A new year, another investigation

The January edition of the journal is out today, which feels strange considering Christmas hasn’t even happened yet (but is definitely coming). In an era of evidence-based medicine, scientific misconduct remains a real threat to medical research. John Carlisle, one of the editors of this journal, has developed an analytical method in order to determine whether baseline data is truly random in what is now known as the Carlisle Method. The new year brings another potential case of data fabrication. This was triggered by the submission of a suspect article to another journal, and when the data from this and other manuscripts by the same author were examined closely, there was evidence of non-random sampling. In other words, that the data was not random in its distribution in 31 trials published by Yujhi Saitoh. The majority of these papers were about neuromuscular monitoring, and they were broadly spread around the anaesthetic journals worldwide. Seven of these were published in the Canadian Journal of Anesthesia, six in the British Journal of Anaesthesia, four in the European Journal of Anaesthesiology, three in Anesthesia and Analgesia, three in Anaesthesia, three in the Journal of Anesthesia, two in Acta Anaesthesiologica Scandinavica, two in the Journal of Clinical Anaesthesia, and one in the Fukushima Journal of Medical Sciences.

This is clearly very concerning, and we await the findings from the investigation that is ongoing by the Japanese Society of Anaesthesia. However, we can’t only look backwards at studies that are already published – we also need to look very closely at what is submitted to journals in all different specialties in the future. To that end, at Anaesthesia, we have decided to screen all randomised controlled trials submitted to the journal from 2016 using the Carlisle Method. We believe we are the first journal to do this. Any that fall foul due to suspicious data that are not consistent with random sampling will be rejected and the authors informed of the reason for rejection. We hope to persuade all the other anaesthetic journals to follow suit soon, and will look to involve other specialties and organisations over the coming years.

We are seeing more and more ‘disposable’ single-use devices in our practice. These include laryngoscopes, bougies, and now even fibreoptic scopes. While there are clear advantages in terms of infection control, there remains concern about comparable efficacy, design, cost and the ‘green’ effect of throwing away so much plastic and other materials. With this in mind, it is very tempting to re-use these single-use devices in the same patient repeatedly, both on the same day and perhaps even on subsequent days, especially in the case of fibreoptic scopes. Surely if they are going back into the same patient then that can’t do any harm? Wrong – a study published in this month’s edition of the journal showed that 16 out of 20 bronchoscopes cleaned then kept after use were contaminated after 48 hours. There is a very clear clinical lesson here – single-use means exactly that, and you can’t re-use them later even in the same patient. This will have significant implications for many hospitals I suspect.

This is a welcome update on consent for anaesthesia in this month’s journal, and this a ‘must read’ for every anaesthetist. The twelve key tenets include intuitive as well extremely thoughtful recommendations. Full consent should be obtained as early in the patient pathway as possible (not in the anaesthetic room), and the information provided should be tailored to each patient, with adequate time allowed for patient questions. Documentation should be made of the consent obtained although specific consent forms are not required. The fluid nature of consent means it is an ongoing process and should be confirmed at each interventional stage. If a patient lacks capacity, the reasons should be documented, efforts should be made to reverse or reduce temporary incapacity, and if this is unachievable we should always act in the patient’s best interest. Seeking a lasting power of attorney (LPA), valid advanced decisions, a validly appointed health and welfare LPA or a court-appointed deputy are legally binding. A knowledge of the existing frameworks regarding consent in patients aged 17 or younger is recommended. Finally, when training in practical procedures is undertaken, maximising benefit whilst minimising risk to the patient is important and alternative means of training, such as virtual models or manikins should be considered. These guidelines are clear and thorough and will be the mainstay of clinical practice for years to come.

Finally for now, we have published a comparison of the adjustable pressure-limiting valves in two well-known anaesthetic machines. The manufacturer of the APL that was shown to be ‘unusual’ in its performance has also commented on the study, and an accompanying editorial has put this into perspective. The clinical lesson here is know the machine you are using and read the instructions for use. Admittedly, so many of us don’t, and if you read this article you will see how important it is to know the difference between different designs of APLs and how they function in practice, especially for paediatric use. My final comment is, why are different APLs produced and why aren’t clinicians telling manufacturers what they want and being involved in the design of new equipment? It seems nonsensical to me that there should be such a difference, with such important implications, in APLs on different common anaesthetic machines. Should we accept this from a safety perspective?

