February 2021 – #TheAnaesthesiaBlog

The phone rings. The pager bleeps. A colleague drops into the theatre to talk. Another message passes over the intercom. Each day, we run a gauntlet of distractions in the operating theatre. In the March issue of Anaesthesia, Van Harten et al. report their observations of 64 staff members lasting 148 hours in an effort at quantifying case-irrelevant verbal communication, smartphone usage and other distractions in the operating theatre. Qualitative research was performed with the collation of vignettes and by obtaining the perspective of participants on the importance of disruptions. In the accompanying editorial by Shelton and Smith, the double-edged sword of the smartphone in daily practice is discussed. Used optimally, the device may be more of an enabler of safety than a threat to it. The outcome is in our own hands – literally.

**Figure 1** Relative importance of the distractors during incision to closure in three studies. Interference (frequency x impact) during surgery caused by different sources. Smartphones were not counted in earlier studies. The pattern in all studies is similar. CIC, case‐irrelevant communication.

How has this pandemic affected our learning as anaesthetists? Fawcett et al. look at the challenges faced in the dissemination of scientific knowledge during the COVID pandemic. During the past 12 months, the need for timely peer review and release of educational materials has coincided with a threat to some of our most trusted methods of accessing them. From challenges with journal printing and distribution to the cancellation of scientific meetings, novel and additional efforts have had to be made to place the journal’s offerings in the hands of its readers. Have we found better ways of doing things that should remain long-term? This journal has increased its use of twitter and podcasting. More recently, we have added live broadcasting to our armamentarium. Our enhanced social media presence was accelerated by the pandemic but we do not envisage this as a short-term effort. Instead, we expect twitter, podcasting and live broadcasting to become permanent fixtures of the broader conversation with our readers.

COVID-related research continues to feature prominently in this journal. At the onset of the pandemic, concerns regarding occupational COVID-19 risk were greatest for anaesthesia and intensive care staff, and in particular their proximity to aerosol-generating procedures and patients utilising respiratory support devices. An editorial by Cook and Lennane explores this area by comparing expected and actual mortality and the implications of the findings on staff and patient safety. This pandemic has resulted in a re-appraisal of the risks of benefits of regional and general anaesthesia in some scenarios. Bhatia et al. examine the impact of COVID-19 on general anaesthesia rates for caesarean section across six maternity units in the north-west of England and hypothesise as to why this pandemic could influence our decision-making processes. With respect to critically ill patients with COVID-19, this journal issue contains two retrospective reviews on the impact of renal impairment and of high-intensity pharmacological thromboprophylaxis on clinical outcomes in this setting. As each month passes, our COVID-19 knowledge base grows, but as some uncertainties resolve, others arise.

Irrespective of any pandemic, the access of surgical patients to critical care units for postoperative care has always faced challenges. Understanding them has perhaps never been more important. Which patients should be admitted to critical care post-operatively and who should be managed at ward level? What are the main benefits of peri-operative critical care admission and what are the challenges faced in the provision of this care?

The answers to these questions were amongst those sought as part of the second Sprint National Anaesthesia Project. Quantitative and qualitative analyses of the survey responses of 10,383 clinicians from 237 hospitals across the UK are reported in this month’s issue of the journal. The decision-making process is complex and coloured by experience. Clinicians face real pressures to deviate from their preferred care pathways when the ability to perform surgery is threatened by limitations in critical care provision.

**Figure 2** Thematic summary of respondents’ comments on critical care capacity.

Perhaps second only to sugammadex, dexmedetomidine is the pharmacological agent that has seen greatest acceleration of use in anaesthesia practice this past decade. In a previous issue of Anaesthesia, Lee-Archer et al. examined the impact of dexmedetomidine on post-operative behavioural changes in children. An accompanying editorial by Bailey explores the broader evidence base for this alpha-2 agonist in paediatric anaesthesia, placed in the context of real-world considerations such as cost and pharmacological alternatives. Should dexmedetomidine become a staple of the day-case surgery routine or is the evidence base lacking for further expansions in use?

Regional anaesthesia – old and new – also features in this issue. In celebration of the 75^th anniversary of Anaesthesia, we continue our look at some of the journal’s seminal papers in our Contemporary Classics series. This month, we have selected an article from the 1960s – an analysis by Dawkins on epidural complications. In their review, Collins and Yentis explore how both neuraxial blockade and the make-up of scientific publications have changed over the last fifty years. Whether it relates to indications, technique, equipment, dosing or awareness of complications, clinical practice has certainly evolved! Meanwhile, two systematic reviews and meta-analyses examine the evidence for fascial plane blocks. El-Boghdadly et al. compare quadratus lumborum and transversus abdominis plan blocks for caesarean delivery, while Leong et al. examine the efficacy of erector spinae blocks in breast surgery.

**Figure 3** Methods of identifying the epidural space used by Dawkins in 2145 cases (in the remaining cases, Odom’s indicator was used but no figures are given for dural puncture).

Clotting is another area of focus in this month’s journal. What is the role of four factor prothrombin complex concentrate in haemostatic resuscitation during surgical procedures? Members of the Transfusion and Haemostasis Subcommittee of the European Association of Cardiothoracic Anaesthesiology summarise the available evidence for dosing, efficacy, drug safety and monitoring in different scenarios and issue a consensus statement on the use of this agent. Meanwhile, Oberladstätter et al pubish a prospective observational study of the rapid detection of clinically relevant plasma direct oral anticoagulant levels following acute traumatic injury.

