The American Society of Anesthesiologists (ASA) physical status classification system has previously been shown to be inconsistently applied by anaesthetists. One hundred and sixty questionnaires were sent out to all specialist anaesthetists in Hong Kong. Ten hypothetical patients, identical to those of a similar study undertaken 20 years ago, each with different types and degrees of physical disability were described. Respondents were asked about their country of training and type of anaesthetic practice and to assign an ASA classification status for each patient. Ninety-seven questionnaires were returned (61%) after two mailings. Agreement for each patient within groups, between groups and overall comparisons were made. Percentage of agreement was between 31 to 85%. Overall correlation was only fair in all groups (Kappa indices: 0.21-0.4). We found that the current pattern of inter-observer inconsistency of classification was similar to that 20 years ago and exaggerated between locally and overseas trained specialists (P<0.05). The validity of the ASA system, its usefulness and the need for a new, more precise scoring system is discussed.

SummaryThis re-survey of neurosurgical centres was conducted to determine whether the publication of management guidelines has resulted in changes in the intensive care management of severely headinjured patients (defined as Glasgow Coma Score , 9) in the UK and Ireland. Results were compared with data collected from a similar survey conducted 2 years earlier. Almost 75% of centres monitor intracranial pressure in the majority of patients and 80% now set a target cerebral perfusion pressure of . 70 mmHg. The use of prolonged hyperventilation (. 12 h) is declining and the target P a co 2 is now most commonly . 4 kPa. More centres maintain core temperature , 36.5 8C. Although wide variations in the management of severely head-injured patients still exist, we found evidence of practice changing to comply with published guidelines. In surveys carried out 2 years ago, we highlighted the wide variation in the intensive care management of severely head-injured patients [defined as Glasgow Coma Score (GCS) , 9] in neurosurgical centres throughout the UK and Ireland [1, 2]. Since these initial surveys, two expert bodies have produced guidelines for the management of severe head injury [3, 4]. We surveyed neurosurgical centres to examine whether the management of severely head-injured patients had changed following publication of these guidelines. MethodsThe directors of 44 neurosurgical centres in the UK and Ireland were asked to complete a questionnaire identical to that used 2 years earlier. After 4 weeks, a copy of the questionnaire was sent to all non-responders with a covering letter urging them to reply. The data collected in this survey were compared with results obtained 2 years ago using a Chi-squared test. The significance level was set at 0.05 and statistical analysis was performed using statview 4.0 (Abacus Concepts Inc., Berkeley, CA, USA). ResultsAll 44 centres replied, but four of these did not treat severely head-injured patients and so were not analysed further. Compared with 1996, a greater proportion of units had dedicated junior staff (87 vs. 66%; Chisquared 13, d.f. 1, p , 0.05) and identifiable high-dependency unit (HDU) facilities (68 vs. 43%; Chi-squared 17, d.f. 1, p , 0.05). Only 54% of units had a written protocol for the management of raised intracranial pressure. The changes in management that we observed between the two survey periods are listed in Tables 1±3. DiscussionRecent guidelines [3, 4] suggest monitoring intracranial pressure (ICP) in all patients with a GCS , 9 or an abnormal computed tomography scan. Mean arterial pressure (MAP) should be maintained . 90 mmHg and cerebral perfusion pressure (CPP) . 70 mmHg. Intracranial hypertension should be treated when ICP is . 25 mmHg. The guidelines advise against severe or prolonged hyperventilation and found no evidence to support the use of steroids in head injury. The availability of these guidelines appears to have altered ICU care for severely head-injured patients.Organisational changes in admission practice, unit staffing and HDU bed...

In the Intraoperative Hypothermia for Aneurysm Surgery Trial, neither systemic hypothermia nor supplemental protective drug affected short- or long-term neurologic outcomes of patients undergoing temporary clipping.