Andrew Klein


Understanding Uncertainty

How good are you at understanding chance, risk, uncertainty and probability? The UK referendum on whether to leave or remain in the European Union has brought statistics, risk and uncertainty back into our everyday language. We have (re) learnt that statistics without context can be misleading, tolerance of an acceptable risk is opinion–based, and that both financial markets and individuals struggle to deal with uncertainty. This is emphasised in an excellent article, which makes the point that 50% of anaesthetists are actually worse than average at understanding risk. Anaesthesia has made a point of providing easy-to-understand, concise, educational articles in the last year, our statistically speaking series, and this will continue into next year. We plan to publish a series called ‘methodological madness’, in which we invite readers to write in and ask our statistical guru (Dr Choi from Hong Kong email: msmethodmatters@gmail.com) about what authors have got up to when designing their methods for studies. The main message is, we all need to understand more about statistics, probabilities and risks.

Airway management is the prime professional skill of the anaesthetist; research into this topic is widespread, and Anaesthesia receives many such submissions. In a study from Switzerland, Kleine-Brueggeney and colleagues compared the performance of the Bonfils™ and SensaScope™ rigid fibreoptic scopes in 200 patients with a simulated difficult airway. They note in their introduction that rigid scopes such as the two studied are relatively underused in anaesthesia despite being favoured in otolaryngology and respiratory medicine.  The authors simulated a difficult airway by applying a cervical collar to each patient such that mouth opening was limited to a mean of 23 mm. The patients were randomly allocated into two groups; the primary outcome of the study was overall success of intubation. In this, the overall success rates were high for both devices (88% for the Bonfils and 89% for the SensaScope (p = 0.83), although median intubation times were a little shorter with the SensaScope (34 vs. 45  seconds).

In an accompanying editorial, Ward and Irwin explore the ethical implications of airway research where the normal airways of routine patients are rendered ‘difficult’ for the purpose of evaluating the performance of new devices (or those using them). Notwithstanding the fact that there are many reasons for an airway being ‘difficult’, and the difficulty created by the methods commonly used in the research context may not reproduce all of them, there are also important questions to consider about the nature of risk and benefit in such studies.

As Ward and Irwin note, patients taking part in such studies do not themselves benefit from such participation; instead, the data may contribute to the common good of future patients in general. In this context, the possible harms implied by the intervention are thrown into sharper focus. The members of research ethics committees may lack the specialist knowledge of anaesthesia devices to allow them to make a fully informed judgement about the balance of benefits and harms. Here, the anaesthetist’s first duty is the responsibility of a physician to a patient, not a researcher to data. An innovative Consensus on Airway Research Ethics is proposed, and I have also added a note advising anyone conducting airway device evaluation studies that manuscripts will need to comply with the recommendations in the Consensus if they wish to be considered for publication in Anaesthesia.

Also on the theme of airway management, this report from the Netherlands details the development of an audit tool to identify prospectively all peri-operative adverse events during airway management over an 8 week period. Data were collected daily by  questionnaires from, and interviews with, anaesthesia trainees and anaesthetic department staff members. A total of 168 airway-related events were reported out of 2803 patients undergoing general anaesthesia. The incidence of severe airway management-related events was 24/2803 (0.86%). There were 12 (0.42%) unanticipated ICU admissions and two patients (0.07%) required a surgical airway. There was one (0.04%) death, one ‘cannot intubate cannot oxygenate’ (0.04%), one pulmonary aspiration of gastric contents (0.04%) and eight (0.29%) severe desaturations (defined as an oxygen saturation less than 50%). Whilst this survey is restricted to one hospital, the authors suggest that the methodology they used could easily be followed by others within their own departments of anaesthesia.

Finally, this being December and Christmas being just around the corner, we have published our first-ever Christmas special in the journal, CRAC-ON, as in why don’t you just CRAC ON and give the anaesthetic! CRAC ON stands for complete relinquishing of anaesthetic conscientiousness, optimisation and nuance. This special article is meant to be light-hearted and satirical, and I really enjoyed reading it. It is included as an extra article, and the rest of the journal contains as many serious articles as normal. I hope you enjoy it too, and would be interested in receiving your feedback. CRAC ON and have a good Christmas!

Andrew Klein


Just breathe!

Breathing seems to be a major theme in the literature (and at meetings) at the moment, and there are a number of articles in this month’s edition of the journal that are relevant.

