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

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

Old problems and new realities

Between the application of artificial intelligence to regional anaesthesia, the use of virtual reality in pain management and a modern interpretation of the iron lung for respiratory failure, the May issue of Anaesthesia examines some modern solutions to longstanding challenges.

Bowness, El-Boghdadly and Burckett-St Laurent discuss the role artificial intelligence for image interpretation in ultrasound-guided regional anaesthesia. The identification of anatomy under ultrasound is an essential step in the performance of regional blockade. Challenges with anatomical recognition and needle guidance limit the number of clinicians willing to learn or perform regional techniques. Might artificial intelligence become reliable to the point of recognising and highlighting different anatomical structures, whilst accounting for patient anatomical differences and proceduralist variability in image acquisition? Additionally, could this technology propose optimal needle trajectories to reduce the likelihood of nerve injury or intravascular injection of local anaesthetic?

Figure 1 Sono-anatomy of the adductor canal block. (a) Illustration showing a cross-section of the mid-thigh. (b) Enlarged illustration of the structures seen on ultrasound during performance adductor canal block. (c) Ultrasound view during adductor canal block. (d) Ultrasound view labelled by AnatomyGuide.

The application of virtual reality as a non-pharmacological pain therapy is reviewed by Chuan et al. in this issue. They discuss its potential role in acute and chronic pain scenarios, addressing the impact of their varied aetiological and biopsychosocial components on the efficacy of these programmes. In an accompanying editorial, Small and Laycock examine the broader application of virtual reality systems within healthcare along with the complexities involved in their evaluation in clinical trials

The familiarity of many clinicians with the ‘iron lung’ relates solely to their readings on polio epidemics. Improvements in positive-pressure ventilation technology in the mid-20th century resulted in a decline in the use of negative-pressure ventilation. But could the positive be turned into a negative once more with a comeback for the iron lung? This issue of the journal publishes an evaluation of the Exovent, a torso-only negative-pressure ventilatory support system, in volunteers. The device aims to generate continuous negative extra-thoracic pressure in order to increase functional residual capacity and avoid patient-ventilator dyssynchrony. The risk-benefit profile of the Exovent in clinical practice remains unknown at this time. 

Figure 2 Volunteer being ventilated in the Exovent in the semi‐recumbent position.

A new PROSPECT guideline on post-operative pain management for elective caesarean section features in the May issue of Anaesthesia. The guideline is based on analysis of 145 studies and addresses systemic non-opioid and opioid analgesics, neuraxial adjuvants, local and regional techniques, and surgical interventions. In an accompanying editorial, Landau and Richebé discuss procedure-specific and patient-specific approaches to pain management. They highlight procedure-related variations in caesarean delivery, such as parity, plurality and prior history. Patient-specific circumstances, such as substance abuse, mental health issues and patient expectations, also influence pain outcomes. The authors therefore advise caution against the indiscriminate application of such guidelines and encourage more comprehensive algorithmic approaches to address individual needs. 

Recent studies on peri-operative iron supplementation have raised as many questions as answers on this practice. This journal issue features two original research articles on the pre-operative use of intravenous iron in anaemic patients undergoing cardiac surgery. Both studies (one retrospective and one prospective observational) examine the impact of this intervention on haemoglobin level, transfusion rate and other complications. Meanwhile, Wittenmeier et al report the results of their prospective study on the detection of pre-operative anaemia in elective surgical patients using non-invasive haemoglobin measurement. The authors address the potential implications of these devices during pre-operative anaesthetic evaluation along with their limitations in determining when to administer a blood transfusion.

Meta-analyses and trial sequential analyses are only as good as their component trials enable them to be – working back to the methodological robustness of each study and individual patient enrolment. In this issue, an editorial by Kirkham and Taljaard discusses the role of trial sequential analysis in enabling us to draw firmer conclusions on existing literature and project future research needs. They use a recent meta-analysis and trial sequential analysis by Desai et al. on the role of epidural vs transverse abdominis plane block for abdominal surgery as a backdrop for their discussion. Ultimately, the conclusion of a meta-analysis traces its way back into the hands of every researcher involved in the included studies, each generating the bigger picture one paint stroke at a time.  

COVID-related research continues to feature prominently in Anaesthesia. Cook and Roberts model the impact of vaccination by priority group on UK deaths, hospital admissions and intensive care admissions from this illness. Meanwhile, Clinkard et al. evaluate the filtration efficacy of N95 respirators and modified snorkel masks in healthcare workers.

Chronic obstructive pulmonary disease is a co-morbidity frequently encountered by anaesthetists and an independent risk factor for peri-operative morbidity and mortality. In this issue, a review by Lee et al. provides advice on pre-operative optimisation of patients with this condition. Specific focus is afforded to pulmonary rehabilitation, smoking cessation, symptom and pharmacological optimization, nutrition and lung volume reduction procedures. The authors also discuss unmet research needs in this area and the potential role for a peri-operative disease pathway for the delivery of holistic care to patients with this potentially debilitating condition. 

In our Contemporary Classics series, commemorating 75 years of AnaesthesiaPearce, Duggan and El-Boghdadly ask whether Cormac and Lehane grading has stood the test of time. They examine the origins of this classification system, its subsequent modifications, and its role going forward, particularly as use of videolaryngoscopy increases.

