Cusum analysis is a statistical technique to distinguish deviations from an acceptable failure rate. The progress of anaesthetic trainees learning four practical procedures (obstetric extradural anaesthesia, spinal anaesthesia, central venous cannulation and arterial cannulation) was monitored from their first attempt using cusum analysis. Suitable acceptable and unacceptable failure rates for each procedure were chosen by consultant anaesthetists. For obstetric extradural anaesthesia, four trainees eventually achieved acceptable failure rates (5%) and the number of attempts required to demonstrate this statistically ranged from 29 to 185; three trainees had an unacceptable failure rate (10%) and five trainees had inconclusive records. For spinal anaesthesia, two trainees achieved an acceptable failure rate (10%) and the number of attempts required to demonstrate this statistically ranged from 39 to 67; two trainees had an unacceptable failure rate (20%) and four trainees had inconclusive records. One trainee demonstrated statistically an acceptable failure rate in arterial cannulation (20%) after 14 attempts and four trainees had inconclusive records. Two records of central venous cannulation were inconclusive. Some records showed variable failure rates which were sometimes associated with lack of practice or a change in technique. Cusum analysis can be used to monitor training in practical procedures and as a continuous audit of quality of clinical practice.

SummaryThe tracheas of 20 ASA grade 1 and 2 patients were each consecutively intubated with an oral and nasal cuffed tracheal tube. Measurements of tube movement, as the position of the head and neck altered, were made with ajbreoptic bronchoscope. Both oral and nasal tubes moved an average distance of l5mm towards the carina with head and neck flexion and 8.5mm away with head and neck extension. Movement in both directions occurred with lateral rotation of the head. Optimal placement of tracheal tubes can be aided with a single guide mark placed 3 cm proximal to the cufland 8 cm proximal to the distal end, which may reduce complications arising from this movement. This is a better method in women than inserting a pre-determined length of tracheal tube measured from the lips or nares. However, current guide marks vary in their position relative to the cuff and tip of the tube.

Paracetamol and diclofenac have different mechanisms of action, and the combination may be more effective than each drug used alone in treating postoperative pain. In a double-blind, controlled design, we studied 60 patients undergoing elective abdominal gynaecological surgery, who received suppositories of paracetamol 1.5 g, diclofenac 100 mg or a combination of the two before the start of surgery. Patients received morphine in the intraoperative period, and cumulative morphine use from a patient-controlled analgesia system was recorded to measure the analgesic effect of the suppositories. Morphine consumption was greatest in the group that received paracetamol alone and lowest in the group given the combination (P < 0.01). There was no difference in the incidence of morphine-related side effects between the groups. We conclude that a diclofenac-paracetamol combination reduced the amount of morphine used compared with paracetamol alone.

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