Apnoeic oxygenation and nasal oxygen administration are two concepts that are hardly new in anaesthesia, but are rapidly taking centre-stage for management in a wide variety of situations. Dr’s Patel and Nouraei coined the term THRIVE – Transnasal Humidified Rapid-Insufflation Ventilatory Exchange – and described a case series in Anaesthesia in 2015. This paper has just received the award for ‘Best paper in Anaesthesia of 2015’ at the AAGBI Annual Scientific Meeting in Birmingham.

The situation of rapid sequence induction of general anaesthesia is one in which we are poor at predicting airway management difficulty (see e.g. Norskov et al. Anaesthesia 2015; 70: 272 – number 2 ranked of the 2015 Anaesthesia articles), yet we produce an unstable situation of complete muscle paralysis before the definitive tracheal intubation procedure. In this edition of the journal, Pillai et al. using the Nottingham Physiology Simulator have  shown that, under ideal conditions, oxygen delivery during apnoea might increase the time to desaturation of a pregnant subject from 4.5 min to 58 min. This is incredible if true, and will be of great interest to all obstetric anaesthetists, but needs to be further investigated in pregnant patients – I believe such trials are ongoing.

There are likely to be more papers on this subject in Anaesthesia in the near future – watch this space for progress that may dramatically change how we do things in one of the high-risk areas of our practice.

This edition of the journal also includes a paper describing the current state of airway training in UK anaesthetic departments. The Fourth National Audit Project (NAP4) recommended routine and regular airway training for trainee and trained anaesthetists. However, in this survey from 206 hospitals (62%) covering all regions of the UK, 16% of hospitals did not provide airway workshops for staff at all, and 51% only for trainees. Of those providing workshops, more than half were being run less than annually. The authors concluded that workshop-based airway training is variable in provision, frequency and content, and is often not prioritised by departments or individual trainers. I agree that the provision of appropriate training identified in NAP4 is sadly lacking in many hospitals, and the reasons for this are many, but surely include resources as well as motivation. Getting Consultants out of the operating theatre into an hour or two-long airway workshop is what is needed, and regularly, but this isn’t easy, especially when getting any time out of theatre (or ICU) is getting harder and harder in the current climate. Should this be made part of mandatory training? And are workshops really the answer?

Finally, what about trainees challenging consultants? There is a perception that trainees should challenge their ‘seniors’ more frequently, especially when they are obviously wrong. This is borne out by this simulation study which explores the concept of ‘barriers to challenging seniors’ for anaesthetic trainees. The authors concluded that more senior trainees challenged their consultant supervisor quicker, allowed fewer intubation attempts, established quicker adequate rescue oxygenation and ventilation and less simulated patient desaturation was observed. This is not really surprising as experience and maturity should improve performance, especially in this sort of scenario, but the authors make some interesting observations about improving training to give trainees the confidence to challenge more effectively and with less hesitation. Take a deep breath and go for it!


Andrew Klein


Occam’s razor

Occam’s razor (or the law of parsimony) is a problem-solving principle attributed to William of Ockham (c. 1287–1347), who was an English Franciscan friar, scholastic philosopher and theologian. The principle states: ‘other things being equal, simpler explanations are generally better than more complex ones’. This month’s blog looks at simple interventions and principles, and whether Occam’s razor hold true in our practice.

Paracetamol – great drug, right? I swear by it, and dispense it liberally, both at home and in the operating theatre and the intensive care unit. A simple study with a very simple hypothesis is published in October’s edition of the journal, comparing oral (enteral) with intravenous (parenteral) paracetamol in ICU patients. Patients who received the intravenous formulation were much more likely to suffer hypotension and require vasoconstrictors to ameliorate this. Wow – so paracetamol is not as harmless as we all think? If one off doses can cause hypotension like this should we still be giving it at all in our ICU patients, or should we only be giving it enterally (presumably via the NG tube – hypotension still occurred but less commonly)? Maybe this simple, effective drug is not the panacea? A very interesting study I am sure you will agree.

What about teaching tracheal intubation to novices? We have traditionally taught the use of the Macintosh laryngoscope first, but will they learn it and remember it better if they are taught with a videolaryngoscope? Actually, perhaps not – this excellent study studied a group of medical students and looked at skill retention. This study showed that the students learnt how to use the Macintosh, A.P. Advance™, C-MAC® and Airtraq® laryngoscopes equally well at first, but one month later, they seemed to have retained the skill-set required for laryngoscopy significantly better with the Macintosh and Airtraq laryngoscopes. In this instance, simpler seems to be easier to pick up again and get to grips with more quickly, a salutary lesson.

