#TheAnaesthesiaBlog

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’.

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. 

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 countries; a 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

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). 

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.

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

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.

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. 

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 surgery; an 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

The February issue of Anaesthesia attempts to answer the age-old question plaguing anaesthetists – what blood pressure should we be targeting and how much does it matter? We are delighted to present the first publication from the iHype study – a prospective cohort study designed and conducted by the Research and Audit Federation of Trainees (RAFT). Data from 4750 patients aged >65 y were collected over a 48 h period. They found intra-operative hypotension, and its many different definitions, to be common, with incongruence between the blood pressure anaesthetists say they will treat and their actual treatment threshold. This study is a great example of what trainee research networks can achieve and how they are a relatively untapped resource. The podcast discussion with the authors is a must for any budding trainee researcher on how to plan and perform such a large and effective study. The associated editorial highlights the discrepancy between blood pressure recordings and explores why we feel may feel the need to “fudge” the anaesthetic chart. With electronic recording becoming more prevalent in the future there may be nowhere to hide! 

The effect of intra-operative hypotension on acute kidney injury, postoperative mortality and length of stay following emergency hip fracture surgery is a neat single centre study investigating the incidence of intra-operative hypotension in a vulnerable group. Interestingly, they did not find an association with intra-operative hypotension and acute kidney injury. However, delay to surgery was associated with increased mortality. North Shore Hospital Anaesthetic department do use electronic intra-operative recording and the MAP was (truly) rarely below 65mmHg in their cohort. 

Why does blood pressure drop during anaesthesia and is there anything we can do to predict which patients will be most affected? The editorial by Frandsen et al. goes back to basic physiology and highlights the often forgotten about autonomic system – it is not all about intra-vascular volume. Anaesthesia causes both sympatholysis and vagolysis. If a patient already has pre-existing autonomic dysfunction, despite adequate fluid volume, anaesthesia could and does provoke hypotension and cardiac instability. By using pre-operative markers of vagal tone, such as heart rate variability, can we identify high risk patients and tailor our anaesthesia accordingly?

The pandemic has sharpened and exacerbated health and social inequalities globally. There is no doubt that patients of non-white ethnicity have poorer outcomes from SARS-CoV-2 infection. The underlying cause for this is likely to be multi-factorial but there has been anxiety that pulse oximetry is less accurate in patients with darker skin pigmentations. Wiles et al. performed a retrospective observational study to address this important concern. They compared S_aO₂ and S_pO₂ measured concurrently in patients on different ethnicities and reassuringly found no clinically significant difference. However, as mentioned in the accompanying editorial – is ethnicity the correct question to be asking, and should we actually be comparing skin pigmentation levels in order to accurately validate the use of pulse oximetry in different groups? The inclusion of different ethnic groups in both clinical research and validation studies of commercial monitoring is improving, but this topic highlights the need for both patients and medical staff to be confident that what we are both doing and using to monitor patients in different diseases is correct for all patients. 

The pandemic has also made us aware of the vital importance of oxygen and how hypoxic patients do not always look the same! However, aside from being able to sketch out the oxygen dissociation curve, our actual understanding of oxygen physiology is limited. Slingo and Pandit present a narrative review aiming to introduce hypoxia-inducible factor and oxygen sensing pathways to the wider clinical community. The ability of cells to detect and respond to varying oxygen concentrations relies on a complex cascade. Manipulation of this pathway may have many clinical implications, including targeted oxygen therapy. This fascinating review also highlights the requirement for more basic science research in anaesthesia.

The expanding field of peri-operative medicine is changing the focus of anaesthesia research. Along with clinical shared decision-making, patient involvement in study design is improving and with that the need for outcomes that are important for patients. Days alive and at home (DAH) is one such outcome that neatly encompasses the many factors of the post-operative journey for a patient. Ferguson et al. surveyed patients and found the minimal clinically important difference to be 3 days, with an early discharge and being discharged to home rated as important. This is important work that will guide study design in future trials. Indeed Moore et al. used a similar patient-centred outcome measure (days alive and out of hospital) to audit the implementation of the WHO Surgical Safety Checklist.