Figure 3 Views obtained at laryngoscopy, assuming correct technique, as described by Cormack and Lehane [1]. (a) Grade-1 view; (b) grade-2 view; (c) grade-3 view; and (d) grade-4 view.

And… hot off the press! The May issue of Anaesthesia contains the malignant hyperthermia 2020 guideline from the Association of Anaesthetists. There have been a number of developments in the diagnosis and management of malignant hyperthermia since the last iteration of this guideline was published in 2011. Guidance is provided for anaesthetists beyond the acute period of the reaction, including critical care management, patient and family counselling, and referral for investigation. Patient populations at increased risk of developing malignant hyperthermia under anaesthesia are also discussed. You can listen to the podcast with Professor Phil Hopkins and patient, Connor Phillips, here!

All this, plus our popular correspondence section, is now available in the May issue of Anaesthesia. Please keep an eye on the journal’s twitter feed for live broadcasts, podcast releases and social media discussion surrounding our latest journal articles!

Craig Lyons and Andrew Klein 

Zombies circulate among us

Detecting false data presents reviewers, editors, journals, publishers and readers with many problems. Manuscripts alone, which are submitted to journals for peer review and consideration for publication, are seldom enough to make an informed judgment on the truth of included data. In this new study, John Carlisle reports his analysis of 153 randomised controlled trials submitted to Anaesthesia for which he requested authors supply individual patient data spreadsheets (Fig. 1). He detected false data in almost half of these spreadsheets, which likely translates to around a quarter of all randomised controlled trials submitted to the journal. He concludes that journals and editors should ask more questions about data on which submitted trials are based, rather than relying on summary statistics alone, which may not contain vital clues about data trustworthiness. In the accompanying editorial, Ioannidis looks at the nature and scale of the problem, as well as what can be done. The solutions are far from perfect, but include: more widespread use of individual patient data spreadsheets during review processes; a new focus on methods to interrogate other designs, such as observational studies; incorporation of the likelihood of false data into the design of systematic reviews; and promotion of transparency by funders and regulators. 

Figure 1 The cumulative submission of 526 randomised controlled trials (black line), in 73 (14%) of which Carlisle identified false data (solid red line) and in turn 43 (8%) he categorised ‘zombie’ (dashed red line). The rates Carlisle identified false data and categorised trials zombie increased after March 2019, when Anaesthesia adopted a policy of routinely requesting individual patient data spreadsheets from countries that submitted the most trials.

We have a number of important papers this month that each have an associated podcast, which can be accessed for free on PodbeanSpotify and iTunes. First, Odor et al. report the results from DREAMY in relation to general anaesthetic and airway management practice for obstetric surgery in England. They find that propofol and, to a lesser extent, rocuronium are now being used more frequently. The associated editorial from Wilson and Wrench suggests the UK is currently lagging the adoption of change, rather than leading it. Cook and Farrar, in our second most popular paper on social media, ever, discuss everything to do with COVID-19 vaccines, including the many implications for peri-operative practice as well as other wider issues for society (Fig. 2).

Figure 2 The access to COVID‐19 tools (ACT)‐accelerator is a collaboration whose stakeholders aim to speed up development, production and access to novel agents that are central to the response to COVID‐19, including diagnostics, therapeutics and vaccines. Stakeholders include organisations and individuals from the public, industry, commerce, academia and politics. Synergistic cooperation should mean its efficacy is greater than the sum of its parts. From https://www.who.int/initiatives/act‐accelerator with permission from ACT‐accelerator.

We were also delighted to publish this new consensus statement on the prevention of opioid-related harm in adult surgical patients by Levy et al. The document allows for all healthcare professionals to be aware of the risks and benefits of peri-operative opioid use, which will hopefully lead to better informed patients.

In 2008, it was predicted that there would be no publications in relation to peri-operative practice from UK authors by the year 2020. This new analysis from Ratnayake et al. provides and updated perspective, with ~124 papers per year published by UK groups in indexed journals. A worrying feature is the predominance of secondary research (for example, reviews) as compared with primary research (for example, clinical trials). Overall, the trend identified by Feneck et al. in 2008 seems to have been halted but not yet reversed. Paul Myles offers some insights and reminds us that the studies by Feneck et al. and Ratanayake et al. provide a UK-centric view, and that most peri-operative medicine journals across the world have improved in quality over the last ten years. Moreover, there are now more many more studies in high-impact general medical journals led or contributed to by UK anaesthetists, which is great progress. Yeung and Shelton argue that academic anaesthesia does not belong to the elite, as it belongs to us all. Perhaps where the real work is needed is advocacy, to encourage recognition of how and why research is fundamental to high-quality patient care. 

Each month, we are taking a look back through our archives at important papers from each decade, since the first issue of the journal was published 75 years ago. This month, Laycock and Harrop-Griffiths tackle the assessment of pain with reference to a key paper from 1976 by Revill et al. Note that the ‘assessment’ of pain and not its measurement is discussed, the importance of which is thoughtfully discussed. They argue that what perhaps is even more important than the assessment or measurement of pain is how we respond to its occurrence. 

