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Notes: Introduction  Several recent high profile medical cases where doctors' clinical competence has been questioned has led to questions being asked about their fitness to practise. As a consequence higher medical training has been put under the spotlight. The media circus around such events has raised broader concerns with a public increasingly demanding information about their doctors' abilities. The Royal Medical Colleges in conjunction with central government have accepted the need to develop competency-based training, in an attempt to address these concerns. We describe the educational process whereby a pragmatic, practical and achievable training programme has been created to provide basic level paediatric anaesthetic competence.Educational Methods in Programme Development  Competency-based training requires significant changes in approach for both trainee and trainers. This can be problematic if not introduced in a planned manner. The need for insight into the adult educational process is central to successful implementation. Competence can be defined as the ability of a professional to perform to a predefined standard, tasks appropriate to their position. Establishing whether a trainee is competent or not is more time consuming for the trainers. This is unavoidable, as evidence of learning has to be sought directly for each trainee to support the competence claim. The programme was developed by addressing the following educational requirements.〈list style="custom"〉1An educational needs assessment of both trainer and trainee, associated with a learning opportunities assessment. Ultimately this will incorporate the Royal College of Anaesthetists competency-based training targets once published.2Development of a learning plan, identifying core and secondary learning areas and highlighting teaching methodology and training ethos. Core areas were separated into skills, knowledge and attitudes and standards expected.3Implementation of the learning plan, including module structure, declaration of the curriculum, introduction and orientation of the trainee.4Assessment of learning through a package aimed at identifying evidence of learning including index case, scenarios, resuscitation skills and attitude.〈tabular xml:id="t16-1"〉1〈title type="main"〉 Analgesia required for each surgical approach 〈table frame="topbot"〉〈tgroup cols="16" align="left"〉〈colspec colnum="1" colname="col1"/〉〈colspec colnum="2" colname="col2"/〉〈colspec colnum="3" colname="col3"/〉〈colspec colnum="4" colname="col4"/〉〈colspec colnum="5" colname="col5"/〉〈colspec colnum="6" colname="col6"/〉〈colspec colnum="7" colname="col7" align="char" char="."/〉〈colspec colnum="8" colname="col8"/〉〈colspec colnum="9" colname="col9"/〉〈colspec colnum="10" colname="col10"/〉〈colspec colnum="11" colname="col11"/〉〈colspec colnum="12" colname="col12" align="char" char="."/〉〈colspec colnum="13" colname="col13" align="char" char="."/〉〈colspec colnum="14" colname="col14" align="char" char="."/〉〈colspec colnum="15" colname="col15" align="char" char="."/〉〈colspec colnum="16" colname="col16" align="char" char="."/〉〈thead valign="bottom"〉〈row rowsep="1"〉〈entry rowsep="1" namest="col2" nameend="col6"〉 Laparotomy (Epidural) 〈entry rowsep="1" namest="col7" nameend="col11"〉 Laparotomy (NCA) 〈entry rowsep="1" namest="col12" nameend="col16"〉 Laparoscopy (NCA) 〈tbody valign="top"〉Intra-op fentanyl〈entry namest="col2" nameend="col6"〉2 mcg/kg〈entry namest="col7" nameend="col11"〉3 mcg/kg〈entry namest="col12" nameend="col16"〉3 mcg/kgIntra-op morphine〈entry namest="col2" nameend="col6"〉0 mg/kg〈entry namest="col7" nameend="col11"〉0.1 mg/kg〈entry namest="col12" nameend="col16"〉0.15 mg/kg% Patients requiring infusion per day (D)D1 100D2 100D3 95D4 68D5 4D1 100D2 94D3 50D4 17D5 6D1 100D2 100D3 92D4 42D5 8% Patients requiring paracetamol per day (D)D1 86D2 90D3 80D4 100D5 0D1 100D2 94D3 100D4 100D5 0D1 88D2 68D3 90D4 50D5 0% Patients requiring diclofenac per day (D)D1 73D2 71D3 67D4 100D5 0D1 67D2 71D3 89D4 100D5 0D1 63D2 41D3 30D4 50D5 0〈note xml:id="t16-1_note60" numbered="no"〉NCA = nurse controlled analgesia〈list style="custom"〉5Evaluation of teaching including feedback from trainees and trainers, other senior members of the paediatric multidisciplinary team.Discussion  We have been running this assessment package since June 2001 and whilst there were inevitable teething problems the package has been well received by trainees and staff. It confirms the need to be practical when setting core learning goals as these goals essentially become your core curriculum and therefore also become mandatory for inclusion in your assessment package. Other pertinent issues relate to the consequences of deeming a trainee not competent, and the legal implications of this conclusion for service provision and career progression.Conclusion  Competency based training will require a sea change in attitude of both trainees and trainers. However, demands for proven clinical competence cannot be ignored.

