Getting it right first time

This month, in a stinging editorial, Professor Pandit argues a lack of rational data on theatre performance and efficiency make the NHSI report on operating theatres an almost worthless read. It is perhaps the claim that list over-runs are due to late starts or gaps between cases that will strike a chord with clinicians. He argues such claims are not backed by evidence and are at odds with existing literature. This editorial is a must read for all theatre staff and you can read a response from one of the report’s authors here.

Tranexamic acid has revolutionised the management of traumatic and non-traumatic haemorrhage following the publication of the landmark CRASH-2 and WOMAN trials. Whilst the peri-operative benefits of tranexamic acid are well documented, Patel et al. provide data on catastrophic drug errors that have arisen as a result of intrathecal administration. They identified 21 cases with a mortality rate of just under 50% (10 out of 21 cases). Of the remaining 11 cases, 10 required ICU admission for refractory convulsions and/or tachyarrhythmias with a high incidence of permanent neurological injury in survivors. Perhaps the most worrying (and disappointing) finding is that an ampoule error (i.e. not checking or reading the label, similar size ampoules) occurred in 20 patients. This is unsurprising, given the similarities shown in Figure 1In the accompanying editorial, Palanisamy and Kinsella discuss potential causes of such errors and provide practically useful solutions to reduce the risk of such rare, but catastrophic errors, down to zero

Figure 1. Similarity of tranexamic acid and bupivacaine ampoules.

Gastric ultrasound is becoming increasingly popular. Studies so far have used a variety of different participant positions to evaluate gastric volume using ultrasound, and the ideal position is unknown. Bouvet et al. address this by evaluating the effect of different patient positions and different bed angles on gastric ultrasound contents in healthy volunteers. They found the angle of the bed can significantly affect ultrasound performance, and a 45°angle performed the best to detect gastric fluid volume > 1.5 ml.kg-1. Nascimento et al., in a non-inferiority randomised trial of labouring women, observed that maltodextrin was cleared from the stomach faster than coffee with milk and orange juice. These studies add to the growing body of evidence suggesting gastric emptying and volume are not solely dependent on volume ingested and total calories, but also on other factors such as protein and lipid content and patient positioning. Mohta et al. carried out a randomised trial of 100 mg phenylephrine boluses versus 5 mg noradrenaline boluses to treat maternal postspinal hypotension during elective caesarean section. They hypothesised that noradrenaline would be less likely to cause bradycardia, due its weak b-agonist chronotropic action. Results showed no difference in the primary outcome of bradycardia, but the total number of phenylephrine boluses required was, perhaps unsurprisingly, greater than noradrenaline. Interestingly, the umbilical artery pH, bicarbonate and base excess were lower in the noradrenaline group which could have been as a result of placental transfer, but the mechanisms and clinical implications of this requires further investigation. 

Reducing the environmental impact of anaesthesia is a key strategic issue for the Association of AnaesthetistsKennedy et al., in a quality improvement study, provide novel data on how a single episode of high fresh gas flow at the start of anaesthesia can have a significantly modifiable effect on overall gas flow and vapour consumption. The authors provide us with useful conceptual framework (Figure 2) that suggests we need to be more mindful of our gas flows during induction. Hade et al. modified an existing central line insertion checklist by recommending insertion depths and adding a picture of a chest radiograph with a traffic light coloured tick-box system to assist with post-insertion tip confirmation (Figure 3). They report an impressive reduction in line tip malpositioning, along with improvements in documentation of other components of the checklist such as sterility measures. 

Figure 2. The three factors that are directly under the control of the anaesthetist that determine overall fresh gas flow (FGF) and vapour consumption: (1) the initial (high) FGF; (2) the duration of the initial FGF; (3) the FGF during the maintenance phase.

Figure 3. Central venous catheter checklist accompanied with the traffic light system.

Elsewhere, Luther et al., in a bench top study, observed that the brand of bougie, brand of double-lumen tube and size of double-lumen tube all influence the degree of bougie fragment shearing. This has implications for tube manufacturers who may consider specifying in advance which bougie could be safely used with their double-lumen tube. Dingley et al. investigated the effect of temperature control in different designs of emergency drug transport bags, which can have important consequences on the efficacy of emergency drugsGratz et al. successfully demonstrated the uptake of thromboelastometric-guided algorithms in emergency departments with no previous experience of such technology. Implementation of such algorithms has the potential to improve outcomes in patients with traumatic brain injury and suspected haemorrhage. 

In our reviews section, Roth et al. performed an excellent and highly clinically relevant abridged Cochrane review on the beside accuracy of bedside tests for predicting difficult airways. They found that, although none of the current tests are well suited for detecting anticipated difficult airways, the upper lip bite test had the most favourable test accuracy properties with a sensitivity of 67% and specificity of 92%. In the accompanying editorial, Law and Duggan discuss the challenges of current airway assessment strategies, offer advice on what to screen for and how to act if difficulty is predicted and suggest directions for future researchPoldermans et al. found no evidence that perioperative dexamethasone increases the risk of developing wound infections. It did produce a transient increase in glucose levels by a mean difference on 0.7 mmol.l-1, but data were on patients without diabetes mellitus. Surprisingly very little evidence currently exists on glycaemic control in patients with diabetes who receive dexamethasone, but the results of a large trial (8800 patients) with stratification of diabetes status are awaited. Some of the issues around dexamethasone administration and diabetes are discussed in an editorial by Albrecht and Wiles. They primarily focus on the some of the key findings of a recent NCEPOD report which reviewed the care of patients with diabetes who underwent surgical procedures. The authors make a strong case for departments to have clinical leads for the perioperative management with diabetes, alongside better utilisation the existing expertise of diabetic nurse specialists and better recognition of inadequate diabetic control in the operating theatre. 

