Preventing oesophageal intubation

This new guideline is without doubt one of the most important papers from 2022 and essential reading for all. Oesophageal intubation during attempted tracheal intubation could happen to any one of us, yet traditional teachings and practice might lead to misdiagnosis. The case of Glenda Logsdail demonstrates the very real consequences when things go wrong. The key elements of the paper are the 11 core recommendations, the criteria for ‘sustained exhaled carbon dioxide’ and an algorithm for what should happen when these criteria are not met. Because many will not be skilled with airway ultrasound and because most will not have even seen an oesophageal detector device, the guideline reinforces the recently published Association of Anaesthetists recommendation for flexible bronchoscopes to be available for every general anaesthetic. The paper is free for all forever and as we saw live at Annual Congress, the associated cognitive aids located in the right place at the right time might just save a life. Ahmad and Wong provide the accompanying editorial and discuss the likely real-world impact of the guidelines. Afterall, it is extremely difficult to quantify true implementation and adherence of the recommendations provided.

If the PUMA guideline was the most important paper from this year, the results from NAP7 promise to deliver the same in 2023. But before all is revealed, this new paper takes us through the methods in detail. That the authorship delivered the project during the COVID-19 pandemic is a remarkable achievement and underscores the drive and determination behind the whole team. Not only that, the NAP7 infrastructure was activated to monitor the impact of COVID-19 on anaesthetic and surgical activity between October 2020 and January 2021 (ACCC-track). One of the many difficulties faced was to derive a unified definition of ‘peri-operative cardiac arrest’, which has been a source of controversy for many years. Although these events are rare and there is a great deal to learn from the analysis of individual cases, the project will also report some interesting trends at a national level with implications for all doctors, patients and policy makers.

Was it worth treating patient with COVID-19 in critical care areas? This new prospective single centre study from Schallner et al. found that direct medical costs for the treatment of COVID-19 patients were higher than for other critically ill patients, which was not exclusively due to longer length of stay (Fig. 1). Despite these high costs, they conclude the associated care to be cost-effective and beneficial regarding QALYS gained in relation to other medical measures. In the associated editorial, Pandit highlights several limitations of the analysis which suggest that we should not allow these data to inform public policy

Figure 1 Comparison of ICU treatment costs and simplified acute physiology score-2 (SAPS-2)/therapeutic intervention scoring system (TISS) scores in patients with (black circles) and without (grey triangles) COVID-19. (a) Total treatment costs (£); (b) Treatment costs per day (£); (c) Mean daily SAPS-2/TISS scores. Circles and triangles are individual patients, thick lines are means and thin lines are SD.

Postoperative morbidity following colorectal surgery can only be improved if it is measured and modelled. This new study from Bedford et al. describes the development and internal validation of the PQIP colorectal risk model. It demonstrates good calibration to risk-adjust postoperative day 7 morbidity defined by the POMS in the setting of elective major colorectal surgery with discrimination performance superior to published morbidity risk models. In the associated editorial, Coulson et al. set the work in its context and describe a pyramid model of investigation into unexpected variation is proposed (Fig 2.). 

Figure 2 Pyramid model of investigation. Investigation should start at the base, progressing towards the apex if a cause for variation is not established.

This new study aims to break the cycle of unnecessary lengthy periods of pre-operative fasting by using iterative ‘plan-do-study-act’ methods. They managed overall to reduce the median liquid fasting time from 12 h to 2 h, which is in keeping with international guidance. The key factor here is use of the term ‘unrestricted’, because putting limits on pre-operative clear fluid quantity and time presents logistical issues for staff, patients and hospitals. Is pre-oxygenation with high flow nasal oxygen easier for the anaesthetist and more comfortable for patients as compared with a facemask? This new RCT from Merry et al. finds this to be the case albeit with no clinically relevant differences in effectiveness (Fig. 3).

Figure 3 Median (boxes), interquartile range (lines) and outliers of ratings (dots) by (a) anaesthetists for ease of pre-oxygenation on a 10-cm visual analogue scale (0, easiest; 10, hardest); and (b) patients for comfort on a six-point comfort scale (0, most comfortable; 5, least comfortable) comparing pre-oxygenation with facemask or high-flow nasal oxygen (HFNO).

Elsewhere we have: a review of obstetric anaesthesia emergenciesa review of peri-operative frailty; and a comparison of standard and flexible tip bougies for tracheal intubation using a non-channelled hyperangulated videolaryngoscope. Finally, Shelton and Goodwin provide a guide on how to plan, report and get your qualitative study accepted. Teaching in this important area is scarce in undergraduate and postgraduate medical curricula, but this paper aims to bring us all up to speed on aspects such as reflexivity, generalisability and credibility. That’s all for 2022, but make sure you join us next year for WSM23 and look out for our new special supplement issue in the early new year!

Mike Charlesworth and Andrew Klein

Bridging the workforce gap

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.

Figure 3 Relationship between healthcare utilisation by COVID-19 (top panel) and organ donation and transplant activity (lower panel). Numbers of mean weekly people hospitalised with COVID-19 (blue) and people with COVID-19 undergoing mechanical ventilation (red) are showed in relationship to the total weekly referrals to NHSBT (navy), and the number of resulting donors (pink), total transplanted organs (green) and number of transplanted kidneys after deceased donation (purple).

Elsewhere we have: a review of novel wearable contactless heart rate, respiratory rate, and oxygen saturation monitoring devicesa narrative review of transporting the trauma patienta state-of-the-art review of management of the acutely unwell child; and a retrospective observational multicentre study of the prevalence of pre-operative anaemia in surgical patients. Finally, you can now book your place at the 2023 Winter Scientific Meeting where we will be hearing all about the recently published PUMA guidelines, NAP7 and our 2023 Supplement in intensive care

Mike Charlesworth and Andrew Klein

Emergencies in anaesthesia

This month, we are delighted to publish our new special selection of review articles on emergencies in anaesthesia. Some of these reviews appear in the October issue and the others on Early View and in future issues. All are free to access for all, forever! 