Notes: A new form of airway has recently been described, which is introduced blindly into the hypopharynx to form a seal around the larynx, so permitting spontaneous or positive pressure ventilation without penetration of the larynx or oesophagus. The further development of this new airway is described and the results of 18 months' clinical experience are presented. The airway was used successfully in 118 patients, 17 of whom received controlled ventilation of their lungs. It was used in place of the facemask in routine anaesthesia, and was of particular value in ophthalmic, dental and ear, nose and throat procedures and where difficulties with the airway were expected. The incidence of sore throat and other problems was low. Experience of more than 500 cases suggests that the laryngeal mask airway may have a valuable rôle to play in all types of inhalational anaesthesia, while its proven value in some cases of difficult intubation indicates that it may contribute significantly to the safety of general anaesthesia.

Notes: A double-blind, randomised study of 60 patients who received intravenous increments of nalbuphine 3 mg or pethidine 15 mg by patient-controlled analgesia during the first stage of labour, was carried out. Pain intensity, sedation, uterine contractions, maternal cardioventilatory variables and fetal heart rate were recorded as well as any side effects. Apgar scores, time to sustained respiration and resuscitative measures required for the neonate were noted at delivery. Modified neonatal neurobehavioural studies and a retrospective assessment of maternal analgesia, satisfaction and tolerance were also carried out. Group mean values of pain scores of nalbuphine-medicated primiparous women were statistically significantly lower than those of pethidine-medicated patients (p 〈 0.01). Other assessments did not demonstrate a statistical significance between the two groups.

Notes: Conditions for tracheal intubation at 90 seconds, time to onset of maximum block and duration of clinical relaxation after jive different doses of atracurium, which ranged from 0.4 to 1.0 mg/kg were studied in 200 adult patients who were anaesthetised with nitrous oxide, oxygen and halothane or fentanyl. The conditions for intubation improved significantly with increasing doses, and were acceptable in 55% patients with a 0.4 mg/kg dose and in about 90% of those who received the two higher doses. The time to onset of complete block was 257 seconds with 0.4 mg/kg and decreased progressively to 124 seconds with 1.0 mg/kg. The duration of clinical relaxation under fentanyl anaesthesia averaged 29 minutes with 0.4 mg/kg and increased in a dose-related manner to 57 minutes with 1.0 mg/kg: halothane anaesthesia produced only a marginal increase. There was no evidence of cumulation with up to six repeat doses of 0.125 mglkg. The only side effect noticed was cutaneous flushing observed in 42% of patients. This was again dose dependent, being 18% with 0.4 mg/kg and increasing to 73% after 1.0 mg/kg. There was associated hypotension and bronchospasm in one patient.

Notes: Midazolam, administered intramuscularly was compared with papaveretum and hyoscine for premedication in patients undergoing gynaecological surgery. Midazolam proved to be a satisfactory agent for premedication compared with papaveretum and hyoscine, producing a similar degree of sedation and anxiolysis, but causing significantly more anterograde amnesia.

Notes: Pain caused by intravenous injection in the dorsum of the hand of ICI 35,868 and diazepam (Valium) was studied. The effect of pretreatment with intravenous aspirin was compared with two groups—one pretreated with fentanyl and an untreated group. In the case of diazepam neither analgesic drug prevented pain on injection whereas with ICI 35,868 pain was significantly reduced by both drugs.

Notes: Abstract In this study, the effects of histamine, antihistamines (terfenadine and mepyramine), 5-hydroxytryptamine, and muscle relaxants, atracurium, vecuronium and gallamine, on the tone and contractility of rat ileum were studied and compared in vitro. The aim of the present investigation was to measure, pharmacologically, the histamine releasing effect of muscle relaxants, e.g. atracurium, vecuronium and gallamine, by comparing their contractile response in the absence and presence of antihistamines and comparing their mechanical responses with those produced by histamine and 5-hydroxytryptamine (5-HT). The results showed that the antihistamines, triludan (terfenadine) and mepyramine produced opposite effects in rat ileum. Terfenadine (0.1–20 μM) produced concentration-dependent contractions in the rat ileum, whereas mepyramine (0.1–10 μM) relaxed the muscle, e.g. by 1.2 g tension. Atracurium (0.5–500 μM), vecuronium (0.2–200 μM), and gallamine (0.1–7.0 μM) produced marked contractions (1.5–4.0 g tension) in rat ileum, and these contractions were markedly reduced by mepyramine (1.3 μM) or terfenadine (5 μM), implicating histamine release in the generation of these contractions. However, there was some residual contraction which was not blocked by mepyramine, but by 5-HT antagonist, methysergide (1 μM), indicating that a mechanism other than histamine release may be responsible for the residual contraction, i.e. release of other mediators such as 5-HT, prostaglandins, or calcium. 5-HT (0.5–500 μM) and histamine (0.5–500 μM) produced contractions in the rat ileum, but 5-HT was more effective than histamine in producing these contractions. Similarly, gall amine was more effective than atracurium and vecuronium in contracting the rat ileum. Since very high concentrations of muscle relaxants were used, it is suggested that in clinical concentrations, the histamine releasing effect of muscle relaxants was minimal, except that of gallamine, which may release histamine event at very low concentrations. The results are discussed in terms of pharmacologic and immunologic implications of drug reactions at the rat intestinal smooth muscle.