This month, we also publish an interesting systematic review of the effect of propofol compared with inhalational anaesthesia on postoperative outcomes including pain. This well-conducted rigorous review found that patients who received total intravenous anaesthesia with propofol did indeed have reduced pain scores 24 hours after surgery, although the effect size was quite small. But, it also confirmed that postoperative nausea and vomiting was markedly less common. Is this enough to make you switch your technique to TIVA? Maybe not, after all these are not really important outcomes like mortality, but will we ever recruit enough patients to see a difference in mortality if there was one – I doubt it. So what are we waiting for, or do we just not believe there is actually a difference? Perhaps it is simpler to believe the opposite, that inhalational and propofol are much of a muchness for maintenance of anaesthesia and we are not convinced either way yet.

Finally, our statistics article explains why odds and risks (and other numbers) often confuse things, both for researchers and for readers (consumers). Why do we like to use complicated statistics to describe things, when simpler explanations are often possible if not preferable? If you, like me, don’t know the difference between the odds of something and the risk of the same thing, then read it and learn – I did, and I am off to put a bet on the 2-30 at Newmarket…


Andrew Klein


The Olympics for anaesthetists

Well, that’s it for another four years. Months and years of preparations, and in the end it came down to five days of non-stop action and one night of celebration, then everyone goes home. This is the week that was the World Congress of Anaesthesiologists in Hong Kong, and what a good one it has been. I am going to give you a bit of a flavour of the event and how this journal fared at the pinnacle of our professional calendar of conferences.

The whole event was organised by Mike Irwin, Professor at Hong Kong University and one of the editors of Anaesthesia. Siu Wai Choi, the statistical advisor to this journal was also ever-present, coaching us to rise above any mathematical missed passes. However, John Carlisle, another editor of the journal, was the real star turn when he shared the podium with Steve Shafer (ex Editor-in-Chief of Anesthesia and Analgesia @stevenlshafer) and Nathan Pace (from the University of Utah and Senior Statistical Advisor at Cochrane). John presented his initial analysis of Fujii that led to the retraction of 183 publications and his undisputed Number 1 position on the Retraction Watch Hall of Shame (@RetractionWatch). He then presented the rationale for Monte Carlo simulation and his updated analysis – the Carlisle Method – which he announced he has now applied to all randomised controlled trials published over the last 15 years in this and seven other journals. Interestingly, another author has come to light after the application of the Carlisle Method following the submission of a suspicious manuscript to another journal, and this further analysis previewed at the World Congress will be published shortly in Anaesthesia.


One of my own personal highlights was the sight of the delegates queuing patiently to get hold of souvenir USB sticks containing the China Special Edition and World Special Edition of Anaesthesia produced especially for the Congress, and you can see these special editions yourself on our website by clicking on the links above. I also particularly enjoyed crossing the city to Hong Kong University to present a workshop to upcoming biomedical researchers on what and how to publish. The researchers packed the room and posed many questions about publication, research and the world of journal intrigue and peer review.



There was great interest at the Congress in several recently published articles. A Korean group presented their findings about complications during subclavian central venous catheterisation, and their conclusion that a wire-through-needle technique is safer than a catheter-over-needle technique should finally put to bed the longstanding debate about the two techniques. There were several fiery debates and discussions about routine or otherwise use of dexamethasone, with the presentation of data about the inescapable rise in glucose concentration associated with its use in diabetics and non-diabetics. Finally, novel regional blocks were much in evidence, and particularly the serratus anterior plane block, which was dissected in detail.

To finish up, a bit about the final night of celebration. A crowd of us were shown the sights of the harbor from the top deck of a boat, followed by a seafood dinner and even one or two local beverages. I understand that a number then went on to do a crawl around the top 10 rooftop bars of the city, but myself, I was tucked up in bed ready for the Closing Ceremony. I am sure everyone is looking forward to the next Olympics in Prague in 2020 – I certainly am.


Andrew Klein


Stop, Look, Listen, Think

The theme of this month’s blog is Safety (the capital S is deliberate). We teach road safety to our children by telling them to “Stop, look, listen and think” before crossing the road, and maybe as medical providers we need to try this too?

