Anaesthesia and the ageing brain

People with dementia present for elective and emergency surgery and there has been, until now, no formal peri-operative guideline for this important patient group. This new document puts this surprising lack of guidance right by providing pragmatic instruction on aspects such as standards of care, access to services, communication of risk, pre-operative assessment, multidisciplinary teams, and training for healthcare staff. As with all Association of Anaesthetists guidelines, we encourage members to inspect the contents and share the key messages with colleagues, departments, and hospitals. The infographic below summarises ten key recommendations.

Dementia

In their editorial, Scott and Evered describe a large number of unmet challenges in the peri-operative care of elderly patients and those with dementia. Though there are large gaps in the literature, and the new guidelines are not heavily evidence-based, we should all nonetheless utilise them to raise awareness of team-based care for older patients and those with dementia. Arguably, peri-operative care for those with dementia is decades behind other fields such as pre-operative optimisation. Is it time to catch up? We think so!

Upper limb disorders are common, but this new survey finds a far higher incidence in anaesthetists (34%) as compared with the general population. Interestingly, the years since starting training, having children (irrespective of respondents’ sex or number of children) and right‐handedness were the main risk factors identified. Vargas-Prada and Macdonald remind us that doctors are a group of workers who take little sickness leave and are usually reluctant to access appropriate healthcare. Perhaps we all now need to think about how best to redesign equipment/workplaces and eliminate hazardous working postures from our daily activities? Send us your thoughts through our correspondence site!

Anaesthetists seldom prescribe discharge medications for patients in the UK, but there has been a worrying worldwide increase in opioid prescribing over the last decade. This new quality improvement study finds that 27% of all postoperative discharge prescriptions for oxycodone were inappropriate. The authors employ five sequential interventions and show that it is possible to reduce this to just 10% over a three-year period.

Figure 1Figure 1 Time series of monthly oxycodone prescriptions per 100 surgical cases (left y‐axis). Dashed lines represent the end of the first month following the first intervention of five, and the audit‐feedback plus academic detailing interventions (number 5), respectively. Fitted trend‐lines show the predicted values from segmented regression analyses in the three observation periods.

The grading of physical status using the American Society of Anesthesiologists (ASA) system is common practice throughout the world. This new review article describes the history of ASA grading and explains why, despite its apparent subjectivity, we will probably be using it for many years to come. More recently, it has been successfully incorporated into other systems to help generate more accurate predictions of patient outcomes.

Table 1Table 1 The ASA classification of physical status, as revised in 2014. The addition of ‘E’ denotes emergency surgery, defined as a threat to survival or body part if delayed.

This new editorial from Marshall and Chrimes was commissioned by an editor following an interesting discussion about medication handling on Twitter. It is accompanied with an excellent infographic (which are all available to download here) and already has an Altmetric score of 150! Should remifentanil patient-controlled analgesia be used as a first-line analgesic strategy in labour? This editorial comments on a trial recently published in The Lancet and sets out the key messages from the RemiPCA SAFE Network. These include clinicians taking responsibility; using research to answer urgent clinical questions, such as vital signs monitoring and feedback mechanisms; and a need to define key quality indicators for different analgesic methods.

The anaesthesia practice in children observational trial (APRICOT) was a prospective multi‐centre observational study of severe critical events during paediatric anaesthesia from 261 hospitals in 33 European countries. This new, secondary analysis of the study data finds that the incidence of peri-operative severe critical events was less in the UK cohort as compared with the non-UK cohort. This is likely due to a number of factors such as more experienced dedicated paediatric anaesthetists managing higher risk patients in the UK.

Figure 2Figure 2 The incidence of severe respiratory (striped) and cardiovascular (solid) critical events according to age of the patient.

Elsewhere there is a review of the effect of dexmedetomidine on delirium and agitation in patients in intensive care; a comparison of the new ROTEMsigma with its predecessor, the ROTEMdelta; a study of the use of spectral reflectance to distinguish between tracheal and oesophageal tissue; an observational study of the The LMA® ProtectorTM in anaesthetised, non‐paralysed patients; a study measuring depth of anaesthesia using changes in directional connectivity; and a study to identify the optimal predictor of right ventricular global function.

The journal is currently advertising for new editors to join the team! We are also nearly ready to launch our new journal, Anaesthesia Reports, and they are also advertising for new Assistant Editors. These are exciting opportunities not to be missed. Finally, tonight we will be hosting a TweetChat with the authors of this new paper and you can join the discussion by searching for (and including in your tweets) the hashtag #Hyperoxia.

See you at 1900 GMT!

 

Dr Mike Charlesworth and Professor Andrew Klein

Airway management research – what next?