Elsewhere we have: a systematic review of intra-articular infiltration analgesia for arthroscopic surgery; two prospective observational studies of alternative devices for postoperative patient temperature measurement;an ethnographic study of decision-making around admission to intensive care; and a feasibility study of the effect of advanced recovery room care on postoperative outcomes in moderate-risk surgical patients

Finally, we are looking for new Assistant Editors (deadline March 31st) and a new Trainee Fellow (deadline May 31st). Both adverts and all the details are provided here, on the journal webpage, on Twitter, in this month’s Anaesthesia News and via the Association of Anaesthetists. Join us!

Mike Charlesworth and Andrew Klein

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

Between evidence and aerosols

In the February issue, we are delighted to publish the articles by Brown et al., Dhillon et al. and the associated editorial by Nestor et al. Brown et al. report that both tracheal intubation and extubation sequences produce less aerosol than voluntary coughing (Fig. 1). On the other hand, Dhillon et al. find that tracheal intubation and extubation are aerosol generating procedures (Fig. 1) Who is right? The answer is probably that neither group is right or wrong, and differences in the experimental methods used might instead account for their different findings. This is all summed up nicely in the associated editorial and podcast.

Figure 1 Simulation of aerosol measurement approach within operating theatre environment. The sampling funnel was positioned 0.5 m above the source of aerosol in the airway management zone allowing a sampling stream of air (1 l.min−1) to be routed to the optical particle sizer.

When we use local anaesthetic agents in clinical practice, we usually go to great lengths to avoid local anaesthetic systemic toxicity, so injecting local anaesthetic agents intravenously might seem counterintuitive. That said, any anaesthetist who has used intravenous lidocaine as part of their peri-operative analgesic strategy will no doubt stand by the safety and efficacy of its use. This new guideline is the first of its kind, which is surprising as the use of intravenous lidocaine for analgesia seems to be widespread. It will hopefully provide a framework for hospitals and departments to write their own protocols, as well as standardising practices more generally. In the associated editorial, Pandit and McGuire discuss the evidence as well as the issues raised by using intravenous lidocaine as an unlicensed medication. They instead provide ‘a license to stop an infusion’ if a clinician encounters a patient in their care and they do not believe the drug to be efficacious. You can listen to both groups of authors debate the arguments for and against on the relevant podcast.

Which is best for patients with hip fracture, spinal or general anaesthesia? Thankfully, and although anaesthetists might always see this as an interesting talking point, guidance and expert opinion have moved beyond the debate of superiority of one mode of anaesthesia over another. Instead, and 11 years since the last iteration, this new guideline shifts focus onto areas such as anaemia, anticoagulation and getting patients to theatre in a timely manner. Direct oral anticoagulant agents seem to be the new major issue facing anaesthetists, and many will be pleased to see something on this topic written down. Again, the paper also has an excellent podcast where you can listen to Iain Moppett and Ciara O’Donnell take us through all the peri-operative considerations and controversies.

Constipation is common in critically unwell adults and this new study from Launey et al. suggests some associations and clinical implicationsThe associated editorial from Charlesworth and Ashworth discusses the many limitations of research in this area more generally and compares it with something more widely studied and understood – delirium. On the back of the recent regional anaesthesia supplement, Mariano, El-Boghdadly and Ilfeld present their thoughts this month in an editorial about postoperative pain trajectories and personalised pain medicine. They argue that If we knew the typical pain trajectories and patterns of postoperative pain regression and resolution for common surgical procedures, the data could guide our approaches to regional analgesia. Is it time to put the horse back in front of the cart? We think so! Few diseases in healthcare are as controversial and emotive as obesity. This new editorial from Selak and Selak has generated a lot of interest on social media as well as several items of correspondence. They argue that an empathetic approach to all patients, including those with obesity, may in fact be more patient‐centred and also protect against litigation.

Last but by no means least we have three excellent reviews this month which have all been extremely popular on Twitter. First, this airway management guidance document for the endemic phase of COVID-19 sensibly points out that current evidence does not support or necessitate dramatic changes to choices for anaesthetic airway management (Fig. 2). Second, this systematic review from Koyuncu et al. finds that trials on postoperative pain management after total hip and knee arthroplasty reported numerous outcome measures with heterogeneous timing of outcome assessmentFinally, Mallama et al. find that the peri‐operative route of paracetamol administration, intravenous vs. oral, did not affect pain or any other postoperative outcome. There was simply insufficient evidence to exclude important clinical effects and the quality of evidence overall was poor.

Figure 2 Aerosol generation during supraglottic airway (SGA) use: risk‐factors and considerations. AGP, aerosol‐generating procedure.

To celebrate our 75th anniversary each month there will be a brand-new article looking at a seminal paper from a different decade. This month it is the 1950s, and Aitkenhead and Irwin take on the topic of deaths associated with anaesthesia. A striking feature is the difference between anaesthetic practice during the study period and modern anaesthesia. More than 10% of the deaths were categorised as “circulatory failure immediately following intravenous barbiturate injection”. You can read the full paper for free, forever! Elsewhere we have: a study of ultrasound-activated needle tip tracker technologya randomised controlled trial of intra-operative methadone vs. morphine on quality of recovery following laparoscopic gastroplasty; and a study looking at the effect of intra-operative intravenous lidocaine on opioid consumption after bariatric surgery. You can also check out what is new in Anaesthesia Reportswho recently advertised for a new Executive Editor, by going over to their homepage or Twitter account

We have recently published five live broadcasts, with topics including COVID-19 vaccines, regional anaesthesia, obstetric anaesthesia and critical care outcomes. We plan to keep refining these events and if you have any feedback for us, please let us know! In total, these have now received nearly 30k views!

