Search

Summary: Peri‐operative medication safety is complex. Avoidance of medication errors is both system‐ and practitioner‐based, and many departments within the hospital contribute to safe and effective systems. For the individual anaesthetist, drawing up, labelling and then the correct administration of medications are key components in a patient's peri‐operative journey. These guidelines aim to provide pragmatic safety steps for the practitioner and other individuals within the operative environment, as well as short‐ to long‐term goals for development of a collaborative approach to reducing errors. The aim is that they will be used as a basis for instilling good practice. [ABSTRACT FROM AUTHOR]

Summary: The Earth's mean surface temperature is already approximately 1.1°C higher than pre‐industrial levels. Exceeding a mean 1.5°C rise by 2050 will make global adaptation to the consequences of climate change less possible. To protect public health, anaesthesia providers need to reduce the contribution their practice makes to global warming. We convened a Working Group of 45 anaesthesia providers with a recognised interest in sustainability, and used a three‐stage modified Delphi consensus process to agree on principles of environmentally sustainable anaesthesia that are achievable worldwide. The Working Group agreed on the following three important underlying statements: patient safety should not be compromised by sustainable anaesthetic practices; high‐, middle‐ and low‐income countries should support each other appropriately in delivering sustainable healthcare (including anaesthesia); and healthcare systems should be mandated to reduce their contribution to global warming. We set out seven fundamental principles to guide anaesthesia providers in the move to environmentally sustainable practice, including: choice of medications and equipment; minimising waste and overuse of resources; and addressing environmental sustainability in anaesthetists' education, research, quality improvement and local healthcare leadership activities. These changes are achievable with minimal material resource and financial investment, and should undergo re‐evaluation and updates as better evidence is published. This paper discusses each principle individually, and directs readers towards further important references. [ABSTRACT FROM AUTHOR]

This decision, and any subsequent surgery and anaesthesia, should be undertaken by senior staff in consultation with obstetric, neonatology, midwifery and obstetric anaesthetic teams. Identifying research priorities in anaesthesia and peri-operative care: final report of the joint National Institute of academic Anaesthesia/James Lind Alliance research priority setting partnership. Keywords: anaesthesia; complications; pre-natal EN anaesthesia complications pre-natal 143 146 4 01/10/23 20230201 NES 230201 Surgery for non-obstetric issues occurs in up to 1:100 pregnancies and can be an anxiety-provoking experience for the mother and healthcare staff, with concerns for maternal and fetal well-being [[1]]. Neurodevelopmental outcomes after prenatal exposure to anaesthesia for maternal surgery: a propensity-score weighted bidirectional cohort study. [Extracted from the article]

Which journals cite work published in anaesthetic journals is of potential interest to authors, editors and publishers. We analysed citations made in 2017-2018 for articles, reviews, editorials and letters published by 12 anaesthetic journals in 2016, using the Web of Science™ citation index platform. We analysed 12,544 citations made for 3518 items. Citations were most often made by specialist anaesthesia journals and critical care journals, and occurred most commonly in articles, followed by reviews, editorials and letters. The median (IQR [range]) number of citations made per item was 3.3 (2.6-4.1 [1.6-5.1]). The median (IQR [range]) number of journals that cited the 12 source journals was 302 (236-449 [139-671]). The median (IQR [range]) proportion of citations made by the same journal that published the items (i.e. 'self-citations') was 15% (11-17% [5-32%]). There were 1305/1932 (68%) citations made by North American journals for items published in North American journals and 1712/2063 (83%) citations made by European journals for items published in European journals, p < 0.0001. Our analysis may inform authors, editors and publishers where to submit work, what editorial policy to pursue and what journal strategy to follow, respectively. [ABSTRACT FROM AUTHOR]

The NHS Sustainable Development Unit has estimated that anaesthetic gases (including nitrous oxide) contribute ~5% of the carbon footprint of UK hospitals (~0.56/10.4 million tons CO SB 2 sb e; ~0.08 mt (~0.8%) inhalational anaesthetic agents only) [10]. 19 Al-Rifai Z, Mulvey D. Principles of total intravenous anaesthesia: practical aspects of using total intravenous anaesthesia. Anesthesia, inhalation, adverse effects, anesthesia, toxicity, air pollutants, environmental. [Extracted from the article]

