Anaesthesia and the ageing brain

People with dementia present for elective and emergency surgery and there has been, until now, no formal peri-operative guideline for this important patient group. This new document puts this surprising lack of guidance right by providing pragmatic instruction on aspects such as standards of care, access to services, communication of risk, pre-operative assessment, multidisciplinary teams, and training for healthcare staff. As with all Association of Anaesthetists guidelines, we encourage members to inspect the contents and share the key messages with colleagues, departments, and hospitals. The infographic below summarises ten key recommendations.

Dementia

In their editorial, Scott and Evered describe a large number of unmet challenges in the peri-operative care of elderly patients and those with dementia. Though there are large gaps in the literature, and the new guidelines are not heavily evidence-based, we should all nonetheless utilise them to raise awareness of team-based care for older patients and those with dementia. Arguably, peri-operative care for those with dementia is decades behind other fields such as pre-operative optimisation. Is it time to catch up? We think so!

Upper limb disorders are common, but this new survey finds a far higher incidence in anaesthetists (34%) as compared with the general population. Interestingly, the years since starting training, having children (irrespective of respondents’ sex or number of children) and right‐handedness were the main risk factors identified. Vargas-Prada and Macdonald remind us that doctors are a group of workers who take little sickness leave and are usually reluctant to access appropriate healthcare. Perhaps we all now need to think about how best to redesign equipment/workplaces and eliminate hazardous working postures from our daily activities? Send us your thoughts through our correspondence site!

Anaesthetists seldom prescribe discharge medications for patients in the UK, but there has been a worrying worldwide increase in opioid prescribing over the last decade. This new quality improvement study finds that 27% of all postoperative discharge prescriptions for oxycodone were inappropriate. The authors employ five sequential interventions and show that it is possible to reduce this to just 10% over a three-year period.

Figure 1Figure 1 Time series of monthly oxycodone prescriptions per 100 surgical cases (left y‐axis). Dashed lines represent the end of the first month following the first intervention of five, and the audit‐feedback plus academic detailing interventions (number 5), respectively. Fitted trend‐lines show the predicted values from segmented regression analyses in the three observation periods.

The grading of physical status using the American Society of Anesthesiologists (ASA) system is common practice throughout the world. This new review article describes the history of ASA grading and explains why, despite its apparent subjectivity, we will probably be using it for many years to come. More recently, it has been successfully incorporated into other systems to help generate more accurate predictions of patient outcomes.

Table 1Table 1 The ASA classification of physical status, as revised in 2014. The addition of ‘E’ denotes emergency surgery, defined as a threat to survival or body part if delayed.

This new editorial from Marshall and Chrimes was commissioned by an editor following an interesting discussion about medication handling on Twitter. It is accompanied with an excellent infographic (which are all available to download here) and already has an Altmetric score of 150! Should remifentanil patient-controlled analgesia be used as a first-line analgesic strategy in labour? This editorial comments on a trial recently published in The Lancet and sets out the key messages from the RemiPCA SAFE Network. These include clinicians taking responsibility; using research to answer urgent clinical questions, such as vital signs monitoring and feedback mechanisms; and a need to define key quality indicators for different analgesic methods.

The anaesthesia practice in children observational trial (APRICOT) was a prospective multi‐centre observational study of severe critical events during paediatric anaesthesia from 261 hospitals in 33 European countries. This new, secondary analysis of the study data finds that the incidence of peri-operative severe critical events was less in the UK cohort as compared with the non-UK cohort. This is likely due to a number of factors such as more experienced dedicated paediatric anaesthetists managing higher risk patients in the UK.

Figure 2Figure 2 The incidence of severe respiratory (striped) and cardiovascular (solid) critical events according to age of the patient.

Elsewhere there is a review of the effect of dexmedetomidine on delirium and agitation in patients in intensive care; a comparison of the new ROTEMsigma with its predecessor, the ROTEMdelta; a study of the use of spectral reflectance to distinguish between tracheal and oesophageal tissue; an observational study of the The LMA® ProtectorTM in anaesthetised, non‐paralysed patients; a study measuring depth of anaesthesia using changes in directional connectivity; and a study to identify the optimal predictor of right ventricular global function.

The journal is currently advertising for new editors to join the team! We are also nearly ready to launch our new journal, Anaesthesia Reports, and they are also advertising for new Assistant Editors. These are exciting opportunities not to be missed. Finally, tonight we will be hosting a TweetChat with the authors of this new paper and you can join the discussion by searching for (and including in your tweets) the hashtag #Hyperoxia.

See you at 1900 GMT!

 

Dr Mike Charlesworth and Professor Andrew Klein

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