Make sure you also check this new special issue of COVID-19 correspondence that was published just last week.

Mike Charlesworth and Andrew Klein

Fundamentals and innovations in regional anaesthesia: excellence and access for all

Since 2009, Anaesthesia has published annual special issues focusing on novel and clinically-important topics in peri-operative medicine, critical care and pain. This year, for the first time, we are revisiting a subject that was previously featured in 2009: regional anaesthesia. This is an acknowledgement, not only of widespread public interest, but also the fundamental importance of this field in modern anaesthetic practice, and the pace of innovation in recent years. The special issue was launched on 11 January 2021 with another first: a live video discussion involving 15 of the authors to give readers  their personal insights into the key concepts in each paper (see here and here).

The accompanying editorial highlights what we believe is the next frontier: increasing patient access to safe and effective regional anaesthesia. The evolution of regional anaesthesia is marked by multiple pivotal innovations that have driven its rise in popularity within our specialty (Fig. 1). These have transformed it from an arcane art practiced only by enthusiasts to a core skillset taught to all trainees. This, however, has also been accompanied by an increased complexity in scope that threatens to overwhelm the general practitioner. There is thus a need to refine, and even simplify, our techniques to maximise provider uptake and in turn, patient benefit. 

Four key themes run through the supplement: safety, efficacy, quality and innovation.

Figure 1. Key landmarks in the development of regional anaesthesia along with changes in patient access to regional anaesthesia over time (green line). LAST, local anaesthetic systemic toxicity. From Chin, Mariano and El-Boghdadly (2021).

Safety

Nerve localisation has traditionally been based on landmark or peripheral nerve stimulator-guided techniques. Not surprisingly, this has declined in recent years with the advent of ultrasound-guided approaches. However, rather than abandoning the use of nerve stimulation entirely, Dr Gadsden recommends that we reframe its purpose. Instead of using it to tell us when we are ‘close enough’ (a tool for efficacy), we should use it in combination with ultrasound visualisation of the needle tip to tell us when we are ‘too close’ (a tool for safety). As he states in a clever analogy, why choose between seatbelts or airbags when you can have both?

Macfarlane et al. delve further into the safety of regional anaesthesia, providing an up-to-date understanding of local anaesthetic systemic toxicity (LAST). This is still a highly-relevant complication even in the era of ultrasound-guidance, and there have been important changes in the typical clinical presentation thanks to the current enthusiasm for fascial plane blocks, intravenous lidocaine infusions and high-dose local anaesthetic infiltration techniques by non-anaesthetists. The authors highlight the considerations pertinent to modern anaesthetic practice and also describe a management algorithm that incorporates technique- and patient-related risk factors (Fig. 2). We would consider this paper essential reading for any clinician using local anaesthetics in their practice.

Figure 2. Risk of local anaesthetic systemic toxicity depending on anaesthetic technique and patient factors. From Macfarlane et al. (2021).

A final paper focusing on safety comes from Levy and Lirk, who describe the challenges and considerations for regional anaesthesia in patients with diabetes. Key characteristics of this patient population, include a higher current threshold for peripheral nerve stimulation; a tendency to prolonged conduction blockade; and lower local anaesthetic dose requirements. There is also concern over a higher risk of infection with both central and peripheral nerve blocks, emphasising the need for strict adherence to aseptic precautions.

Efficacy

The contributions of regional anaesthesia to improved care in specific patient populations is highlighted in several articles. Regional anaesthesia has been relatively under-utilised in paediatric practice, but several factors have driven a recent resurgence, including concerns over the effects of general anesthesia on cognitive development in younger children. Heydinger et al. also point to several innovations that have improved efficacy in this setting, including fascial plane techniques such as quadratus lumborum and erector spinae plane blocks. 

In contrast, regional anaesthesia is well-established in the obstetric setting, but there continues to be debate over the role of fascial plane blocks versus intrathecal opioids in post-caesarean analgesia.  Sultan et al.summarise the latest evidence and offer suggestions on how we can rationally incorporate peripheral nerve blocks into our daily practice. 

In another article, Dockrell and Buggy describe the current role of regional anaesthesia within the context of onco-anaesthesia. The pathophysiology of cancer recurrence is incredibly complex and multi-faceted, which makes it difficult to tease out the specific contribution of any one factor in peri-operative care. The evidence is just starting to accumulate and, in the meantime,, the authors point to the other advantages that regional anaesthesia may have on enhancing patient recovery and make a good case for its continued investigation and use.

Regional anaesthesia may also have an impact on chronic postoperative pain, a condition that affects between 5–50% of patients. Like cancer recurrence, the aetiology of chronic postoperative pain is complex and incompletely understood (Fig. 3). Nevertheless, as Chen et al. point out, regional anaesthesia remains an essential component of the “multimodal analgesic toolbox”. Procedure, patient or technique-specific approaches to peri-operative care may be required to have a real impact, but further evidence is needed before definitive recommendations can be made.

Figure 3. Timing, events and risk factors contributing to the development of chronic postoperative pain; with assessment and treatment to prevent chronic postoperative pain. From Chen et al. (2021).