Over on Anaesthesia Reports, we have two new cases – one on the use of high flow nasal oxygen in a high-risk obese patient requiring sedation in the prone position, and another on awake tracheal intubation for blunt airway trauma. We hope you enjoyed our most recent #FrontOfNeck TweetChat as much as we did. We were never really going to definitively settle the scalpel vs. cannula eFONA debate, but some of the associated discussions were fascinating! Finally, we look forward to seeing you at Association of Anaesthetists Trainee Conference in early July. Matt Wiles will be discussing evidence-based advances in trauma, Mike Charlesworth will be discussing contemporary mechanical circulatory support and Andy Klein will be presenting some of the best papers from Anaesthesia.

See you in Telford!

Professor Andy Klein and Dr Akshay Shah

Fluid warmers and aluminium toxicity

Summer is almost upon us and we have a bumper issue of Anaesthesia lined up for you this month. In a landmark study Perl et al. report that uncoated aluminium plates in the CE-marked enFlow® fluid warming system release aluminium when used with a balanced crystalloid solution at levels far above FDA-recommended limits. The short and long-term clinical implications are unclear at present, but the manufacturer of enFlow® recently issued a global market recall. This received widespread attention from many news outlets, including The Guardian. Long-term sequelae of aluminium toxicity may include neurological impairment, Alzheimer’s disease and metabolic bone disease. Professor Exley, a chemist from Keele University and a recognised aluminium toxicity expert, argues a full investigation is now required. In the accompanying editorial, Charlesworth and van Zundert make a strong case for clinicians to be at the forefront of research on commonly used medical devices whilst also promoting clinical vigilance. A newly published paper from Taylor et al. seems to validate the conclusions drawn by Perl et al., more so for other balanced crystalloid solutions and blood products. Watch this space for more news!

Figure 1.pngFigure 1 Sketch of fluid‐warming disposables with aluminium heating plate in the fluid chamber. a: parylene (purple)‐coated device; b: non‐coated device. PVC tubing is drawn in black and the aluminium plate is drawn in grey. Note in (b), the fluid is in direct contact with aluminium.

Articles related to transfusion medicine and patient blood management are always popular. In this month’s issue, Trentino et al., retrospectively investigated the interaction between anaemia and red cell transfusion and what effect transfusion may have on mortality and length of stay at various levels of nadir haemoglobin. They retrospectively analysed 60,955 surgical admissions and observed higher mortality with red cell transfusion at haemoglobin levels greater than 90 g.l−1, whereas at all levels below 90 g.l−1 mortality was not significantly different. This is an important study which adds to the evidence base supporting restrictive transfusion, but like most observational studies, it demonstrates an association and uncontrolled confounding is likely. In addition, the effects of restrictive transfusion strategies are still unclear in certain perioperative subgroups such as those with cardiovascular disease.

Staying on the theme of anaemia and transfusion, Keeler et al. report a secondary analysis of a previously published randomised trial that evaluated the effect of intravenous iron versus oral iron on haemoglobin and transfusion requirements in patients with colorectal cancer-associated anaemia. In this secondary analysis, they compared quality of life scores between both study groups using validated questionnaires such as the EQ-5D-5L, SF-36 and FACT-An. Intravenous was associated with higher quality of life scores across multiple domains as compared with oral iron three months following surgery. In their accompanying editorial, Shah and Bailey discuss some of the current challenges in measuring outcomes following surgery with regards the methods used to determine a minimum clinically important difference and the choice of outcome measurement tools.

Elsewhere, Oller et al. evaluated the effect of a novel crystalloid fluid (Oxsealife®) on recovery from haemorrhagic shock in pigs. One of the beneficial properties of this fluid is that it is able to generate microvascular nitric oxide and scavenge reactive oxygen species generated during the ischaemia-reperfusion injury. Through a series of experiments, they observed improvements in serum markers of organ function, oxygen delivery, and better maintenance of glycocalyx integrity in pigs receiving this fluid compared to those receiving whole blood. This is a very promising physiological alternative to blood in the management of haemorrhage shock and early phase human studies are warranted.

There is growing interest in the measurement and impact of frailty across all medical specialities, yet there is no gold-standard method to achieve this. Pugh et al. prospectively evaluated the inter-rater reliability of the Clinical Frailty Scale (CFS), on a variety of healthcare professionals, for assessing frailty in patients admitted to critical care. They used this tool based on the findings of a systematic review which identified the CFS as the most commonly reported frailty assessment tool in critical care. The CFS is a nine-category assessment tool (Fig. 2) that is easy to administer and a CFS rating >4 is considered frail. They observed a good level of inter-rater agreement in frailty assessment using the CFS but identified independent factors, such as the assessor having a medical background, which could influence ratings. In the accompanying editorial, Falvey & Ferrante discuss the challenges in defining frailty, and why it is important to assess for it in the critically ill patients.