This month, researchers from Manchester publish an analysis of patient safety incidents reported to the National Patients Safety Agency (NPSA), now the National Reporting and Learning Service (NRLS), between 2004 and 2014 from critical care units in England and Wales. Of 1743 incidents, 389 (22%) may have contributed to the patient’s death, and 1555 (89%) may have been avoidable. Over the 10 years, the number of reported incidents per year went up, as did the number of patients cared for in ICU (but not enough to explain the increase in safety incidents). Why are patient safety incidents on the increase, despite our best efforts? Are we just reporting them more frequently? Or are they actually more common, despite the introduction of numerous guidelines, safety procedures and other central and local initiatives? Can we as medical practitioners and the ICU team as a whole do more? The study shows that there was a decrease in the number of incidents related to infection, but an increase in the number of medication incidents. There is certainly much to reflect on in this excellent analysis.

What about cricoid pressure? We were/are all taught to use it for rapid sequence induction, but, although a number of studies have cast doubt on its efficacy and safety, our practice hasn’t really changed. This month, a new study using ultrasound in awake volunteers shows that standard cricoid pressure does not actually narrow the oesophagus at all, let alone occlude it. This would be an interesting study to repeat in anaesthetised patients, but if it held true, does cricoid pressure do what we think it does? The authors also studied a newly described technique which they name paralaryngeal pressure. This was found to be much more effective at occluding the oesophagus, and certainly merits further study. the future of cricoid pressure is eloquently debated in the accompanying editorial, including its safety and when to release the pressure to prevent patient harm, and I urge you to read both the article and the editorial and join in the debate in our correspondence pages or on Twitter.

The final article related to safety describes an investigation modelling oxygen supplementation during tracheal intubation in pregnant women. Because pregnant women desaturate much more quickly during apnoea, rapid sequence induction can be more fraught and dangerous. Recent studies (THRIVE) have shown that high-flow nasal oxygen during intubation can prolong the time to desaturation during apnoea in the non-pregnant population. This most recent study demonstrated that increasing FiO2 at the open glottis increased the time to desaturation, extending the time taken for SaO2 to reach 40% from 4.5 min to 58 min in the average parturient model (not in labour). The greatest increases in time to desaturation were seen at FiO2 1.0, which could be delivered by high-flow nasal cannulae under ideal conditions. Obviously, clinical studies are needed in pregnant women, but my conclusion from this modelling study is – should we now be administering oxygen routinely via nasal specs during rapid sequence intubation, and certainly in pregnant women? Weighing up the risk-benefit model it would certainly seem to, and this may be a very significant change which will increase safety in this and other patient populations. I look forward to more research in this rapidly evolving safety field.

Finally, I am about to decamp to China (for the Chinese Society of Anesthesiology meeting) and Hong Kong (for the World Congress). I will be blogging from there with some special editions of the journal to coincide with these meetings and more updates on breaking research.


Andrew Klein


The times they are a-changin

Anaesthesia Blog, July 2016.

“The Times They Are a-Changin'” was a song written by Bob Dylan and released as the title track of his 1964 album of the same name. Ever since its release, the song has been influential to people’s views on society, with critics noting the general yet universal lyrics as contributing to the song’s lasting message of change, which seems particularly apt with Brexit and a new Prime Minister imminent. This month’s blog is also about change, and I particularly wish to highlight a Special Article on Pensions, Tax and the Anaesthetist. Over the last few years, a series of changes have been made to our pensions as doctors, and in April 2016 the biggest of these was introduced, with very little fanfare. Many of my local colleagues have not heard about the latest changes, and those that have are confused as to their effects on their pension. This article in the journal explains very clearly the changes that have been made and their effect on our expected pension income, and the choices we now have. There is no doubt that a good pension at the end of many years of hard work is one of the greatest incentives to working in the NHS, but can we still expect that and is there anything we can do to maintain our expected benefits? The changes to pension laws will increasingly affect workforce planning and may lead to even more experienced anaesthetists leaving the NHS – I urge you to read this and digest and discuss the implications.

