Clinical Consequences

Each and every issue of Anaesthesia contains clinical messages that may change practice. Though there are a number of ways in which to measure academic impact, it is difficult to gauge the true clinical implications of published research. In the new, quarterly ‘Clinical Consequences’ series of articles, the implications of recently published research for clinically practicing anaesthetists will be discussed in depth. This first analysis focusses on the growing popularity of pre‐operative gastric ultrasound, and whether it should become part of routine clinical practice. Should we use an ultrasound probe to look inside Schrödinger’s gut? Be sure to read the full article for the answer!

Figure 1Figure 1 Sonographic image of (a) empty (b) fluid‐filled and (c) solid‐filled gastric antrum. L, liver; P, pancreas; Ao, aorta; A, antrum.

The battle against research misconduct has been well documented in Anaesthesia, with much focus on the detection of unreliable data and fraudulent authors. This new paper reports on the number of unretracted, retractable papers authored by Reuben, Boldt and Fujii, and the reasons given for this by journals, editors and publishers. It seems there is an urgent need to improve the way in which fraudulent or unethical articles are handled following publication. Why does retraction take so much longer than publication? Look no further than this excellent editorial from Loadsman, the Chief Editor of Anaesthesia and Intensive Care.

Pre-operative fasting guidance is changing to acknowledge the physiological and psychological risks associated with prolonged fasting. This new review article from Fawcett and Thomas synthesises clinical evidence and practice recommendations, and suggests we should now consider how best to manage fasting in patients with diabetes mellitus. We will soon be publishing our January 2019 supplement issue – ‘Patient optimisation before surgery’. Despite the fact that half the world’s population live in developing countries, this new review finds that such countries are poorly represented in systematically reviewed evidence on pre-operative optimisation.

Figure 2Figure 2 Cartograms showing (a) immediate and (b) extended pre‐operative interventions. The country polygon size is proportional to the cumulative sample size contribution to the literature.

Cricoid force is well and truly back on the agenda. This month, Gautier et al. report a new technique which may better prevent air entry into the gastric antrum during facemask ventilation – lower left paratracheal force. Perhaps, somewhere in a parallel universe, paratracheal force was described before cricoid force, with its use enshrined in clinical practice. What are the arguments for and against cricoid force? Naik and Frerk summarise several years of controversy in just a few lines, though whether or not the fact ‘they don’t use it in Europe’ continues to be relevant after Brexit will remain to be seen!

Figure 3Figure 3 For paratracheal compression applied manually, the thumb is positioned just cephalad to the clavicle between the trachea and the sternocleidomastoid muscle. A force of 30 N is applied to compress the oesophagus against the vertebral body.

These new Association of Anaesthetists guidelines on anaesthesia and peri‐operative care for Jehovah’s Witnesses and patients who refuse blood has already been extremely well received on Twitter, with an Altmetric score of 125! They are much more than a useful FRCA examination resource, they are a core document and essential reading for all anaesthetists, surgeons and clinical managers. On the subject of guidelines, should the next iteration of Association of Anaesthetists malignant hyperthermia guidelines address the use of activated charcoal filters? Yes, argue Bilmen and Hopkins, who also suggest they should be stored in all areas where volatile agents are used.

How best to accurately monitor the true injection pressure generated during performance of regional anaesthesia? This study from Saporito et al. suggests pressure measurement at the tip is more accurate as compared with measurement along the injection line. Barrington and Lirk argue there are more important factors to consider, such as education and core skills development, situational awareness, adequate organisation, preparation, non‐technical skills, standardised processes such as safety checklists, and routine patient follow‐up.

This prospective observational study in cardiac surgical patients suggests an association between impaired postoperative cerebrovascular autoregulation, as measured with cerebral oximetry, and delirium. You can still read this open access editorial from last year about cerebral oximetry which discusses all the controversies and much more. When marking the cricothyroid membrane (CTM) prior to surgery and anaesthesia, should the head and neck be in a neutral or extended position? This observational study suggests a skin mark made over the CTM in the neutral position cannot be relied upon when performing a surgical cricothyroidotomy in the extended position. Finally, this systematic review from Gerth et al. finds that patients surviving critical illness had a worse health-related quality of life when compared with population norms.

Elsewhere this month we have a study of the impact of emergency department patient‐controlled analgesia on the incidence of chronic pain following trauma and non‐traumatic abdominal pain, a narrative review of the association between attention deficit hyperactivity disorder and general anaesthesia, parental perception on the effects of early exposure to anaesthesia on neurodevelopment, and a prospective observational study of EEG density spectral array monitoring in children during sevoflurane anaesthesia.

January is a busy month for the journal, and we are very much looking forward to the Winter Scientific Meeting taking place 9th-11th January in London. This year, there will be two journal workshops taking place on Thursday. You can now register for ‘Social media for anaesthetic practice and education’ which takes place at 0900 and includes an introduction to Twitter with special guest Stuart Marshall (@hypoxicchicken). We will also be running our popular ‘How to publish a paper’ session in the afternoon.

We are very close to going live with our new journal, ‘Anaesthesia Reports’, an official journal of the Association of Anaesthetists which replaces what was known as ‘Anaesthesia Cases. It is international in scope and will publish original, peer-reviewed case reports, media content, and associated papers on all aspects of anaesthesia, peri-operative medicine, intensive care and pain therapy. We want you to send us your interesting cases, airway videos, blocks, and echo’s.

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See you in London!

Mike Charlesworth and Andrew Klein

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