First, Matt Wiles lists the evidence for airway management strategies in patients with suspected or confirmed traumatic spinal cord injury. He discusses: airway manoeuvres; manual in-line stabilisation; cricoid force; direct and indirect laryngoscopy; flexible bronchoscopy; and the associated risks of tracheal intubation. Overall, the risk of spinal cord injury during tracheal intubation appears to be minimal even in the presence of gross cervical spine instability. The evidence supporting practice choices is difficult to generalise to clinical practice, and practitioners should choose the tracheal intubation technique with which they are most proficient in the circumstances. 

Spoelder et al. discuss the transport of the patient with trauma, which is a complex process influenced by many factors. Immediate and precise identification of injury severity, with correct prioritisation of medical treatment and identification of the best mode of transport from accident scene to definite care, may impact morbidity and mortality. Edelman et al. bring together the last 5 years of studies reporting the prevalence and commonality of non-technical skills and human factors in airway management guidelines. They found that human factors were generally well represented in airway management guidelines but that further considerations are necessary for future clinical guidelines. McCahill et al. describe high quality basic care for the acutely unwell child, as well as advancements in the field which address issues around low case exposure and maintaining skills in different settings. Anaesthetists play a key role in the team of clinicians caring for sick children, which can be complex. Developments in training, cognitive aids, knowledge sharing and addressing human factors are vital to keep a workforce ‘paediatric ready’ to deal with these important emergencies. 

Prior et al. review six areas of obstetric emergencies: category-1 caesarean section; difficult and failed airway; massive obstetric haemorrhage; hypertensive crisis; emergencies related to neuraxial anaesthesia; and maternal cardiac arrest. They point to a need for more multidisciplinary training and simulation and outline the central role of obstetric anaesthetists in enhancing a culture of peri-delivery safety. Gottesman et al. review the concept of frailty, its epidemiology and approaches to evidence-based peri-operative management in the setting of emergency non-cardiac surgery. In the future there should be: specific focus on applying shared decision-making in time limited emergency surgery situations; optimal multidisciplinary peri-operative care pathways; effective frailty-friendly analgesic regimens; and effective physical and cognitive recovery after surgery. Finally, Shah et al. review the past, present and future of major haemorrhage.  They discuss: mechanisms; transfusion support; blood components;  ratios; pharmacological interventions; monitoring; and directions for future research (Fig. 1).

Figure 1 Key principles for the management of major haemorrhage in general, and across different clinical situations. MHP, major haemorrhage protocol; Hb, haemoglobin; RBC, red blood cell; PT, prothrombin time; FFP, fresh frozen plasma; PCC, prothrombin complex concentrate; TBI, traumatic brain injury; TXA, tranexamic acid. 

In the October issue, Sajayan et al. present their analysis of a national difficult airway database (Fig. 2). They find that unanticipated difficult airway management continues to occur despite airway assessment, and the rate of critical incidents in this cohort of patients is high. As has been reported before, there is still insufficient utilisation of safe techniques such as awake tracheal intubation when a difficult airway is anticipated. In the associated editorial, Smith and Rosenstock ask whether difficult airway cards help if practice doesn’t change?Anticipating airway management difficulties is an imperfect science, but we must better match the available techniques with patients identified or predicted to be at risk. 

Figure 2 Anticipated (blue) and observed (red) difficulties in airway management in patients included in this analysis (n = 675). Anticipated and observed values are not mutually exclusive as more than one difficulty can occur. FMV, facemask ventilation; SGA, supraglottic airway.

This new prospective study from Kohse et al. has been extremely well received already on social media, with over 500 likes for one tweet! They developed a multivariable model and score that associates intubation-related characteristics with subsequent issuing of a difficult airway alert after videolaryngoscopy, tailored to be used as a classification tool to grade difficult videolaryngoscopic intubation (Fig. 3). It demonstrates high discrimination and even outperformed the Cormack–Lehane classification. Will you be using it? 

Figure 3 The VIDIAC score is comprised of: E, the interaction between the blade tip and epiglottis; V, the best view of the vocal cords from the blade camera; and A, enlargement of the arytenoids. Illustration by Rasmus Borkamp, Hamburg, Germany.

In addition, we have: a systematic review of the analgesic benefits of the quadratus lumborum block in total hip arthroplastya review of mechanical ventilation in patients receiving extracorporeal membrane oxygenationa study of nocebo language in anaesthetic patient written informationa randomised controlled trial of interscalene block with 10 ml or 20 ml levobupivacaine 0.25% in patients undergoing arthroscopic shoulder surgery; and a study of the measurement of aerosols using a real-time sensor network

Dr Dmitri Nepogodiev presenting the Paper of the Year at Annual Congress 2022 in Belfast on behalf of the COVIDSurg collaborative.

Shelton and Kearsley provide their top tips on how to write and publish a case report in anaesthesia and peri-operative medicine. This article is a must for anyone wishing to write about their interesting cases and achieve publication in a high-quality journal such as Anaesthesia Reports! We hope you enjoyed the recent Annual Congress 2022 meeting in Belfast as we did. Here are those top 10 article from 2021, which are all free to download forever. Congratulations to the COVIDSurg collaborative, who achieved three spots in the countdown, including paper of the year!