Quality

One of the challenges of regional anaesthesia is determining its overall benefit to healthcare. Johnston and Turbitt argue that successful regional anaesthesia should be judged in four domains : patient‐centred, population‐centred, healthcare‐centred and training‐centred outcomes. Each of these contain several metrics that must be quantified, analysed and improved upon for patient benefit. This landmark paper serves to refocus our exploration of regional anaesthesia on outcomes that matter, with implications for both research activity and clinical implementation.

With respect to healthcare- and population-centred outcomes, Hamilton et al. report the results of a systematic review of the quality indicators that have been used in regional anaesthesia studies. Using a Donabedian framework, they sought structure (administrative settings supporting care provision), process (the act of providing care) and outcome (patient recovery, restoration of function or survival) indicators. Predictably, the latter was most commonly reported, with only 6% and 18% of studies reporting structure or process indicators, respectively.

The importance of imparting regional anaesthesia skills to all trainees has already been mentioned. Ramlogan et al. highlight contemporary training methods in regional anaesthesia, in particular the use of modern technologies such as web-based learning, wearable devices and virtual reality systems. The effectiveness of these novel methods must be tracked using the appropriate training-centred outcomes.

Finally, McCombe and Bogod tackle the challenging subject of risk, consent and complications in regional anaesthesia. The significance of how we communicate risk is described, and how this communication leads to appropriate and legally sound consent, particularly in the post-Montgomery era.

Innovations

Both clinical and technological innovations share the spotlight in this issue. One of the foremost clinical innovations in recent years is the development of chest wall blocks. The current state of the art and future directions for this class of blocks are summarised by Chin et al. Pharmacological adjuncts for peripheral and central neuraxial blocks have also been an area of intense clinical and research interest. Desai et al. conduct a deep dive into these adjuncts that among other things, may leave many readers convinced that intravenous dexamethasone has effects beyond anti-emesis and therapy for COVID-19. 

The rapid pace of technological advancement and its application to regional anaesthesia are described in a complementary pair of articles. McKendrick et al. provide fascinating insights on how artificial intelligence and robotics will not only support clinical practice but potentially be the standard of practice in their own right. Finally, safe and successful regional anaesthesia has been described as primarily a matter of “getting the right drug into the right place”. Dr McLeod describes the exciting prospects for solving this perennial problem with technologically-enhanced needle-tip tracking  in ultrasound-guided regional anaesthesia.

Conclusion

The papers in this special issue provide a broad overview of the current state of regional anaesthesia. The hope is that all anaesthetists, and not just the enthusiasts, will find value in the content. More importantly, we hope that it will spur the continued expansion in provision of regional anaesthesia to our patients. There is a tremendous opportunity to improve delivery of healthcare and patient outcome, and we invite readers to join us as we take the next step forward on the path to regional anaesthesia excellence and access for all.

Ki-Jinn Chin, Kariem El-Boghdadly and Edward R. Mariano

Curarisation compared with other methods of securing relaxation in anaesthesia

We begin 2021, the year of our 75th anniversary, with a special commentary on our first ever original article, which was published in 1946 and was all about initial experiences with curare. This is the first in a new limited monthly series of articles we have called ‘Contemporary Classics’, and each looks at a popular paper from a subsequent decade. This month’s offering reminds us of three important areas for future research: studying the effects of deep intra‐operative neuromuscular blockade on patient‐centred outcomes; the implementation of quantitative neuromuscular blocking monitoring into widespread clinical practice; and the need for an ideal neuromuscular blocking drug that can be readily switched on and off. Next month, we tackle the subject of deaths associated with anaesthesia, and the index paper from the 1950s shows just how far clinical governance and audit have come in 60 or so years. We hope you enjoy these articles and all that the Association of Anaesthetists have planned to celebrate the occasion throughout the year.

Resternotomy following cardiac surgery has always been suspected to be associated with poor outcomes, and this new national audit from Agarwal et al. seems to confirm these suspicions. They were able to pool data from 23 UK centres and found that the mortality in these patients was 15%, with ~90% requiring transfusion of red cells and ~23% requiring renal replacement therapy (Fig. 1). Kendall and O’Keeffe list strategies that may one day enable us to eradicate resternotomy from clinical practice, and provide a discussion of the associated historical context. In October 2020, the PREVENTT trial of pre-operative intravenous iron to treat anaemia before major abdominal surgery was published in The LancetA summary of the methods, results and clinical implications is provided this month by Lachlan Miles, who suggests we should now all re-evaluate our practice but also that the story of intravenous iron in the pre-operative period is by no means over. In their editorial, Sharma et al. discuss the role of routine postoperative troponin measurement in the diagnosis and management of myocardial injury after non-cardiac surgery. They argue there should now be a shift to the use of pre-operative biochemical marker measurements instead of tools such as the modified revised cardiac risk index to risk stratify patients before surgery. 

Figure 1 Time from arrival in ICU to resternotomy in those who did and did not require renal replacement therapy. The (median (IQR [range]) of those who required renal replacement therapy 960 (293–3805 [5–44,640]) min vs. those who did not 420 (180–1046 [0–60,500]) min. *, p < 0.001.