This month, we are delighted to publish the first systematic bibliometric review of airway management research. This stemmed from a series of exchanges on the benefits, risks, and ethics of conducting airway research in manikins vs. patients. Ahmad et al. included 1505 studies published between 2006 and 2017, of which 1082 (71.9%) were patient studies and 322 (21.4%) were manikin studies (Figure 1). They observed an increase in the annual number of airway management studies over time. Patient studies mostly included elective ASA 1-2 patients and reported on tracheal intubation. A total of 77 primary outcomes were measured with success rate (27.4%) and procedure time (22.7%) the most common. Only seven trials used patient-centered primary outcomes and the authors highlight the need for a core outcome set. McGrenaghan and Smith agree with these sentiments and discuss how airway research may be conducted in the future.

figure 1Figure 1 Flow diagram demonstrating study subjects, study design and type of patient airway involved in experimental patient studies. Grey circles are for all studies, blue circles are for patient studies, green circles are for manikin studies and yellow circles are for all other subject types.

Supraglottic airway devices (SAD) play an important role in difficult airway management. In this retrospective registry study, Thomsen et al. describe the use of SADs in cases of difficult airway management. The Danish database is a unique repository and receives information from over 75% of Danish hospitals – their work is always of interest. From a cohort of 658,104 patients, difficult intubation occurred in 4898 (0.74%) cases. The most striking and perhaps worrying finding was that only 18.9% received a SAD in the course of their management. When SADs were used as rescue devices, they were successful two-thirds of the time. In their accompanying editorial, Ahmad and El-Boghdadly discuss possible reasons as to why SADs were so underutilised, and provide a framework for difficult airway management research (Figure 2). How does fibreoptic-guided tracheal intubation through a SAD compare between an I-gel® with the LMA® Protector™? Mendonca et al. observed no differences in mean intubation time, success rate, glottic view and ease of tracheal intubation.

figure 2Figure 2 Proposed framework for developing a difficult airway management research strategy.

The Global Capnography Project is arguably one of the most important projects in anaesthesia safety in the last decade. The results from their new study in Malawi support the development of an international project to help make global capnography provision a reality, so that like pulse oximetry, it can be included in the WHO surgical safety checklist and improve patient safety worldwide. In their accompanying editorial, Lipnick et al. call upon the global anaesthesia community (i.e. providers, researchers, national societies, manufacturers and donors) to accelerate research, education and development, manufacture, and distribution to make capnography accessible to anaesthesia providers in all practice settings.

Kwikiriza et al. report their RCT of intrathecal morphine versus ultra-sounded guided transverse abdominis plane block after caesarean section at a Ugandan regional referral hospital. Overall, the authors found both approaches were clinically effective in terms of providing adequate pain relief. The authors should be commended on this well-conducted study and for demonstrating the potential of using ultrasound in a low-resource setting. In the accompanying editorial, Bashford and Vercueil, provide suggestions on supporting and conducting such research and what role journals can play in developing and promoting authors from low‐ and middle‐income countries.

This case series on anaphylaxis to intravenous gelatin‐based solutions from Farooque et al. attracted plenty of attention during a TweetChat in December. Twelve patients were identified over a five-year period, 11 of which had severe or life-threatening reactions with three progressing to cardiac arrest. Unlike the classic presentation of anaphylaxis, which occurs within five minutes, the majority of patients developed signs/symptoms 10-70 minutes after administration. The commonest clinical features were cutaneous signs and hypotension. In view of the risk of severe allergy, along with the lack of any other clear benefits, is this the final nail in the coffin for the use of gelatins? Catch up with all the discussion on Twitter by searching for #Gelophylaxis.

The guidelines for the safe practice of total intravenous anaesthesia (TIVA) are a core document and essential reading for all anaesthetists (Figure 4). They have been extremely well received on social media with an Altmetric score of >300. Irwin and Wong argue that more work needs to be done on the practical education of TIVA and processed EEG monitoring so that more patients can benefit from this technique.

figure 4 - tiva guidelineFigure 4 Key recommendations from the TIVA guidelines.

Elsewhere, Morrison et al. suggest that fibrinogen concentrate may be used as an alternative to fresh frozen plasma to treat hypofibrinogenemia and coagulopathy during thoraco-abdominal aortic aneurysm repair. Tabl et al. were unable to demonstrate non-inferiority in uterine tone induced at elective caesarean delivery by carbetocin 20 mg to that induced by carbetocin 100 mg. Wittenmeier et al. report that point of care and non-invasive haemoglobin measurement devices are still not reliable enough to replace the laboratory measurement in term and pre-term infants. Lastly, Ferguson & Dennis review the literature regarding various definitions of anaemia in pregnant women (Figure 5) and provide a framework for patient blood management in obstetrics.

table 1Table 1 Definitions of anaemia in pregnancy in guidelines.

