Major trauma, marginal gains

There is little doubt that major trauma care has significantly improved over the last three decades. This is likely due to the cumulative effect of a number of practice changes such as, but not limited to, regional trauma networks, education (though ATLS and its limitations have been discussed at length) and the implementation of systems and procedures from the military setting. In this month’s Anaesthesia, Stein et al. report retrospective observational data from University Hospital, Zürich before (2005-07) and after (2012-14) establishing several quality improvement bundles, including the implementation of a goal-directed transfusion and coagulation algorithm. They found significant reductions in the incidence of massive transfusion, administration of blood products, mortality and ICU stay (Table 1).

Table 1 Raw and adjusted differences in transfusion of allogeneic blood products and outcome between the two cohorts (2005–2007 and 2012–2014). Values are number (proportion), mean (SD) and odds ratio (95%CI)

Smith and Choi urge for cautions interpretation of these results. The main issue seems to be the retrospective manner of data collection and the resultant difficulty in determining the exact size of the effect. This begs the question, why do we persist with retrospective studies when they have clear limitations? One suggestion is that, through versatility and pragmatism, retrospective observation can force rapid advances in patient care by allowing us to form testable hypotheses, establish trends and make sense of clinical practice. As we have seen with ERAS+, comparing outcomes before and after a series of quality improvement interventions can provide powerful evidence for these practice changes. There are several retrospective observational studies this month and we will no doubt see many more in the future.

We are seeing more older adults with injuries sustained through major trauma and the results from Stein et al. support this perception. In the UK, over half of all those entered onto a recent national trauma database were over 60 years old. Griffiths and Kumar discuss the implications of this changing demographic and ask whether systems for the management of major trauma are fit for the needs of older adults? The recent ‘Trauma Audit and Research Network (TARN)’ report suggests that many improvements are required, starting with more effective ways of injury prevention in the home. The one bit of good news (and there isn’t much) is that many older patients do well and return home following a full recovery. The report and editorial are essential reading for anyone with an interest in trauma management.

Green et al. report an analysis of CLWRota data from 2.5 million anaesthetic sessions during 2015. Their aim was to look at the number of supervised sessions trainees undertook as compared with the three per week RCoA standard. The results show the majority of trainees did not achieve this, more so with increasing seniority (Figure 1). It is suggested, amongst other measures, that logbook inspection should be more frequent so that training can be tailored to individual trainee requirements.

Figure 1 Number of supervised sessions worked by trainees per week in 89 Trusts, for individual training grades (the dotted horizontal line indicating the three sessions per week RCoA recommendation). Horizontal line, median; box, IQR; whiskers, 1.5 × IQR; crosses, outliers.

Penfold and Carey, the Joint Chairs of the Training Committee of the RCoA, write in their accompanying editorial that although trainees may not be meeting RCoA supervision standards, the overall impact of this may be difficult to quantify. Moreover, there are many barriers for Schools in their quest to meet these standards. Keeping with the training theme, England and Jenkins argue that clinical time is the most important aspect of a training programme and that it should be protected. They call for efficiency in the delivery of training outside the clinical environment and for trainers to provide this without reducing clinical time. What do you think about supervision and training time? Send us a letter through our correspondence website, or tweet us!

We continue to invite authors to submit narrative as well as systematic reviews to Anaesthesia, as we believe both evidence and opinion have their place in modern science and medicine. This month, Trend et al. present a narrative review of aerosolised drug therapy in children receiving respiratory support. It seems that we know less about the use of such drugs in these circumstances, and this review provides guidance as to when and how the inhaled route may be of value for such patients (Table 2).

Table 2 The clinical use of inhaled medications in children within speciﬁc therapeutic contexts.

Elsewhere, Bagchi et al. examine the association between the mode of perioperative ventilation and postoperative pulmonary complications (POPCs) in 109,360 patients (this has already generated a lot of interest on Twitter!). They found pressure-controlled ventilation to be associated with more POPCs, possibly due to higher driving pressures, higher tidal volumes and low or no PEEP. Heesen et al. report their results from a systematic review of epidural volume extension (EVE) by saline injection, and its effect on the efficacy and safety of intrathecal local anaesthetics. They found inadequate evidence in general, although a shorter motor block recovery time may result. Onodi et al. examine the difference between arterial and end-tidal carbon dioxide in 799 children undergoing mechanical ventilation during general anaesthesia. They conclude end-tidal monitoring of carbon dioxide may lead to an unrecognised hypocarbia.

There is much more in this month’s edition including a case series of apnoeic oxygenation for laryngeal surgery, an evaluation of various epidural drug mixes for labour analgesia and a comparison of gastric emptying for soluble solid meals and clear fluids matched for volume and energy content.

Finally, we were delighted to reveal the Top 10 Papers of 2016 at the recent Annual Congress meeting in Liverpool. You can find all these high-impact articles online in one convenient location. Our ‘How to publish a paper’ workshop continues to be well attended (Figure 2), and we look forward to seeing the abundance of ideas, enthusiasm and creativity transform into an article or two. Will they make the Top 10 Papers of 2017, or possibly even win? We certainly hope so!