Last year, Khan et al. published their secondary analysis showing that fluid optimisation before induction of general anaesthesia did not significantly affect the occurrence or degree of haemodynamic instability during induction. This month, Wong and Irwin discuss the implications, including the limitations of the study by Khan et al., and conclude it is not possible to determine from the available data whether modest fluid administration, presumably to compensate for fasting, can indisputably prevent post‐induction hypotension. Do you agree? Send us a letter and there is a good chance we will publish it! There is reasonable evidence to suggest there is an increase in positive airway pressure in spontaneously breathing patients receiving high-flow nasal oxygen, but what about when it is used for apnoeic oxygenation? This new randomised controlled trial from Riva et al.finds that high flow nasal oxygen generates positive airway pressures during apnoea when the mouth is closed. The airway pressures depend on flow rate, but remained < 10 cmH2O despite flow rates of up to 80 l.min−1. They conclude that maintenance of high oxygen concentration appears to be of greater importance than flow rate and airway pressure (Fig. 2).

Figure 2 Fitted mean trajectories of airway pressure with 95%CIs for combined closed and open mouth based on linear mixed models with different assumptions for the effect of flow rate (as indicated right).

The environmental impact of our work has been in the spotlight again recently, and this new cohort study from Zucco et al. suggests that desflurane is not associated with reduced risk of postoperative respiratory complications as compared with sevoflurane. This new piece of evidence might help organisations make decisions about the use of desflurane in their operating theatres. A more surprising result was reported in this randomised controlled trial from Albrecht et al. on the impact of short-acting vs. standard anaesthetic agents on obstructive sleep apnoea. They found that agents such as desflurane and remifentanil did not reduce obstructive sleep apnoea on postoperative nights one and three compared with standard agents (Fig. 3).

Figure 3 Change in the apnoea‐hypopnoea index (AHI) in the supine position over time (values are shown as mean with 95%CI). PreOP, pre‐operative; PON1, postoperative night 1; PON3, postoperative night 3. Blue line, standard agents; red line, short‐acting agents

An accurate, non‐invasive and economical method of pre‐operative anaemia screening would help with early diagnosis and hence expedite further investigations into its aetiology. This new study by Ke et al. finds that the Rad‐67 Rainbow was found to be inadequate for estimating actual haemoglobin levels and insensitive for detecting pre‐operative anaemia. Elsewhere, we have: a review of fit testing N95, FFP2 and FFP3 masksa review of apnoeic oxygenation in paediatric anaesthesiaa randomised controlled trial of trimodal prehabilitation in patients undergoing colorectal surgerya comparison of cardiopulmonary exercise testing in severe osteoarthritis; and a population based study of gestational anaemia and severe acute maternal morbidity. Finally, will this new systematic review, meta-analysis and trial sequential analysis by Desai et al. finally settle the question of epidural vs. transversus abdominis plane (TAP) block for abdominal surgery? They find that epidural analgesia was statistically superior to TAP block in the postoperative pain score at rest at 12 h and the need for intravenous morphine‐equivalent consumption at the 0–24 h interval, but these differences were not clinically important. They suggest clinicians should balance the risks against the benefits for individual patients and decide on that basis.

We hope you enjoyed our first live broadcast all about a new paper on COVID-19 vaccines by Professor Sir Jeremy Farrar and Professor Tim Cook, which has now been viewed > 10k times! We are planning a special live Twitter broadcast on the 11th of January to launch our new 2020 regional anaesthesia supplement with our editors, authors and you! Chairing the sessions will be Kariem El-Boghdadly, Ed Mariano, Ki Jinn Chin and Laura Duggan.

See you there!

Mike Charlesworth and Andrew Klein

Principles for guidelines and guidelines for principles

This month, we are delighted to publish the concept and methods for the Project for Universal Management of Airways (PUMA) (Fig. 1). This extraordinary project aims to develop a single set of airway management guidelines that can be applied across various domains to improve implementation, promote standardisation and facilitate collaboration. Ahmad and Smith provide the accompanying editorial and ask, is there justification for yet another airway management guideline? They highlight how the methods used by Chrimes et al. are unique as well as highlighting issues which will need to be addressed by the authors in the forthcoming guidance. We simply cannot wait to see them!

Figure 1 Summary flowchart of the methodology used in the development of these guidelines. COVID, coronavirus disease 2019.

Last month, we brought together the authors of two papers with seemingly contradictory conclusions as well as an expert in aerobiology for #TheGreatAirwayDebate. The podcast has now been downloaded over a thousand times! We have a number of related papers this month, including this simulation study by Simpson et al., which shows that devices such as the aerosol box confer minimal to no benefit in containing aerosols during tracheal intubation. In their editorial, Turner et al. propose a framework for the safer adoption of a ‘McGyvered’ device, which includes a recommendation to not adopt, publish, endorse or disseminate via social media such devices without data to support safety. That said, social media was no doubt very useful during the early part of the pandemic for rapid knowledge transfer, as demonstrated by this editorial by Chan et al. along with their now famous infographic. Thankfully, we did not see any such devices attempting to solve the various issues associated with tracheostomy insertion, and instead this new guideline from McGrath et al. provides some sensible evidence-based practice recommendations. It will no doubt become very relevant once again for the second surge and beyond.