Figure 2.pngFigure 2 Rockwood clinical frailty scale.

There is huge interest currently in the potential advantages of the peri-operative use of dexmedetomidine, and in this month’s issue, we have two such articles. Cheng et al. performed a multicentre randomised trial evaluating the effect of intra-operative dexmedetomidine on cognitive decline in patients aged >65 years undergoing elective gastrointestinal laparotomy surgery. They observed a reduction in cognitive decline up to one postoperative month, which was mechanistically associated with changes in serum brain-derived neurotrophic factor. Whether or not this beneficial effect persists at longer follow-up time points requires further investigation. Grape et al. also performed a systematic review comparing the analgesic efficacy on intra-operative dexmedetomidine with remifentanil. They found improvements in pain scores during the first 24 hours and fewer side effects in patients who received dexmedetomidine.

Gomez-Rios evaluated the performance of a new video laryngeal mask, TotaltrackTM, which combines a supraglottic airway with a videolaryngoscope (Figure 3). The device was found to be acceptable in 300 patients, though further studies comparing it to current standards of airway management are required to determine its precise role in airway management. Boisson et al compared a non-invasive, cardiac output photoplethysmographic device (Clearsight) with a conventional PiCCO device in 20 adults undergoing elective surgery. They observed no differences in overall performance with regards to measuring absolute and changing stroke volumes. The non-invasive nature of this device may increase the uptake of goal-directed therapy.

Figure 3.jpgFigure 3 The Totaltrack video laryngeal mask and its components. Side and rear view of the device. 1. Videotrack; 2. memory card; 3. non‐rechargeable battery‐operated light; 4. supraglottic airway; 5. high‐volume, low‐pressure cuff; 6. rigid blade; 7. tip of the blade protected by a silicone cover; 8. intubation channel guide; 9. laryngeal suction channel; 10. gastric suction channel; 11. tracheal tube; 12. tracheal tube connector; and 13. distal aperture of the gastric suction channel.

In our reviews and guidelines section, we are pleased to publish the 2019 Association of Anaesthetists and British Association of Day Surgery guidelines for day-case surgery (Fig. 4). This is essential reading for all anaesthetists, clinical leads and theatre managers. Lastly, we have a very interesting, narrative review by Sepulveda et al. on neural inertia, a phenomenon that may explain the resistance observed to changes in consciousness induced by total intravenous anaesthesia, independent of drug kinetics.

Figure 4Figure 4 Key recommendations from the day-case surgery guidelines.

Over on Anaesthesia Reports, we have some fascinating articles on a triple regional analgesia technique for pleuropulmonary sarcoma resection, analgesia using a wound catheter after clamshell thoracotomy (Fig. 5), CSF-cutaneous fistula formation following accidental dural puncture, and delayed presentation of cardiac tamponade following traumatic diaphragmatic hernia repair. This case report from Saunders et al. has the highest Altmetric score from our new journal. Congratulations to the authors!

Figure 5.jpgFigure 5 Intra-operative placement of a wound catheter.

We are sad to report that two of our senior editors are stepping down after many years of service at the journal. Good luck to Professor Jaideep Pandit and Dr Stuart White on their future endeavours. We have appointed several new editors including Dr’s Laura Duggan, Seema Agarwal, and two of our previous Trainee Fellows, Helen Laycock and Kariem El-Boghdadly. Finally, we have a new system for manuscript submissions with separate sites for Anaesthesia and Anaesthesia Reports. Make sure you send us your work for an efficient, friendly and helpful peer review service.

Dr Akshay Shah and Professor Andrew Klein

A wider role for anaesthesia?

This month in Anaesthesia, Sinmyee et al. discuss the legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying. They examine the means used to achieve unconsciousness from around the world and report a relatively high incidence of vomiting, prolongation of death and reawakening. That said, the very act of defining an optimum method for inducing unconsciousness in assisted dying has complex legal and ethical implications for the public, legislators and physician groups. In the accompanying editorial, Savulescu and Radcliffe-Richards argue the prevention of suffering at the end of life is hardly controversial, and we must consider the use of anaesthesia in this context. These papers, together with the accompanying commentary in the BMJ, are ‘must reads’ for all.

Rib fractures are a significant cause of suffering following blunt trauma and can lead to deadly pulmonary complications. This new retrospective cohort study suggests the erector spinae block improves respiratory function, pain control and haemodynamic stability in such patients. Similarly, Womack et al. find that paravertebral catheters are another safe and effective option. In their editorial, El-Boghdadly and Wiles argue thoracic epidural analgesia should no longer be considered a first line regional anaesthesia strategy in such patients. They summarise the evidence for other techniques such as paravertebral, intercostal, erector spinae, mid-point transverse process to pleura (MTP), retrolaminar, rhomboid intercostal, and serratus plane blockade. Confused as to which block goes where? Look no further than this excellent figure from @elboghdadly!

