Human factors and peri-operative care

This month, we are delighted to publish a narrative review and guideline on human factors in anaesthesia. The guideline recently received > 11k downloads after being shared widely by Martin Bromiley and holds an Altmetric score of > 200, having been tweeted by 250 users and reported by two news outlets. Publishing a review and guideline together in this way seems to work well, as the review can synthesise and comment on the relevant scientific evidence whilst the guideline builds on this with expert analysis, opinion and consensus. The authors should be congratulated, as the work going into such an endeavour is extraordinary and the content of both papers are clinically useful for doctors and aim to make care for patients safer. In the associated editorial, Professor Marshall takes us through the background to the papers, how views have changed over time and how organisations should continue to move beyond error as a cause of incidents. 

The April issue also contains several articles featuring in our special intensive care collection. A former ICU patient, Catherine White, shares her perspectives following a critical illness in 2006. She describes how things were then, which may come as a shock to some. That said, there remains work to be done to properly embrace multidisciplinary collaboration, eliminate ICU delirium and examine our outcome metrics and the support patients and their relatives are provided well beyond discharge from hospital. Dr Matt Morgan reflects on 70 years of modern critical care, highlights the importance of all the associated papers and calls for more routine use of patient-centred and functional outcomes. This month, we have included reviews on the management of traumatic brain injury in the non-neurosurgical ICU and the problems around making a clinical diagnosis in ICU.

Around 70% of surgical patients are prescribed postoperative opioids, but there is much we do not know about opioid type and persistent use rates. This new retrospective cohort study from Lam et al. compared oxycodone and tapentadol in > 100k patients discharged from one of four Australian centres (Fig. 1). They found that, after controlling for socio-economic characteristics, comorbidities and other established risk factors, there were lower odds of patients developing persistent postoperative opioid use with tapentadol compared with oxycodone in those that received modified release opioids at discharge and those undergoing orthopaedic surgery. The associated editorial from Bicket et al. set the results in the context of the US opioid epidemic and provide seven principles for effective acute peri-operative pain management. The solutions provided might not be simple and they go far beyond substituting one drug for another, but they do make sense.

Figure 1 Flowchart of study design with full sample size across study groups.

Persistent pain after breast cancer surgery has important socio-economic and healthcare implications. From their prospective cohort study of 210 patients, Tan et al. developed a risk-stratification model for persistent pain after breast cancer surgery by analysing a wide range of potential risk factors (Fig. 2). Four months after surgery, persistent pain was present in 64% of patients and was independently associated with younger age, diabetes, increased pre-operative pain score at sites other than the breast, previous mastitis and higher perceived stress scale score. Can virtual reality be used for cancer-related neuropathic pain? This new pilot RCT from Chuan et al. might be the first step towards answering that question, as it demonstrates feasibility of recruitment for a definitive trial. Elsewhere, Diallo et al. review the predictors and impact of postoperative atrial fibrillation following thoracic surgery and Xu et al. compare the ESP and paravertebral block for laparoscopic nephro-uretectomy.

Figure 2 Multivariable model for persistent pain at four months after breast cancer surgery. DUMC, Duke University Medical Center; KKH, KK Women’s and Children’s Hospital; NSAID, non-steroidal anti-inflammatory drug; PSS, perceived stress scale; PCS, pain catastrophising scale.

Finally, this month’s Reviewer Recommendations tackles retrospective cohort studies. These papers account for a large proportion of submissions to the journal, but the acceptance rate is low as compared with other study design types. This guide lists and discusses: their advantages and disadvantages; the difference between research, audit and service evaluation; how to collect and analyse data; considerations for databases; statistical corrections; and manuscript preparation and publication. The full collection can be found here, and is an excellent ‘how to’ manual for all who wish to get involved with research and the communication of scientific fact and opinion.

Mike Charlesworth and Andrew Klein