By: 15 September 2015
Acronyms again with Sher Mohammad

Acronyms again with Sher Mohammad

Sher Mohammad and colleagues share tips for avoiding some of the pitfalls of anaesthesia and peri-operative care

In the February 2013 issue of Journal of Anaesthesia Practice, some of our unique educational abbreviations and mnemonics were published. We have since created more acronyms relating to complications of anaesthesia and peri-operative care that we hope will benefit the profession.
Sadly, complications do happen on occasion, even in the best hands, and as anaesthetists we could find ourselves in front of the judge in a court of law if something goes wrong. A system that will enable us to remember a logical approach to a problem in a time of crisis will always be helpful. At the time of going to press, we are about to publish The STH-KTH Nexus Handbook on acronyms. The following memorising aids are taken from that booklet.JAP_9.2_Website_News_Acronyms_Sher_Mohammad_Anaesthesia_Peri-operative_care_photo2

Factors causing aspiration pneumonitis
Aspiration pneumonitis was first recognised as a cause of anaesthetic-related death in 1848 by James Simpson [1]. In 1946, Mendelson described aspiration pneumonitis in obstetric patients [2]. Today it remains a rare but potentially devastating complication of general anaesthesia. Aspiration pneumonitis is quoted as occurring in one out of 3000 to 6000 cases of general anaesthesia – this increases to one in 600 in emergency procedures.
The following are some of the causes of aspiration pneumonitis.

Remember the acronym  ASPIRATION :

A     Anaesthetic (inadequate depth of anaesthesia)
S     Splinting of the diaphragm, e.g. hiatus hernia in obesity
P     Pyloric stenosis
Prune Belly syndrome
Procedure, e.g. emergency
I     Insufflation of stomach during bag-mask ventilation
Intestinal obstruction
R     Reflux, e.g. GORD (gastro-oesohageal reflux disease)
Renal failure
A     Age, i.e. elderly patients
Atonia of stomach, e.g. gastroparesis
T     Tracheo-oesophageal fistula
I     Injury to head resulting in coma
O     Oesophageal obstruction due to malignancy
N     Non-fasted patients presenting for surgery
Neuromuscular diseases

Factors causing laryngospasm
Remember the acronym  LARYNGOSPASM :

L     LMA insertion
Long uvula
A     Anaphylaxis
R     RBC transfusion reaction
Y     Young age
N     Nocturnal asthma
G     GORD
O     Oesophageal dilatation (distal afferent stimulation)
S     Smokers
P     Parkinsonism patients going into primary laryngospasm
Parathyroidectomy leading to hypocalcaemia
A     Adenotonsillectomy
Anaesthetic, e.g.barbiturates and isoflurane
Anaesthetist with less experience
S     Spinal anaesthesia resulting in unopposed vagal tone
Suction of larynx
M     Mediastinoscopy

Contraindication to prone position
Spinal instability is an absolute contraindication for anaesthesia in the prone position, and haemodynamic instability and arrhythmias are other strong relative contraindications. To help remember a few more contraindications, refer to the acronym  PRONE

P     Pelvic fracture
R     Raised ICP
Recent sternotomy and tracheal surgery
O     Obesity – may pose special problems
N     Non-stable spine
E     Eye and ENT surgeries

For other complications of anaesthesia in the prone position, please read our handbook mentioned above.

Factors causing awareness during general anaesthesia
In recent times, the incidence of awareness with explicit recall of severe pain has been estimated at 0.03 per cent of general anaesthetics (one in 3000). Conscious awareness without recall of pain is more common (0.1–0.7 per cent of cases of general anaesthesia, or one in 140–1000). Awareness is twice as common when muscle relaxant is used. To remember a few risk factors causing awareness refer to the 13 Cs :