This blog follows an excellent Winter Scientific Meeting. Highlights from the journal session included Dr Kariem El-Boghdadly announcing the imminent arrival of Anaesthesia Reports (@Anaes_Reports), Professor Bruce Biccard’s talk on delivering pragmatic clinical trials in low resource settings, and Professor Peter Marfoher’s update in regional anaesthesia for shoulder surgery. Our journal workshop on ‘How to publish a paper’ also proved popular.

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Dr Akshay Shah and Professor Andrew Klein

Patient optimisation before surgery

Imagine a future where complete patient data are precisely recorded and seamlessly transferred between clinicians; where patients are presented with plain, accurate facts; where decision-making is shared; where patients experience less post-operative complications and shorter hospital stays; and where patients rapidly return to their functional and cognitive baseline. In their editorial, Levy et al. argue all this and much more is achievable, now. This year’s supplement contains 14 evidence-based free to access review articles and is a user-friendly, complete, and practical manual for all healthcare workers, patients, and relatives/carers. This month’s blog aims to pick out the key clinical messages.

Much time and effort seem to be spent developing models to predict postoperative morbidity and mortality, and we all use them to inform discussions with patients. John Carlisle asks, are they fit for purpose? Far from it, he argues, and we should instead focus on selecting who to operate on and how. This is a must-read for all anaesthetists as it challenges the fundamentals of how we think about peri-operative risk, communication of risk, care of the dying (and living!), patient selection, and healthcare priorities.

We all know what we mean by ‘shared decision-making’, but how does it differ from informed consent (which has its own problems), risk assessment, and decision aids? This review from Sturgess et al. discusses the relevant legal background; the barriers to peri-operative shared decision-making; the need for patient-focused processes; and how shared decision-making might be implemented. Perhaps a good place to start is with the SHARE approach (Table 1) and MAGIC questions (Table 2).

Table 1Table 1 The SHARE approach to shared decision-making: five essential steps for clinicians

Table 2Table 2 MAGIC questions for patients to ask their healthcare professionals

Multi-modal prehabilitation may reduce post-operative complications by 30% and shorten hospital stay after major surgery. This review from Sheede-Bergdahl et al. addresses the ‘why, when, what, how and where next?’. It seems nutritional and psychological optimisation are just as important as physical activity and exercise, and the pre-operative period should be fully utilised in order to promote more effective care (Figure 1). Gillis and Wischmeyer set out the case for pre-operative nutrition screening for the diagnosis, treatment, and prevention of peri-operative malnutrition, which may prevent complications and shorten hospital length of stay. Likewise, Levett and Grimmett present strategies for psychological prehabilitation and describe the limitations of the relevant evidence. Perhaps this should be a high priority area for future research?

Figure 1Figure 1 An overview of a multi-modal prehabilitation programme and related goals. SF-36, 36-Item Short Form Health Survey; HADS, Hospital Anxiety and Depression Scale.

The prevalence of asthma is increasing and now stands at 10-15% in developed countries. The incidence of peri-operative bronchospasm in those with asthma is ~1.7%, and Andrew Lumb argues pre-operative optimisation of respiratory disease such as asthma together with smoking cessation (which alone may reduce complications by as much as 41% if stopped four weeks prior to surgery) are high-impact evidence-based interventions. The evidence for exercise training for the prevention of postoperative pulmonary complications is mixed, but it does remain an important strategy. Around 40% of patients presenting for major surgery are anaemic and peri-operative anaemia is associated with poor postoperative outcomes. Munting and Klein provide an evidence-based treatment algorithm that should be used by everyone encountering patients scheduled for surgery. Print it out and put it on the wall!

Figure 2Figure 2 Treatment algorithm for preoperative anaemia.

Optimisation of diabetes prior to major surgery can take as long as three months. Gathering information and making a referral at an early stage is vital. Levy and Dhatariya argue the identification of poorly controlled or undiagnosed diabetes just prior to elective surgery is no longer acceptable. They propose criteria for diabetes screening prior to the initial referral for surgery (Table 3).

Table 3Table 3 Proposal for who should be screened for diabetes before referral for surgery.

Two hundred million major operations are performed worldwide every year with 10% of patients suffering postoperative complications. Though death due to surgery and/or anaesthesia is rare, 40% of peri-operative deaths may be attributed to a cardiac complication. Lee et al. discuss how assessment and management of cardiac conditions in the peri-operative period can significantly improve outcomes, especially for high-risk patients. Topics include hypertension; chronic heart failure; cardiac murmurs; and implantable devices. These should all be seen as modifiable risk factors that require attention well in advance of surgery. The proportion of the population aged over 65 years in the UK is expected to increase from 16.9% to 24.7% between 2006 and 2046. More than 40% of patients aged over 80 years are considered to be frail, with frailty more common in women. Chan et al. discuss the principles of peri-operative optimisation as applied to elderly and frail patients, and call for tailored pathways incorporating social issues; shared decision-making for patients and families; multidisciplinary care; personal values; and quality of life.

