Can sugammadex reverse hypnosis?

The May issue is now available online and is full of excellent content. We encourage all readers to study carefully its contents and a enjoy a break from the infodemic amongst the COVID-19 pandemic. Firstly, this new randomised controlled trial seems to suggest that rapid reversal of deep neuromuscular blockade with sugammadex is associated with a rise in the BIS value and clinical signs of awakening. Can sugammadex really lead to sudden arousal? Avidan suggests there are several possible explanations for the findings, including that avoidance of neuromuscular blocking drugs is the best way to reduce the incidence of accidental awareness during general anaesthesia. Furthermore, he offers interesting commentary on how we sometimes might draw the wrong inference from the correct observation. 

In this study of pre-hospital emergency front-of-neck airway procedures from a nationwide trauma database in Japan, the authors describe the development and validation of a predictive model (Fig. 1). They argue it may aid in the prepare for and predict such events. In the associated editorial, Flexman et al. discuss the problems facing trialists when attempting to study rare clinical events, as well as the need for consensus guidelines for the use, reporting and analytical approaches to healthcare database research

Figure 1 The predicted, observed probability and diagnostic ability in each risk group by ‘eFONA’ score. The predicted and observed probability grouped by sum of the risk score are shown in each cohort. The observed probability is the proportion of actual eFONA procedures performed. The predictions are well‐calibrated with the observations. Error bars, 95%CI.

Robot‐assisted radical prostatectomy causes considerable discomfort, mainly during the first postoperative day. This new randomised controlled trial seems to support the use of a single shot of intrathecal bupivacaine/morphine as part of the anaesthetic technique, as it was associated with increased quality of recovery (Fig. 2). Burns and Perlas discuss the use of QoR-15 to provide a standardised, validated measure of postoperative recovery. Those wishing to determine the value of new peri-operative interventions are encouraged to use it. This new Delphi project identifies a core set of standards to be the most important and useful as quality indicators for an obstetric anaesthetic service. These include: the rate of accidental dural puncture during epidural insertion; the use of guidelines for antenatal anaesthetic referral; the use of dedicated teams for elective caesarean section; whether point-of-care testing haemoglobin testing is available; and the effectiveness of epidural labour analgesia. Carvalho and Kinsella argue this is an important step towards the creation of quality indicators for obstetric anaesthesia care. That said, more patient-centred input, rational performance metrics and evaluation of the impact of such standards are required. A further obstetric anaesthesia paper is this biased-coin up-down sequential allocation trial of the effective pre-oxygenation interval. Worryingly, one in ten parturients will be inadequately pre-oxygenated after 3.6 minutes of tidal volume breathing with a standard flow rate facemask, and the use of high-flow nasal oxygen with and without a facemask was less effective.  

Figure 2 The total Quality of Recovery (QoR)‐15 scores per time‐point. The data are presented as mean with SD error bars. The percentage and absolute decrease between pre‐operative QoR‐15 and postoperative 1 were different (p = 0.019 and p = 0.013) between the intervention and control groups. There were no significant differences between absolute values between the groups. A score of 118 (dashed line) is defined as acceptable symptom state.

How efficient are your operating theatres? How are your lists scheduled and who does it? Given operating theatres across the country are about the open again for elective work, efficiency will be key to ensuring resources are used in the best possible way. This new study from Professor Pandit undertakes a comparison of ‘booking to the mean’ vs. ‘probabilistic case scheduling’, and finds that the former is an extremely poor method of scheduling lists. With this method, 88% of lists may over-run by > 30 min and 40% will cancel patients (Fig. 3). You can read more about operating theatre efficiency in this article from our joint supplement with the British Journal of Surgery

Rightly or wrongly, Impact Factor remains the most widely used performance metric against which scientific journals are judged. According to this new analysis from McHugh and Yentis, we published 115 original articles, 22 reviews, 56 editorials and 186 letters in 2016. In the following two years, these 379 articles were cited in 1506 articles. Of these, 476 (32%) were from Anaesthesia and 1030 (68%) were from elsewhere. Some might argue 32% is too high, but there is currently no consensus on what an ‘optimal’ self-citation rate should be. Too low, and the relevance or appropriateness of the journal comes into question. Too high, and there might be a suggestion of Impact Factor gaming. One possible solution is transparency, and it is the policy for all Anaesthesia editors and reviewers not to ask authors to add or remove specific references/citations to any journal, including Anaesthesia, in their final revisions.

Figure 3 Results of booking to the mean. The actual list duration is plotted against the intended list duration (from y‐axis in Fig. 1). Had booking to the mean been accurate, most points would lie on or close to the line of identity, but the majority lie above it. Hollow circles are lists that suffered a patient cancellation (for these times, the mean time of the cancelled cases is included in the actual list time).

Elsewhere we have: a review of choice of local anaesthetic for epidural caesarean sectiona PROSPECT guideline for oncological breast surgeryan observational study of the impact of fluid optimisation before induction of anaesthesia on hypotension after inductiona discussion of carbon dioxide clearance during apnoea with high-flow nasal cannula; and a survey of regional anaesthesia practice for arteriovenous fistula formation surgeryOver in Anaesthesia Reports this new paper from Ahmad reports the first awake tracheal intubation in a suspected COVID-19 patient. You can read all new articles on COVID19 that have been accepted for publication here or that have gone through the typesetting and proofing process here.

Finally, make sure you catch up with the new guidelines for the management of glucocorticoids during the peri-operative period, which currently has an Altmetric score of 348!

Stay safe.

Mike Charlesworth and Andrew Klein

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