None of the above research into patient outcomes however is important if we do not have a world in which to practice anaesthesia! In light of COP26 in Glasgow in November the World Federation of Societies of Anaesthesiologists has produced a consensus statement on the principles of environmentally-sustainable anaesthesia. The main points are that patient safety should not be compromised and healthcare systems should be mandated to reduce their contributions to global heating in order to limit global heating to 1.5℃ by 2050. There is a lack of scientific evidence to underpin these guidelines and further work and investment is needed to ensure that we protect our world and current and future generations.

Elsewhere we also have a feasibility study on the use of cryoprecipitate in post-partum haemorrhage. Finally, we are recruiting! We have adverts for a Trainee Fellow, Editor-in-Chief and three Editors posts at Anaesthesia Reports! Join us!

Cara Hughes and Andrew Klein

What better way to see in any new year than with a brand-new Anaesthesia Special Supplement! This year, it is all about the peri-operative and critical care management of the brain, which has been guest edited by Dr Jugdeep Dhesi and Professor Alana Flexman. Flexman and Tung begin by appraising outcomes used in neuroanaesthesia and neurocritical care. They call for a shift towards PROMS as well as perspectives from LMICs, and the tools are available now – we just have to use them. Dhesi and Moppett discuss the implications of the older brain in peri-operative care and ask – what should we do? As we most things, there is no one right answer and no ‘magic bullet’, but one of the key themes appearing throughout the issue is of multidisciplinary thinking and working. The first review seems to have caught the imagination of our followers already, which looks at the implications of nocebo. This is a key paper that could potentially change practice, but not everyone will agree, as many of the nocebos in use are enshrined in practice already (Fig. 1). Time now for phrases such as ‘bee sting’ and ‘sharp scratch’ to be thought of as clumsy verbal relics of the past? We think so!

Stubbs et al. use a stereotyped peri-operative journey to highlight the decision-making points where the expertise of professionals from across the peri-operative medicine team may play an important role for patients with chronic subdural haematoma. The key point is that most patients are managed outside neuroscience centres, and more research is needed to improve the associated care pathways. Peri-operative neurocognitive disorders are the most common complication experienced by older individuals undergoing anaesthesia and surgery. Evered et al. discuss the clinical and practical implications of peri-operative neurocognitive disorder on patients, and possible pathways for identifying at-risk individuals and assessment of modifiable factors.Possible mechanisms include: neurodegenerative disease; inflammation; neuronal damage; and frailty. No longer should we refer to patients as ‘pleasantly confused’ as arguably, there is nothing pleasant about delirium. 

There is much emerging evidence of COVID-19-associated delirium, and White and Jackson have brought it all together for us. They describe how it differs from ‘classical’ delirium, as well as potential mechanisms and practical approaches to management (Fig. 2). It turns out that it is more prevalent, longer lasting and associated with worse outcomes. The management remains the same, except for distressing end of life agitation where the need for higher-than-normal doses of sedatives may be required. One area of persistent controversy in neuroanaesthesia relates to the mode of anaesthesia and its relation with outcomes for mechanical thrombectomy. Dinsmore and Tan review the evidence, and suggest more important targets such as blood pressure management, diagnosis and timely management. 

Is anyone using POCUS for acute brain injury? Dinsmore and Venkatraghavan describe the techniques and applications for and provide evidence of its utility in guiding clinical management both in the peri-operative period and on ICU. They list the commonly used acoustic windows and the structures that are visible. They argue it is an effective, non-invasive, safe and readily available technique for the rapid assessment of cerebral anatomy and cerebral haemodynamics. Will it become an alternative routine imaging technique? The results seem comparable. Most doctors will encounter status epilepticus in their carrer. Migdady et al. discuss the definitions of status epilepticus, evidence behind treatment regimens at various stages, treatment goals, outcomes and the role for newer drugs. Implementing early, evidence-based treatment modalities is important to prevent mortality and complications from prolonged status epilepticus, and this paper is arguably of important relevance for all!