Figure 1Figure 1 Axial cross‐sectional illustration of a thoracic vertebra demonstrating the key anatomical structures (left) and the site of injection of local anaesthesia for blocks (right) used in the management of traumatic rib fractures. ESM, erector spinae muscle; SAM, serratus anterior muscle; SCTL, superior costotransverse ligament.

Given the many recent advances in regional anaesthesia and analgesia, is intra-operative opioid administration still necessary? This new systematic review and meta-analysis suggests ‘opioid-inclusive anaesthesia’ does not reduce pain and is associated with postoperative nausea and vomiting. The accompanying editorial by Elkassabany and Mariano has already been extremely well received on Twitter! They set out the case for multi-modal analgesia and derive a new definition for opioid free anaesthesia – “a peri‐operative care strategy that maximises non‐opioid modalities for anaesthesia and analgesia and reserves the use of opioids for severe acute pain unrelieved by other methods from admission to discharge from the hospital”.

Figure 2Figure 2 Infographic showing one approach to practically applying multi‐modal analgesia; some modalities should be considered for all patients (except when contraindicated), whereas other modalities should be considered for some patients (only when indicated).

In February, we facilitated a TweetChat on this new analysis by Myles, Carlisle and Scarr (#Hyperoxia). Their article challenges the integrity of data from studies of liberal peri-operative inspired oxygen by Mario Schietroma’s group, and provides an updated systematic review and meta-analysis of supplemental oxygen and its effect on surgical site infections (SSIs). The figure below seems to suggest a lack of evidence to support the recent WHO guideline on preventing SSIs, and the debate looks set to continue!

Figure 3Figure 3 Updated systematic review and meta‐analysis: forest plot of supplemental oxygen‐surgical site infection trials.

New neuraxial and regional anaesthesia non-Luer connectors will soon be coming to a hospital near you. This new evaluation of the non-Luer ISO 80369-6 connector finds it to be acceptable in terms of its ease of use, reliability, lack of leakage and versatility. It is hoped these new devices will solve the problem of neuraxial-i.v. wrong-route errors.

Figure 4Figure 4 Illustrations of NRFit (ISO 80369‐6) connectors. Top left. male slip connector, with floating collar; top right, male lock connector, bottom left female connector from the side and bottom right, oblique view. The neuraxial non‐Luer connector (NRFit) retains the approximate appearance of a Luer connector, with a proximal conical male component fitting into a receiving female component. The 5% angle of the cone and its dimensions differentiate it from a Luer device (6%). Additional features are ‘lugs’ in the distal male cone to reduce the chances of a leak‐free misconnection with other connectors and a floating collar on the male slip connector to create an additional barrier to misconnections.

Elsewhere we have a systematic review of  the analgesic efficacy of the Pecs II block, a study of postoperative microcirculatory perfusion and endothelial glycocalyx shedding following cardiac surgery with cardiopulmonary bypass, a comparison of sufentanil vs. remifentanil in fast‐track cardiac surgery patients, a synopsis of the recent legal challenges to the concept of brain death in the USA, Canada and the UK, and the new Association of Anaesthetists guidelines for the safe provision of anaesthesia in magnetic resonance units.

MRI

Over in Anaesthesia Reports, we recently published five new papers including a description of the MTP block for surgical anaesthesia, reversal of clonidine with naloxone, cord injury following spinal anaesthesia, ECMO-CPR for drowning and pulsed radiotherapy of the brachial plexus. All reports (including our entire back catalogue) are open access for a limited introductory period and you can submit your interesting reports (including pictures, videos and much more) here. We have already accepted a number of excellent new reports and you can keep an eye out for new material on the Anaesthesia Reports homepage.

Dr Mike Charlesworth and Professor Andrew Klein

Harmful effects of sleep deprivation – it’s in the genes!

The association between sleep deprivation and poor health outcomes is well-recognised. In this month’s issue of Anaesthesia, Cheung et al. conducted a mechanistic study aiming to unravel the effects of sleep deprivation on DNA damage in healthy, full-time doctors. Doctors who worked on-site overnight shifts had higher levels of oxidative DNA damage and lower DNA repair gene expression when compared to those did not work overnight shifts. These changes were detected even after only one night of sleep deprivation. The authors should be congratulated on their work which attracted attention from over 20 news outlets and racked up an Altmetric score of >1000 in a just under one week. This is a timely study in view of the Association of Anaesthetist’s current #FightFatigue campaign. In an accompanying editorial, Fuller and Eikermann provide suggestions for future research on how we can build on the findings from this study.

In this month’s issue, we have a series of articles dedicated to elucidating some of the mechanisms underlying high-flow nasal oxygen (HFNO) therapy, which is becoming increasingly popular in anaesthesia, perioperative medicine, and intensive care. One area of interest is carbon dioxide clearance. Hermez et al. carried out a laboratory study of three physical airway models and through a series of clever experiments, which included three-dimensional printing of trachea models, they observed that carbon dioxide clearance may be facilitated by cardiac. Shippam et al., in a randomised physiological study of healthy, non-labouring healthy pregnant patients, found that pre-oxygenation with HFNO performed worse than standard facemask oxygenation. There are important caveats to this study including the use of end-tidal oxygen concentration as a surrogate for adequate oxygenation, the exclusion of obese patients and those with difficult airways, and its efficacy was not tested in an urgent/emergency scenario. Given the current enthusiasm regarding HFNO, these findings certainly warrant further investigation. An accompanying editorial by Lumb and Thomas and a narrative review by Lyons and Callaghan succinctly describe the underlying mechanisms of HFNO and the evidence-based supporting its clinical application.