I have noticed that there has been a marked change in attitudes to sedation over the last few years, and more and more of my non-anaesthetic colleagues want us anaesthetists to sedate their patients instead of anaesthetising them, because they perceive this to be better (though it is not always clear who for). The evidence comparing sedation and general anaesthesia is surprisingly sparse, but this retrospective propensity-matched cohort study in my centre demonstrated, much to our amazement, that sedation for high-risk patients with aortic stenosis undergoing transcatheter valve replacement actually had a number of significant advantages compared with GA, and our practice has now completely changed as a result, with more patients on a list, patients going home much sooner and everyone (patients and cardiologists/surgeons) much happier. An unexpected consequence is that the surgeons now think every patient should have sedation instead of GA, so the debate is set to continue for some time. I hope to see more trials comparing sedation with GA in the future.

Another interesting article in this month’s journal may herald a change in the local anaesthetic solution we use for regional anaesthesia. The authors compared liposomal bupivacaine with plain bupivacaine, and they found that the liposomal formulation provided up to 72 hours of analgesia when used for transversus abdominis plane (TAP) blocks. I think this is a very interesting development and I am sure we are going to read a lot more about liposomal local anaesthetic solutions in the near future.

Finally, there have definitely been changes to the way we teach medicine and anaesthesia, and particularly with respect to the use of simulators. Manufacturers have striven to develop advanced and technologically impressive simulation platforms, and a lot of surgeons now learn using cadavers, but this article compares a simple home-made meat model with cadaveric teaching for ultrasound-guided sciatic nerve block. Surprisingly, the cheap and simple home-made model was better for teaching novices than the cadaveric method, which will interest those running regional anaesthesia teaching courses and anyone teaching their trainees how to put in a nerve block. It seems simple is best under such circumstances.

I hope this month’s Anaesthesia will stimulate you to embrace change in your practice, and remember “Human happiness may rely on our ability to conquer a natural fear of upsetting the status quo”  (A. L. Kennedy).


Andrew Klein


Help – I need somebody!


I have to come clean – I borrowed the title of this blog from an editorial in July’s edition of the journal, which is my compliment to the authors. This famous song was not only sung by the Beatles in 1965, but also by John Farnham, Bananarama (another Bananarama song title in one of my blogs – that will get people talking), The Carpenters and many others. Calling for help, or communicating efficiently and effectively, is discussed in the aforementioned editorial on calling for help in the emergency situation, which is really about how we train our medical students and junior doctors to call for help. Knowing who to call and how is actually incredibly important. I was involved in a car accident recently, and it was obvious to me to call the police immediately, but everyone else was telling me not to bother. It was clearly the right decision, and we all know to call 999, outside of a hospital at least, but if an anaesthetic emergency is brewing, who should you call and how?

This excellent study compares two methods of urgent communication in theatre; one that is current teaching and a new Traffic Lights tool (‘red alert’, ‘amber assist’ and ‘green query). In a simulated theatre environment, the trainee anaesthetists instructed the go-between to relay information much quicker and more effectively using the Traffic Lights tool, and everyone involved preferred it to the situation, background, assessment, recommendation (SBAR) tool. Studies such as this one examining the effect of different communication styles and tools in the emergency setting are novel and, in my view, important. All the algorithms we refer to say “call for help”, but not who and how.

Understanding and communicating the risks of surgery to our patients is an important facet of healthcare, and this month we have published an interesting study linking caudal anaesthesia in children having hypospadias surgery with postoperative surgical complications. This was a retrospective, observational study, and the authors are not implying causation, only association, but it raises a number of interesting issues, such as mechanism (?swelling) and the need for a randomised controlled trial.

Pre-hospital treatment, communication between helicopter physicians and their patients about analgesia, is the subject of another article from the Swiss Alpine Helicopter Emergency Medical Service. Patients who clearly had a fractured limb most often received intravenous fentanyl, but the physicians who were trained anaesthetists used ketamine more frequently, especially for patients with reported severe pain or who had more severe injuries. This brings up up a number of questions: is ketamine better?; should non-anaesthetists be trained to use ketamine?; should ketamine be first-line for injured patients? I look forward to further research in this area of practice.

Finally, an editorial about the new NICE guidelines for the peripartum management of diabetes begs the question – how much did NICE actually communicate with anaesthetists who look after pregnant patients when drawing up these latest guidelines? The authors of this editorial certainly believe that the new guidelines are at best controversial, and that NICE should re-examine them as a matter of urgency as they confict with other recent NICE guidance. They pointed out that the new advice seems to follow historical strategies and does not give sufficient weight to more recent work, and that the recommendations will lead to an increased risk of maternal and neonatal hyponatraemia, as well as maternal hypoglycaemia. The authors of this editorial go as far as suggesting that obstetric anaesthetists should target a capillary blood glucose of 6 – 8 mmol.l−1 and use dextrose 5% in saline 0.9% with premixed potassium chloride 0.15% as the recommended initial substrate solution to run alongside the variable rate intravenous insulin infusion. There is clearly an urgent need for more and better communication between NICE and experts in this field. On that note, I am off to ring my insurance company and try and find out where my poor car is….


