October 2022 – #TheAnaesthesiaBlog

Increasing numbers of NHS consultants are voluntarily reducing their time spent delivering contracted direct clinical care. The result is concerning, with experienced clinicians working less hours and retiring early. This new guidance aims to highlight contributory issues and list clear, implementable solutions. One theme is that ‘age’ in anaesthesia should not be perceived negatively and should instead be celebrated. Experienced clinicians have much to offer departments, hospitals and patients, and younger clinicians should think carefully now about how to ‘pace’ careers and continue to work well with age. However, to make the guidance work we all need now to signpost the eight recommendations to departments, colleagues and hospital managers because without action, the workforce gap will continue to increase.

When faced with a theatre list, some cases are plainly more complex than others. The reasons for this might be obvious to us, but less so for patients, surgeons, schedulers and managers. This is where the new OxAnCo score is useful, as it allows for the tacit to be quantified. Importantly, this is not about risk or outcomes, which are different. The score incorporates patient, anaesthetic, surgical and system factors related to complexity and was derived through a survey of clinicians. The authors validated their score prospectively against 688 cases and found a correlation with the grade of anaesthetist. One conclusion must be therefore that we are good already at rating complexity and matching it with resources. This brings the need to implement the score to this end into question. However, it could also be argued that with predicted problems with future workforce planning, a score such as this allows everyone involved with planning elective surgery and resources to read off the same peri-operative page.

We now know that the most environmentally damaging anaesthetic agents are desflurane and nitrous oxide, and we can reduce their use to zero in operating theatres through using alternatives. However, inhaled nitrous oxide continues to be used in maternity units as a first-line strategy for labour analgesia. As well as environmental harm, exhaled nitrous oxide is an important occupational risk for healthcare staff. Thankfully, technology is here to the rescue us and this new paper reports results from the use of catalytic nitrous oxide cracking equipment in clinical practice (Fig. 1). The equipment works and we know that from previous bench experiments. This translational work finds only minor issues with its implementation amongst participating staff. Importantly, ambient nitrous oxide levels were reduced by 71-81%. However, this is following a brief period of coaching and is dependent on parturient cooperation.

**Figure 1** Mobile Destruction Unit (Medclair Invest AB, Stockholm, Sweden) and Ultraflow demand valve (BPR Medical Ltd, Mansfield, UK), with a low-profile facemask (size 4 Clear Lite Facemask, Intersurgical, Wokingham, UK).

There has been much discussion in the literature and on social media about anaesthetic single syringe admixtures. This new study tests a combination that might be useful for low- and middle-income countries such as South Africa: ketamine; lidocaine; and magnesium. They found that all three drugs were stable in solution and remained so 24 h later. Pharmacokinetic simulations suggested that a 24-h infusion of the described admixture would provide favourable plasma concentrations for analgesic efficacy. There is a theoretical basis for superiority of various modes of mechanical ventilation over others. However, clinical evidence tends to suggest differences in core outcomes are small or negligible. This new randomised controlled trial in patients having lung resection surgery finds that the selection of ventilation mode in the context of lung-protective ventilation had no impact on the occurrence of postoperative pulmonary complications within the first seven postoperative days (Fig. 2). Perhaps rather than the mode of intra-operative ventilation, factors such as patient selection, optimisation and enhanced recovery have a greater bearing on patient outcomes.

**Figure 2** Kaplan–Meier survival curve represents occurrence of the pulmonary complications in VCV (black line), PCV (dotted line), and PCV-VG (grey line) groups during postoperative 7 days.

During the pandemic, transplant centres undertook few solid organ transplants for a variety of reasons. This new analysis from NHS Blood and Transplant finds that during the first year of the COVID-19 pandemic, hospitals saw an overall decrease in causes of deaths which typically contribute strongly to organ donation and, as such, fewer eligible potential deceased organ donors (predominantly DCD donors) were referred (Fig. 3). However, there were signs that the organ donation and transplantation system performed well despite pressures on the wider healthcare system. In this month’s Reviewer Recommendations, Bramley and Wiles tackle how to perform and write a meta-analysis. If you are planning a systematic review and meta-analysis and you would like to get it accepted at Anaesthesia, read this paper first. Everything is covered.