Figure 1

Figure 1 Apnoeic oxygenation involves the mass flow of a high fraction of inspired oxygen, aided by flushing of dead space, generation of positive airway pressure and cardiogenic oscillations. Higher flow rates can enable clearance of carbon dioxide.

We all fear being involved in a ‘cannot intubate cannot oxygenate’ scenario. Adequate training in emergency front of neck access (eFONA) is therefore crucial. Le Fevre et al. evaluated a novel obese-synthetic manikin against an obese-meat manikin and a conventional slim manikin. They observed that eFONA times were significantly longer in both obese manikins when compared to the slim manikin. The obese-synthetic manikin’s performance was broadly similar to the obese-meat manikin, with the added advantages of hygiene and convenience. If your department provides training in emergency front of neck access, this model is worth considering.

Figure 2

Figure 2 Three manikins (a) obese-synthetic; (b) obese-meat; and (c) slim

In the first of two articles related to human factors, Chrimes et al. discuss strategies on utilising human factors knowledge to improve the design of airway trolleys. One recommendation is to minimise the number of devices available in the trolley to simplify decision-making and avoid ‘analysis paralysis’. Another important and often underappreciated recommendation is to standardise difficult airway trolleys across all areas where difficult airway management can occur e.g. ICU, ED, theatres, recovery. In the second article, Evain et al., in a prospective, randomised, simulation study, demonstrated that a planning discussion before a simulated emergency scenario improved clinical team performance, crisis resource management, and stress response.

Figure 3

Figure 3 Icons facilitate locating equipment and integrate with cognitive aids.

The association between poor patient outcomes and out-of-hours admissions continues to be hotly debated. Goulden et al., studied 20,922 adults admitted to a UK critical care unit with status epilepticus over a 5-year period and found no evidence that weekend admissions were associated with higher mortality than those admitted during the week. Hepple et al., performed a retrospective analysis of the Trauma Audit and Research Network (TARN) database and found no evidence of a survival benefit in patients treated by an enhanced care team that included a pre-hospital physician. However, these patients were more likely to be younger, male and with a higher injury severity score. Rostin et al. conducted a large retrospective study investigating the effect of a single episode of postoperative desaturation (<90%) on discharge destination. They observed that early and prolonged desaturation was associated with greater odds of being discharged to a nursing facility. Several recognised, and potentially modifiable factors were identified including high intra-operative opioid use and high neostigmine doses. In an accompanying editorial, Coulson and Karalapillai question the biological plausibility of their findings, stress that ‘association is not causation’ and suggest useful methods for future research, such as nesting interventions within database studies where prospective randomised.

We also have three excellent review articles in this month’s issue. Smith and Plunkett, in a thought-provoking article, highlight recent developments in safety science and challenge the current approach of only addressing negative outcomes. We should also be promoting excellence through appreciative inquiry, positive deviance and excellence reporting and the authors provide practical and useful suggestions on how to achieve this.

Figure 4

Figure 4 An example of an appreciative conversation. Taken from EP’s work with appreciating people and reproduced with permission.

In the second of our Clinical Consequences series, Wojcikiewicz & El-Boghdadly provide a succinct review on analgesic strategies for day-case knee surgery. The authors conclude multi-modal analgesia should be the standard of care and that administration of local anaesthesia may only provide short-term analgesic benefits. Finally, Andersson et al. performed a systematic review of the anaesthetic implications of butyrylcholinesterase deficiency. They conclude that deficiency prolongs the action of succinylcholine and mivacurium by a few minutes to several hours and these effects are more pronounced with homozygous variants, increasing age, pregnancy, severe liver disease and burn injuries. A useful flowchart is provided on how to best manage these patients.

Figure 5

Figure 5 Flowchart to guide anaesthetists for managing patients with known or suspected butyrylcholinesterase deficiency.

Over on early view, this paper is certainly causing a stir! It seems uncoated fluid warming devices may result in the release of high levels of aluminium into infusion fluids. This research was recently featured as a leading story in The Guardian and the story continues to evolve, with the MHRA recently issuing a field safety notice. We hope you enjoy this month’s issue and we look forward to seeing your feedback over on Twitter as we make each paper #FreeForADay!

 

Dr Akshay Shah and Professor Andrew Klein

Anaesthesia and the ageing brain

People with dementia present for elective and emergency surgery and there has been, until now, no formal peri-operative guideline for this important patient group. This new document puts this surprising lack of guidance right by providing pragmatic instruction on aspects such as standards of care, access to services, communication of risk, pre-operative assessment, multidisciplinary teams, and training for healthcare staff. As with all Association of Anaesthetists guidelines, we encourage members to inspect the contents and share the key messages with colleagues, departments, and hospitals. The infographic below summarises ten key recommendations.