Andrew Klein


Blood – thicker than water?

Anaesthesia Blog, May 2016.

The first use of this phrase was probably in a German proverb (originally: Blut ist dicker als Wasser), Reinhart Fuchs by Heinrich der Glîchezære. By 1670, the modern version was included in John Ray’s collected Proverbs, and later appeared in Sir Walter Scott’s novel Guy Mannering (1815) and in Thomas Hughes’s Tom Brown’s School Days (1857). The June edition of Anaesthesia contains a number of articles that look at how thick blood actually needs to be and why this is important in the peri-operative period.

Anaemia is an increasingly prevalent condition, and has actually been described as an epidemic by the WHO. The Association of Cardiothoracic Anaesthetists (ACTA) undertook their first National Audit which is published here and describes how the rate of anaemia varies in different regions of the UK, from 23% to nearly double at 45%. The major finding of this study was confirmation of the association between anaemia and worse outcomes, and specifically that the lower the haemoglobin concentration is before surgery, the greater the chance of death is after cardiac surgery. In other words, thicker blood is good (except it seems if Hb > 150 g.l-1, which is also associated with increased mortality – is the blood too thick?).

Predicting which patients are more likely to bleed is one of the holy grails of peri-operative care, so that these high-risk patients can be targeted and actively managed. A group of authors used two point-of-care analysers to measure platelet function and found that a measurement performed soon after coming off bypass was best at predicting excessive bleeding. Tests performed at the start of surgery were not predictive, which is important as many manufacturers do recommend measuring at this point as a ‘baseline’, but this study suggests this may not be important. Also of interest was that patients taking pre-operative aspirin or clopidogrel were not more likely to bleed excessively, but anaemic patients were. Back to thicker blood is better!

Postpartum haemorrhage is the leading cause of maternal mortality globally, and this important study looked at the effect of platelets on major haemorrhage. Out of over 6000 deliveries over a one-year period, 356 (6%) women experienced moderate or severe haemorrhage, most commonly due to uterine atony, surgical bleeding or genital tract trauma. However, only 12 women required transfusion of platelets, which is much lower than in major haemorrhage due to trauma or following cardiac surgery, and this is a very interesting finding. Indeed, if the women had a normal platelet count before delivery and did not have placental abruption or other cause of consumptive coagulopathy, they had to bleed 5000 ml before requiring platelet transfusion. All this means that a fixed protocol including platelets is unnecessary for obstetric haemorrhage, and this is certainly relevant to clinical practice in every obstetric unit.

The final study that looked at bleeding was undertaken following major liver resection.  Not many anaesthetists look after these patients in the peri-operative period, but the authors finding that most patients were in fact less likely to bleed (were hypercoagulable – thicker blood?) after surgery, as measured using point-of-care tests, is relevant to all anaesthetists. This implies that instead of bleeding, most patients are at increased risk of thrombosis postoperatively, despite major surgery/transfusion, and that laboratory tests are in fact misleading during the immediate postoperative period. This would mean that prophylactic anti-thrombotic agents such as low-molecular weight heparin should be started earlier, and that laboratory tests should be replaced by point-of-care tests, a fact which is emphasised in this editorial. It really seems to me that the time has come to use point-of-care tests more widely, even once surgery has finished.

To finish off this blog on blood and bleeding, the new AAGBI Guidelines on transfusion have just been published, and they replace three previous guidelines on blood component therapy, massive haemorrhage and red cell transfusion. They will appear in the journal next month and will be sent round to every anaesthetic department as well as the Chief Executive of every NHS Trust in the UK. Read them yourself and see if blood really is thicker than water, or at least how important it is in the peri-operative period.



Andrew Klein


Its not what you do it’s the way that you do it.

Anaesthesia Blog, April 2016.

Ella Fitzgerald, Little Richard and Bananarama all famously sang “It ain’t what you do it’s the way that you do it”, and the May edition of the journal reinforces this in several ways.

