Charting the way forward

COVID-19 has had a tremendous impact on access to healthcare services, including anaesthesia and surgery. What is the best way to proceed for those patients who have been infected with SARS-CoV-2? In this issue of AnaesthesiaEl-Boghdadly et al. outline key principles in the timing of surgery after SARS-CoV-2 infection in a multidisciplinary consensus statement supported by the Association of Anaesthetists, the Centre for Peri-operative Care, the Federation of Surgical Specialty Associations, the Royal College of Anaesthetists and the Royal College of Surgeons of England. Specific focus is afforded to symptoms and severity of disease, comorbid and functional status, priority and complexity of surgery, and anaesthetic technique. The consensus statement is informed by recent studies, such as the international prospective cohort study of the COVIDSurg and GlobalSurg Collaboratives, which was published in Anaesthesia, and which quantified mortality risk in patients with pre-operative SARS-CoV-2 infection based on the time interval between diagnosis and surgery. An accompanying editorial by Price et al. addresses the curtailment in surgical activity caused by the pandemic and its effects on the workforce, both in terms of reallocation of duties and psychological consequences. A further editorial by Stuart White asks whether a role exists for mandatory psychological assessment of those working in anaesthesia and critical care medicine during the pandemic. The impact of this pandemic on patients, healthcare workers and broader society will extend long beyond its end. 

Even in a world without COVID-19, access to safe and affordable surgical care in low- and middle-income countries can be erratic. Reliable data is essential for the evaluation and advancement of peri-operative care in these regions. In this issue, the Network for Peri-operative Critical Care reports on the establishment and initial output of an Ethiopian data registry that incorporated national surgery and quality indicators. There were 1748 care episodes in four hospitals recorded in the registry over a 12-month period, including data on anaesthetic adverse events and post-operative morbidity and mortality. In an accompanying editorial, Kluyts and Biccard discuss the role of peri-operative registries in improving the quality of care in low-resource environments and the challenges associated with their creation and interpretation.

The prevention and treatment of postoperative nausea and vomiting is one of the commonest everyday challenges faced by anaesthetists. Weibel et al. publish an abridged Cochrane network meta-analysis of the drugs used for preventing post-operative nausea and vomiting in adults after general anaesthesia (Fig. 1). Data are included from 585 trials and 97,516 participants, evaluating 44 single drugs and 51 drug combinations, making this the most comprehensive, up to date review of the evidence in this area. An accompanying editorial by Collier and Smith places these findings in the context of current anaesthesia practices and the broader challenges faced in preventing post-operative nausea and vomiting

Figure 1 Network geometry of eligible comparisons for postoperative vomiting within 24 h after surgery. The thickness of the edges is proportional to the number of included studies comparing two treatments.

As researchers continue to investigate the exact risks and benefits of apnoeic oxygenation with high-flow nasal oxygen in anaesthesia, areas of uncertainty include its merits in the paediatric population and capacity for clearance of carbon dioxide. The ability of apnoeic oxygenation with high-flow nasal oxygen to clear carbon dioxide in adults was first postulated by Patel and Nouraei in this journal in 2014. This phenomenon has not been demonstrated in paediatric patients. In this issue, Riva et al. publish their transcutaneous evaluation of carbon dioxide elevations in apnoeic children weighing 10-15 kg by comparing two oxygen flow rates.  

Regional anaesthesia also features in this issue – from assessment of the needle manipulation of novices to the role of adjunctive agents in brachial plexus blockade. Chuan et al. report the results of their randomised controlled trial examining the potential role for visuospatial ability screening in learning ultrasound-guided regional techniques. The visuospatial ability of anaesthetists, as measured by their ability to identify similar three-dimensional objects from different perspectives, was hypothesised to correlate with their ability to perform ultrasound-guided needle manipulation, which is an essential component of regional anaesthesia performance. The needling times of 140 medical students during ultrasound-guided tasks are reported, after randomisation by visuospatial ability, with some participants receiving deliberate practice and others assigned to discovery learning. Meanwhile, Sehmbi et al. report their meta-analysis of 100 trials on supraclavicular brachial plexus block characteristics when dexamethasone and dexmedetomidine are administered as adjunctive agents. The authors evaluated the effects of these agents on sensory block, motor block and analgesic duration by comparing with control supraclavicular blocks that were performed without adjuncts. The route of administration of the agents (perineural or intravenous) was incorporated into their analysis.

The bleeding post-cardiac surgery patient is both a unique haematological challenge and a commonly faced problem in cardiac intensive care units. How best to identify and manage specific deficits in coagulation, and measure the response, remains a matter of ongoing debate. This issue features a pilot randomised controlled trial comparing the use of prothrombin complex concentrate and fresh frozen plasma in adult patients who required coagulation factor replacement for bleeding within 24-hours of cardiac surgery. Elsewhere, Kataife et al. evaluate the impact of the Haemostasis Traffic Light cognitive aid on clinician performance during simulated bleeding scenarios (Fig. 2).

Figure 2 Design of the Haemostasis Traffic Light. The five steps are described (0 to 4) from left to right. Each step has its rationale and an example of an intervention (dotted line) to show how the Haemostasis Traffic Light concept may be adapted to institutional coagulation management protocols.

The dose of oxytocin administered during elective caesarean delivery has reduced over the last two decades. In this issue, Peska et al. report the results of an oxytocin dose-finding study in obese women at elective caesarean delivery, using the biased coin up-down method. The primary outcome was uterine tone as assessed by the operating obstetrician two minutes after drug administration.

Finally, in this month’s Contemporary Classics series, revisiting some notable papers that have featured in Anaesthesia in celebration of its 75th anniversary, Tim Cook, Ellen O’Sullivan and Fiona Kelly discuss the origins and impact of the 2004 Difficult Airway Society guidelines for the management of difficult tracheal intubation. To round off this issue, our popular Correspondence section has its reliable mixture of personal observations and insights along with commentary and debate surrounding recently published research in Anaesthesia.

We hope you enjoy the diverse range of topics featured in this month’s issue. Stay tuned to our twitter feed for daily updates on the journal’s articles, podcasts and live broadcasts!

Craig Lyons and Andrew Klein