The first Anaesthesia blog – April edition

This is the first Anaesthesia Blog, which will mostly talk about the new April edition of the journal. The reason for the discrepancy in months is that the following month’s edition is published online two weeks or so before it is posted out to AAGBI members and print journal subscribers. The idea of the new journal Blog is to direct you to interesting, topical or controversial articles, editorials, reviews, guidelines and letters.

Deciding what to read as a clinician is increasingly hard, as more and more journals seem to spring up each month, and thousands of anaesthetic, intensive care, pain or peri-operative medicine articles are published each year, seemingly continuously. Each journal needs a raison d’être, and ours is to publish clinically relevant, important and novel literature. As a UK-based journal, we have traditionally published a lot of papers from the UK, but that is changing, as more and more submissions arrive from upcoming powerhouses in the research world like China and Korea. Despite all the changes over the last few years, we strive to improve our standards year by year, and to be the best most clinically relevant journal out there.

The new April edition of the journal focuses on a number of sub-specialist areas, but also contains a review of capnography for sedation, which is likely to be relevant to all anaesthetists. The authors, having examined six trials containing 2524 participants, concluded that the use of capnography reduced hypoxaemic episodes. However, they also commented that the quality of the evidence was poor and that this was an area ripe for future research, which was re-iterated by Professor Cook in his accompanying editorial. This discusses what progress has been made towards much more widespread use of capnography outside of the operating theatre. I have certainly noticed that capnography is now routinely used in the ICU and during recovery from anaesthesia, and also for transferring patients around the hospital, but it is yet to be used more widely for sedation, and I agree that further evaluation for such use is urgently required.

Regional anaesthesia is a burgeoning sub-specialty of our practice, and there are a number of innovative and important articles in this issue. The first reports on 1505 patients who received continuous interscalene analgesia at home via a ultrasound-guided catheter. The authors managed to get around the myriad of logistical and safety concerns related to ambulatory administration of the block, and the catheters themselves were taken out by the patients. They reported that 27% of patients reported mild dyspnoea, 13% hoarseness and 7% dysphagia. Twelve percent sought medical advice and 2% reported technical issues with the pump or tubing. The relevance of the excellent large series to practice in other institutions and healthcare settings are described in an accompanying editorial, aptly entitled interscalene catheters – should we give them the cold shoulder? Finally, the use of dexamethasone, either intravenously or added to the local anaesthetic mixture, is examined in a randomised controlled trial of interscalene blocks. The authors concluded that giving dexamethasone intravenously at a dose of 8mg was just as good as giving it perineurally, and probably safer.

Pain relief in the emergency or trauma setting is a controversial subject, and an age-old anaesthetic drug in a new formulation, methoxyflurane, was tested in patients having burns dressings changed. The authors reported a 97% success rate of methoxyflurane analgesia to facilitate these procedures, but noted that limitations included maximal daily and weekly doses, and uncertainty regarding safety in patients with pre-existing renal disease.

The final review I am going to mention concerns radiation safety, which examined a number of studies that showed that at 1.5 m from the source of radiation, anaesthetists received almost no radiation, and that the radiation doses at this distance were often at the limits of the sensitivity of the measuring dosimeter. Does that mean we can take our leads off in theatre as long as we sit more than 1.5m away? I can’t see that happening but in an evidence-based environment perhaps it should?

Teamwork and communication are both buzzwords for all peri-operative physicians, and of vital importance to our everyday practice. Examining different ways of communicating and evaluating their effectiveness is quite a new area of research, and we are seeing more and more submissions to the journal about this subject. This month sees the publication of an excellent study that examined the use of cognitive aids during a simulated intra-operative emergency (anaphylaxis). Team performance was improved by the use of a cognitive aid, and a linear type of aid had the greatest effect. This study should help the design of future cognitive aids, be they on paper or on our smartphones or other innovative technology, and the study methodology was very well-planned and executed to allow the authors to answer their questions about how teams work best.

My final word is a look into what is coming up in the journal. Next month we will feature a lesson in the ethics of clinical trials, which makes scary reading and should prompt us all to re-examine how we categorise research, audits and service evaluations, a thorny issue. Next month will also see the publication of a trial comparing patient-administered with nurse-administered oral analgesia after caesarean section, which could mean the end of the drug round. In April, we will be holding our first Twitter-moderated ‘Chat’ about an interesting new article on analgesia for patients carried on emergency medical evacuation helicopters.

Andrew Klein, Editor-in-Chief, Anaesthesia