Patient blood management is an international multidisciplinary initiative that aims to reduce the unnecessary transfusion of allogeneic blood components. Strategies include: the avoidance of oversampling; the use of appropriate transfusion triggers; the preoperative management of anaemia; and means of blood conservation, such as intra-operative cell salvage. One area that has perhaps been overlooked is the postoperative period, and this new international consensus statement on the management of postoperative anaemia after major surgical procedures aims to put this surprising lack of guidance right. Recommendations include screening those who have undergone major surgery for anaemia, monitoring the haemoglobin concentration until at least the third postoperative day, and the consideration of intravenous iron therapy or erythropoiesis stimulating agents. In their editorial, Hatton and Smith discuss several implications for clinical practice. An interesting consequence is the suggestion of increased cost-effectiveness, though there remain many unanswered questions about the role of iron therapy for certain patient populations, such as the elderly and frail.
The National Tracheostomy Patient Safety Project started as four intensive care doctors in Manchester wanting to improve the management of patients with tracheostomies. In 2012, we published their first multidisciplinary guideline on the management of tracheostomy and laryngectomy airway emergencies. Now, signs providing crucial information and algorithms can be found on the bedhead of every inpatient with a tracheostomy. This month, we are delighted to publish new guidelines for the management of paediatric tracheostomy emergencies. There are key differences when managing the routine and emergency care of children with tracheostomies and their reading is essential for all anaesthetists and intensivists working in a hospital that cares for children. Mackinnon and Volk discuss the need such guidelines, the use of simulation, their implementation and likely impact. They argue the guidelines will only work if shared and disseminated widely, and we call for all our readers and followers to do just that!
Figure 1 National tracheostomy safety project emergency paediatric tracheostomy emergency management algorithm.
On the subject of paediatric airway management, this survey of paediatric and neonatal intensive care units has provoked much discussion on Twitter and was reported by BBC News. The authors found wide variations in practice with regards, for example, the availability of capnography, the existence of a difficult airway policy and the use of pre-intubation checklists. We expect there will be several letters from those working in such areas and we look forward to seeing the discussion continue.
There is a need to provide better training for junior medical staff who may care for patients in the perioperative period. This new mixed methods study evaluates the implantation of a new Foundation Programme in perioperative medicine for older people. The new programme proved popular and was able to deliver generic competencies alongside training in specialist topics, and the authors suggest such training may better meet the needs of an increasingly multimorbid surgical patient population. How best to optimise preoperative assessment for older people? This editorial has already been well received on Twitter and issues key clinical recommendation for such patients, including: the use of frailty scores and cognition checks; offering enhanced support where required; collaborating with geriatricians; shared decision making and admission planning.
Can a single, pre-operative dose of methylprednisolone reduce the severity of postoperative delirium? No, concludes this new randomised controlled trial, though it may reduce the prevalence of delirium and the severity of fatigue after hip fracture surgery in older patients, enabling remobilisation and recovery. Last month, we published an article on the characteristics of children aged less than 2 years undergoing anaesthesia in Danish hospitals between 2005-2015. This month, important information on children aged 2-17 undergoing anaesthesia during the same period is provided. Younger children were more frequently anaesthetised for non-surgical reasons and the use of inhalational agents was common. Reassuringly, complications were rare. The use of focussed cardiac ultrasound has many emerging uses and this paper demonstrates its utility for evaluating the haemodynamics of various positions in term pregnant women. It turns out that, in the ramped position, left lateral tilt may be unnecessary. Fascinating!
Elsewhere this month we have a study of cognitive recovery assessments in patients with low‐baseline cognition, an in‐vitro analysis of a novel ‘add‐on’ silicone cuff to improve sealing properties of tracheal tubes, a retrospective study of the association of time of emergency surgery with postoperative 30-day hospital mortality, and a study of the volume of 0.2% ropivacaine and common peroneal nerve block duration. Finally, in this month’s Snippet, we are reminded of the importance of ensuring not only monitoring wires but also oxygen tubing remains in sight at patient height during transfer.
Figure 2 Sheared oxygen hose.
Over in Anaesthesia Cases we have a great new case report of anaphylaxis to all neuromuscular blocking agents, the first such case! Again, this has already attracted much attention on Twitter including a discussion of triggers to commence CPR in the context of perioperative anaphylaxis. Finally, as the end of the year draws closer, we begin to look forward to our Christmas article, which features in the December issue, and our January preoperative optimisation supplement, which will be published towards the end of December.
Mike Charlesworth Andrew Klein
Social Media Editor Editor-in-Chief