As depicted by the title picture for this blog, our traditional working environment is still seen by many as the operating theatre. Grocott et al. argue there is a need for us to adapt to the changing nature of our work and align our interests with those of patients. Their proposed ‘re-engineered’ pre-operative pathway hints at what the future of peri-operative medicine could look like (Figure 3 and 4).

Figure 3Figure 3 Traditional pre-operative pathway. MDT, multidisciplinary team.

Figure 4Figure 4 Proposed ‘re-engineered’ pre-operative pathway.

So far there has been much discussion about elective surgery. Poulton and Murray argue the principles of optimisation should also be applied to patients undergoing emergency laparotomy. Strategies include the timely administration of antibiotics; rational fluid resuscitation and electrolyte balance; omitting and optimising medications; nutrition; glycaemic control; pre-operative physiotherapy; damage control surgery; reducing delays; timely access to CT scans and other investigations; standardisation and surgical pathways; recognising high-risk cases; consultant-lead care; and shared decision-making. The time available to address each of these components should be traded against the need for timely surgery, particularly in the context of sepsis or circulatory shock.

Finally, we have included two reviews from the January issue, which were extremely well received last month. The review of pre-operative fasting in adults and children from Fawcett and Thomas currently has an Altmetric score of 156! The paper from du Toit et al. reminds us that half the world’s population live in low and middle Human Developmental Index (HDI) countries, and patients from these countries are poorly represented in systematically reviewed evidence on pre-operative optimisation.

We hope you enjoy this year’s supplement, which is the most complete, accurate and up to date synthesis of evidence, consensus and expert opinion relevant to patient optimisation before surgery. More importantly, we hope it contributes to further incremental improvements in the quality of care for patients in the peri-operative period.

See you next week for #WSMLondon19!

Dr Mike Charlesworth and Professor Andrew Klein

Clinical Consequences

Each and every issue of Anaesthesia contains clinical messages that may change practice. Though there are a number of ways in which to measure academic impact, it is difficult to gauge the true clinical implications of published research. In the new, quarterly ‘Clinical Consequences’ series of articles, the implications of recently published research for clinically practicing anaesthetists will be discussed in depth. This first analysis focusses on the growing popularity of pre‐operative gastric ultrasound, and whether it should become part of routine clinical practice. Should we use an ultrasound probe to look inside Schrödinger’s gut? Be sure to read the full article for the answer!

Figure 1Figure 1 Sonographic image of (a) empty (b) fluid‐filled and (c) solid‐filled gastric antrum. L, liver; P, pancreas; Ao, aorta; A, antrum.

The battle against research misconduct has been well documented in Anaesthesia, with much focus on the detection of unreliable data and fraudulent authors. This new paper reports on the number of unretracted, retractable papers authored by Reuben, Boldt and Fujii, and the reasons given for this by journals, editors and publishers. It seems there is an urgent need to improve the way in which fraudulent or unethical articles are handled following publication. Why does retraction take so much longer than publication? Look no further than this excellent editorial from Loadsman, the Chief Editor of Anaesthesia and Intensive Care.

Pre-operative fasting guidance is changing to acknowledge the physiological and psychological risks associated with prolonged fasting. This new review article from Fawcett and Thomas synthesises clinical evidence and practice recommendations, and suggests we should now consider how best to manage fasting in patients with diabetes mellitus. We will soon be publishing our January 2019 supplement issue – ‘Patient optimisation before surgery’. Despite the fact that half the world’s population live in developing countries, this new review finds that such countries are poorly represented in systematically reviewed evidence on pre-operative optimisation.

Figure 2Figure 2 Cartograms showing (a) immediate and (b) extended pre‐operative interventions. The country polygon size is proportional to the cumulative sample size contribution to the literature.

Cricoid force is well and truly back on the agenda. This month, Gautier et al. report a new technique which may better prevent air entry into the gastric antrum during facemask ventilation – lower left paratracheal force. Perhaps, somewhere in a parallel universe, paratracheal force was described before cricoid force, with its use enshrined in clinical practice. What are the arguments for and against cricoid force? Naik and Frerk summarise several years of controversy in just a few lines, though whether or not the fact ‘they don’t use it in Europe’ continues to be relevant after Brexit will remain to be seen!

