In need of a distraction?

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 AnaesthesiaLee-Archer et al. examined the impact of dexmedetomidine on post-operative behavioural changes in childrenAn 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 75th 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

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