of clear and detailed notes of any

procedure performed. In the eyes ofthe Courts, it is not the occurrence ofa complication that determines faultand the award of damages, but thefailure to demonstrate that a responsi-ble and appropriately cautious tech-nique was employed.

Competing interests JGH provides medicolegal reports thatsometimes concern regional anaesthesia.

N. M. Bedforth

Consultant Anaesthetist & Honorary

Special Lecturer

J. G. HardmanAssociate Professor & Reader

Honorary Consultant Anaesthetist

Queens Medical Centre, University of

Nottingham

Nottingham, UK

Email: [email protected]

References1 Szypula K, Ashpole KJ, Bogod D,

Yentis SM, Mihai R, Scott S, Cook

TM. Litigation associated with

regional anaesthesia: an analysis of

claims against the NHS in England

19952007. Anaesthesia 2010: 44352.

2 Cranshaw J, Gupta KJ, Cook TM.

Litigation related to drug errors in

anaesthesia: an analysis of claims

against the NHS in England

19952007. Anaesthesia 2009; 64:

131723.

3 Bedforth NM, Aitkenhead AR,

Hardman JG. Haematoma and abscess

after epidural analgesia. British Journal

of Anaesthesia 2008; 101: 2913.

4 Cook TM, Counsell D, Wildsmith

JA. Major complications of central

neuraxial block: report on theThird National Audit Project of the

Royal College of Anaesthetists. British

Journal of Anaesthesia 2009; 102: 179

90.

5 Brull R, McCartney CJ, Chan VW,

El-Beheiry H. Neurological

complications after regional anesthesia:

contemporary estimates of risk. Anes-

thesia and Analgesia 2007; 104: 96574.

6 Rigg JR, Jamrozik K, Myles PS, et al.

Epidural anaesthesia and analgesia and

outcome of major surgery: a rando-

mised trial. Lancet2002; 359: 127682.

7 Werrett G, French R. Epiduralanalgesia: first do no harm. Anaesthesia

2008; 63: 5534.

doi:10.1111/j.1365-2044.2010.06364.x

Editorial

Sedation is delegationappropriate?

Very few, if any, senior professionalspersonally perform all the activities forwhich they are responsible, and dele-

gation of specific tasks to others whoare less well trained and qualified iscommonplace. Where long-term, closeworking relationships exist and super-

vision is both direct and continuing, it

may be possible to maintain highstandards of practice without externalvalidation of process. However, in themodern health service, this situationseldom pertains. It is therefore essentialthat the competence of those carryingout delegated tasks is ensured and thatthe systems in which they operate aresafe. There are several conflictingconcerns when the delegation of tasksor the extension of roles is discussed.

Some professions will see an extensionof their role as something that will

provide additional interest and respon-sibility and may enhance both theirstatus and remuneration. Managers may

consider that getting an alternativeemployee to undertake a task willeither be less expensive per se or willallow greater flexibility in staffing.

However, those who currently under-take the task may perceive a threat to

their status, autonomy and job security,and wish to retain control. Patients andtheir representatives will not be alonein considering quality of service andsafety to be of paramount importance,and at times it can be difficult for thosenot directly involved to separate gen-uine concern about safety from ele-ments of job protection. Almost all ofthe above could relate to many differ-ent professions and it is well known

that integrating new roles can bedifficult.

Anaesthetic practice, in its widestsense, faces a number of challenges inservice delivery. It is not feasible, far less

affordable, for every patient in the UKwho requires sedation to be cared forexclusively by a fully trained anaesthe-tist. Indeed, it may not be feasible for

this to apply to every patient whorequires anaesthesia, the establishment

of epidural analgesia or the provision ofintensive care. How then should thespecialty respond to proposals that someof our traditional roles are undertakenby others; what, for example, should wemake of reports such as the article in thisissue by Edwards et al. [1], suggestingthat it is safe for non-anaesthetists toadminister propofol and alfentanil topatients who are undergoing oocyteretrieval?

Anaesthesia, 2010, 65, pages 435442 Editorial......................................................................................................................................................................................................................

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Journal compilation 2010 The Association of Anaesthetists of Great Britain and Ireland 439

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