Mike Charlesworth and Andrew Klein

Measuring and managing neuromuscular blockade

It is not clear yet why facemask ventilation becomes easier following neuromuscular blockade. This new prospective observational study from Lee et al. evaluates changes in tidal volume after administration of neuromuscular blockade and assesses the correlation of this with changes in the vocal cord angle. They found that tidal volume and vocal cord angle during induction of anaesthesia increased after neuromuscular blockade in patients with normal airways. In addition, both insufficiency of ventilation before neuromuscular blockade and improvement after neuromuscular blockade were correlated with vocal cord angle (Fig. 1). They suggest a new role for considering ‘vocal cord status’ to optimise facemask ventilation using neuromuscular blocking drugs. In the associated editorial, Chau and El-Boghdadly discuss the age-old question of whether adequate facemask ventilation should be confirmed before administering a neuromuscular blocking drug. They argue that drug administration is not just about a point of no return but about making the onward journey easier.

Figure 1 Increase in mean tidal volume before (black bars) and after (white bars) neuromuscular blockade. The bars indicate the mean and SD values. *p < 0.001 vs. before neuromuscular blockade.

In ICU patients, there is a risk of unintended residual neuromuscular blockade and associated complications. This new prospective study from Ross et al. aims to determine the incidence and identify associated factors. They found that it occurred in at least one-third of patients with no difference between postoperative and non-postoperative patients. Worryingly, 63% of New Zealand ICUs rarely test neuromuscular function before tracheal extubation, and 37% never do. In the associated editorial, Bailey simply states that if we cannot measure it, we cannot manage it. Afterall, as far as the administration of neuromuscular blockade is concerned, the ICU environment should be considered the same as the operating theatre.

Figure 2 Model inputs and output, with observed occurrence of residual neuromuscular blockade (RNMB): sex and postoperative status; predicted probability of RNMB; and whether RNMB was observed. Male (black); female (grey); non-postoperative (triangle); postoperative (circle); RNMB not observed (empty); RNMB observed (filled). (a) Rocuronium; (b) atracurium; (c) vecuronium; (d) pancuronium.

In the early COVID-19 pandemic, clinical guidelines in all areas of practices were changed beyond recognition in a matter of weeks and months. This new mixed methods study of UK anaesthetists from Shrimpton et al. looks at current practice and perceptions of so called ‘aerosol generating procedures’. The paper is rich with data and insight as well as lessons for the future. For example, some anaesthetists preferred using high level personal protective equipment during pre-operative patient assessment, despite this being at odds with national guidance. Overall, there was a call for more involvement of professional representative bodies, should practice change rapidly in this manner again. Severe maternal morbidity is of interest given that it is expected that historical reductions in maternal mortality might be reversed by increasing risk factors in the general population, such as obesity. This new cohort study from Masterson et al. found that severe maternal morbidity was recorded for about 1% of pregnant women in Scotland. Morbidity was independently associated with: maternal age; BMI; pre-existing morbidity; previous smoking; previous caesarean section; multiple pregnancy; and maternal birth in Africa or the Middle East. Morbidity was associated with delayed hospital discharge, stillbirths and maternal deaths. This paper was featured in the mainstream media with focussed placed on obesity as a significant risk factor. 

There is a need to prioritise equity, diversity and inclusion (EDI) within anaesthesia and medicine as a whole. This position statement outlines the Anaesthesia Editors’ current policies and practices aiming to achieve equity, represent the diversity of our specialty and actively include people engaged with this journal and beyond. We hope this will be an effective starting point towards embedding EDI into everything that the journal does and influences in clinical practice and academia. You can listen to a discussion of the statement, chaired by Association of Anaesthetists CEO Nicky de Beer, here. We all know that desflurane and nitrous oxide are bad for the environment, but how well can their avoidance and other strategies be implemented into clinical practice? This new guidance document from Devlin-Hegedus et al. provides recommendations for all clinicians that can be implemented right now. Will you start doing something different today? 

Another paper featured in major news outlets recently was this narrative review by Pandit et al. on the effect of overlapping surgical scheduling on operating theatre productivity. This might be a strategy that promises much in terms of reducing the waiting list backlog, but this must be balanced against the risk of adverse patient outcomes, safety, training and patient autonomy. You can read the associated press coverage here. Elsewhere we have: a feasibility trial of angiotensin-2 in cardiac surgerya pooled cross-sectional analysis of trends in country and gender representation on editorial boards in anaesthesia journalsa discussion of SARS-CoV-2 and airway reactivity in children; and a narrative review of the consequences of COVID-19 for chronic pain patients and services.

Finally, this month’s ‘Reviewer Recommendations’ tackles scientific dissemination, with the aim to get research to the people that need it. The authors argue that scientific dissemination is not an optional extra, and there is much work to be done to optimise dissemination tools in academic anaesthesia and peri-operative medicine. 

We have two big papers coming soon from important collaborative groups – PUMA and NAP! Look out for details of publication dates and live broadcasts, with PUMA set to launch their avoidance of oesophageal intubation guideline on Wednesday evening! We will see you for the broadcast on Thursday at 2000 BST. 

Mike Charlesworth and Andrew Klein

Effectiveness of emergency general surgery

We are all familiar with the successes of the National Emergency Laparotomy Audit, but what about those patients where emergency surgery is not appropriate? For five common acute surgical conditions, this new database study from Hutchings et al. compares those who did and did not receive emergency general surgery. They included nearly a million patients who were inpatients between 2010 and 2019. The primary outcome (DAH90) was similar for emergency surgery and non-emergency surgery strategies. However, the most striking result was the influence of frailty, age and number of comorbidities. There is a wealth of information which can be used to assist with discussions between clinicians and patients in the context of emergency general surgery. In the associated editorial, Forrester and Wren put the decision to operate in the context of its epidemiological triad (Fig. 1). They argue for caution when interpreting the results of Hutchings et al. because determining the ‘effectiveness’ of surgery is complex. It seems that more research is required and despite the advantages of instrument variable analysis provides, a prospective randomised study may provider more clarity.