Have you been busy with COVID-19 over the last few years and missed the most recent CPD relevant to the management of traumatic brain injury? Fear not, Matt Wiles has reviewed the recent evidence and brought it all together. In summary, there are few clear therapeutic interventions that are associated with meaningful improvements in mortality, or more importantly, neurological outcome. The early administration of TXA appears to offer a clinically important early mortality benefit and early tracheostomy appears to be of value. Kayambankadzanja et al. review pragmatic sedation strategies to prevent secondary brain injury in low-resource settings, which is common. They emphasise the importance of analgesia, the choice of drugs, the associated risks and the monitoring required for these patients in these settings. Elsewhere we have reviews of: strategies to reduce the incidence of postoperative delirium; peri-operative neurological monitoring with electroencephalography and cerebral oximetry; and the peri-operative management of patients with Parkinson’s disease. 

We hope you enjoyed the live broadcast to accompany the issue which was seen by over 2.5k viewers! This has now been converted into a podcast which available in all the usual places. Enjoy!

Mike Charlesworth and Andrew Klein

Last week, we brought you a live broadcast all about the new editorial from Pandit, Young and Davies, which is available now on early view. We received some excellent commentary on Twitter, none more so than this thread from Tanya Selak. This month, Professor Pandit also argues that ‘no trace, wrong place’ does not mean ‘positive trace, right place’. It seems that a better way of thinking is that absent traces justify tube removal, and abnormal or attenuated waveforms warrant investigation to re-confirm tracheal tube position, with further management guided by the balance of risks (Fig. 1). There is much here in these contributions to think about for all those with an interest in airway management.

Patients generate aerosols, not procedures – say scientists. But most local and national infection control policies in the UK still refer to precautions required around certain procedures, even in low risk isolated test-negative patients. The new paper from the AERATOR study group is all about manual facemask ventilation, and the results will come as no surprise to many. They found that tidal breathing and a volitional cough generate many-fold more aerosol than facemask ventilation. Another so called aerosol generating procedure is the use of nasal high flow oxygen, which is becoming increasingly important in peri-operative practice. Lyons et al. report that pre-oxygenation with high-flow nasal oxygen in combination with oxygen via a mouthpiece causes higher arterial oxygen partial pressures and lengthens the time-to-desaturation after the onset of apnoea when compared with facemask pre-oxygenation. However, Thiruvenkatarajan et al. find that in high-risk patients undergoing ERCP within the context of target-controlled infusion based propofol administration, oxygen delivery using high-flow nasal oxygen did not reduce the rate of hypoxaemia, hypercarbia and the need for major and minor airway interventions, compared with low-flow nasal plus mouthguard oxygen. In the associated editorial, Patel and El-Boghdadly discuss the case for switching to high-flow nasal oxygen in all circumstances. It seems that only when we can seamlessly transition between oxygen delivery systems, without the risk of barotrauma and with optimal monitoring, will this switch be embraced. Until then, high-flow nasal oxygen has a specifically defined role for certain indications only. 

In August, we were delighted to publish the COVIDSurg/GlobalSurg collaborative work on SARS-CoV-2 infection and venous thromboembolism (VTE) after surgery. They found that SARS-CoV-2 infection was independently associated with an increased incidence of postoperative VTE in patients with peri-operative and recent SARS-CoV-2 infection. Marshall and Duggan in their editorial discuss various aspects of the study as well as the effect of VTE on surgical patients, prophylaxis protocols, and how this all fits in with contemporary peri-operative risk management. 

Which size tracheal tube best facilitates general anaesthesia in adults? This new RCT from Cho et al. stimulated a lot of discussion on social media, with the main finding that sore throat and hoarse voice 1 and 24 h after surgery were less frequent and less severe after intubation with smaller tubes. Ventilatory mechanics were unaffected. Another controversy is the management of haematoma after thyroid surgery, but this new guideline aims to change that as the first to report the multidisciplinary management of haematoma following thyroid surgery, either in the anaesthetic or in the surgical literature. A final area of controversy is how best to define the ‘decision-to-delivery’ interval for a non-elective caesarean section. In particular, there is a wide variation as to the interpretation of when the ‘decision’ occurs, ranging from the time that the obstetrician in attendance documents the decision, to when the whole team is alerted, or to when the patient is prepared for the operating theatre. May et al. review all the relevant literature and provide a useful definition that can be used for audits, research and clinical practice.

