November 2018 – #TheAnaesthesiaBlog

What’s in a name? Researchers often want their studies to have catchy acronyms so they are easy to remember, advertise and tweet. This year’s special Christmas article assesses the prevalence of novel acronyms in the titles of anaesthetic and related studies, and the response of anaesthetists to them. Overall, acronyms were memorable at best but did not aid recall of the study topic and were generally unhelpful. It would be interesting to see the results of the ORANGUTAN score (Figure 1) as applied to studies from other specialties, but as Weale et al. quite rightly point out – we probably need to get out more.

Figure 1 The ORANGUTAN scoring system for acronym accuracy and relevance.

An increasing number of patients are prescribed direct oral anticoagulants (DOACs) and there is a need for guidance on issues such as peri-operative cessation, reversal, and management of DOAC-associated bleeding. This month, we are delighted to publish the first multidisciplinary consensus statement on the management of DOACs for cardiac surgical patients. Though specific for cardiac surgery, there is also much useful advice for non-cardiac anaesthetists. In their accompanying editorial, Charlesworth and Arya argue peri-operative costs such as drug level assays and reversal agents should have perhaps been considered in already completed cost-effectiveness analyses.

On the topic of bleeding, what are the implications of activated partial thromboplastin time (APTT) for anaesthesia and surgery? We are perhaps less familiar with APTT as compared with other formal tests of coagulation, and this article will be of interest to all. It seems we should not ignore an isolated abnormal result, as causes may include a lack of coagulation factors VIII (Haemophilia A), IX (Haemophilia B), XI and XII; systemic anticoagulation from heparin; the presence of the lupus anticoagulant; and von Willebrand’s disease. Likewise, a positive bleeding history in a patient with a normal APTT should not be ignored. If in doubt, ask a haematologist!

Figure 2 A suggested pathway for the management of deranged pre‐operative activated partial thromboplastin time (APTT).

“Yuk! That’s disgusting” – we have all heard those words from children when they try new food, drinks, and medicines. Salman et al. address an important clinical need in paediatric anaesthesia by evaluating the effect of a chocolate-based midazolam tablet in children aged 3-16 undergoing surgery. Though this new formulation underwent a higher first-pass metabolism, it was far more tolerable and remained efficacious when compared to i.v. midazolam solution given orally. In their editorial, Yuen and Bailey discuss the implications for other premedicants and drugs (e.g. antibiotics), the effects on the developing brain, and whether other flavours should also be developed.

Postoperative sore throat is an undesirable outcome for both patients and anaesthetists. From their meta-analysis, Kuriyama et al. conclude the topical application of corticosteroids to tracheal tubes significantly reduces the incidence of postoperative sore throat without any adverse effects and with a number needed to prevent of three. The quality of evidence was high and they even performed a trial sequential analysis to enhance the robustness of their findings. A potential practice changer? Let us know!

Traditional airway teachings are that plans ABC are attempted, sequentially, and failure should result in declaring a ‘cannot intubate, cannot oxygenate’ (CICO) situation. When faced with difficulty and in order to maximise ‘next-pass success’, is it possible to define final interventions before declaring CICO? Chrimes and Marshall discuss airway management at the opposite end of the alphabet: attempt XYZ. They call for a rapid, comprehensive and final single attempt at each of facemask ventilation, supraglottic airway insertion, and tracheal intubation that can be implemented independently of prior upper airway interventions (Table 1).

Table 1 Attempt XYZ: suggested optimisations.

How best to monitor cardiac output during surgery? This study finds that when thermodilution is compared with arterial pressure-based measurements, accuracy may be affected by routinely encountered clinical factors. For example, thermodilution is affected by haemodynamic variability and arterial pressure measurements are affected by peripheral vascular physiology. Gillies and Edwards discuss the array of cardiac output monitoring technologies available and ask – does using them to guide therapy in the peri‐operative period actually improve patient outcomes? Though there is little evidence yet that this is the case, the conclusions from OPTIMISE-2 and FLO-ELA are eagerly awaited. Finally, this pragmatic randomised controlled trial was able to show that high-flow nasal oxygen (not THRIVE!) reduced the length of hospital stay in cardiac surgical patients at high risk for respiratory complications. Postoperative high-flow nasal oxygen is becoming more common and it is great to see useful evidence like this emerging to support these practices.

Elsewhere we have a study of body temperature, cutaneous heat loss and skin blood flow during epidural anaesthesia for emergency caesarean section; a comparison of two techniques for induction of anaesthesia with target‐controlled infusion of propofol; a retrospective study of peri-operative extracorporeal cardiopulmonary resuscitation; a pilot study of cardiopulmonary exercise testing and cardiac stress positron emission tomography before major non‐cardiac surgery; and this months ‘Statistically Speaking’.

How would you manage acute life-threatening massive haemoptysis in a patient with a predicted difficult airway and emphysematous lung disease? This great new case report published in Anaesthesia Cases generated a lot of attention and debate earlier this month and is well worth a read. The highest Altmetric scores this month came from this year’s supplement issue, ‘Complications’. We will shortly be publishing our 2019 supplement, ‘Pre-operative optimisation’, with topics including risk prediction, multimodal prehabilitation, shared decision making and a review of best practice for patients undergoing emergency laparotomy. We hope you are looking forward to it as much as we are!

It is also nearly time for the Winter Scientific Meeting in London, and this year we will be running a new workshop to complement our popular ‘How to publish a paper’ session. Make sure you register (limited places available) to find out how Twitter can help you stay up to date (with @hypoxicchicken), how to use and influence Altmetrics, and how to use freely available citation software such as Zotero and Mendeley.