Figure 3Figure 3 For paratracheal compression applied manually, the thumb is positioned just cephalad to the clavicle between the trachea and the sternocleidomastoid muscle. A force of 30 N is applied to compress the oesophagus against the vertebral body.

These new Association of Anaesthetists guidelines on anaesthesia and peri‐operative care for Jehovah’s Witnesses and patients who refuse blood has already been extremely well received on Twitter, with an Altmetric score of 125! They are much more than a useful FRCA examination resource, they are a core document and essential reading for all anaesthetists, surgeons and clinical managers. On the subject of guidelines, should the next iteration of Association of Anaesthetists malignant hyperthermia guidelines address the use of activated charcoal filters? Yes, argue Bilmen and Hopkins, who also suggest they should be stored in all areas where volatile agents are used.

How best to accurately monitor the true injection pressure generated during performance of regional anaesthesia? This study from Saporito et al. suggests pressure measurement at the tip is more accurate as compared with measurement along the injection line. Barrington and Lirk argue there are more important factors to consider, such as education and core skills development, situational awareness, adequate organisation, preparation, non‐technical skills, standardised processes such as safety checklists, and routine patient follow‐up.

This prospective observational study in cardiac surgical patients suggests an association between impaired postoperative cerebrovascular autoregulation, as measured with cerebral oximetry, and delirium. You can still read this open access editorial from last year about cerebral oximetry which discusses all the controversies and much more. When marking the cricothyroid membrane (CTM) prior to surgery and anaesthesia, should the head and neck be in a neutral or extended position? This observational study suggests a skin mark made over the CTM in the neutral position cannot be relied upon when performing a surgical cricothyroidotomy in the extended position. Finally, this systematic review from Gerth et al. finds that patients surviving critical illness had a worse health-related quality of life when compared with population norms.

Elsewhere this month we have a study of the impact of emergency department patient‐controlled analgesia on the incidence of chronic pain following trauma and non‐traumatic abdominal pain, a narrative review of the association between attention deficit hyperactivity disorder and general anaesthesia, parental perception on the effects of early exposure to anaesthesia on neurodevelopment, and a prospective observational study of EEG density spectral array monitoring in children during sevoflurane anaesthesia.

January is a busy month for the journal, and we are very much looking forward to the Winter Scientific Meeting taking place 9th-11th January in London. This year, there will be two journal workshops taking place on Thursday. You can now register for ‘Social media for anaesthetic practice and education’ which takes place at 0900 and includes an introduction to Twitter with special guest Stuart Marshall (@hypoxicchicken). We will also be running our popular ‘How to publish a paper’ session in the afternoon.

We are very close to going live with our new journal, ‘Anaesthesia Reports’, an official journal of the Association of Anaesthetists which replaces what was known as ‘Anaesthesia Cases. It is international in scope and will publish original, peer-reviewed case reports, media content, and associated papers on all aspects of anaesthesia, peri-operative medicine, intensive care and pain therapy. We want you to send us your interesting cases, airway videos, blocks, and echo’s.

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See you in London!

Mike Charlesworth and Andrew Klein

The ORANGUTAN Score

What’s in a name? Researchers often want their studies to have catchy acronyms so they are easy to remember, advertise and tweet. This year’s special Christmas article assesses the prevalence of novel acronyms in the titles of anaesthetic and related studies, and the response of anaesthetists to them. Overall, acronyms were memorable at best but did not aid recall of the study topic and were generally unhelpful. It would be interesting to see the results of the ORANGUTAN score (Figure 1) as applied to studies from other specialties, but as Weale et al. quite rightly point out – we probably need to get out more.

Figure 1.jpgFigure 1 The ORANGUTAN scoring system for acronym accuracy and relevance.

An increasing number of patients are prescribed direct oral anticoagulants (DOACs) and there is a need for guidance on issues such as peri-operative cessation, reversal, and management of DOAC-associated bleeding. This month, we are delighted to publish the first multidisciplinary consensus statement on the management of DOACs for cardiac surgical patients. Though specific for cardiac surgery, there is also much useful advice for non-cardiac anaesthetists. In their accompanying editorial, Charlesworth and Arya argue peri-operative costs such as drug level assays and reversal agents should have perhaps been considered in already completed cost-effectiveness analyses.

On the topic of bleeding, what are the implications of activated partial thromboplastin time (APTT) for anaesthesia and surgery? We are perhaps less familiar with APTT as compared with other formal tests of coagulation, and this article will be of interest to all. It seems we should not ignore an isolated abnormal result, as causes may include a lack of coagulation factors VIII (Haemophilia A), IX (Haemophilia B), XI and XII; systemic anticoagulation from heparin; the presence of the lupus anticoagulant; and von Willebrand’s disease. Likewise, a positive bleeding history in a patient with a normal APTT should not be ignored. If in doubt, ask a haematologist!