Elsewhere we have: an observational study of surgery and general anaesthesia on sleep-wake timing; an observational study of the right supraclavicular fossa ultrasound view for correct catheter tip positioning in right subclavian vein catheterisation; a non-inferiority trial of supraclavicular versus infraclavicular approach for ultrasound-guided right subclavian venous catheterisation; and a discussion of best practice for subclavian central venous access. 

Finally, we are looking forward to releasing our 2022 supplement in early January, which is all about the brain and implications for peri-operative practice. We will also be relaunching our popular ‘how to publish a paper’ workshop at the Winter Scientific Meeting on the 14^th of January. It is free for all delegates. See you there!

Mike Charlesworth and Andrew Klein

Peri-operative literature exploded in early 2020 with much in the way of low-quality COVID-19 anecdotes, secondary analyses, reviews and reviews of reviews. Today, we are delighted to have published several excellent primary scientific experiments that challenge our now well-established and sometimes precautionary guidelines and protocols. The AERATOR study group have done it again with a paper grounded in aerosol science but with significant clinical implications for all. The message is that we should see the issue as one of ‘aerosol-generating patients’ rather than ‘aerosol-generating procedures’ (Fig. 1). However, we remain a long way from truly acknowledging test-positive awake COVID-19 patients as ‘riskier’ to care for than test-negative patients undergoing elective surgery. Thankfully, the AERATOR group have another paper coming soon to reinforce the message!

Obesity is increasingly prevalent in England and there is a suggestion that patients undergoing elective surgery are more likely to be obese than the general population. This new prospective observational study from Shaw et al. finds this to be the case for a population of patients in the London area, with obesity also associated with increased minor airway events. The most common of these was oxygen desaturation below 90% and the second was maintaining adequate ventilation using a supraglottic airway device. In the associated editorial, Duggan and El-Boghdadly set these results in their clinical context and remind us that data were collected before the COVID-19 pandemic. Much has since changed. They remind us of the power of observational studies in airway management: randomised trials are scarce; observational studies can change practice; and collaborative research is the future.

How best to study postoperative recovery after major surgery? There has been (rightly so!) a move away from mortality and complication rates and focus has instead shifted to functional recovery. This new multicentre prospective cohort study from Ladha et al. finds that more participants reported decline than improvement in at least one EQ-5D functional domain 30 days after surgery but not 1 y after surgery. Functional decline was associated with worse pre-operative fitness and moderate or severe postoperative complications. We have two further excellent peri-operative papers this month. First, Drake et al. report a before-and-after analysis of the introduction of a standardised maternity early warning system. They observed a significant and sustained reduction in severe maternal morbidity, and a non-significant reduction in cardiorespiratory arrest calls. Second, Awadalla et al. describe the impact of the Australian/New Zealand organisational position statement on extended-release opioid prescribing among surgical inpatients. They found it was associated with an overall decrease in opioid prescribing among surgical inpatients as well as a decrease in extended-release opioids among patients who received any opioid at two Australian hospitals (Fig. 2). In the associated editorial, Levy et al. list the problems with extended-release opioid preparations as well as strategies for their de-implementation.

How can Never Event data be used to reflect or improve hospital safety performance? Olivarius-McAllister et al. compare annual rates of Never Events and finished consultant episodes from 2017 to 2020 by acute hospital Trust (Fig. 3). The absolute number of Never Events was correlated with workload (r² = 0.51, p < 0.001), but the five Trusts above the upper 95% confidence limit did not have the highest number of Never Events. They argue we should focus now on reducing the mean national Never Event rate through an integrated safety strategy. In the associated editorial, Devlin and Smith describe the problems associated with Never Events, such as that they continue to happen with near certainty and can be well modelled. They argue we should try to improve by redesigning our systems to reinforce their components that create safety, rather than continuing to grant cultural and linguistic supremacy to negative and punitive approaches.