Figure 1 Epidemiological ‘triads’.

Persistent pain following knee arthroplasty is common, and persistent opioid use in these patients is of concern. This new secondary analysis from Kluger et al. identified pre-operative opioid use, increased body mass index and multiple comorbid pain sites as important risk factorsIn the associated editorial, Levy et al. argue for the need to improve opioid prescribing in patients undergoing orthopaedic surgery. They look to the pre-operative period and highlight the fact that opioids are not a benign class of drug. Adverse effects include: increased surgical site infection risk; increased rate of early revision surgery; prolonged hospital stay; and greater likelihood of non-home discharge. 

There has been increasing evidence that lower doses of oxytocin and carbetocin following caesarean section are just as effective as higher doses but with a better side effect profile. This new double-blind, randomised, controlled, non-inferiority trial from McDonagh et al. compared the effect of low- and high-dose carbetocin and low- and high-dose oxytocin on uterine tone intensity at elective caesarean delivery. They found that low-dose carbetocin (20 μg) was non-inferior to high-dose carbetocin (100 μg) for the primary and secondary outcomes of uterine tone intensity at 2, 5 and 10 min after drug administration. Similarly, low-dose oxytocin (0.5 IU) was non-inferior to high-dose oxytocin (5 IU) for these outcomes (Fig. 2). A systematic review and network meta-analysis from Halliday et al. compared ultra-low, low and high concentration local anaesthetic for labour epidural analgesia. They found that ultra-low concentration local anaesthetic is associated with reduced total local anaesthetic dose, shorter first stage of labour and reduced incidence of Apgar < 7 at 1 min compared with low concentration, without compromising maternal analgesia, side-effect profile, satisfaction or neonatal outcomes. A narrative review from McCombe and Bogod brings together learning from 21 years of litigation for anaesthetic negligence resulting in peripartum hypoxic ischaemic encephalopathy. They explore four themes: delay; communication; hypotension following neuraxial anaesthesia; and documentation. Their paper is essential reading for all anaesthetists who work with pregnant women. Earlier this year, Plaat et al. published guidance on prevention and management of intra-operative pain during caesarean section under neuraxial anaesthesiaThis new editorial from McGlennan and Christmas explores the background to the paper as well as the clinical context. They remind us that we should always remain open to the possibility of a suboptimal block, and that true failure on behalf of the anaesthetist is failure to recognise and act. 

Figure 2 Box plot of uterine tone intensity assessed using verbal numerical rating scale (0–10) at 2, 5 and 10 min in each study group. Values are median (horizontal bars), IQR (box) and range (whiskers). Low-dose carbetocin (white solid); high-dose carbetocin (white shaded); low-dose oxytocin (grey solid); high-dose oxytocin (grey shaded). 

Elsewhere we have an evaluation of the outcome metric ‘days alive and at home’ in older patients after hip fracture surgery and an editorial praising developments in adult critical care transfer in England, which it is argued is a positive legacy of the COVID-19 pandemic. Finally, Miles and Story provide us with the first a new series of articles of ‘Reviewer Recommendations’. They takes us through the steps of how to design and publish quality science studies, which examine how readily and effectively research findings and guideline recommendations are translated into clinical practice and the outcomes of iterative quality improvement. These articles will become essential reading for anyone who wishes to increase their chances of publication acceptance not just in Anaesthesia, but wherever authors might choose to send their work. 

Make sure you book your place on the upcoming Annual Congress 2022 meeting in Belfast! We hope to see you there for plenty of great content including our annual paper of the year award. 

Mike Charlesworth and Andrew Klein

Implementing a checklist culture in peri-operative medicine

Despite several published guidelines recommending the use of peri-operative checklists, there is a paucity in reporting team adherence to checklist use. This new 5-year audit from Fuchs et al. aimed to report the adherence of anaesthesia providers to an anaesthesia pre-induction checklist. The checklist was to be undertaken before induction of anaesthesia and it included components related to: equipment; the patient; communication; and feasibility. They included 95,946 anaesthesia procedures with airway management, with overall completion in almost 60% of all procedures. They showed a 4.5% increase in the annual adherence rate (Fig. 1). Factors influencing adherence included the type of anaesthesia, variability between anaesthesia teams for different surgical specialities and urgent and daytime procedures. The checklist was used more frequently in the operating theatre, for non-emergency procedures and during daytime working hours. Saxena et al. draw comparisons with the well-known plane landing on the Hudson. Although well-designed checklists aim to reduce human error, they are only effective if implemented effectively. Regular audits like those reported by Fuchs et al. are useful to study patterns and reasons for non-compliance.

Figure 1 Adherence probability for the entire anaesthesia clinic (All) and stratified by anaesthesia team (as indicated), over time estimated with a binomial logistic regression model. Mean (solid lines) and 95% confidence limits (shaded areas) are shown.

During the early pandemic, there was much anecdotal evidence of a high incidence of right ventricular failure in ICU patients with COVID-19 and a suggestion of an association with mortality. Chotalia et al. undertook a retrospective observational study of 508 patients with COVID-19 pneumonitis of whom 305 (60%) underwent echocardiography. They identified three classes of patients from echocardiographic and clinical variables (Fig. 2). These subphenotypes had distinct clinical and outcome characteristics. McCall et al. add to this with their COVID-RV prospective study of 121 patients, of whom 112 (91%) underwent imaging. They found that the prevalence of right ventricular dysfunction was 6% and this was associated with a mortality of 86%, in contrast to 45% in those without right ventricular dysfunction. The associated editorial discusses the issues around imaging the right ventricle and determining when there is a problem. The key take-home message though is that we need to get better at echocardiography in ICU, perform it more regularly and use it to demonstrate, treat and monitor right ventricular injury earlier than we do currently.