What are the additional risks during the peri-operative period attributable to new ways of working during the pandemic? Kane et al. report their retrospective observational cohort study and conclude there are low rates of COVID-19 infection in elective surgical patients despite a high burden of disease in the community. It seems the current bundles of peri-operative care along with stratified pathways work (Fig. 2). Should we be re-starting elective surgery? Well we obviously have and did so the short answer is yes, as safe surgery is essential for the management of non-communicable diseases and underpins good health and wellbeing. Efforts to ensure this can be done safely present us with enormous challenges that we are fighting collectively. This observational study by Okonkwo et al. is an excellent example demonstrating how it was done for paediatric surgery in north-west England

Figure 2 Urgent elective surgery care bundle during COVID‐19 surge. Details of key elements of the urgent elective surgery care bundle from planning to postoperative follow‐up and COVID‐19 status tracking. PPE, personal protective equipment.

We published recently an international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients, and this new editorial by Bowen et al. calls for current ‘track and trigger’ tools to be updated to reduce opioid-induced ventilatory harm. They discuss risk factors, incidence, detection, sedation scores and track and trigger systems. Opioid-induced ventilatory impairment is a preventable iatrogenic harm, yet some patients have no identifiable risk factors. Is it time we monitored all patients receiving opioids for acute pain with a better designed track and trigger tool? The authors suggest so. 

When anaesthesia is maintained with intravenous drug infusions, real time analysis of the achieved concentrations is not routinely available. This new prospective observational study from Van Hese et al. finds that although target-controlled administration of propofol and remifentanil using the Marsh and Minto models allows clinically safe and stable conduct of anaesthesia, there were significant inaccuracies in both plasma and brain concentration predictions of these models. The Minto pharmacokinetic parameter set resulted in an underprediction of the plasma remifentanil concentrations by 72% and an overprediction of brain tissue remifentanil by 14%. Furthermore, the Marsh model showed an overall underprediction in both plasma and the brain by 12% and 81%, respectively, meaning that the measured brain tissue concentration was 81% higher than the effect‐site concentration predicted by the Marsh model (Fig 3). Irwin et al. suggest that some of the assumptions on which we base our models may be incorrect, and go into detail about what these models and assumptions are as well as their accuracy. They suggest that the issue of effect‐site concentrations probably exists for all anaesthetic drugs as a result of complex interactions with the blood brain barrier, including inhalational anaesthesia. After all, what we are measuring is the end tidal concentration and not the concentration of drug at the effect site in the brain. 

Figure 3 Relation between the performance error (PE) and the target concentrations in plasma and the brain. (a) Predicted TCI target concentrations of remifentanil were calculated using the pharmacokinetic parameter sets of Minto. Remifentanil plasma concentration (open circle); remifentanil effect‐site concentrations (filled circle). (b) Predicted TCI target concentrations of propofol were calculated using the pharmacokinetic parameter sets of Marsh. Propofol plasma concentrations (open diamond); propofol effect‐site concentrations (filled diamond).

Elsewhere we have: a review of COVID-19 infection risk during elective peri-operative carea statistical take on R0 (or more precisely, RE)a randomised study of programmed intermittent epidural bolus vs. patient centred epidural analgesia for maintenance of labour analgesia; and a study of the association of lung ultrasound images with COVID-19 infection in an emergency room cohort. Over in Anaesthesia Reports we have reports of: the use of the erector spinae block in obstetricsacute pulmonary oedema and hyperchloraemic metabolic acidosis following operative hysteroscopy using sodium chloride 0.9%apnoeic ventilation for shared airway surgery; and a novice anaesthetist working and living with malignant hyperthermia.

Finally, we will soon be publishing our 2021 supplement issue which is all about regional anaesthesia. Watch this space for some exciting news about how we aim to bring some of the great content to you in a new digitally immersive and interactive format! 

Mike Charlesworth and Andrew Klein

Time to plan and time to act again — but this time it’s different (Part 2)

“The only certainty in a pandemic is uncertainty”

While there is much that has improved in our understanding and management of COVID-19, there remains a significant concern about how we will deal with and get through this second surge of the pandemic. In some respects, there was more certainty during the first surge than there is in the second. We were certain that all but the most essential healthcare services were to cease. We were certain that all of our time was to be spent addressing the immediate crisis. We were certain about what we were allowed to do, who, how and where we were allowed to meet others, how our income was going to be safeguarded. We were certain that we did not know enough about this disease, but neither did anyone else. We were certain that our resource-capacity for testing, contact tracing, staff protection, PPE, critical care services were going to be stretched to the limit. We were certain that we were all in it together.

Those certainties have all but disappeared, and we have been left in dark territory without a light. Despite all of the lessons we should have learned in the first surge, there remain many we have failed to learn from, and there remain new hurdles for us to overcome. The healthcare-specific challenges are compounded by the fact that this surge will occur during the winter at a time when respiratory illness, hospital workload and mental health stressors are at their greatest.