Guidelines can sometimes present an editorial dilemma. This new document is an Association of Anaesthetists guideline and we are the journal of the Association. Yet, some might suggest this guideline and others are not scientific or clinical enough to warrant publication in the journal. Some initial feedback on Twitter seems to suggest we made the correct decision, as it turns out ergonomics as applied to peri-operative practice is an incredibly important topic to clinically practicing anaesthetists. For example, we received over 200 retweets and 198,532 Twitter impressions on the day of publication, which is great! The guideline is novel too, as there were, until now, no guidelines on ergonomics in the anaesthetic workplace. Much of the included evidence is from other industries which seems to suggest a need for more primary evidence in this area.

Elsewhere we have: a systematic review of intrathecal morphine for analgesia after lower joint arthroplasty; validation of the factors influencing family consent for organ donation in the UK; and editorials commenting on research in regional anaesthesia and organ donation.

Finally, this new statistics contribution describes some fundamental aspects of significance testing, which is the basis of most of what we need to know as clinicians. It is, therefore, essential reading for all, and probably one of the most useful statistics papers that we have read recently. From time-to-time, questions about shifts in practice come up. Should we scrap the p value? Should we use confidence intervals? Should we report the fragility index? Should we use a Bayesian approach? Perhaps rather than shaking up how we ‘do’ statistics, we should instead focus on better understanding. This paper helps greatly to achieve that goal for us all.

As we come towards the end of the year our focus now moves to our 2022 supplement, which will this time be all about the brain and anaesthesia! We will also be rekindling our popular ‘how to publish a paper’ workshop for the Winter Scientific Meeting 2022 which is free to all who register. We look forward to seeing you there.

• 

• 

Mike Charlesworth and Andrew Klein

This month, we are delighted to publish another fantastic study from the COVIDSurg and GlobalSurg collaboratives who were recently awarded a Guinness World Record for work previously published in the journal. This new paper comes from 15,025 global authors based in over 1600 hospitals and reports data for 96,454 patients. The topic this time is pre-operative isolation, which was introduced as a precaution despite limited evidence on its benefits and harms. It aims to keep systems clean and patients safe, but is it risk free? They found that, following correction for various measured confounders, it was associated with a small but clinically important increase in postoperative pulmonary complications (Fig 1). In the associated editorial, Charlesworth and Grossman set out how this new information may help us move towards ‘COVID-19 secure’ elective surgery. If indeed pre-operative isolation is not without risk, then hospitals need to focus on how this may be tackled as well as other ways in which nosocomial transmission can be prevented.

One such area where there remains room for improvement is incorporating what we now know about ‘aerosol-generating procedures’ into policy documents, guidelines and local procedures. This new study from Wilson et al. yet again shows that therapies such as high flow nasal oxygen and continuous positive airway pressure generate less aerosol as comparted with breathing, talking, exercising, shouting or coughing. Such therapies should not therefore be delayed in patients with COVID-19 and we should instead focus on ‘aerosol-generating patients’, not procedures. Also featuring this month is a new Association of Anaesthetists guideline for regional analgesia for lower leg trauma and the risk of acute compartment syndrome. This guideline generated a lot of debate on social media and the associated podcast provides some useful context. Perhaps one of the main talking points was recommendation six, which stated that neither the surgeon nor the anaesthetist has the right to veto a treatment recommended by the other. The associated editorial from Bogod and McCombe expands upon the associated controversies including aspects of patient ownership and autonomy. They also discuss the reasons why the British Orthopaedic Association were unable to endorse the final document. The editorial from Keating and Duckworth focusses on clinical aspects of the guideline with particular emphasis on the need for more monitoring in acute compartment syndrome. Such monitoring has been available now for over three decades and perhaps enables patients to receive appropriate analgesia appropriate to the circumstances.

For patients who have suffered traumatic injuries, reducing time from injury to definitive care is perceived to be associated with improved health outcomes. This new retrospective analysis of linked registry data from Lyons et al. aimed to evaluate the effect of the introduction of the Emergency Medical Retrieval and Transfer Service (EMRTS) on 30-day mortality in patients who had suffered blunt traumatic injuries (Fig. 2). After adjustment for differences in case-mix, they found a 37% reduction in the adjusted OR for 30-day mortality in patients with blunt traumatic injuries who were treated by EMRTS compared with standard pre-hospital care pathways. Hurst and Lendrum remind us of the reasons why this was not a good comparison of ground vs. helicopter emergency medical systems, but there remain some important clinical messages. For example, there is a need to include all trauma patients in national registries and establish why injured patients die in the early post-injury phase.

