Socially accountable anaesthesia

It was reported in 2006 that anaesthetists in Uganda had the facilities to deliver safe anaesthesia for adults, children and pregnant women only 23%, 13% and 6% of the time, respectively. Furthermore, only 13 physician anaesthetists were in place for a population of 29 million. Thereafter, the AAGBI established a fellowship scheme with the primary aim to increase the number of physician anaesthetists in Uganda to 50. In this month’s Anaesthesia, the much-anticipated results of this initiative are presented, analysed and discussed. A mixed-methods approach (you can read all about qualitative research here) clearly demonstrates how a partnership between two professional organisations has profoundly changed healthcare in Uganda beyond the initial goal of improving human resource capacity. Unexpected benefits include greater access to surgery, anaesthesia and intensive care, and improved standards of training and patient care.

The accompanying editorial by Biccard and Green-Thompson describes how, in most low and middle-income countries, the demand for care far outstrips the capacity to provide it. There seems to be a global maldistribution of anaesthetic and surgical expertise, and part of the solution could be socially accountable education of future practitioners. They argue this should produce healthcare graduates who are responsive to the social needs of the local environment. Standards of care can be concurrently formed through partnerships and innovations, such as the Lifebox initiative (more about that here). Motivated learners can then be identified and supported through fellowships and emerge as socially responsive healthcare providers, able to address the limitations of a resource-limited environment. Socially accountable anaesthesia is therefore less about transference of a system into a country and more about supporting an existing system to thrive and become sustainable, and the trainee fellowship programme in Uganda is a remarkable example of this.

In patients undergoing general anaesthesia, does nitrous oxide decrease, increase or have no effect on the risk of accidental awareness under general anaesthesia (AAGA)? (Read all about the recent evidence related to AAGA here!) This Cochrane systematic review of 15 RCTs finds only three cases of reported awareness in the included literature. This, together with the poor quality of evidence meant it was not possible to draw meaningful conclusions, other than that the risk of awareness with or without nitrous oxide is unknown and included trials were not powered to measure awareness as a primary outcome. Is this yet another example of a question that cannot be answered with an RCT and where we may need to rely on observational ‘big-data’ analyses? Possibly….but more on that later!

Gastric ultrasound as a means to assess gastric content prior to, during and following surgery seems to be an increasingly popular area of study. For example, we have recently seen studies of the risk of aspiration through regurgitation of ingested blood in children undergoing ENT surgery, gastric emptying in healthy controls as compared with patients with end-stage renal failure and assessment of the gastric antrum before and after elective caesarean section. The first of two new such studies this month is an RCT of non-labouring pregnant women in the third-trimester randomised to one of six pre-determined volumes of apple juice. Ultrasound measurements following an 8-hour fast and immediately after the drink were taken, and a model for gastric volume estimation was derived. The resultant equation is the first mathematical model to predict gastric volumes in late pregnancy using bedside point of care ultrasound, and may one-day change the way perioperative care is delivered for such patients.

Additionally, a prospective observational study of pre-operative gastric ultrasound assessment in children undergoing elective surgery concludes it may provide more useful information than clinical assessment alone when aiming to predict the risk of pulmonary aspiration. Should we be using gastric ultrasound in our routine clinical practice to assess the risk of aspiration pneumonitis? Van de Putte and Perlas debate what constitutes a clinically insignificant gastric volume prior to anaesthesia, and conclude we may not be far from a simple, clinically-relevant bedside tool to help us accurately assess this risk. They discuss many issues pertaining to the timing of gastric ultrasound, how it should be performed and who should be doing it? There is lots here to discuss and debate and we would very much like to hear your thoughts.

When designing a study, one must decide which outcomes should be measured. For example, when comparing two analgesics, should we aim to demonstrate less pain, faster recovery or shorter length of stay? Say ‘less pain’ is selected, does this equate with lower pain scores, less morphine administered, longer time between requests, or should we use patient-related functional outcomes? A systematic review of outcomes in postoperative pain studies in children and adolescents finds a worrying lack of standardisation in outcome measurements that may prevent the pooling of such studies in a meta-analysis. The authors call for a core outcome set that may improve the quality of future trials and allow for more study-to-study comparisons. With regards outcome selection for systematic reviews, Heesen et al. suggest distinctions between primary and secondary outcomes should be abandoned. They also argue that clinically useful sub-group analyses should be reported regardless of whether or not it was planned to do so. Departures from the study protocol can be easily explained retrospectively in order to provide transparency.

This retrospective observational study in 1,478,977 patients concludes general anaesthesia is associated with a significantly higher risk of new-onset epilepsy, more so in patients with co-existing medical conditions and those suffering postoperative complications. ‘Big-data’ observational analyses are arguably more difficult to understand and interpret than an RCT, yet we are becoming more reliant on such studies to answer the questions RCTs cannot. (You can read all about the limitations and merits of retrospective observation here.) Thankfully, Ms Method Matters is on hand to guide us in our attempts to understand this finding. She concludes that when applying the results to a hypothetical Taiwanese population, there would be one more case of epilepsy for every 1111 undergoing general rather than neuraxial anaesthesia. Despite this context, there are certain limitations that cast doubt over our ability to comment on accuracy and clinical significance. Is the risk of epilepsy greater in those receiving general or neuraxial anaesthesia? Perhaps we will never know!

Elsewhere this month there is a RCT of different perioperative strategies for the management of patients with type-2 diabetes undergoing non-cardiac surgery, a RCT comparing recovery characteristics for patients receiving either sugammadex or neostigmine for reversal of neuromuscular blockade, a before and after observational study of a protocol or use of the C-MAC videolaryngoscope with a Frova introducer in pre-hospital rapid sequence intubation and an observational feasibility study of a new anaesthesia drug storage tray. Finally, with the abstract deadline for #GATASM18 fast approaching, we encourage you to send us your work! We enjoy reading your abstracts and many have the potential to become full papers. We hope you enjoy the March issue as much as we did, and we look forward to discussing each paper with you on Twitter. Don’t forget, each article is free for 24 hours on the day it is tweeted!