Data, answers and questions

This month, we are delighted to publish a new international prospective cohort study from the COVIDSurg and GlobalSURG collaboratives. It is now our best performing paper on social media, ever, with an Altmetric score of > 2400! They studied > 140k patients in 116 countries and concluded that the risks of postoperative morbidity and mortality are greatest if patients are operated within 6 weeks of diagnosis of SARS-CoV-2 infection (Fig. 1). Their work highlights how collaboration on an international stage such as this can give us the answers we need to clinically important questions that matter to hospitals, clinicians and patients. Their work has helped formulate new guidelines which have been implemented across the UK. In the accompanying editorial, Wijeysundera and Khadaroo take us through the complexity of asking when the safest time to operate on a patient with prior SARS-CoV-2 infection is. They highlight the need for quality standards specifically tailored for these large multicentre collaborative studies. Provided that the research question, study design and team are strong and efficient, collaborative research is to be commended and must be continued.

Figure 1 Overall adjusted 30‐day postoperative mortality from main analysis and sensitivity analyses for patients having elective surgery and those patients with a reverse transcription polymerase chain reaction (RT‐PCR) nasopharyngeal swab positive result for SARS‐CoV‐2. ‘No pre‐operative SARS‐CoV‐2’ refers to patients without a diagnosis of SARS‐CoV‐2 infection. The time‐periods relate to the timing of surgery following the diagnosis of SARS‐CoV‐2 infection. Sensitivity analysis for RT‐PCR nasopharyngeal swab proven SARS‐CoV‐2 includes patients who either had RT‐PCR nasopharyngeal swab proven SARS‐CoV‐2 or did not have a SARS‐CoV‐2 diagnosis; patients with a SARS‐CoV‐2 diagnosis which was not supported by a RT‐PCR nasopharyngeal swab were not analysed. 

We have several high-quality obstetric anaesthesia papers this month, as well as a podcast. First, Odor et al. present the findings from their multicentre prospective cohort study – the direct reporting of awareness in maternity patients (DREAMY). Their main finding was that the incidence of accidental awareness during general anaesthesia (AAGA) in obstetrics, assessed by using direct questioning, is almost three times higher than previously ascertained when relying on patient self‐reports: 1 in 256 (95%CI 149–500) vs. 1 in 1200 (95%CI 714–2500). There are many other nuggets of information here of relevance to all anaesthetists, and the paper has reignited the debate about choice of anaesthetic agents for obstetric general anaesthesia as well as a range of other topics. In the accompanying editorial, Palanisamy and Paech discuss these practice changes, the associated controversies and the possible consequences of the work by Odor et al. They argue the most significant contribution is the association between AAGA and post-traumatic stress disorder, the incidence of which is broadly in keeping with previous reports in other patient populations. Therefore, early recognition of AAGA and subsequent intervention is more important now than ever.

Figure 2 Study flowchart of participant recruitment and outcome adjudications. Outcomes are stratified as accidental awareness during general anaesthesia (AAGA) and ‘No AAGA’, with ‘Unlikely AAGA’ included in the latter category. A total of six patients had screening Brice interview responses indicating suspected awareness during general anaesthesia; however, verification assessment was not able to be completed, hence insufficient evidence was available to adjudicate these reports using equivalent criteria to the remaining cases.

Second, this new randomised controlled trial from Chapron et al. finds that spinal anaesthesia with hyperbaric prilocaine induced a shorter and more reliable motor block compared with bupivacaine, administered in spinal anaesthesia for non‐breastfeeding women with uncomplicated pregnancies and undergoing elective caesarean section. The suggestion that prilocaine might be more useful than bupivacaine in this setting is sure to cause, at the very least, some raised eyebrows in the obstetric anaesthetic community. Carvalho and Sultan provide their analysis and conclude that if hyperbaric prilocaine is ever contemplated for routine use, it should be used in conjunction with a combined spinal‐epidural technique. This is so that if the surgical duration exceeded the duration of spinal anaesthesia, the epidural could be dosed to maintain anaesthesia and reduce the need for conversion to general anaesthesia. Third, Heesen et al. discuss the use of noradrenaline as compared with phenylephrine in women undergoing spinal anaesthesia for caesarean section. They highlight that the effect of noradrenaline on fetal acidosis is still unclear, but in the best case scenario it is no worse than phenylephrine. Some excellent suggestions are provided for those undertaking studies in this area. 

Sickle cell disease is one of the most common serious inherited single gene disorders worldwide and has a major impact on the health and life expectancy of the individual. These new Association of Anaesthetists guidelines were developed to highlight advances in peri‐operative care of patients with sickle cell disease, provide anaesthetists with a better understanding of sickle cell disease and to make recommendations about the organisation of care for this complex group of patients. Twelve key recommendations are provided, which are included in the infographic below. 

Elsewhere we have: a systematic review and meta-analysis of conventional landmark vs. preprocedural ultrasound for neuraxial analgesia and anaesthesia in obstetricsa systematic review of reporting quality for anaesthetic interventions in randomised controlled trialsa systematic review of melatonin for anaesthetic indications in paediatric patientsa pilot and feasibility study of postoperative wrist worn accelerometers; and an observational study of exploring the limits of prolonged apnoea with high-flow nasal oxygen

Finally, this new paper from Matt Wiles has been extremely popular on social media. He was tasked with taking on a classic paper from the 1990s and chose an article by Nolan and Wilson about tracheal intubation in patients with spinal injuries. Is manual in-line stabilisation (MILS) during tracheal intubation effective protection or harmful dogma? He presents a persuasive argument against, and urges clinicians to reflect on why they continue to choose to use MILS during tracheal intubation – is this for patient benefit, for protection against later criticism or medicolegal claims, or because ‘we have always done it this way’? Do you disagree? Send us your thoughts in a letter! We might just publish it and get Matt to respond.

Do you want to be our next journal fellow? The deadline for our next post is approaching, so make sure you start working on your application now. Previous fellows include Helen Laycock, Mike Charlesworth and Kariem El-Boghdadly, who are now all fully fledged Editors!

Mike Charlesworth and Andrew Klein

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