Postoperative sleep disturbance is perhaps more common than we think with significant consequences for patients. Earplugs and eye masks are low-cost interventions that may help, yet this is an area which has received little attention in the peri-operative literature. Leong et al. report their randomised controlled trial of effect of the use of earplugs and eye masks on the quality of sleep after major abdominal surgery. They did not find that the use of earplugs and eye masks as sleep aids on postoperative days 1–3 improved the sleep quality of patients after major abdominal surgery, nor did it affect patient satisfaction, reduce the frequency of nursing care required or reduce the incidence of delirium. We look forward to receiving more original articles in this area and there is much to be done. 

Severe pain after total hip arthroplasty can have major negative effects on recovery and mobilisation in the postoperative period. Pascarella et al. report their randomised observer-masked controlled trial of the impact of the pericapsular nerve group (PENG) block on postoperative analgesia and functional recovery following total hip arthroplasty (Fig. 3). They found that the PENG block improved postoperative analgesia following total hip replacement, and decreased pain scores and opioid consumption during the first 48 h after surgery. Time to now consider it as a valid analgesia option for fast-track hip surgery protocols? Finally, Finnerty et al. report their randomised trial of bilateral erector spinae plane block vs. no block for thoracolumbar decompressive spinal surgery. They found that the addition of intra-operative erector spinae block to multimodal analgesia improved recovery and reduced pain up to 24 h after thoracolumbar decompressive spinal surgery. Perhaps another indication for a block that has exploded in popularity despite being discovered and reported for the first time only recently. 

Elsewhere we have: a review of oxytocin at birth and beyond; an observational study of temporomandibular joint dysfunction following the use of a supraglottic airway device during general anaesthesia; and a randomised controlled trial of the effect of saline versus air for cuff inflation on the incidence of high intra-cuff pressure in paediatric MicroCuff® tracheal tubes.

Make sure you check out our top 10 papers of 2020 which we announced only last week at an excellent Annual Congress virtual conference! Congratulations to El-Boghdadly and team for winning paper of the year which was all about risks to healthcare workers following tracheal intubation of patients with COVID‐19!

• 

• 

Mike Charlesworth and Andrew Klein

There has been concern for some time in some areas of the UK that critical care admission is rationed according to age. This new retrospective observational study from Pugh et al., which was conceived and conducted before the outbreak of COVID-19, aimed to investigate trends in patient characteristics for adult critical care admissions in Wales between 2008-2017. They analysed 85,629 cases with the oldest cohort (≥ 80 years) accounting for 15% of critical care admissions. The proportions in each age bracket did not change over the study period. However, in contrast to several recent reports, they identified a significant decline in admissions of older patients (aged ≥ 65 years) relative to the national population, of those with comorbidity and those with a medical diagnosis (Fig. 1).

Has critical care capacity failed to keep pace with the needs of an ageing population? Lone and Suntharalingam make a case for the need to learn, adapt and ensure equity and appropriate best care for our growing cohorts of those aged > 65 years and new octogenarians. That said, the priority for many older critically unwell adults is not always survival at all costs. What will anaesthesia and peri-operative medicine look like to us when many of the current workforce are classed as an older adult in ~25 years? Fawcett and Klein discuss the implications for genomics, AI, service delivery, peri-operative medicine, green anaesthesia and radiology. The only certainty seems to be that our skills will continue to be in demand and there will inevitably be significant workforce shortages. 

Dexmedetomidine is now used widely for several indications in peri-operative practice and critical care medicine. This new randomised controlled trial from van Norden et al. is the first to investigate the effect of peri-operative administration of dexmedetomidine on the incidence of postoperative delirium in major cardiac and non-cardiac surgical patients aged > 60 years. They found that found a significant reduction in postoperative delirium to 18% from 44% when dexmedetomidine was administered as compared with placebo (Fig. 2). In the accompanying editorial from Chuan and Sanders, the biological plausibility of this finding is assessed, and dexmedetomidine might not be the much sought-after magic bullet for the prevention of postoperative.