C     Check list not done in complex, time-sensitive tasks
C     Colour coding scheme for drug labelling and concentration not followed
C     Circuit disconnection during general anaesthesia
C     Cardiac surgery (CPB used)
C     Caesarean section under general anaesthesia
C     Craniocerebral surgery
C     Critically ill patients in ITU are sedated only (would need general anaesthesia for intervention)
C     Concurrent conditions, e.g. pyrexia or hyperthyroidism
C     Cigarette smokers and alcoholics
C     Conscious sedation – patient may become unconscious which may result in recall
C     Cricoid pressure – could be recalled as unpleasant sensation
 C     Chinese study – shows that TIVA is associated with awareness

Rare but fatal complications of interscalene brachial plexus block
Interscalene BPB has become safer with the use of ultrasound. Rare but fatal complications do happen and could be remembered with the acronym  SCALINE :

S     Stellate ganglion block will result in Horner’s syndrome
C     Cervical spinal cord injury
A     Anaesthetic toxicity if injected intravenously
L     Laryngeal hyperaemia and recurrent laryngeal nerve palsy
I     Intervertebral artery injection
N     Needle and or chemical trauma to nerves
E     Epidural/spinal spread

Complications of CVP line insertions
The indications for CVP line insertion are there in our booklet but to remember complications, refer to the acronym  VAS-CATHETER :

V     Vascular injury
A     Arrhythmia
S     Sepsis/infection
C     Cardiac tamponade
A     Air embolism
T     Thoracic duct injury (chylothorax)
H     Haemo- and/or pneumothorax
E     Erosion (late complication)
T     Thrombosis
E     Embolisation of guide wire
R     Reaction to catheter material or antibiotic coating

Never events in the niches of the operating theatre
‘Never events’ are defined as serious, largely preventable, patient safety incidents that should not occur if relevant preventive measures are put in place. Many of these incidents may potentially occur in the niche of the operating theatre. We have coined an acronym  WEIRD PRACTICE  to remember them:

W     Wrong site surgery
Wrong surgical implants/prosthesis
Wrong gas administered
Wrong route of administration, e.g. EN given as TPN
E     Epidural drug given intravenously
I     Insulin overdose
R     Retained foreign object post-operatively
D     Drug overdose such as morphine in opioid naive patient
Drug overdose of midazolam during conscious sedation
P     Potassium maladministration
Porphyrea and thiopentone being given
Prone position with spinal instability
R     Regional anaesthesia in anticoagulated patient
A     Aortic stenosis (severe) and spinal/epidural being given
Awake patient and muscle relaxants being given
Allergic status not checked and the drug injected
Air embolism during IV administration
C     Chest drain open and kept above chest level
CPB without heparisation
T     Thoracic imaging to diagnose tension pneumothorax
Throat pack forgotten at extubation
Transfusion of ABO-incompatible blood components
I     Interscalene BPB done bilaterally
IVRA and bupivacaine being used
C     CVP line and NG tube not confirmed radiologically
CVP line inserted on contralateral side of thoracotomy/thoracoscopy
E     Endobronchial tube tip ligated by surgeon at end of thoracotomy

1. Simpson, J.Y. (1848) The alleged case of death from the action of chloroform. Lancet 1, 175–176
2. Mendelson, C.L. (1946) The aspiration of stomach contents into the lungs during obstetric anaesthesia. Am. J. Obs. Gynae. 52, 191

Sher Mohammad (consultant anaesthetist), Sher Nawaz Khan (consultant anaesthetist, locum), Ahmad Farooq Ahamad (consultant anaesthetist. locum), Amit Ranjan (post-CCT registrar), Rama Pothireddy (SpR year 7 anaesthetics), Abdul Hamid (PA anaesthetist) and Omaima Badri (ex-locum registrar) are all at Sheffield Teaching Hospital NHS Foundation Trust.

Have your say
If you use other helpful acronyms that you think will benefit practising anaesthetists, please send them to us and we will share them with a wider audience.
I use the following reminder for teaching purposes. It relates to  THE ‘A’s OF PREMEDICATION DRUGS

A     Antibiotics
 A     Antiemetics
A     Analgesics
A     Anxiolytics
A     Antisialogogues
A     And… any other medication the patient is taking already, which should not be missed preoperatively

Please send your acronyms by email to
James Watts, Consultant Editor