Safe transfer of the brain-injured patient

Welcome to #TheAnaesthesiaBlog for the February 2020 issue of Anaesthesia, and with it comes the publication of a new guideline on safe transfer of the brain‐injured patient. Produced as a consensus document between the Association of Anaesthetists and the Neuro Anaesthesia and Critical Care Society, the guidelines serve to update the previous 2006 iteration. The document considers recent developments in the management of multiply-injured patients and those with acute ischaemic stroke. Whilst many of the principles of safe transfer are common to all seriously ill patients, specific risks and management strategies apply to those with acute brain injury. For example, the guideline provides new recommendations on the management of blood pressure parameters for common types of brain injury.

Table 1 Physiological variables and fluids for transfer of brain-injured patients. Of note, there is little high-quality evidence to support particular values and this table is the product of discussion and consensus between members of the Working Party. Where possible, the BP targets reflect the recommendations of the European Trauma Course.

The way in which we access information across all walks of life has changed beyond recognition over the last decade, and Johannsson and Selak discuss the implications of this for medical journals. Social media platforms are seemingly ubiquitous, and their use to disseminate new medical knowledge promises to increase the speed at which science is translated to improvements at the bedside.  Smartphones and other handheld digital devices are commonplace, with 65% of nurses reported to use mobile devices for work‐related tasks for at least 30 minutes each day. Unlike medical journals or conferences, accessing resources on social media platforms is usually free, always available and unrestricted by training budgets or work schedules. In the accompanying article, Ng et al. provide evidence that an intelligence‐led multimedia approach is an effective and efficient method to actively disseminate a clinical and educational patient safety message to a defined target audience. They produced videos to communicate recommendations from the safety project and Facebook, Twitter, YouTube and LinkedIn delivered these to their target users. There is now a need to think about measuring and comparing analytical outputs of social media such as reach, engagements, clicks and views, along with value for money.

Figure 1 Global social media activities relating to tracheostomies. A video of a three‐year‐old girl singing through her tracheostomy tube was posted on social media by her mother and was later reported by a newspaper (*). A television documentary about a synthetic organ surgeon, who was accused of falsifying his research on synthetic trachea transplantation, was broadcast (#). The news of a baby born without a nose dying at age two was posted on social media and was later reported by a multimedia news channel. He received a tracheostomy at five days old ($). An imprisoned Nobel Peace Prize laureate Liu Xiaobo’s was reported as being in a ‘life threatening’ state. His family opted against receiving a tracheostomy (^).

In other editorials, the motto adopted in 1945 by the Association of Anaesthetists, when granted the right to bear arms by King George VIis called in to question as Ritchie-McLean and Davies discuss why patient safety training for UK doctors is inadequate. They put forward why they believe anaesthetists would benefit particularly from improved training, and how and when it should happenThe concept that fig leaves (in the guise of the words ‘pilot’ and ‘feasibility’) are used and attached to authors work to hide poorly conceived and conducted studies, is considered by Story in his editorial to accompany the review by Charlesworth et al. After hypothesising that only a small proportion of pilot or feasibility studies published in anaesthesia journals were correctly labelled as such, the authors show that only 34 of 266 (12.8%) pilot studies published in six anaesthesia journals between 2007 and 2017 were correctly labelled as such. Undoubtedly, these results have important consequences for patients, trialists, researchers and funders, and the authors argue that correctly labelled pilot studies enhance the quality of scientific research by encouraging methodological rigour, ensuring scientific validity and reducing research waste. 

Table 2 The difference between pilot/feasibility studies and non-pilot/non-feasibility studies as defined by the National Institute for Health Research and CONSORT guidance.

Finally, Oglesby, Sterne and Gibbison discuss the notion of using ‘big data’ to validate care bundles, consensus guidelines and protocolised care –  all of which have had a positive impact on patient care to date. In the related associated paper, Chiu et al. analysed over half a million sets of vital signs in 13,631 patients discharged from the cardiac intensive care unit to generate a logistic score. Comparisons were made between the national additive score and the composite outcome of: in‐hospital death; cardiac arrest; or unplanned intensive care admission. They conclude that a logistic version of the National Early Warning Score (NEWS), rather than the current additive model, better discriminates patients after cardiac surgery who suffer adverse outcomes following critical care discharge. Furthermore, logistic scores also provide a useful quantified tool of predicted risks for clinicians, which arguably NEWS cannot.