Figure 2.jpg

Figure 2 A suggested pathway for the management of deranged pre‐operative activated partial thromboplastin time (APTT).

“Yuk! That’s disgusting” – we have all heard those words from children when they try new food, drinks, and medicines. Salman et al. address an important clinical need in paediatric anaesthesia by evaluating the effect of a chocolate-based midazolam tablet in children aged 3-16 undergoing surgery. Though this new formulation underwent a higher first-pass metabolism, it was far more tolerable and remained efficacious when compared to i.v. midazolam solution given orally. In their editorial, Yuen and Bailey discuss the implications for other premedicants and drugs (e.g. antibiotics), the effects on the developing brain, and whether other flavours should also be developed.

Postoperative sore throat is an undesirable outcome for both patients and anaesthetists. From their meta-analysis, Kuriyama et al. conclude the topical application of corticosteroids to tracheal tubes significantly reduces the incidence of postoperative sore throat without any adverse effects and with a number needed to prevent of three. The quality of evidence was high and they even performed a trial sequential analysis to enhance the robustness of their findings. A potential practice changer? Let us know!

Traditional airway teachings are that plans ABC are attempted, sequentially, and failure should result in declaring a ‘cannot intubate, cannot oxygenate’ (CICO) situation. When faced with difficulty and in order to maximise ‘next-pass success’, is it possible to define final interventions before declaring CICO? Chrimes and Marshall discuss airway management at the opposite end of the alphabet: attempt XYZ. They call for a rapid, comprehensive and final single attempt at each of facemask ventilation, supraglottic airway insertion, and tracheal intubation that can be implemented independently of prior upper airway interventions (Table 1).

Table 1.png

Table 1 Attempt XYZ: suggested optimisations.

How best to monitor cardiac output during surgery? This study finds that when thermodilution is compared with arterial pressure-based measurements, accuracy may be affected by routinely encountered clinical factors. For example, thermodilution is affected by haemodynamic variability and arterial pressure measurements are affected by peripheral vascular physiology. Gillies and Edwards discuss the array of cardiac output monitoring technologies available and ask – does using them to guide therapy in the peri‐operative period actually improve patient outcomes? Though there is little evidence yet that this is the case, the conclusions from OPTIMISE-2 and FLO-ELA are eagerly awaited. Finally, this pragmatic randomised controlled trial was able to show that high-flow nasal oxygen (not THRIVE!) reduced the length of hospital stay in cardiac surgical patients at high risk for respiratory complications. Postoperative high-flow nasal oxygen is becoming more common and it is great to see useful evidence like this emerging to support these practices.

Elsewhere we have a study of body temperature, cutaneous heat loss and skin blood flow during epidural anaesthesia for emergency caesarean section; a comparison of two techniques for induction of anaesthesia with target‐controlled infusion of propofol; a retrospective study of peri-operative extracorporeal cardiopulmonary resuscitation; a pilot study of cardiopulmonary exercise testing and cardiac stress positron emission tomography before major non‐cardiac surgery; and this months ‘Statistically Speaking’.

How would you manage acute life-threatening massive haemoptysis in a patient with a predicted difficult airway and emphysematous lung disease? This great new case report published in Anaesthesia Cases generated a lot of attention and debate earlier this month and is well worth a read. The highest Altmetric scores this month came from this year’s supplement issue, ‘Complications’. We will shortly be publishing our 2019 supplement, ‘Pre-operative optimisation’, with topics including risk prediction, multimodal prehabilitation, shared decision making and a review of best practice for patients undergoing emergency laparotomy. We hope you are looking forward to it as much as we are!

It is also nearly time for the Winter Scientific Meeting in London, and this year we will be running a new workshop to complement our popular ‘How to publish a paper’ session. Make sure you register (limited places available) to find out how Twitter can help you stay up to date (with @hypoxicchicken), how to use and influence Altmetrics, and how to use freely available citation software such as Zotero and Mendeley.

 

Akshay Shah, Trainee Fellow

Mike Charlesworth, Social Media Editor

Andrew Klein, Editor-in-Chief

Patient Blood Management

Patient blood management is an international multidisciplinary initiative that aims to reduce the unnecessary transfusion of allogeneic blood components. Strategies include: the avoidance of oversampling; the use of appropriate transfusion triggers; the preoperative management of anaemia; and means of blood conservation, such as intra-operative cell salvage. One area that has perhaps been overlooked is the postoperative period, and this new international consensus statement on the management of postoperative anaemia after major surgical procedures aims to put this surprising lack of guidance right. Recommendations include screening those who have undergone major surgery for anaemia, monitoring the haemoglobin concentration until at least the third postoperative day, and the consideration of intravenous iron therapy or erythropoiesis stimulating agents. In their editorial, Hatton and Smith discuss several implications for clinical practice. An interesting consequence is the suggestion of increased cost-effectiveness, though there remain many unanswered questions about the role of iron therapy for certain patient populations, such as the elderly and frail.

