We have, very recently, published a number of papers on proximal approaches to intercostal nerve blockade (Figure 1). Do such blocks confer any advantages over and above direct injection of local anaesthetic into the paravertebral space? Probably not, as there are simply too many clinical unknowns with much of our knowledge derived from cadaveric studies (such as that presented by Yang et al. in this month’s issue). Furthermore, proximal intercostal nerve blocks may exert their effect by spread to the paravertebral space, and this month, Costache et al. call for a precise, unified definition for such blocks – paravertebral by proxy. Importantly, they provide clinical recommendations on which blocks should be selected for given patients in a range of circumstances.
Figure 1 Schematic illustrating the location for the retrolaminar (RLB), intercostal/paraspinal, erector spinae plane (ESP) and midpoint transverse process to pleura (MTP) blocks.
The use of point of care ultrasound (POCUS) is, arguably, revolutionising the practice of modern obstetric anaesthesia. This new narrative review synthesises the current evidence and knowledge on its use to determine gastric contents, for safe airway management, and in order to quickly diagnose the cause(s) of breathlessness or acute circulatory collapse. It is, put simply, all you need to know about obstetric POCUS! When determining gastric contents, what exactly is a ‘full stomach’? Mike Kinsella argues there is no such phenomena, and more generally, that the use of confusing or imprecise language should be avoided. This underlines the belief that effective communication is arguably the key factor in providing safe medical practice.
How best to define ‘intra-operative hypotension’? We all know what it is, but the list of definitions is seemingly endless. This new study from Cleveland suggests intra-operative hypotension, defined as MAP < 65 mmHg, is strongly associated with postoperative acute kidney injury. Hypotension was somewhat more common prior to the first incision, and the authors call for anaesthetists to avoid hypotension immediately following induction of anaesthesia. Some have suggested a simpler message may be to avoid all hypotension, though defining how this sits in the era of bespoke anaesthesia presents more questions than answers. One possible way in which clinicians may negate intra-operative hypotension and postoperative acute kidney injury is though omission of ACE inhibitors/ARBs, but this collaborative study suggests otherwise. Both papers have been tweeted hundreds of times already and will be of interest to all readers!
How good are we at applying cricoid pressure, (or force, if you are so inclined)? This prospective study uses ultrasound to localise the cricoid cartilage as compared with a landmark method. The results are somewhat surprising, and bring into question previous studies of cricoid pressure efficacy. There are major clinical implications and we want to know if your practice will change?
Can this new device reduce the incidence of false passage formation, trauma, and failure as compared with the recommended technique for emergency front of neck access (eFONA) (Figure 2)? The results seem to be promising, at least in an obese porcine model, but how best to ethically study and use such devices in humans? As we have already seen, ‘The Airway App’ is a great way in which to collect data, collaborate, share practices, and learn from eFONA experiences. Are such methods better than large, whole-population database analyses? This new study from Denmark arguably provides important data on the characteristics of children less than two years of age undergoing anaesthesia. The accompanying editorial asks whether or not such databases are useful, and discusses the role of epidemiological surveys with reference to making sense of trends in clinical practice. Finally, this new observational study concludes middle finger length may be better associated with internal uncuffed endotracheal tube diameter in children than traditional formulae. Following on from the editorial by Craig Bailey, we are assured a similar study of cuffed tubes is on the way!
Figure 2 Cricothyroidotomy introducer.
Elsewhere this month, there is a cohort study of the effect of lateral infraclavicular brachial plexus block on the axillary and suprascapular nerves as determined by electromyography, a randomised trial of serratus anterior plane block for analgesia after thoracoscopic surgery, and a meta‐analysis and trial sequential analysis of local vs. general anaesthesia for carotid endarterectomy. Over in Anaesthesia Cases, new reports include a description of spinal subdural haematoma pathophysiology and management following an epidural blood patch, and pharmacological cardioversion with nifekalant after release of the aortic cross-clamp during cardiac surgery.
This month’s blog immediately follows an incredible Annual Congress meeting in Dublin. Highlights included a keynote talk from Professor Rob Dyer (Cape Town, South Africa), a much-valued international advisory panel member for the journal. Professor Dyer also spoke on the peri-operative challenges of pre-eclampsia at the Anaesthesia journal session. Professor Mike Irwin delivered a fascinating talk on the advantages, disadvantages and clinical controversies associated with peri-operative remifentanil. Matt Wiles revealed the Top 10 Papers from 2017, with the award for best paper presented to John Carlisle for his ground-breaking analyses of randomised controlled trials from several major medical journals. John’s paper now has an Altmetric score of nearly 1000, making it the most shared and discussed paper we have ever published! It will most likely become our most cited paper too, replacing the classic paper by Cormack and Lehane. Our journal workshop, ‘How to publish a paper’, again proved popular among trainees and consultants alike, and we hope to see abstracts converted into papers over the next year.
Finally, congratulations to Akshay Shah from Oxford University who joins as trainee fellow. Kariem and Mike join the editorial board as Anaesthesia Cases Editor and Social Media Editor respectively.
Mike Charlesworth Andrew Klein
Social Media Editor Editor-in-Chief