A wider role for anaesthesia?

This month in Anaesthesia, Sinmyee et al. discuss the legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying. They examine the means used to achieve unconsciousness from around the world and report a relatively high incidence of vomiting, prolongation of death and reawakening. That said, the very act of defining an optimum method for inducing unconsciousness in assisted dying has complex legal and ethical implications for the public, legislators and physician groups. In the accompanying editorial, Savulescu and Radcliffe-Richards argue the prevention of suffering at the end of life is hardly controversial, and we must consider the use of anaesthesia in this context. These papers, together with the accompanying commentary in the BMJ, are ‘must reads’ for all.

Rib fractures are a significant cause of suffering following blunt trauma and can lead to deadly pulmonary complications. This new retrospective cohort study suggests the erector spinae block improves respiratory function, pain control and haemodynamic stability in such patients. Similarly, Womack et al. find that paravertebral catheters are another safe and effective option. In their editorial, El-Boghdadly and Wiles argue thoracic epidural analgesia should no longer be considered a first line regional anaesthesia strategy in such patients. They summarise the evidence for other techniques such as paravertebral, intercostal, erector spinae, mid-point transverse process to pleura (MTP), retrolaminar, rhomboid intercostal, and serratus plane blockade. Confused as to which block goes where? Look no further than this excellent figure from @elboghdadly!

Figure 1Figure 1 Axial cross‐sectional illustration of a thoracic vertebra demonstrating the key anatomical structures (left) and the site of injection of local anaesthesia for blocks (right) used in the management of traumatic rib fractures. ESM, erector spinae muscle; SAM, serratus anterior muscle; SCTL, superior costotransverse ligament.

Given the many recent advances in regional anaesthesia and analgesia, is intra-operative opioid administration still necessary? This new systematic review and meta-analysis suggests ‘opioid-inclusive anaesthesia’ does not reduce pain and is associated with postoperative nausea and vomiting. The accompanying editorial by Elkassabany and Mariano has already been extremely well received on Twitter! They set out the case for multi-modal analgesia and derive a new definition for opioid free anaesthesia – “a peri‐operative care strategy that maximises non‐opioid modalities for anaesthesia and analgesia and reserves the use of opioids for severe acute pain unrelieved by other methods from admission to discharge from the hospital”.

Figure 2Figure 2 Infographic showing one approach to practically applying multi‐modal analgesia; some modalities should be considered for all patients (except when contraindicated), whereas other modalities should be considered for some patients (only when indicated).

In February, we facilitated a TweetChat on this new analysis by Myles, Carlisle and Scarr (#Hyperoxia). Their article challenges the integrity of data from studies of liberal peri-operative inspired oxygen by Mario Schietroma’s group, and provides an updated systematic review and meta-analysis of supplemental oxygen and its effect on surgical site infections (SSIs). The figure below seems to suggest a lack of evidence to support the recent WHO guideline on preventing SSIs, and the debate looks set to continue!

Figure 3Figure 3 Updated systematic review and meta‐analysis: forest plot of supplemental oxygen‐surgical site infection trials.

New neuraxial and regional anaesthesia non-Luer connectors will soon be coming to a hospital near you. This new evaluation of the non-Luer ISO 80369-6 connector finds it to be acceptable in terms of its ease of use, reliability, lack of leakage and versatility. It is hoped these new devices will solve the problem of neuraxial-i.v. wrong-route errors.

Figure 4Figure 4 Illustrations of NRFit (ISO 80369‐6) connectors. Top left. male slip connector, with floating collar; top right, male lock connector, bottom left female connector from the side and bottom right, oblique view. The neuraxial non‐Luer connector (NRFit) retains the approximate appearance of a Luer connector, with a proximal conical male component fitting into a receiving female component. The 5% angle of the cone and its dimensions differentiate it from a Luer device (6%). Additional features are ‘lugs’ in the distal male cone to reduce the chances of a leak‐free misconnection with other connectors and a floating collar on the male slip connector to create an additional barrier to misconnections.

Elsewhere we have a systematic review of  the analgesic efficacy of the Pecs II block, a study of postoperative microcirculatory perfusion and endothelial glycocalyx shedding following cardiac surgery with cardiopulmonary bypass, a comparison of sufentanil vs. remifentanil in fast‐track cardiac surgery patients, a synopsis of the recent legal challenges to the concept of brain death in the USA, Canada and the UK, and the new Association of Anaesthetists guidelines for the safe provision of anaesthesia in magnetic resonance units.

MRI

Over in Anaesthesia Reports, we recently published five new papers including a description of the MTP block for surgical anaesthesia, reversal of clonidine with naloxone, cord injury following spinal anaesthesia, ECMO-CPR for drowning and pulsed radiotherapy of the brachial plexus. All reports (including our entire back catalogue) are open access for a limited introductory period and you can submit your interesting reports (including pictures, videos and much more) here. We have already accepted a number of excellent new reports and you can keep an eye out for new material on the Anaesthesia Reports homepage.

Dr Mike Charlesworth and Professor Andrew Klein

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