Dementia

In their editorial, Scott and Evered describe a large number of unmet challenges in the peri-operative care of elderly patients and those with dementia. Though there are large gaps in the literature, and the new guidelines are not heavily evidence-based, we should all nonetheless utilise them to raise awareness of team-based care for older patients and those with dementia. Arguably, peri-operative care for those with dementia is decades behind other fields such as pre-operative optimisation. Is it time to catch up? We think so!

Upper limb disorders are common, but this new survey finds a far higher incidence in anaesthetists (34%) as compared with the general population. Interestingly, the years since starting training, having children (irrespective of respondents’ sex or number of children) and right‐handedness were the main risk factors identified. Vargas-Prada and Macdonald remind us that doctors are a group of workers who take little sickness leave and are usually reluctant to access appropriate healthcare. Perhaps we all now need to think about how best to redesign equipment/workplaces and eliminate hazardous working postures from our daily activities? Send us your thoughts through our correspondence site!

Anaesthetists seldom prescribe discharge medications for patients in the UK, but there has been a worrying worldwide increase in opioid prescribing over the last decade. This new quality improvement study finds that 27% of all postoperative discharge prescriptions for oxycodone were inappropriate. The authors employ five sequential interventions and show that it is possible to reduce this to just 10% over a three-year period.

Figure 1Figure 1 Time series of monthly oxycodone prescriptions per 100 surgical cases (left y‐axis). Dashed lines represent the end of the first month following the first intervention of five, and the audit‐feedback plus academic detailing interventions (number 5), respectively. Fitted trend‐lines show the predicted values from segmented regression analyses in the three observation periods.

The grading of physical status using the American Society of Anesthesiologists (ASA) system is common practice throughout the world. This new review article describes the history of ASA grading and explains why, despite its apparent subjectivity, we will probably be using it for many years to come. More recently, it has been successfully incorporated into other systems to help generate more accurate predictions of patient outcomes.

Table 1Table 1 The ASA classification of physical status, as revised in 2014. The addition of ‘E’ denotes emergency surgery, defined as a threat to survival or body part if delayed.

This new editorial from Marshall and Chrimes was commissioned by an editor following an interesting discussion about medication handling on Twitter. It is accompanied with an excellent infographic (which are all available to download here) and already has an Altmetric score of 150! Should remifentanil patient-controlled analgesia be used as a first-line analgesic strategy in labour? This editorial comments on a trial recently published in The Lancet and sets out the key messages from the RemiPCA SAFE Network. These include clinicians taking responsibility; using research to answer urgent clinical questions, such as vital signs monitoring and feedback mechanisms; and a need to define key quality indicators for different analgesic methods.

The anaesthesia practice in children observational trial (APRICOT) was a prospective multi‐centre observational study of severe critical events during paediatric anaesthesia from 261 hospitals in 33 European countries. This new, secondary analysis of the study data finds that the incidence of peri-operative severe critical events was less in the UK cohort as compared with the non-UK cohort. This is likely due to a number of factors such as more experienced dedicated paediatric anaesthetists managing higher risk patients in the UK.

Figure 2Figure 2 The incidence of severe respiratory (striped) and cardiovascular (solid) critical events according to age of the patient.

Elsewhere there is a review of the effect of dexmedetomidine on delirium and agitation in patients in intensive care; a comparison of the new ROTEMsigma with its predecessor, the ROTEMdelta; a study of the use of spectral reflectance to distinguish between tracheal and oesophageal tissue; an observational study of the The LMA® ProtectorTM in anaesthetised, non‐paralysed patients; a study measuring depth of anaesthesia using changes in directional connectivity; and a study to identify the optimal predictor of right ventricular global function.

The journal is currently advertising for new editors to join the team! We are also nearly ready to launch our new journal, Anaesthesia Reports, and they are also advertising for new Assistant Editors. These are exciting opportunities not to be missed. Finally, tonight we will be hosting a TweetChat with the authors of this new paper and you can join the discussion by searching for (and including in your tweets) the hashtag #Hyperoxia.

See you at 1900 GMT!

 

Dr Mike Charlesworth and Professor Andrew Klein

Airway management research – what next?

This month, we are delighted to publish the first systematic bibliometric review of airway management research. This stemmed from a series of exchanges on the benefits, risks, and ethics of conducting airway research in manikins vs. patients. Ahmad et al. included 1505 studies published between 2006 and 2017, of which 1082 (71.9%) were patient studies and 322 (21.4%) were manikin studies (Figure 1). They observed an increase in the annual number of airway management studies over time. Patient studies mostly included elective ASA 1-2 patients and reported on tracheal intubation. A total of 77 primary outcomes were measured with success rate (27.4%) and procedure time (22.7%) the most common. Only seven trials used patient-centered primary outcomes and the authors highlight the need for a core outcome set. McGrenaghan and Smith agree with these sentiments and discuss how airway research may be conducted in the future.

figure 1Figure 1 Flow diagram demonstrating study subjects, study design and type of patient airway involved in experimental patient studies. Grey circles are for all studies, blue circles are for patient studies, green circles are for manikin studies and yellow circles are for all other subject types.