This new science letter from Shah et al. reports results from a retrospective cohort study of general ICU survivors in two large health regions in the UK aiming to benchmark how many patients had anaemia-specific treatment (excluding blood transfusion) initiated before hospital discharge. The key findings were: a high prevalence of anaemia at ICU discharge and subsequently hospital discharge; little active management of anaemia during this important time period; and Hb of < 100 g.l^-1 was associated with prolonged hospitalisation following ICU discharge. Also in this month’s issue, van der Laan et al. report their retrospective analysis of anaemia among intensive care unit survivors and its association with days alive and at home. They found that among ICU survivors, anaemia was highly prevalent and persistent in most patients at hospital discharge. Haemoglobin concentration < 100 g.l^-1 at ICU discharge was experienced by 2886 (45.4%) of ICU survivors and independently associated with five fewer days alive and at home to day 90. This association remained significant when accounting for confounders including ICU length of stay, illness severity and red blood cell transfusion, and was attributable predominantly to fewer days at home among anaemic ICU survivors. In addition, ICU discharge anaemia was also an independent predictor of ICU and hospital re-admission (Fig. 3). In the accompanying editorial, Agarwal and Karkouti discuss both studies and remind us that the findings from each might at best be hypothesis generating only. They remind us of the vast amount of work still to be done in what is becoming and increasingly important area of clinical practice.

We are delighted to publish a Special Article from Takla et al. in this month’s issue, which raises some difficult ethical and legal issues around the use of general anaesthesia in end-of-life care. They remind us that our speciality already has a self-declared mission to extend the role of anaesthetists beyond the operating theatre in its strategy of championing ‘peri-operative medicine’. They argue that their redefinition of the scope and reach of general anaesthesia through end-of-life care, radical though it is, would be entirely in line with that philosophy, recognising that anaesthetists have skills that can help alleviate suffering for the dying patient. Their main findings were that peri-operative lidocaine infusions of extended duration can be delivered safely and effectively in patients undergoing breast cancer surgery, and that a definitive, multicentre trial employing these design features is feasible. 

One of our most popular podcasts episodes was about the use of intravenous lidocaine in peri-operative practice released November 2020. This new pilot multicentre randomised controlled trial of lidocaine infusion in women undergoing breast cancer surgery from Toner et al. enrolled 150 patients and looked at safety, effectiveness and the feasibility of a larger trial. Daliya et al. report their retrospective observational study of Opioid prescription at postoperative discharge. They were able to isolate a number of recognised risk-factors in the prescribing habits of clinicians at discharge that could contribute to a large unused pool of opioids in the community. In the accompanying editorial, Albrecht and Brummett remind us that if you cannot measure it, you cannot improve it. They argue that improvement can be made through: proper adherence to education and guidelines; by embracing simple measures such as prescription of non-opioid analgesics at regular intervals; specification on the duration of the course of immediate-release opioid tablets; avoidance of long-acting opioid formulations and compound analgesic preparations; and advice on deprescribing.

Elsewhere this month we have: a systematic review of suicide in anaesthetists; a systematic review of simulation-based team training in airway management; new Association of Anaesthetists fire safety and evacuation guidelines; and a time-sensitivity analysis of the prognostic utility of vasopressor dose in septic shock. 

Finally, make sure you do not miss our next live broadcast with our Associate Editor Dr Tanya Selak chairing which is all about a new paper on the safety of day-case paediatric tonsillectomy in England from the Getting It Right First Time programme. You can tune in by coming to @Anaes_Journal (or following this link) at 1200 BST on Friday 17^th September!

See you then!

• 

• 

Mike Charlesworth and Andrew Klein

In the UK, COVID-19 continues to impact upon the provision of all NHS services. This new serial service evaluation from Kursumovic et al. was able to measure and report on the impact on anaesthesia and critical care services in the UK between October 2020 and January 2021. Interestingly, this study made use of the NAP6 infrastructure, as the project was on hold during the pandemic. During this time, one in eight anaesthetic staff were not available for work and one in five operating theatres were closed, with activity falling significantly in those theatres that were open. During January 2021, the system was largely overwhelmed. Redeployed anaesthesia staff increased the critical care workforce by 125% and three quarters of critical care units were expanded. This all helps us to work out what happened which will hopefully mean we are better placed to respond to future pandemics. 

