A new year, another investigation

The January edition of the journal is out today, which feels strange considering Christmas hasn’t even happened yet (but is definitely coming). In an era of evidence-based medicine, scientific misconduct remains a real threat to medical research. John Carlisle, one of the editors of this journal, has developed an analytical method in order to determine whether baseline data is truly random in what is now known as the Carlisle Method. The new year brings another potential case of data fabrication. This was triggered by the submission of a suspect article to another journal, and when the data from this and other manuscripts by the same author were examined closely, there was evidence of non-random sampling. In other words, that the data was not random in its distribution in 31 trials published by Yujhi Saitoh. The majority of these papers were about neuromuscular monitoring, and they were broadly spread around the anaesthetic journals worldwide. Seven of these were published in the Canadian Journal of Anesthesia, six in the British Journal of Anaesthesia, four in the European Journal of Anaesthesiology, three in Anesthesia and Analgesia, three in Anaesthesia, three in the Journal of Anesthesia, two in Acta Anaesthesiologica Scandinavica, two in the Journal of Clinical Anaesthesia, and one in the Fukushima Journal of Medical Sciences.

This is clearly very concerning, and we await the findings from the investigation that is ongoing by the Japanese Society of Anaesthesia. However, we can’t only look backwards at studies that are already published – we also need to look very closely at what is submitted to journals in all different specialties in the future. To that end, at Anaesthesia, we have decided to screen all randomised controlled trials submitted to the journal from 2016 using the Carlisle Method. We believe we are the first journal to do this. Any that fall foul due to suspicious data that are not consistent with random sampling will be rejected and the authors informed of the reason for rejection. We hope to persuade all the other anaesthetic journals to follow suit soon, and will look to involve other specialties and organisations over the coming years.

We are seeing more and more ‘disposable’ single-use devices in our practice. These include laryngoscopes, bougies, and now even fibreoptic scopes. While there are clear advantages in terms of infection control, there remains concern about comparable efficacy, design, cost and the ‘green’ effect of throwing away so much plastic and other materials. With this in mind, it is very tempting to re-use these single-use devices in the same patient repeatedly, both on the same day and perhaps even on subsequent days, especially in the case of fibreoptic scopes. Surely if they are going back into the same patient then that can’t do any harm? Wrong – a study published in this month’s edition of the journal showed that 16 out of 20 bronchoscopes cleaned then kept after use were contaminated after 48 hours. There is a very clear clinical lesson here – single-use means exactly that, and you can’t re-use them later even in the same patient. This will have significant implications for many hospitals I suspect.

This is a welcome update on consent for anaesthesia in this month’s journal, and this a ‘must read’ for every anaesthetist. The twelve key tenets include intuitive as well extremely thoughtful recommendations. Full consent should be obtained as early in the patient pathway as possible (not in the anaesthetic room), and the information provided should be tailored to each patient, with adequate time allowed for patient questions. Documentation should be made of the consent obtained although specific consent forms are not required. The fluid nature of consent means it is an ongoing process and should be confirmed at each interventional stage. If a patient lacks capacity, the reasons should be documented, efforts should be made to reverse or reduce temporary incapacity, and if this is unachievable we should always act in the patient’s best interest. Seeking a lasting power of attorney (LPA), valid advanced decisions, a validly appointed health and welfare LPA or a court-appointed deputy are legally binding. A knowledge of the existing frameworks regarding consent in patients aged 17 or younger is recommended. Finally, when training in practical procedures is undertaken, maximising benefit whilst minimising risk to the patient is important and alternative means of training, such as virtual models or manikins should be considered. These guidelines are clear and thorough and will be the mainstay of clinical practice for years to come.

Finally for now, we have published a comparison of the adjustable pressure-limiting valves in two well-known anaesthetic machines. The manufacturer of the APL that was shown to be ‘unusual’ in its performance has also commented on the study, and an accompanying editorial has put this into perspective. The clinical lesson here is know the machine you are using and read the instructions for use. Admittedly, so many of us don’t, and if you read this article you will see how important it is to know the difference between different designs of APLs and how they function in practice, especially for paediatric use. My final comment is, why are different APLs produced and why aren’t clinicians telling manufacturers what they want and being involved in the design of new equipment? It seems nonsensical to me that there should be such a difference, with such important implications, in APLs on different common anaesthetic machines. Should we accept this from a safety perspective?

Andrew Klein

Editor-in-Chief