The National Tracheostomy Patient Safety Project started as four intensive care doctors in Manchester wanting to improve the management of patients with tracheostomies. In 2012, we published their first multidisciplinary guideline on the management of tracheostomy and laryngectomy airway emergencies. Now, signs providing crucial information and algorithms can be found on the bedhead of every inpatient with a tracheostomy. This month, we are delighted to publish new guidelines for the management of paediatric tracheostomy emergencies. There are key differences when managing the routine and emergency care of children with tracheostomies and their reading is essential for all anaesthetists and intensivists working in a hospital that cares for children. Mackinnon and Volk discuss the need such guidelines, the use of simulation, their implementation and likely impact. They argue the guidelines will only work if shared and disseminated widely, and we call for all our readers and followers to do just that!

Figure 1

Figure 1 National tracheostomy safety project emergency paediatric tracheostomy emergency management algorithm.

On the subject of paediatric airway management, this survey of paediatric and neonatal intensive care units has provoked much discussion on Twitter and was reported by BBC News. The authors found wide variations in practice with regards, for example, the availability of capnography, the existence of a difficult airway policy and the use of pre-intubation checklists. We expect there will be several letters from those working in such areas and we look forward to seeing the discussion continue.

There is a need to provide better training for junior medical staff who may care for patients in the perioperative period. This new mixed methods study evaluates the implantation of a new Foundation Programme in perioperative medicine for older people. The new programme proved popular and was able to deliver generic competencies alongside training in specialist topics, and the authors suggest such training may better meet the needs of an increasingly multimorbid surgical patient population. How best to optimise preoperative assessment for older people? This editorial has already been well received on Twitter and issues key clinical recommendation for such patients, including: the use of frailty scores and cognition checks; offering enhanced support where required; collaborating with geriatricians; shared decision making and admission planning.

Can a single, pre-operative dose of methylprednisolone reduce the severity of postoperative delirium? No, concludes this new randomised controlled trial, though it may reduce the prevalence of delirium and the severity of fatigue after hip fracture surgery in older patients, enabling remobilisation and recovery. Last month, we published an article on the characteristics of children aged less than 2 years undergoing anaesthesia in Danish hospitals between 2005-2015. This month, important information on children aged 2-17 undergoing anaesthesia during the same period is provided. Younger children were more frequently anaesthetised for non-surgical reasons and the use of inhalational agents was common. Reassuringly, complications were rare. The use of focussed cardiac ultrasound has many emerging uses and this paper demonstrates its utility for evaluating the haemodynamics of various positions in term pregnant women. It turns out that, in the ramped position, left lateral tilt may be unnecessary. Fascinating!

Elsewhere this month we have a study of cognitive recovery assessments in patients with low‐baseline cognition, an in‐vitro analysis of a novel ‘add‐on’ silicone cuff to improve sealing properties of tracheal tubes, a retrospective study of the association of time of emergency surgery with postoperative 30-day hospital mortality, and a study of the volume of 0.2% ropivacaine and common peroneal nerve block duration. Finally, in this month’s Snippet, we are reminded of the importance of ensuring not only monitoring wires but also oxygen tubing remains in sight at patient height during transfer.

Figure 2

Figure 2 Sheared oxygen hose.

Over in Anaesthesia Cases we have a great new case report of anaphylaxis to all neuromuscular blocking agents, the first such case! Again, this has already attracted much attention on Twitter including a discussion of triggers to commence CPR in the context of perioperative anaphylaxis. Finally, as the end of the year draws closer, we begin to look forward to our Christmas article, which features in the December issue, and our January preoperative optimisation supplement, which will be published towards the end of December.

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Mike Charlesworth                   Andrew Klein

Social Media Editor                  Editor-in-Chief

Full time for sloppy terminology?

We have, very recently, published a number of papers on proximal approaches to intercostal nerve blockade (Figure 1). Do such blocks confer any advantages over and above direct injection of local anaesthetic into the paravertebral space? Probably not, as there are simply too many clinical unknowns with much of our knowledge derived from cadaveric studies (such as that presented by Yang et al. in this month’s issue). Furthermore, proximal intercostal nerve blocks may exert their effect by spread to the paravertebral space, and this month, Costache et al. call for a precise, unified definition for such blocks – paravertebral by proxy. Importantly, they provide clinical recommendations on which blocks should be selected for given patients in a range of circumstances.