The survey focusses on three key factors – staff, space and stuff. In the accompanying editorial, Wong et al. argue that staff are our most valuable asset. We have all and will continue to work in new ways because of the pandemic, and there has been much focus on ways in which to combat the effects of workforce burnout. It nevertheless remains to be seen whether recommendations such as better provision of mental health support, improved pay, combating workplace bullying and delivering better workforce planning will be implemented. The arguments provided by Wong et al. are compelling and their thoughts seemed to resonate with our followers over on Twitter. For this workforce will also be the one that looks after our nation’s health for years to come. 

There have been numerous observational studies reporting on outcomes in patients with COVID-19 admitted to intensive care. This new systematic review and meta-analysis from Taylor et al. finds that increasing age, pre-existing comorbidities and greater severity of illness are associated with mortality in patients admitted to ICU with COVID-19, but male sex and increasing BMI were not. This surprising finding attracted a lot of attention on social media and with nine news outlets also featuring the study. In the associated editorial from Cook and Comporota, state the case for core datasets for critical care outcomes from COVID-19. These will not only be of benefit for this and other pandemics, but also for the major health challenges that affect ICUs across the world. 

How best to pre-oxygenate patients prior to rapid sequence intubation (RSI) continues to be debated. This new randomised controlled trial from Sjöblom aimed to compare high-flow nasal oxygen with tight-fitting facemask pre-oxygenation during RSI in patients undergoing emergency surgery in several different centres. They showed no difference in the number of patients desaturating < 93% between pre-oxygenation using high-flow nasal oxygen vs. tight facemask. Lam and Irwin ask, is high-flow nasal oxygen worth the hassle? It does seem to be safe, but it is more expensive, time-consuming, technically more difficult to prepare does not appear to have any major benefits over other accepted techniques. We need more research in specific patient groups such as obese, pregnant and high-risk patients more generally. Also this month, Sud et al. compare gastric gas volumes measured by computed tomography between high-flow nasal oxygen therapy and conventional facemask ventilation. They find that high-flow nasal oxygen does not increase gastric gas volume in fasted patients undergoing induction of anaesthesia in the supine position, which adds further support to the safety of its use. 

Every year, > 130k patients survive an episode of critical illness in the UK. Focus on this patient group will no doubt increase as the pandemic hopefully eases. This new mixed-methods systematic review from Bench et al. finds that fatigue is common in critical illness survivors, with a prevalence ranging from 13.8–80.9%. This rises around one month following ICU discharge and improves over time but seldom resolves completely. There is a paucity of evidence on how best it should be detected or managed. In the accompanying editorial, Hosey et al. argue that we must help ICU survivors find new ways to live with chronic symptoms, with clinicians and researchers striving to design and evaluate multidisciplinary and comprehensive treatment modalities that support recovery from the ICU to home. 

The new Association of Anaesthetists 2021 recommendations for standards of monitoring during anaesthesia and recovery have now been cited 7 times and attracts an Altmetric score of > 250. Areas of controversy include new guidance on: capnography; transfer; quantitative neuromuscular monitoring; processed electroencephalogram monitoring; and electronic record keeping. They feature in this month’s issue, and they are essential reading for all. Elsewhere we have: a randomised controlled trial of deep serratus anterior plane block vs. sham block in ambulatory breast cancer surgery; a narrative review of adjunctive treatments for the management of septic shock; a systematic review of the association between intra-operative cardiac arrest and country Human Development Index status; an evaluation of group teaching before surgery (Fit-4-Surgery School); and a feasibility and pilot study of volatile anaesthesia and peri-operative outcomes related to cancer. 

Many of this month’s articles have an associated podcast which you can listen to here. It also features the most recent podcast which looks at the new COVIDSurg international prospective cohort study on the effects of pre-operative isolation on postoperative pulmonary complication rates. The paper remains free to access forever!

• 

• 

Mike Charlesworth and Andrew Klein