Figure 2 Alluvial plot demonstrating the relationship between, on the left, clinically derived subphenotypes and on the right, latent class analysis-derived subphenotypes.

These new guidelines from the British Heart Rhythm were extremely well received on social media. Recommendations are provided around peri-operative pacemaker checking, functioning, deactivation and follow up. Before their initial release in 2016, there were no specific UK guidelines on this topic. Whilst much of the new update is based on expert opinion due mainly to a lack of trial date, anaesthetists are seeing more patients with cardiac implantable devices and the recommendations provided are of relevance to all. Two editorials feature in this issue that are associated with papers published earlier in the year. First, Ruslan and Smith make an argument for shorter and safer pre-operative fasting times in children. Afterall, the incidence of aspiration during anaesthesia for children in the associated study was approximately 0.1% and more than half of those that aspirated had an uneventful outcome. Second, Bailey and George ask, is further peri-operative research necessary for patients undergoing colorectal cancer surgery? They suggest that future trials should focus on homogenous surgery, a specific TIVA technique, a fixed intrathecal dose of opioid and patient outcome measures that matter.

Elsewhere we have a retrospective cohort study of ultrasound-guided caudal blockade and sedation for paediatric surgery and a randomised controlled feasibility trial of a clinical protocol to manage hypotension during major non-cardiac surgery. Finally, this meta-analysis from Pivetta et al. finds that the presence of obstructive sleep apnoea is associated with an almost two-fold increased risk of postoperative complications. There was also moderate certainty for patients with obstructive sleep apnoea having increased risk of cardiovascular complications (OR 1.56), atrial fibrillation (OR 1.74), respiratory complications, neurological complications, hospital and ICU re-admission postoperatively (Fig. 3).

Figure 3 Meta-analysis forest plots displaying odds ratio for postoperative complications in (a) non-cardiac surgeries and (b) cardiac surgeries. The odds ratio of each included study is plotted. A pooled estimate of overall odds ratio (diamonds) and 95%CIs (width of diamonds) summarises the effect size using the random-effects model. OSA, obstructive sleep apnoea; M-H, Mantel–Haenszel.

We have two livestreams coming very soon! The first is a live face-to-face discussion between our Associate Editor, Dr Tanya Selak and her colleague Dr Jessica Devlin-Hegedus. Dr Devlin-Hegedus was an author of a new paper which calls us all to action to reduce the environmental harms associated with volatile anaesthetics. This will be live on Twitter at 1000 BST on the 1st of July. The following week, we will be discussing our new position statement from the Editors on equity, diversity and inclusion. Date and time to be confirmed!

Mike Charlesworth and Andrew Klein

Major peri-operative complications

Major airway complications are rare and the best evidence on which we base current practice comes from NAP4, which was published in 2011. This new contribution from Cumberworth et al. used similar methods within six hospitals to see what has changed and highlight key areas for further training and development. They found an overall incidence of 1 in 3600 general anaesthetics, which is over six time that cited in NAP4. Even when certain cases were excluded that would have similarly been excluded in NAP4, the incidence remained higher. A key finding is that in those with a predicted easy airway, a standard approach of ‘anaesthesia induction followed by SAD/tracheal intubation’ very rarely results in serious airway complications. However, in those with a predicted difficult airway, this standard approach results in serious airway complication 45 times more frequently (Fig. 1). In the accompanying editorial, Armstrong and Cook list reasons as to why this new contribution is difficult to compare with NAP4. Importantly, it does not tell us the extent to which NAP4 recommendations were implemented. There still seems to be much to be done. Elsewhere, a more specialist paper from Peterson et al. reports complications associated with paediatric airway management during the COVID-19 pandemic. Their results, including that children with COVID-19 were 2.7 times more likely to experience hypoxaemia during tracheal intubation and extubation, challenge the belief that the implications of COVID-19 in children are insignificant. Clinicians should consider this when general anaesthesia is required.

Figure 1 Sequential management of the 17 cases of airway complication. ATI, awake tracheal intubation; DL, direct laryngoscopy; FONA, front of neck access; ICU, intensive care unit; PACU, post-anaesthesia care unit (recovery); SAD, supraglottic airway device; TT, tracheal tube. 

There has long been concern about patients undergoing major surgery with pre- or undiagnosed diabetes. This large prospective cohort study reveals a causal relationship between prevalent diabetes and adverse postoperative outcomes, which supports previous work. Going one step further though, the strength of the relationship between HbA1C and postoperative risk was lessened following adjustment for comorbid disease (Fig. 2). This begs the question, should we be targeting comorbidities, rather than short term glycaemic control? In the accompanying editorial, Polderman and Sieglaar argue the time has now come to find a place for pre-operative HbA1C screening, but how to optimise glycaemic control before surgery to improve outcomes remains a question with no answers.

Figure 2 Directed acyclic graph representing the casual relationship between HbA1c and postoperative complications. HbA1c, glycated haemoglobin; MI, myocardial infarction; CCF, congestive cardiac disease; PVD, peripheral vascular disease; and Composite, 30-day major postoperative complication and 90-day all-cause mortality. The green line from HbA1c to the composite outcome represents the direct casual pathway of HbA1c (direct effect). The blue risk factors represent mediators through which HbA1c also acts. If, after adjustment of mediators, an association is found between HbA1c and the composite outcome, this would suggest that HbA1c is not dependent on the mediators, that is, has a direct effect on the composite outcome. A direct effect would support optimisation of HbA1c before surgery. No direct effect would support optimisation of the mediators before surgery. 