Figure 1

Figure 1 Schematic illustrating the location for the retrolaminar (RLB), intercostal/paraspinal, erector spinae plane (ESP) and midpoint transverse process to pleura (MTP) blocks.

The use of point of care ultrasound (POCUS) is, arguably, revolutionising the practice of modern obstetric anaesthesia. This new narrative review synthesises the current evidence and knowledge on its use to determine gastric contents, for safe airway management, and in order to quickly diagnose the cause(s) of breathlessness or acute circulatory collapse. It is, put simply, all you need to know about obstetric POCUS! When determining gastric contents, what exactly is a ‘full stomach’? Mike Kinsella argues there is no such phenomena, and more generally, that the use of confusing or imprecise language should be avoided. This underlines the belief that effective communication is arguably the key factor in providing safe medical practice.

How best to define ‘intra-operative hypotension’? We all know what it is, but the list of definitions is seemingly endless. This new study from Cleveland suggests intra-operative hypotension, defined as MAP < 65 mmHg, is strongly associated with postoperative acute kidney injury. Hypotension was somewhat more common prior to the first incision, and the authors call for anaesthetists to avoid hypotension immediately following induction of anaesthesia. Some have suggested a simpler message may be to avoid all hypotension, though defining how this sits in the era of bespoke anaesthesia presents more questions than answers. One possible way in which clinicians may negate intra-operative hypotension and postoperative acute kidney injury is though omission of ACE inhibitors/ARBs, but this collaborative study suggests otherwise. Both papers have been tweeted hundreds of times already and will be of interest to all readers!

How good are we at applying cricoid pressure, (or force, if you are so inclined)? This prospective study uses ultrasound to localise the cricoid cartilage as compared with a landmark method. The results are somewhat surprising, and bring into question previous studies of cricoid pressure efficacy. There are major clinical implications and we want to know if your practice will change?

Can this new device reduce the incidence of false passage formation, trauma, and failure as compared with the recommended technique for emergency front of neck access (eFONA) (Figure 2)? The results seem to be promising, at least in an obese porcine model, but how best to ethically study and use such devices in humans? As we have already seen, ‘The Airway App’ is a great way in which to collect data, collaborate, share practices, and learn from eFONA experiences. Are such methods better than large, whole-population database analyses? This new study from Denmark arguably provides important data on the characteristics of children less than two years of age undergoing anaesthesia. The accompanying editorial asks whether or not such databases are useful, and discusses the role of epidemiological surveys with reference to making sense of trends in clinical practice. Finally, this new observational study concludes middle finger length may be better associated with internal uncuffed endotracheal tube diameter in children than traditional formulae. Following on from the editorial by Craig Bailey, we are assured a similar study of cuffed tubes is on the way!

Figure 2

Figure 2 Cricothyroidotomy introducer.

Elsewhere this month, there is a cohort study of the effect of lateral infraclavicular brachial plexus block on the axillary and suprascapular nerves as determined by electromyography, a randomised trial of serratus anterior plane block for analgesia after thoracoscopic surgery, and a meta‐analysis and trial sequential analysis of local vs. general anaesthesia for carotid endarterectomy. Over in Anaesthesia Cases, new reports include a description of spinal subdural haematoma pathophysiology and management following an epidural blood patch, and pharmacological cardioversion with nifekalant after release of the aortic cross-clamp during cardiac surgery.

This month’s blog immediately follows an incredible Annual Congress meeting in Dublin. Highlights included a keynote talk from Professor Rob Dyer (Cape Town, South Africa), a much-valued international advisory panel member for the journal. Professor Dyer also spoke on the peri-operative challenges of pre-eclampsia at the Anaesthesia journal session. Professor Mike Irwin delivered a fascinating talk on the advantages, disadvantages and clinical controversies associated with peri-operative remifentanil. Matt Wiles revealed the Top 10 Papers from 2017, with the award for best paper presented to John Carlisle for his ground-breaking analyses of randomised controlled trials from several major medical journals. John’s paper now has an Altmetric score of nearly 1000, making it the most shared and discussed paper we have ever published! It will most likely become our most cited paper too, replacing the classic paper by Cormack and Lehane. Our journal workshop, ‘How to publish a paper’, again proved popular among trainees and consultants alike, and we hope to see abstracts converted into papers over the next year.

Finally, congratulations to Akshay Shah from Oxford University who joins as trainee fellow. Kariem and Mike join the editorial board as Anaesthesia Cases Editor and Social Media Editor respectively.

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M_Charlesworth                  A_Klein

Mike Charlesworth          Andrew Klein

Social Media Editor         Editor-in-Chief