Supraglottic airway devices (SAD) play an important role in difficult airway management. In this retrospective registry study, Thomsen et al. describe the use of SADs in cases of difficult airway management. The Danish database is a unique repository and receives information from over 75% of Danish hospitals – their work is always of interest. From a cohort of 658,104 patients, difficult intubation occurred in 4898 (0.74%) cases. The most striking and perhaps worrying finding was that only 18.9% received a SAD in the course of their management. When SADs were used as rescue devices, they were successful two-thirds of the time. In their accompanying editorial, Ahmad and El-Boghdadly discuss possible reasons as to why SADs were so underutilised, and provide a framework for difficult airway management research (Figure 2). How does fibreoptic-guided tracheal intubation through a SAD compare between an I-gel® with the LMA® Protector™? Mendonca et al. observed no differences in mean intubation time, success rate, glottic view and ease of tracheal intubation.

figure 2Figure 2 Proposed framework for developing a difficult airway management research strategy.

The Global Capnography Project is arguably one of the most important projects in anaesthesia safety in the last decade. The results from their new study in Malawi support the development of an international project to help make global capnography provision a reality, so that like pulse oximetry, it can be included in the WHO surgical safety checklist and improve patient safety worldwide. In their accompanying editorial, Lipnick et al. call upon the global anaesthesia community (i.e. providers, researchers, national societies, manufacturers and donors) to accelerate research, education and development, manufacture, and distribution to make capnography accessible to anaesthesia providers in all practice settings.

Kwikiriza et al. report their RCT of intrathecal morphine versus ultra-sounded guided transverse abdominis plane block after caesarean section at a Ugandan regional referral hospital. Overall, the authors found both approaches were clinically effective in terms of providing adequate pain relief. The authors should be commended on this well-conducted study and for demonstrating the potential of using ultrasound in a low-resource setting. In the accompanying editorial, Bashford and Vercueil, provide suggestions on supporting and conducting such research and what role journals can play in developing and promoting authors from low‐ and middle‐income countries.

This case series on anaphylaxis to intravenous gelatin‐based solutions from Farooque et al. attracted plenty of attention during a TweetChat in December. Twelve patients were identified over a five-year period, 11 of which had severe or life-threatening reactions with three progressing to cardiac arrest. Unlike the classic presentation of anaphylaxis, which occurs within five minutes, the majority of patients developed signs/symptoms 10-70 minutes after administration. The commonest clinical features were cutaneous signs and hypotension. In view of the risk of severe allergy, along with the lack of any other clear benefits, is this the final nail in the coffin for the use of gelatins? Catch up with all the discussion on Twitter by searching for #Gelophylaxis.

The guidelines for the safe practice of total intravenous anaesthesia (TIVA) are a core document and essential reading for all anaesthetists (Figure 4). They have been extremely well received on social media with an Altmetric score of >300. Irwin and Wong argue that more work needs to be done on the practical education of TIVA and processed EEG monitoring so that more patients can benefit from this technique.

figure 4 - tiva guidelineFigure 4 Key recommendations from the TIVA guidelines.

Elsewhere, Morrison et al. suggest that fibrinogen concentrate may be used as an alternative to fresh frozen plasma to treat hypofibrinogenemia and coagulopathy during thoraco-abdominal aortic aneurysm repair. Tabl et al. were unable to demonstrate non-inferiority in uterine tone induced at elective caesarean delivery by carbetocin 20 mg to that induced by carbetocin 100 mg. Wittenmeier et al. report that point of care and non-invasive haemoglobin measurement devices are still not reliable enough to replace the laboratory measurement in term and pre-term infants. Lastly, Ferguson & Dennis review the literature regarding various definitions of anaemia in pregnant women (Figure 5) and provide a framework for patient blood management in obstetrics.

table 1Table 1 Definitions of anaemia in pregnancy in guidelines.

This blog follows an excellent Winter Scientific Meeting. Highlights from the journal session included Dr Kariem El-Boghdadly announcing the imminent arrival of Anaesthesia Reports (@Anaes_Reports), Professor Bruce Biccard’s talk on delivering pragmatic clinical trials in low resource settings, and Professor Peter Marfoher’s update in regional anaesthesia for shoulder surgery. Our journal workshop on ‘How to publish a paper’ also proved popular.

prof bb pic

 

Dr Akshay Shah and Professor Andrew Klein

Patient optimisation before surgery

Imagine a future where complete patient data are precisely recorded and seamlessly transferred between clinicians; where patients are presented with plain, accurate facts; where decision-making is shared; where patients experience less post-operative complications and shorter hospital stays; and where patients rapidly return to their functional and cognitive baseline. In their editorial, Levy et al. argue all this and much more is achievable, now. This year’s supplement contains 14 evidence-based free to access review articles and is a user-friendly, complete, and practical manual for all healthcare workers, patients, and relatives/carers. This month’s blog aims to pick out the key clinical messages.

Much time and effort seem to be spent developing models to predict postoperative morbidity and mortality, and we all use them to inform discussions with patients. John Carlisle asks, are they fit for purpose? Far from it, he argues, and we should instead focus on selecting who to operate on and how. This is a must-read for all anaesthetists as it challenges the fundamentals of how we think about peri-operative risk, communication of risk, care of the dying (and living!), patient selection, and healthcare priorities.

