Burning the candle

This month, we are delighted to publish two studies from the SWeAT study investigator group. The first is a quantitative analysis of survey responses from 397 UK anaesthetic trainees on the safety and wellbeing of these doctors and the patients they treat. They conclude that stress, burnout risk, depression risk and low work satisfaction are common. Interestingly, negative psychological outcomes might be independently predicted by having: no children; more than three days of sickness in the previous year; less than one hour of exercise per week; and more than 7.5 hours per week additional non-clinical work. The qualitative paper focusses on themes from interviews with ten trainees, of whom most were in the higher risk group for burnout and depression. Suggestions include: contracted hours for non-clinical work; individuals taking responsibility for self-care; cultural acceptance that doctors can struggle; and embedding wellbeing support more deeply. 

Figure 1 Euler diagram displaying the proportion of all respondents categorised with high perceived stress, high burnout risk and high depression risk, and the co‐existence of these issues.

Brian Jenkins discusses fatigue vs. resilience and what can be done. Decreasing on-call requirements might be one suggestion, but this has important implications for training. Good role models are important, as is recognition of the process by which resilience is taught and learned throughout training. McCrossan et al. argue that looking after our own and our colleagues wellbeing should be a core element of training. Perhaps it is now time to increase the availability of mentoring, but, for this to happen, we need to train more mentors and have a better collective understanding of what mentoring is. 

In July, we published the first international consensus statement on the use of uterotonic agents during caesarean section. The paper was a success on social media and currently holds an Altmetric score of over 200. Doses of oxytocin for routine elective caesarean section are lower than in other guidelines, and higher doses are recommended for women at increased risk of postpartum haemorrhage. Monks and Palanisamy highlight some issues with the quality of literature on which the consensus statement is based. They offer the pragmatic suggestion that we should use the smallest possible dose of oxytocin in combination with proper stewardship. Perhaps future research should focus on the longer-term consequences of this potent neuropeptide. 

Is it safe to give propofol to those with allergies to egg? It’s time to answer the question once and for all, at least in children. Somerfield et al. identified 2608 children with a clinical food allergy, of which 304 were exposed to propofol. There were 13 potential reactions in ten children. One was deemed a probable allergy and it could not be excluded in another. Both reactions were non-severe. They conclude that, overall, propofol was safely administered to children with allergies to egg, peanut, soybean or other legumes. Anderson and Sinclair discuss allergy vs. sensitivity with specific examples. They argue the study by Somerfield et al. supports current consensus, and that the main risk factor for a peri-operative anaphylactic event is a previous history of a peri-operative reaction.

We already know that airway management research sometimes fails to address commonly used techniques in clinically relevant patient populations. This month, Lundstrøm et al. report data on the DIFFMASK score for predicting difficult facemask ventilation. They study 48,804 patient records and report a prevalence of difficult facemask ventilation of 1.1%. Age, increased BMI, the presence of a beard and neck radiation changes were identified as risk factors. In the accompanying editorial, El-Boghdadly and Aziz discuss the limitations of this evidence and on approaches that are known to improve FMV conditions, such as utilising neuromuscular blockade and optimising the patient’s position

Figure 2 a) Possible sequences of events relating to face‐mask ventilation (FMV) during anaesthetic induction with a traditional approach. There are three broad phases after induction, delineated by colour‐coded boxes: first check of FMV; then a choice of three options depending upon the ability to mask ventilate (neuromuscular blocking drug (NMBD)/immediate choice); then several consequences of those choices. Note that waking a patient up after difficult FMV (dashed red line) is rarely done, and administration of a long‐acting NMBD after difficult FMV was thought to be dangerous (dotted red line). Waking patients up in the third phase is only possible if suxamethonium is given. Green lines indicate successful outcomes, red lines indicate unsuccessful outcomes. Redrawn from 13 with permission. (b) Possible sequences of events relating to FMV during anaesthetic induction with an approach based on recent data. There are three broad phases after induction, delineated by colour‐coded boxes: administration of a long‐acting NMBD before checking FMV; then FMV; then the consequences, which could be either tracheal intubation, or if unsuccessful, the failed intubation algorithm.

Despite the existence of many guidelines for postoperative pain management, we do not always get it right for all patients and all procedures. This month, we describe the methods used for the development of evidence-based recommendations for procedure-specific pain management: PROSPECT methodologyThe first PROSPECT paper focusses on rotator cuff repair surgery, and recommendations include: an arthroscopic approach; systemic multimodal analgesia; interscalene brachial plexus blockade; i.v. dexamethasone; and opioids reserved for rescue analgesia. We look forward to seeing further articles describing specific approaches for other procedures. Elsewhere, we have: a study of postoperative delirium screeninga randomised controlled trial of the PECS-2 block for radical mastectomya prospective cohort study of extravascular lung water measurement in patients undergoing pulmonary endarterectomy; and the educational impact of the SAFE® paediatric anaesthesia course.

Over in Anaesthesia Reportswe have a description of three ventilatory techniques to maintain oxygenation in a patient undergoing laser tracheal tumour resection and a report of McArdle disease causing rhabdomyolysis following vaginal delivery. You can now comment on any of our articles using our new DISQUS function. Click on the comment button next to an article or go straight to the comment box at the end of the article. If you write an interesting comment, we will ask you to consider submitting it as a formal letter for publication.

Finally, we have all now returned from an excellent trip to Glasgow where we announced our 4th annual article of the year. Kariem El-Boghdadly simply blew the audience away with his presentation, which was streamed on multiple platforms and with all winners announced in real time on Twitter. You can watch his presentation here. The author of our winning article, Marcelle Crowther, flew in to collect her award from South Africa, along with her parents. Her paper is free forever and supports recommendations from the Joint Guidelines from the Association of Anaesthetists and the British Hypertension Society. Her colleagues from the department of anaesthesia and peri-operative medicine at the University of Cape Town watched her receive the award, and we watched them watch us. According to Nick Chrimes, we were all well and truly sucked into the vortex.

Dr Mike Charlesworth and Professor Andrew Klein

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