The first example of this is a fascinating and shocking editorial about sugammadex that has important lessons for all of us who undertake (or take part in) research, audit and service evaluations in our institutions. The authors describe how they determined that a proposed study was a service evaluation and registered their study with their institution, but did not seek formal ethical approval, as advised under recommendations for service evaluations in the NHS, and did not gain patient consent or even discuss participation in the study with their patients. After ENT surgery, they exchanged the tracheal tube for a laryngeal mask, and then administered sugammadex to reverse neuromuscular blockade; the first two patients in their study then developed sudden and dramatic airway obstruction. The study team decided to investigate this further by performing fibreoptic endoscopy through the laryngeal mask on the next three patients and saw that the vocal cords were completely closed following sugammadex administration, a totally unexpected finding that had not been described in the literature before at this point. However, the key point was that they didn’t discuss this and other protocol changes with anyone else, namely their institution or more importantly, the patients themselves. They also didn’t report the adverse events locally. The Editor-in-Chief at the time of submission of the resulting article (Professor Yentis) contacted the authors, and eventually the local ethics committee, and a formal investigation into their ethical conduct resulted. Finally, the patients who took part in the study were contacted, and all agreed that data arising from the study could be published.

There are numerous lessons to learn. What someone thinks is a service evaluation or audit may be much closer to a research study in the opinion of others, and Professor Yentis, in his accompanying commentary, argues that study protocols should be discussed with an ethics committee in many more cases, if not routinely, and prospective patient consent sought. The journal receives numerous submissions where there is doubt about the ethical conduct of the study, and one of the commonest questions I am asked is “Do I need formal ethical permission?” Perhaps the new NHS system of all applications for studies in England (including audits and service evaluations) needing to apply for HRA approval (see http://www.hra.nhs.uk/research-community/applying-for-approvals/) will sort this conundrum out once and for all? From the journal point of view, we expect to change our guidelines to authors and insist that HRA approval has been granted before starting any study from April 2016 – more about this to follow.

What about the actual findings of the work of these authors? Well, these are interesting and quite novel. The adverse effect of sugammadex, namely that it may lead to airway obstruction if given to patients who do not have a tracheal tube in situ, due to vocal cord closure, is important and should be communicated to the anaesthetic community who have started to embrace sugammadex into their more mainstream practice recently, hence the decision to publish the account of this study as an editorial. The way the authors conducted the study may have been flawed, without formal ethical approval or patient consent, but the lessons from their conduct and work still need to be learnt.


There has been much debate in the literature about anaesthetic technique for surgery following fractured neck of femur, between general and spinal anaesthetics (with or without nerve blocks). An excellent article, which analysed the data from over 16,000 operations carried out in 2013 as part of the Anaesthesia Sprint Audit of Practice (ASAP-1), is published in this month’s journal. The overall message I took from this article was that the type of anaesthetic technique (GA or spinal) did not affect mortality, but how, and with what degree of care, especially with regards to blood pressure, the anaesthetic was provided, did matter. On one hand, this is not that surprising – we know that anaesthesia is a craft specialty, and how you give an anaesthetic is important, as demonstrated so eloquently in this article. On the other hand, the lack of a difference between the two major choices of technique (at least with respect to mortality), is surprising, as so many anaesthetists have polarised views one way or another. The question about whether the study design may have affected the findings is also an important one, as discussed in the accompanying editorial. The argument over the relative advantages and disadvantages between large observational studies, such as ASAP-1, and randomised controlled trials (the current so-called gold standard for level of evidence) will no doubt rage on, but in the meantime, the evidence we have is that conduct of anaesthesia is more important than actual technique with regards to mortality after fracture neck of femur. In other words, how you give your anaesthetic, not what anaesthetic you give.

Finally, the first guidelines for safe vascular access are published in May’s edition of the journal. This lists some very important recommendations that I believe will shape our practice with regards to vascular access for years to come. Vascular access, be it peripheral, central or arterial, is the most common invasive procedure carried out in hospitals, and if carried out with care and attention, and with meticulous aftercare, is safe. These guidelines recommend more widespread/earlier use of ultrasound, more formal training and supervision, better systems (including specific policies regarding safety and proficiency), all with the aim of improving safety, effectiveness and timeliness of all vascular access. Remember, it’s the way that you do it (and look after it, in this case), that’s important.



Andrew Klein