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SummaryThirty-day mortality following emergency laparotomy is high, and greater amongst elderly patients. Studies systematically describing peri-operative complications are sparse, and heterogeneous. We used the postoperative morbidity survey to describe the type and frequency of complications, and their relationship with outcomes for 144 patients: 114 < 80 years old, and 30 ≥ 80 years old. Cumulative postoperative morbidity survey scores and patterns of morbidity were similar (p = 0.454); however, 28-day mortality was higher in the elderly (10/30 (33.3%) vs 11/114 (9.6%), p = 0.008), and hospital stay was longer (median (IQR [range]) 17 (13-35 [6-62]) days vs 11 (7-21 [2-159]) days, p = 0.006). Regression analysis indicated that cardiovascular, haematological, renal and wound complications were associated with longer hospital stay, and that cardiovascular complications predicted mortality. The postoperative morbidity survey system enabled structured mapping of the number and type of complications, and their relationship with outcome, following emergency laparotomy. These results indicate that rather than a greater propensity to complications following surgery, it was the failure to tolerate these that increased mortality in the elderly.

Significantly greater technical difficulty was experienced with our 'morbidly obese' manikin compared with the unmodified manikin. Failure rates and times to completion were considerably more consistent with real-life reports. Modifying a standard manikin to simulate an obese patient is likely to better prepare anaesthetists for this challenging situation. Development of a commercial manikin with such properties would be of value.

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Implementation of a quality improvement bundle for peri-operative management of emergency laparotomy (ELPQuIC) improved mortality in a previous study. We used data from one site that participated in that study to examine whether it was associated with the cost of care. We collected data from 396 patients: 144 before, 144 during and 108 after implementation of the bundle. We estimated costs incurred using previously published methodology based on the time the patient spent in hospital, in the operating theatre and in critical care. Duration of stay in hospital and critical care did not differ between time periods, p = 0.14 and p = 0.28, respectively. The costs per patient and per survivor did not differ between the time periods, p = 0.87 and p = 0.17, respectively. Costs were similar for patients aged < 80 years vs. ≥ 80 years. Implementation of a quality improvement bundle for emergency laparotomy has the capacity to save lives without increasing hospital costs.

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radiographic contrast and continuous imaging to confirm paravertebral spread (after ultrasound-guided needle placement) before administration of local anaesthetic. There is consistent demonstration that injection outside the SCTL shows very localised spread whilst injection deep to the SCTL shows typical multilevel paravertebral dispersion.Whilst we eagerly await the results of the authors' further cadaveric studies, we would caution against the changing of practice based on singular demonstrations of anatomic variability.

repeatability of only one scale point on a range 0-100, which seems unlikely for a score derived from responses to questions concerning subjective symptoms. They say they have used the method of Bland and Altman,2 but the results given-the mean difference and the distribution of the differences-are not good measures of reliability. Moreover, Bland and Altman proposed that the limits of agreement should be used to assess repeatability. For example, twice the standard deviation of the differences gives a range within which 95% of the differences will lie.A mean difference of zero implies that there is no consistent trend affecting test and retest results (all the patients getting better, for example). It does not imply that the measure is reliable. The table