Figure 2 Black curves represent predicted probability of the physiological variable given the other predictors being controlled for logistic Early Warning Score (EWS). Horizontal red lines represent individual parameter dividing bins used by National EWS (NEWS, right axis).

Elsewhere (and not disguised with a fig leaf!), Webb et al. discuss their pilot study, which aimed to assess the feasibility and effectiveness of an offer of a free five-week supply of nicotine replacement patches provided to smokers at the time of listing for surgery, and to determine the effect on sustained abstinence for four weeks before surgery. Whilst the offer stimulated more cessation attempts before surgery, with many more in the intervention group either quitting or making attempts to quit, a large proportion (59%) had relapsed at six months.

Cricoid pressure has been a matter of debate since its introduction in 1961, and numerous studies have supported or contradicted its use. In this issue, Kim et al compared the effect of cricoid and paralaryngeal force on upper oeseophageal occlusion during induction of anaesthesia in a randomised crossover study involving 74 patients. Both cricoid and paralaryngeal force decreased the oesophageal inlet diameter, however, occlusion of the oesophageal entrance was more frequently observed with cricoid force application. As per recommended standards for monitoring during anaesthesia, a peripheral nerve stimulator should be used whenever neuromuscular blocking drugs are given during anaesthesia. That said, mechanomyography is seldom employed outside of the laboratory, and Bowdle find that acceleromyography and electromyography monitors are validated against such a device, with results consistent with previous comparative studies. Mechanisms underlying loss of consciousness following propofol administration remain incompletely understood. Sepúlveda et al. set out to study the pharmacodynamic effects of propofol through comparison of frontal lobe electroencephalography activity and brainstem reflexes during intravenous induction of general anaesthesia. Two independent mechanisms underlying the loss of consciousness have been postulated, and the authors demonstrate both to have a significant role depending on the rate of propofol infusion. 

For those of you with an interest in intensive care medicine and ultrasound, this new study from Dransart‐Rayé might be right up your street. Given that pulmonary complications have a significant impact on morbidity and mortality after major surgery, the authors conducted a prospective study in 109 patients to evaluate whether lung ultrasound could be used as a predictive marker for postoperative ventilatory support in high‐risk surgical patients. Using an easy‐to‐implement method, it was demonstrated that lung ultrasound abnormalities were indeed associated with postoperative pulmonary complications, and as such they conclude that the use of ultrasound could allow for earlier interventions and thus improve clinical outcomes.

Figure 3 Ability of lung ultrasound (LUS) score to predict requirement for postoperative ventilatory support (a) Receiver operating characteristic curve (b) inconclusive limits of LUS score (grey area).

Anaemia is an independent risk factor for poor peri‐operative outcomes after major intra‐abdominal surgery, and is associated with an increased risk of 30‐day postoperative mortality after non‐cardiac surgery. Miles et al. report data from 1554 women undergoing elective, major abdominal surgery stratified as a function of pre‐operative haemoglobin concentration. Borderline anaemia was associated with increased duration of hospital stay, fewer days alive and out of hospital, and an increased incidence of complications following major abdominal surgery. However, after correction for confounding factors the relationship between borderline anaemia and adverse outcomes was attenuated. 

Elsewhere, Jewer et al. report their findings of a Cochrane systematic review conducted on the effectiveness of supplemental intravenous crystalloid administration in preventing postoperative nausea and vomitingChae et al. discuss the development and validation of a dynamic predictive model for nausea and vomiting during the first 48 postoperative hours for patients receiving i.v. fentanyl PCA available as an online web application, and the Charlesworth and Shelton pose the question as to whether intravenous gelatins have a role in contemporary peri‐operative and critical care.

Finally, make sure you check out the first of our monthly podcasts, which will feature a key article from each issue. This month, Mike Charlesworth interviews Tanya Selak and Helgi Johannsson about all things social media, and how they collaborated on their work. Enjoy!

Dr Edward Gilbert-Kawai and Professor Andrew Klein