Keywords: maternal outcomes; obstetric anaesthesia; process metrics; quality indicators EN maternal outcomes obstetric anaesthesia process metrics quality indicators 573 575 3 04/14/20 20200501 NES 200501 The aim of delivering high-quality clinical care that optimises patient outcomes has always been a driving principle in the practice of medicine. This shortcoming related to quality indicators, outlined above, is not unique; a systematic review of published studies of quality indicators in anaesthesia found that 64% were process indicators, and that patient-centred metrics accounted for the fewest published clinical indicators [1]. [Extracted from the article]

The article presents the consensus statement from the International Fragility Fracture Network Delphi on the principles of anaesthesia for hip fracture patients. It mentions that anaesthesia is an important part of multidisciplinary care of hip fracture patients. It offers information on the Fragility Fracture Network (FFN), organization for parctitioners, whoare interested in improving the standards of care for fragility fractures.

The author focuses on prospective clinical trial registration, a process in which clinical researchers publicize trial methodology details and conduct before participants are enrolled. Topics discussed include the purpose of prospectively registering a trial, such as increased transparency and decreased selective reporting about results; the role of journals in publication of clinical trial data; and the need for improving the consistency between trial registration and resulting articles.

The article discusses the guidelines used for the management of hypotension with vasopressors during caesarean section under spinal anaesthesia. It mentions that hypotension following combined or spinal spinal epidural anaesthesia at caesarean section causes both maternal and fetal/neonatal adverse effects. It also mentions that hypotension is a common consequence of the sympathetic vasomotor block caused by spinal anaesthesia.

Previous guidelines on consent for anaesthesia were issued by the Association of Anaesthetists of Great Britain and Ireland in 1999 and revised in 2006. The following guidelines have been produced in response to the changing ethical and legal background against which anaesthetists, and also intensivists and pain specialists, currently work, while retaining the key principles of respect for patients' autonomy and the need to provide adequate information. The main points of difference between the relevant legal frameworks in England and Wales and Scotland, Northern Ireland and the Republic of Ireland are also highlighted. [ABSTRACT FROM AUTHOR]

The authors discuss the artificial variation in anaesthetic practice for hip fracture surgery that results from a lack of evidence on which to base care. They cite the potential of continuous audit to determine whether adherence to the standards improves outcome compared with non-adherence if anaesthesia care for hip fracture is standardised nationally. The reduction of artificial variation in care and the achievement of high levels of safety and performance through standardisation is noted.

The author offers his view regarding the inaugural Featherstone Oration, Research not research – a rant in four acts, and Ireland's Winter Scientific Meeting that was held at the Association of Anaesthetists of Great Britain and in London, January 2016, respectively. He mentions that the his four area of concern about research such as precision in communications, absurd situation, and training programs in managing research.

Background: Current methods for verification of endotracheal intubation can fail, particularly in emergency settings. We investigated whether a verification method using electrical stimulation through electrodes placed on the endotracheal tube cuff could distinguish endotracheal and esophageal intubations in an experimental setting.Methods: During three sequential sessions simulating emergency intubation without paralysis, rapid sequence intubation (RSI) with neuromuscular blockade, and intubation during cardiopulmonary resuscitation, eight pigs were intubated with an endotracheal tube fitted with two electrodes exposed on the cuff of the tube, first in the esophagus and next in the trachea or in reverse sequence. Cuff pressure was monitored during a 5-s electrical stimulation (20 mA, 80 Hz, 500 μs), and delta pressure was calculated as the difference between baseline cuff pressure and maximum cuff pressure during the electrical stimulation.Results: Delta pressure was significantly higher in esophageal than in tracheal placements in all three sequential sessions (86.0 [78.3-89.7] vs. 6.5 [2.0-7.9] mmHg, P = 0.001; 16.6 [13.2-22.8] vs. 0.8 [0.3-2.6] mmHg, P = 0.004; 66.1 [60.0-84.7] vs. 2.7 [0.7-9.7] mmHg, P = 0.001). The delta pressure did not overlap between tracheal and esophageal intubations except for the session simulating RSI with neuromuscular blockade, in which one of eight esophageal placements showed a delta pressure within the delta pressure range of tracheal placements.Conclusion: Electrical stimulation through electrodes placed on the endotracheal tube cuff produced remarkably greater increases in cuff pressure in esophageal intubations than in tracheal intubations in an experimental setting. [ABSTRACT FROM AUTHOR]

