Fatigue in the workplace – a ‘wicked problem’?

This month, we are delighted to publish a national survey of out-of-hours working and fatigue in consultants in anaesthesia and paediatric intensive care medicine. There were nearly four thousand respondents and the majority had experienced work-related fatigue that impacts all areas of life (Fig. 1). For consultants, on-call duty often follows of a day of clinical work, and calls or requests to reattend hospital are common. There are several recommendations in areas such as: education; insight; job planning; rest periods; facilities provided by hospitals; and risk management. The accompanying editorial from Dawson and Thomas focusses on the identification and management of fatigue risk. They suggest solutions such as ‘more staff’ or ‘better rotas’ are unimplementable in the current UK healthcare environment, and we should instead focus efforts on strategies to measure and mitigate against the risks of fatigue. 

Figure 1 What impact do you believe that work‐related fatigue has had on your life in the following areas? From left to right, bars for proportion reporting significant negative impact (blue); moderate negative impact (orange); minimal negative impact (grey); no negative impact (yellow). (Answered by all respondents who had experienced work‐related fatigue, n = 3495)

The first logbook for anaesthetists was designed in 1983, and there now exists a variety of electronic means to record clinical activity. This new retrospective analysis from Perella et al., which is the largest of its type, brings together data from the log books of 964 anaesthetists over a 4-year period. Key findings include: a continued trend towards fewer case numbers over time; less supervision for trainees out-of-hours; appropriate exposure to basic procedures for trainees; and core trainees being supervised the most. Patients increasingly present for surgery with undiagnosed obstructive sleep apnoea, and there is an association with postoperative complications. This new observational study from Strutz et al. finds that obstructive sleep apnoea is not associated with the incidence of postoperative delirium or the severity of postoperative painThe accompanying editorial from Memtsoudis supports this finding and highlights areas where the data provided by Strutz et al. add to what is currently an incomplete picture. We expect to see more on this topic in the future! 

It has been suggested that epidural injection of particulate corticosteroid is associated with greater pain relief as compared with non-particulate suspensions, but their use has been blamed for a small number of serious neurological complications. This new study finds that the dose administered is affected by injection filters, and that choice of diluent might be associated with the risk of serious complications due to a differential effect on particle sizeCheung argues patients should be fully informed about the possibility of catastrophic neurological damage with epidural steroid use. There is an urgent need for more research in this area, but, for now, clinicians must remain vigilant to the risk of these complications. This makes these articles essential reading for all clinicians performing these procedures.

Figure 2 (a) Mass spectra of TA+BP‐HCL before filtration with the (b) 5‐μm filter and (c) 0.2‐μm filter. Representative percentage abundance graphs are shown, and the characteristic m/z peak is highlighted in blue. (b) TA is clearly detectable in all samples before filtration with 5‐μm filter, but completely disappears as highlighted in red. (c) TA is clearly detectable in all samples before filtration with 0.2‐μm filter, but completely disappears as highlighted in red. TA, triamcinolone acetonide; BP‐HCL, bupivacaine hydrochloride.

Last year, Maheshwari et al. presented data highlighting the importance of identifying and managing hypotension following induction of anaesthesia and prior to the first surgical incision. This month, El-Ghazali and Pandit present an in-depth analysis of the methods used and the clinical implications of the conclusions drawn. One interpretation is that blood pressure measurements should be recorded and acted on every minute during this period, but a number needed to treat of over 400 makes this recommendation difficult to justify for all patients. Hypotension is just one consequence of general anaesthesia, and for some patients or procedures, the associated risks might be negated by using sedation. This new narrative review brings together the evidence for sedation-analgesia during cataract surgery, which is one of the most common operations performed worldwide. Most patients require no sedation (or fasting period) at all. The use of sedation and opioid analgesics in these patients should be no substitute for adequate local, topical or regional anaesthesia, as it significantly increases the risk of complications. 

Patients undergoing general anaesthesia are usually warned of the risk of dental trauma. This new manikin study finds that hyperangulated videolaryngoscopy is associated with significantly decreased forces acting on maxillary incisors, which may reduce the incidence of dental damage in the clinical setting (Fig. 3). Though one conclusion is it should be considered for all patients at increased risk of dental damage, some might instead argue it should be a first line technique for all patients. Many risks of anaesthesia and surgery can be addressed in the pre-operative period by patients. This new study looks at behaviour change before surgery among 301 patients from three UK hospitals. The results are positive, as patients demonstrated favourable attitudes towards changing single and multiple health behaviours, such as: low physical activity; an unhealthy BMI; and hazardous alcohol consumption. Smoking is a difficult area to address, and this is supported by the findings from a recently published (ahead of print) pilot study, which is now available on early view. Another important topic in this month’s issue is the need for peri-operative medicine to prioritise pregnant women. Dennis and Sheridan argue pregnant women are an integral peri-operative medicine population, and present the PARCEL approach to maternal peri-operative medicine. Perhaps it is now time to develop a core and extended outcome set for pregnant women undergoing caesarean section?

Figure 3 Anterior view anatomic mapping of peak resulting force on individual maxillary incisors of different laryngoscopy techniques in normal and difficult airway conditions.

Elsewhere this month we have: a retrospective impact study on the implementation of a hospital-wide Patient Blood Management monitoring and feedback programmea randomised controlled trial of PECS 2 block vs. serratus plane block for chronic pain after mastectomya retrospective study of risk factors for children requiring adenotonsillectomy; and a consensus statement on the role of fibrinogen concentrate in cardiac surgery. Over in Anaesthesia Reportsthere is an excellent account of peri-operative brachial plexus injury following self-positioning for stereotactic radiofrequency ablation. It reminds us that, despite all appropriate measures, patient injury is at times unavoidable.  

Finally, we will soon be publishing the new Difficult Airway Society awake tracheal intubation guidelines. These will be launched on Friday at the World Airway Management Meeting in Amsterdam, and there will be several ways in which you can get involved. We hope to see you there!

Dr Mike Charlesworth and Professor Andrew Klein