We all know what we mean by ‘shared decision-making’, but how does it differ from informed consent (which has its own problems), risk assessment, and decision aids? This review from Sturgess et al. discusses the relevant legal background; the barriers to peri-operative shared decision-making; the need for patient-focused processes; and how shared decision-making might be implemented. Perhaps a good place to start is with the SHARE approach (Table 1) and MAGIC questions (Table 2).

Table 1Table 1 The SHARE approach to shared decision-making: five essential steps for clinicians

Table 2Table 2 MAGIC questions for patients to ask their healthcare professionals

Multi-modal prehabilitation may reduce post-operative complications by 30% and shorten hospital stay after major surgery. This review from Sheede-Bergdahl et al. addresses the ‘why, when, what, how and where next?’. It seems nutritional and psychological optimisation are just as important as physical activity and exercise, and the pre-operative period should be fully utilised in order to promote more effective care (Figure 1). Gillis and Wischmeyer set out the case for pre-operative nutrition screening for the diagnosis, treatment, and prevention of peri-operative malnutrition, which may prevent complications and shorten hospital length of stay. Likewise, Levett and Grimmett present strategies for psychological prehabilitation and describe the limitations of the relevant evidence. Perhaps this should be a high priority area for future research?

Figure 1Figure 1 An overview of a multi-modal prehabilitation programme and related goals. SF-36, 36-Item Short Form Health Survey; HADS, Hospital Anxiety and Depression Scale.

The prevalence of asthma is increasing and now stands at 10-15% in developed countries. The incidence of peri-operative bronchospasm in those with asthma is ~1.7%, and Andrew Lumb argues pre-operative optimisation of respiratory disease such as asthma together with smoking cessation (which alone may reduce complications by as much as 41% if stopped four weeks prior to surgery) are high-impact evidence-based interventions. The evidence for exercise training for the prevention of postoperative pulmonary complications is mixed, but it does remain an important strategy. Around 40% of patients presenting for major surgery are anaemic and peri-operative anaemia is associated with poor postoperative outcomes. Munting and Klein provide an evidence-based treatment algorithm that should be used by everyone encountering patients scheduled for surgery. Print it out and put it on the wall!

Figure 2Figure 2 Treatment algorithm for preoperative anaemia.

Optimisation of diabetes prior to major surgery can take as long as three months. Gathering information and making a referral at an early stage is vital. Levy and Dhatariya argue the identification of poorly controlled or undiagnosed diabetes just prior to elective surgery is no longer acceptable. They propose criteria for diabetes screening prior to the initial referral for surgery (Table 3).

Table 3Table 3 Proposal for who should be screened for diabetes before referral for surgery.

Two hundred million major operations are performed worldwide every year with 10% of patients suffering postoperative complications. Though death due to surgery and/or anaesthesia is rare, 40% of peri-operative deaths may be attributed to a cardiac complication. Lee et al. discuss how assessment and management of cardiac conditions in the peri-operative period can significantly improve outcomes, especially for high-risk patients. Topics include hypertension; chronic heart failure; cardiac murmurs; and implantable devices. These should all be seen as modifiable risk factors that require attention well in advance of surgery. The proportion of the population aged over 65 years in the UK is expected to increase from 16.9% to 24.7% between 2006 and 2046. More than 40% of patients aged over 80 years are considered to be frail, with frailty more common in women. Chan et al. discuss the principles of peri-operative optimisation as applied to elderly and frail patients, and call for tailored pathways incorporating social issues; shared decision-making for patients and families; multidisciplinary care; personal values; and quality of life.

As depicted by the title picture for this blog, our traditional working environment is still seen by many as the operating theatre. Grocott et al. argue there is a need for us to adapt to the changing nature of our work and align our interests with those of patients. Their proposed ‘re-engineered’ pre-operative pathway hints at what the future of peri-operative medicine could look like (Figure 3 and 4).

Figure 3Figure 3 Traditional pre-operative pathway. MDT, multidisciplinary team.

Figure 4Figure 4 Proposed ‘re-engineered’ pre-operative pathway.

So far there has been much discussion about elective surgery. Poulton and Murray argue the principles of optimisation should also be applied to patients undergoing emergency laparotomy. Strategies include the timely administration of antibiotics; rational fluid resuscitation and electrolyte balance; omitting and optimising medications; nutrition; glycaemic control; pre-operative physiotherapy; damage control surgery; reducing delays; timely access to CT scans and other investigations; standardisation and surgical pathways; recognising high-risk cases; consultant-lead care; and shared decision-making. The time available to address each of these components should be traded against the need for timely surgery, particularly in the context of sepsis or circulatory shock.

Finally, we have included two reviews from the January issue, which were extremely well received last month. The review of pre-operative fasting in adults and children from Fawcett and Thomas currently has an Altmetric score of 156! The paper from du Toit et al. reminds us that half the world’s population live in low and middle Human Developmental Index (HDI) countries, and patients from these countries are poorly represented in systematically reviewed evidence on pre-operative optimisation.

We hope you enjoy this year’s supplement, which is the most complete, accurate and up to date synthesis of evidence, consensus and expert opinion relevant to patient optimisation before surgery. More importantly, we hope it contributes to further incremental improvements in the quality of care for patients in the peri-operative period.

See you next week for #WSMLondon19!

Dr Mike Charlesworth and Professor Andrew Klein