Elsewhere, Blackburn et al. compare CT scans and ruler measurements of three commonly used manikins with human CT scans. The translatability of airway manikin research into clinical practice has always been a contentious matter, with the most fundamental concern being the anatomic accuracy of manikins. Also, Trentino et al. perform a cost-effectiveness analysis of the screening and treatment of suboptimal iron stores in elective colorectal surgery. The great iron debate rolls on!

Keep an eye on our twitter feed for the latest journal article releases, links to new podcasts and future live broadcasts. We hope you’ll find them to be positive distractions!

Craig Lyons and Andrew Klein

In the February issue, we are delighted to publish the articles by Brown et al., Dhillon et al. and the associated editorial by Nestor et al. Brown et al. report that both tracheal intubation and extubation sequences produce less aerosol than voluntary coughing (Fig. 1). On the other hand, Dhillon et al. find that tracheal intubation and extubation are aerosol generating procedures (Fig. 1) Who is right? The answer is probably that neither group is right or wrong, and differences in the experimental methods used might instead account for their different findings. This is all summed up nicely in the associated editorial and podcast.

**Figure 1** Simulation of aerosol measurement approach within operating theatre environment. The sampling funnel was positioned 0.5 m above the source of aerosol in the airway management zone allowing a sampling stream of air (1 l.min⁻¹*) to be routed to the optical particle sizer.*

When we use local anaesthetic agents in clinical practice, we usually go to great lengths to avoid local anaesthetic systemic toxicity, so injecting local anaesthetic agents intravenously might seem counterintuitive. That said, any anaesthetist who has used intravenous lidocaine as part of their peri-operative analgesic strategy will no doubt stand by the safety and efficacy of its use. This new guideline is the first of its kind, which is surprising as the use of intravenous lidocaine for analgesia seems to be widespread. It will hopefully provide a framework for hospitals and departments to write their own protocols, as well as standardising practices more generally. In the associated editorial, Pandit and McGuire discuss the evidence as well as the issues raised by using intravenous lidocaine as an unlicensed medication. They instead provide ‘a license to stop an infusion’ if a clinician encounters a patient in their care and they do not believe the drug to be efficacious. You can listen to both groups of authors debate the arguments for and against on the relevant podcast.

Which is best for patients with hip fracture, spinal or general anaesthesia? Thankfully, and although anaesthetists might always see this as an interesting talking point, guidance and expert opinion have moved beyond the debate of superiority of one mode of anaesthesia over another. Instead, and 11 years since the last iteration, this new guideline shifts focus onto areas such as anaemia, anticoagulation and getting patients to theatre in a timely manner. Direct oral anticoagulant agents seem to be the new major issue facing anaesthetists, and many will be pleased to see something on this topic written down. Again, the paper also has an excellent podcast where you can listen to Iain Moppett and Ciara O’Donnell take us through all the peri-operative considerations and controversies.

Constipation is common in critically unwell adults and this new study from Launey et al. suggests some associations and clinical implications. The associated editorial from Charlesworth and Ashworth discusses the many limitations of research in this area more generally and compares it with something more widely studied and understood – delirium. On the back of the recent regional anaesthesia supplement, Mariano, El-Boghdadly and Ilfeld present their thoughts this month in an editorial about postoperative pain trajectories and personalised pain medicine. They argue that If we knew the typical pain trajectories and patterns of postoperative pain regression and resolution for common surgical procedures, the data could guide our approaches to regional analgesia. Is it time to put the horse back in front of the cart? We think so! Few diseases in healthcare are as controversial and emotive as obesity. This new editorial from Selak and Selak has generated a lot of interest on social media as well as several items of correspondence. They argue that an empathetic approach to all patients, including those with obesity, may in fact be more patient‐centred and also protect against litigation.

Last but by no means least we have three excellent reviews this month which have all been extremely popular on Twitter. First, this airway management guidance document for the endemic phase of COVID-19 sensibly points out that current evidence does not support or necessitate dramatic changes to choices for anaesthetic airway management (Fig. 2). Second, this systematic review from Koyuncu et al. finds that trials on postoperative pain management after total hip and knee arthroplasty reported numerous outcome measures with heterogeneous timing of outcome assessment. Finally, Mallama et al. find that the peri‐operative route of paracetamol administration, intravenous vs. oral, did not affect pain or any other postoperative outcome. There was simply insufficient evidence to exclude important clinical effects and the quality of evidence overall was poor.

**Figure 2** Aerosol generation during supraglottic airway (SGA) use: risk‐factors and considerations. AGP, aerosol‐generating procedure.

To celebrate our 75^th anniversary each month there will be a brand-new article looking at a seminal paper from a different decade. This month it is the 1950s, and Aitkenhead and Irwin take on the topic of deaths associated with anaesthesia. A striking feature is the difference between anaesthetic practice during the study period and modern anaesthesia. More than 10% of the deaths were categorised as “circulatory failure immediately following intravenous barbiturate injection”. You can read the full paper for free, forever! Elsewhere we have: a study of ultrasound-activated needle tip tracker technology; a randomised controlled trial of intra-operative methadone vs. morphine on quality of recovery following laparoscopic gastroplasty; and a study looking at the effect of intra-operative intravenous lidocaine on opioid consumption after bariatric surgery. You can also check out what is new in Anaesthesia Reports, who recently advertised for a new Executive Editor, by going over to their homepage or Twitter account.

We have recently published five live broadcasts, with topics including COVID-19 vaccines, regional anaesthesia, obstetric anaesthesia and critical care outcomes. We plan to keep refining these events and if you have any feedback for us, please let us know! In total, these have now received nearly 30k views!