There has been increasing concern about an increase in stress and mental illness including alcohol and substance use disorder in the medical workplace. There has also been more recent evidence suggesting a risk of suicide/accidental overdose among anaesthetists. This new Association of Anaesthetists guideline provides several recommendations in an area where there are insufficient resources available for anaesthetists, colleagues and medical managers. The good news is that over 75% of anaesthetists return to full practice if they co-operate fully with the required treatment and supervision. This new randomised controlled trial from Friedman et al. attracted a lot of attention recently on social media. They deliberate deceived trainee simulation participants by being told that the consultant was a subject in the study. Learners then participated in a simulated crisis that presented them with situational opportunities to challenge the consultant regarding clearly wrong decisions. They found that anaesthesia trainees were more effective at challenging a consultant’s clearly wrong clinical decision when they thought he was acting and a part of the simulation scenario. 

Has the shift to digital prehabilitation been forced by the COVID-19 pandemic? Durrand et al. remind us that patients are facing extended waits for surgery and we need to help patients wait better. Although digital solutions have advantages, one size can never fit all (Fig. 3). A co-ordinated national response comprising innovative solutions is required urgently to address this problem.

Figure 3 Framework for digitally facilitated prehabilitation support. PROM, patient-reported outcome measure; PREM, patient-reported experience measure.

Elsewhere we have: a narrative review of point-of-care assays in the management of postpartum haemorrhagea review of peri-operative care of elective adult surgical patients with a learning disability; and a study of ultrasound assessment of gastric contents in children before general anaesthesia for acute appendicitis

Finally, make sure you join us for this week’s livestream which is all about a paper looking at the effectiveness of emergency surgery for five common acute conditions. Friday 20th May 1000 BST, on Twitter!

Mike Charlesworth and Andrew Klein

Recruitment to higher specialty training in anaesthesia – we must do better

Any department will be familiar with the difficulties faced when appointing consultants or other senior doctors. We simply need more trained anaesthetists. Yet, the current trainee cohort have experienced major issues around all aspects of training, and this new survey elicits the associated consequences. It is, I believe, a landmark paper for several reasons. First, surveys are notoriously difficult to get right, especially as a full paper for publication in Anaesthesia. It serves as an excellent reminder of their utility, as well as how to do it. Second, this is a survey of trainees, by trainees, for trainees. The authors have responded to their own difficulties by producing a fine piece of academic work that will undoubtedly change things for others. Third, anyone involved with trainees and training should study the contents of the paper carefully, as we all have a duty to do better. Carey et al. discuss the recent curriculum and COVID-19 on training. It seems clear that more collaboration is needed between Royal Colleges, regulators and those who plan and run national recruitment processes. Clyburn et al. ask whether we have now created another lost tribe and make several recommendations as to how this cohort may one day be ‘found’.

Figure 1 Responses to questions about future plans (n = 437).

Are we all clear on how SARS-CoV-2 infection influences the timing of elective surgery, given that we now have vaccines and new variants? No? Look no further than this timely update from the Association of Anaesthetists, Centre for Perioperative Care, Federation of Surgical Specialty Associations, Royal College of Anaesthetists and Royal College of Surgeons of England. The main news is that previous recommendations that, where possible, patients should avoid elective surgery within 7 weeks of SARS-CoV-2 infection remain, unless the benefits of doing so exceed the risk of waiting. This is the key point though, as it is less about absolute rules and more about bespoke risk assessment and shared decision making. The paper contains a useful risk assessment template as well as a nicely written reminder about the importance of understanding relative vs. absolute risk.

Although we work in a low-risk specialty for litigation against doctors, it is important that we learn from claims to better understand clinical risk regarding trends, procedures and specialist areas of practice. This new analysis of claims made during 2008-2018 updates our understanding, which was based previously on work that is now a decade old. There are around 200 claims related to anaesthesia costing £14.5 million each year. Although this sounds like a lot, it is the equivalent of £4.39 per case. One of the surprises here is our reliance on researchers to do this work, as there are no formal processes to bring these data together. There must be a better way and the authors provide some excellent suggestions. Crosby argues that It’s time to eliminate tort from the management of medical mishaps in the NHS. Perhaps modifying the operation of NHS Resolution may allow it to do so meaningfully and eliminate the need for a new agency? D’Sa and Griffiths ask whether we can learn from our mistakes by looking in depth at medicolegal claims? They remind us that medicolegal risk is not the same as clinical risk, and we should reflect on which type of risk should drive changes in our practice. 

Figure 2 Proportion of claims by category in each of two time periods, 1995–2007 (blue) and 2008–2018 (grey).

Litigation arising from pain during caesarean section under neuraxial anaesthesia has replaced accidental awareness under general anaesthesia as the most common successful medicolegal claim against obstetric anaesthetists. These new recommendations are the only ones available in this area and benefit from the experience of a patient, who is also an author. The importance of effective communication is a strong theme running throughout as is the need to support clinicians and promote standardisation of practice in this area. The guidelines are accompanied by a systematic review from Patel et al. which find that approximately 1 in 1750 women require conversion to general anaesthesia due to inadequate neuraxial anaesthesia, and 15% require supplemental analgesia or anaesthesia ranging from nitrous oxide to general anaesthesia. In the associated editorial, Stanford (the patient author of on the authorship group) reminds us that the ends (a well baby) do not always justify the means, and inadequate neuraxial anaesthesia is associated with long-term psychological consequences. Afterall, physical safety is the bare minimum of what should be expected during caesarean sections.  