Uncertainty in non-COVID-19 services

There is a moral and practical need to maintain non-COVID-19 work alongside surge-related activity. While all but genuine emergency work was postponed in the first surge, this is no longer feasible. There is now therefore a massive backlog of elective work the NHS has committed to both maintaining that elective clinical work and ensuring it continues to deliver healthcare services for all needs. This will pose new challenges which may be at least be equal or even greater than the challenges of the first surge. There is no new capacity in the NHS, but we will undoubtedly need to expand ICUs again, this time while protecting peri-operative pathways. The Anaesthesia-ICM hub has published guidance on how this may be achieved and in it emphasises the important of co-ordinated planning and collaboration between anaesthesia, surgery and critical care. There is likely to be a need for increased liaison and mutual aid not only involving critical care but also elective surgery. This may be between hospitals, regionally or nationally. To achieve this, departments of anaesthesia need to engage with their critical care colleagues if they are separate and it is likely that regional anaesthetic networks, similar to existing critical care networks, will need to be established. The Nightingale facilities (they lack the breadth of structures and services to be called hospitals) remain an important part of the response but only if the rest of the NHS is failing. Critically, Nightingale facilities provide space but not staffed space. So, if opened they will need to be staffed by the same staff who currently work in the very hospitals the Nightingales are designed to decompress. Their use will be a sure signal that the normal NHS is overwhelmed and will likely only occur when quality of care is already decreasing. We must hope they lie idle.

Maintenance of hospital safety

There is the challenge of keeping hospitals, their staff and patients safe from COVID-19. During the first surge hospitals were effectively closed except for COVID-19 patients and true emergency care. The country was in lockdown, schools, universities, pubs and restaurants were closed and social mixing was non-existent. The mantra was ‘protect the NHS’. Yet despite this the rate of infection in hospitals was three- of four-fold higher than in their communities – in one hospital almost half of healthcare workers became infected in a 3-week period. Hospitals such as Weston General and Hillingdon Hospitals had to close temporarily because of COVID-19 outbreaks. In the second surge, ‘the NHS is open’, elective care will continue while in the community town centres, schools and pubs are open and social contact is much increased, and adherence to guidelines has dropped as confidence in these has fallen. The number of staff off work due to illness or precautionary self-isolation as family members are in contact with others is already noticeable and impacting on delivery of care. To worsen matters, barriers such as self-isolation for 14 days before elective admission to hospital and use of high level PPE in elective patients have been removed so that patients may be admitted after no more than 3 days self-isolation (which, based on viral dynamics provides little if any barrier) and for these patients  transmission-based precautions such as increased levels of PPE or fallow theatre periods are currently not recommendedWard-based outbreaks can fuel nosocomial infection and currently approximately 10% of patients in hospital with COVID-19 acquired it there, with rates much higher in some locations. These patients are set for a difficult course: almost one in four surgical and medical patients who develop COVID-19 in hospital will die: far higher than if acquired in the community. Hospital outbreaks lead to patient and staff harm and ward closures, but also removal from work of large numbers of staff making it difficult to run services: we must avoid them at all costs. Hospitals need to monitor local and in-hospital infection rates to determine if and when the barriers that have been lowered need once more to be raised. The flux of patient risk pathways, be it red/amber/green; high/medium/low risk; COVID-free/COVID-positive or any other permutation that varies both temporally or spatially, has thrown healthcare workers into a constant state of confusion. Consistent, well-designed pathways for patients should be agreed upon and not be updated reactively, but rather planned proactively. Last but not least, hospital staff need to improve their behaviour to reduce transmission within hospitals. Social distancing, adhering to the designated numbers of people in any room, strict and proper wearing of facemasks and high infection control standards are essential. Despite weariness and the need to relax and decompress, it is not acceptable for the staff coffee room, doctors mess or departmental offices to be transmission hubs for the virus. 

Staff wellbeing

Mental health problems have increased across society during the pandemic. Hospital staff are significantly affected and it is likely that major changes in healthcare worker support will be needed to address the psychological harm already caused. The jump from a traumatic first surge, to the non-COVID-19 recovery, followed once again by a COVID-19 surge has left healthcare professionals fatigued and verging on burnout. Data suggest that more than half of all frontline healthcare workers are suffering either anxiety, depression or PTSD. This psychological burden will be carried forward to this second surge, leaving even greater uncertainty about the wellbeing of the very individuals on whom our healthcare service is dependent. Further, shielding of at-risk individuals is no longer required, and so healthcare workers with higher personal risks may have a significant increase in their absolute risk. Those with the power to do so must act, and we need to look after ourselves and our colleagues, actively managing our own mental health and workload, staying alert for signs in others and supporting those who are struggling. The Association of Anaesthetists and Intensive Care Society amongst others have provided excellent resources and these should be used alongside professional support. 

The world around us

Our lack of confidence in predicting the world around us has cast a further shadow on this second surge. Social restrictions change day to day, region to region, and country to country. Financial stabilityjob security, and government support have all become less predictable for many  families. Travel restrictions have meant that a large proportion of the healthcare workforce who have settled in the UK are unable to visit family members abroad. Political disquiet, both in the UK and globally, add to the ongoing state of flux. Leadership that provides long-term strategies and vision appear to be in short supply, given the predictability of many of our current challenges. And of course, there remain questions regarding the role of a potential vaccine on our ability to get through the pandemic. 

Hope

We are headed into the darkness of a long winter in which every aspect our lives will be affected. This winter is predicted to be one of the most challenging we are likely to face. However, the darkness and the surge will pass. We have always found ways of coming together and finding strength in adversity, and the strength of our healthcare workforce, both as individuals and as a community, will overcome the challenges ahead.

The first surge passed and so will this one.

Tim Cook and Kariem El-Boghdadly