Elsewhere we have: an e-Delphi process with training facilitators of Priorities for content for a short-course on postoperative care relevant for low- and middle-income countriesa retrospective study of the effect of iron deficiency without anaemia on days alive and out of hospital in patients undergoing valvular heart surgery; anda prospective study of functional recovery after discharge in enhanced recovery video-assisted thoracoscopic lobectomy.

Finally, this prospective randomised trial from Hestin et al. aimed to elucidate whether general or regional anaesthesia is better for surgical evacuation of chonic subdural haematoma. In terms of time to become medically fit for discharge or postoperative complications, there was no difference and both techniques were comparable. In the associated editorial, Dinsmore and Wiles argue that patients should receive the anaesthetic that is best for them, and no large RCT will ever prove one technique to be superior than the other. Perhaps we now need to treat surgery for chronic subdural haematoma like that for hip fracture. This would require standardised care packages for the whole patient journey, rather than just the peri-operative period.  

Booking is now open for Annual Congress in September later this year, which be a face-to-face meeting! We hope to see you there! Our journal session will focus on emergencies relevant to those working in anaesthesia, critical care and pain.

Mike Charlesworth and Andrew Klein

Advanced care plans in the peri-operative period

For many, the COVID-19 pandemic brought the stark reality of our mortality into focus. Along with the controversial application of ‘blanket’ DNACPR orders, it has forced all in the profession to consider how we involve our patients in the difficult conversations and decisions regarding end-of-life care. The development of the ReSPECT process by the Resuscitation Council (UK) encourages patients in the community and hospital to create personalised recommendations for clinical care if they are unable to make or express their choices in a future emergency. In view of the changing landscape of advance care planning, the Association of Anaesthetists has created guidelines on implementing advance care plans in the peri-operative period. This is a consensus document produced by expert members of a working party and endorsed by the Resuscitation Council (UK) and Compassion in Dying. It highlights that advance care plans are to allow for patient-centred outcomes, and clarifies how to discuss, and deal with, DNACPR decisions in the peri-operative period. 

Continuing with the theme of patient-centred outcomes, this important systematic review and meta-analysis by McPeake et al. looked at hospital readmission after critical care and found that over 50% of previous critical care patients were readmitted to hospital within one year. Risk factors included co-morbidities, delirium, mechanical ventilation during the initial admission and infection after discharge. In the associated editorial, Plummer and Lonecomment on how these risk factors might be modified, and if so, what interventions are appropriate and possible. We all too often do not think past mortality for our outcomes; this study highlights how critical illness impacts patients, their families and healthcare resources, and states the case for targeted interventions for at-risk critical care survivors to reduce morbidity post-discharge. 

Clearly you should never judge an article purely by its title but ‘Regional analgesia following caesarean section: new kid and a block?’ is as incisive as an editorial as its title is witty (especially if you are a child of the 80-90’s). Kearsley et al. provide comment on a network meta-analysis performed by Singh et al. looking at the efficacy of regional blocks or local anaesthetic infiltration for caesarean section analgesia. Using a random effects Bayesian model they performed a network meta-analysis including 8730 parturients and found that bilateral ilio-inguinal blocks provided the highest reduction in 24-hour morphine equivalents, regardless of whether intrathecal morphine was administered. The associated editorial suggests that perhaps the time for transversus abdominus plane blocks is over and that ilio-inguinal blocks could be added to the RA-UKs Plan A blocks; but also appreciate the resource implication this may have as ilio-inguinal blocks require ultrasound provision. Step by step regional analgesia for caesarean section is becoming clearer.

One article that has garnered a lot of social media debate is a randomised controlled trial of a novel tramadol chewable tablet: pharmacokinetics and tolerability in children. Yoo et al. formulated a chocolate-flavoured tramadol tablet and performed a pilot RCT in a single centre. The chocolate tramadol tablet was found to have a higher bioavailability, quicker absorption and be better tolerated than liquid tramadol (Fig. 1). 

Figure 1 Taste tolerability scores obtained from children, parents and nurses for (A) the tramadol chocolate-based drug delivery system tablet and (B) tramadol liquid formulation. The 5-point facial hedonic scale was: 1 = dislike very much; 2 = dislike a little; 3 = not sure; 4 = like a little; and 5 = like very much.

If tramadol isn’t your paediatric analgesic of choice, Saffer et al. present a randomised controlled trial comparing oral paracetamol with water versus just water 1 h pre-operatively. They found that, in 97 children aged between 1 and 96 months, there was no significant difference in either gastric aspirate volume or pH between the groups. The authors acknowledge that some centres may already give pre-operative oral paracetamol, but this study provides reassurance that with reducing fasting times, pre-operative oral paracetamol is a safe alternative to the more expensive intra-operative intravenous option. 

Following on from last month’s consensus statement on academic publishing of papers from low-to-middle-income countries, Stahlschmidt et al., present a convincing before and after cohort study on enhanced peri-operative care to improve outcomes for high-risk surgical patients in Brazil. They created a 48-hour post-operative care bundle (Fig. 2) and demonstrated that increased surveillance of these high-risk patients reduced 30-day mortality. Enhanced post-operative surveillance of high-risk patients is potentially viable for use in other LMIC settings where critical care resource is scarce.

Figure 2 High-risk bundle compliance evaluation.

This month also sees the publication of an randomised controlled trial of a text message intervention to reduce burnout amongst trainee anaesthetists. No significant difference was demonstrated between trainees who received fortnightly text messages based on behavioural techniques to reduce burnout and those who did not. However, exploratory post-hoc analysis did demonstrate that burnout symptoms were reduced in trainees identified as having personal or work-related difficulties, and those particularly affected by the pandemic. Importantly, the authors found that there was no backfire effect which makes this a safe intervention. It is unfortunate that studies such as this are having to be performed, and the associated podcast discusses some of the factors surrounding trainee burnout.

Elsewhere, we have a retrospective cohort study on obstetric anaesthesia and analgesic practices for in SARS-CoV-2 positive patients; a service evaluation on the effect of transfer from critical care areas for mechanically ventilated SARS-CoV-2 patients; an editorial with practical tips on how we, as anaesthetists, can contribute towards combatting the global heating emergency and an editorial on the future of space anaesthesia!

Finally, attention now shifts to meeting again face-to-face later this year in Belfast. Booking for Annual Congress 2022 is now open! We are very much looking forward to seeing you there.

Cara Hughes and Andrew Klein

Advancing global health research equity

Parachute (or ‘helicopter’) research is the practice of conducting primary research within a host country and subsequently publishing findings with inadequate recognition of local researchers, staff and/or supporting infrastructure. In fact, almost 30% of publications of primary research conducted in LMICs did not contain any local authors. This new consensus statement from Morton et al. contains six recommendations which apply not just to research in our field, but broadly within academic publishing. It has achieved an Altmetric score of nearly 400, which demonstrates how well it was received by the academic community. A key element is the structured reflexivity statement, which the authors suggest should be completed with manuscript submissions from international research partnerships involving researchers from high- and low-to-middle-income countries. In the accompanying editorial, Jumbam et al. build upon this by encouraging journals and journal editors to adopt the recommendations (Fig. 1), and by encouraging us all to consider the reflexivity statement at every timepoint during project conception and implementation.

Figure 1 The position and power of journals within the global health research ecosystem. Journals influence the ecosystem by: (a) brokering research outputs which are predominantly led from HIC institutions; and (b) direct editorial statements (e.g. through ‘commissions’). These journal activities influence research prioritisation and funding allocation. The current predominance of HIC outputs and perspectives in journal activities further amplifies the impact of HIC perspectives on donor funding and research agendas. This can worsen existing inequities. 

In the UK, the Getting It Right First Time (GIRFT) programme was established by the Department of Health and Social Care as an initiative to investigate variation in healthcare delivery and patient outcomes between hospital Trusts in England. For their new paper, Gray et al. used the Hospital Episodes Statistics (HES) database to investigate variation in the rates Trusts discharged children the same day after tonsillectomy and associations with adverse postoperative outcomes. They provide evidence that outcomes for day-case and overnight stay tonsillectomy are similar, and argue the majority of specialist and non-specialist Trusts should increase day-case surgery rates. In the associated editorial, Stocker asks, why is there still a debate? Afterall, admitting a child to hospital is disruptive and, on occasions, distressing for not just the child but their extended family, as it necessitates the child and a parent to be away from the family home overnight. 

Video-assisted thoracoscopic surgery is associated with less pain and better recovery as compared with thoracotomy. Although enhanced recovery after surgery guidelines have been described, this PROSPECT guideline is the first specifically address evidence-based analgesia strategies. Recommendations support the use of: paravertebral and erector spinae plane blocks; systemic multimodal analgesia; intra-operative dexmedetomidine; and rescue opioids. The authors do not support thoracic epidural analgesia. In the associated editorial, Shelley et al. remind us that the supportive evidence for regional anaesthetic techniques in this cohort is weak. Although the guidelines are a useful benchmark, an individualised approach remains paramount, and more evidence is required urgently.

Obstructive sleep apnoea (OSA) is highly prevalent in the general population. This new secondary analysis from Moringo et al. aims to determine whether the STOP-Bang questionnaire can be distilled to develop an abbreviated screening tool to identify patients at high risk for severe OSA. They found that it can be reduced from eight to four variables to effectively identify patients at high risk for severe OSA. Neck circumference was most strongly associated with severe OSA, while observed apnoea, high blood pressure and BMI trended towards significance (Fig. 2). These four variables were termed the B-APNEIC score and together they demonstrated similar predictive accuracy to the STOP-Bang questionnaire for identifying individuals at high risk for severe OSA. In the associated editorial, Singh and Ramachandran welcome the B-APNEIC score and call for more research in areas such as POCUS screening, outcome prediction models and individualised evidence-based postoperative management strategies

Figure 2 Receiver operating characteristic curves of STOP-Bang questionnaire vs. B-APNEIC score for clinical diagnosis of severe obstructive sleep apnoea (OSA), severe apnoea-hypopnoea index (AHI), severe respiratory disturbance index (RDI) and severe oxygen desaturation index (ODI).

Many will routinely mix local anaesthetic agents or add adjuncts to alter block characteristics, but what are the true clinical consequences of this practice? Nestor et al. review the evidence, and find the supportive evidence to be lacking. They remind us that the long list of potential adjuncts will continue to grow if the vogue for mixing untested and unlicensed medications persists. Furthermore, doctors must be cognisant that, once the decision is made to use an ad-hoc admixture, they bear all responsibility and will be liable in the event of an adverse event. The same team also discuss mixtures of intravenous infusions in the context of target-controlled infusion systems. They argue that mixing two or more drugs in a syringe constitutes an unjustifiable patient risk, and has no place in modern practice. Do you agree? Send us a letter and we will publish it!

Elsewhere we have: a randomised controlled trial of erector spinae plane block vs. peri-articular injection for pain control after arthroscopic shoulder surgeryan assessment of introducers used for airway management; and a network meta-analysis of videolaryngoscopy vs. direct laryngoscopy for tracheal intubation in adults

Finally, make sure you catch up with two recent podcasts looking at perceptions of recruitment to higher specialty training during the COVID-19 pandemic and a randomised controlled trial of a text message intervention to reduce burnout in trainee anaesthetists. Both are essential listening and reading for all!

Mike Charlesworth and Andrew Klein