We re-analysed prospective data collected by anaesthetists in the Anaesthesia Sprint Audit of Practice (ASAP-1) to describe associations with linked outcome data. Mortality was 165/11,085 (1.5%) 5 days and 563/11,085 (5.1%) 30 days after surgery and was not associated with anaesthetic technique (general vs. spinal, with or without peripheral nerve blockade). The risk of death increased as blood pressure fell: the odds ratio (95% CI) for mortality within five days after surgery was 0.983 (0.973-0.994) for each 5 mmHg intra-operative increment in systolic blood pressure, p = 0.0016, and 0.980 (0.967-0.993) for each mmHg increment in mean pressure, p = 0.0039. The equivalent odds ratios (95% CI) for 30-day mortality were 0.968 (0.951-0.985), p = 0.0003 and 0.976 (0.964-0.988), p = 0.0001, respectively. The lowest systolic blood pressure after intrathecal local anaesthetic relative to before induction was weakly correlated with a higher volume of subarachnoid bupivacaine: r(2) -0.10 and -0.16 for hyperbaric and isobaric bupivacaine, respectively. A mean 20% relative fall in systolic blood pressure correlated with an administered volume of 1.44 ml hyperbaric bupivacaine. Future research should focus on refining standardised anaesthesia towards administering lower doses of spinal (and general) anaesthesia and maintaining normotension. [ABSTRACT FROM AUTHOR]

The care of the elderly with hip fractures and their outcomes might be improved with resources targeted by the accurate calculation of risks of mortality and morbidity. We used a multicentre national dataset to evaluate and recalibrate the Nottingham Hip Fracture Score and Surgical Outcome Risk Tool. We split 9,017 hip fracture cases from the Anaesthesia Sprint Audit of Practice into derivation and validation data sets and used logistic regression to derive new model co-efficients for death at 30 postoperative days. The area (95% CI) under the receiver operator characteristic curve of 0.71 (0.67-0.75) indicated acceptable discrimination by the Nottingham Hip Fracture Score and acceptable calibration fit (Hosmer-Lemeshow test), p = 0.23, with a similar discrimination by the Surgical Outcome Risk Tool, 0.70 (0.66-0.74), which was miscalibrated to the observed data, p = 0.001. We recommend that studies test these scores for patients with hip fractures in other countries. We also recommend these models are compared with case-mix adjustment tools used in the UK. [ABSTRACT FROM AUTHOR]

The authors discuss the impact of the reports on anesthesia by the 5th National Audit Project (NAP5) and by the Mothers and Babies: Reducing Risk Through Audit and Confidential Enquiries Across the UK (MBRRACE-UK) on obstetric general anesthesia. Topics discussed include cases of awareness in obstetric anesthesia, recommendations of the reports for anaesthetists, and a forecast for general anaesthesia.

The authors comment on the study "Analgesic Efficacy of Pre-operative Stellate Ganglion Block on Postoperative Pain Relief: A Randomised Control Trial" published within the issue. The authors discuss the contributions of the study in terms of tramadol consumption administered to patients through analgesia, the methods of evaluating the benefits of analgesic intervention and ways by which the study has prompted a debate on whether including an invasive placebo in a clinical trial is appropriate.

Background Post-operative pain continues to be a major problem. Some previous studies have suggested that patients anaesthetised with propofol have less pain after surgery than those anesthetised with volatiles. However, the results of previous studies are conflicting. We designed a large-scale trial to study, whether propofol or sevoflurane is more analgesic than the other. We measured opioid consumption in the acute post-operative phase after laparoscopic hysterectomy. Methods In a randomised, prospective single-blind trial, we evaluated the consumption of oxycodone and pain intensity in 148 women for 20 h after laparoscopic hysterectomy under propofol or sevoflurane anaesthesia. The primary endpoint was the cumulative amount of oxycodone consumed. Secondary endpoints were pain scores [numeric rating scale ( NRS)] at rest and with coughing, severity of nausea and state of sedation. Results The consumption of oxycodone and the NRS pain scores did not differ between the groups. The oxycodone consumed during first 20 h after surgery was 42.5 (95% confidence interval 38.3-46.6) mg and 42.8 (37.3-48.4) mg in propofol- and sevoflurane-anaesthetised patients, respectively ( P = 0.919). NRS scores for nausea were higher in the patients receiving sevoflurane during the first 60 min in the post-anaesthesia care unit, leading to higher consumption of rescue antiemetics. Sedation scores differed in favour of sevoflurane only at 4 h time point after anaesthesia. Patient characteristics did not differ. Conclusions In this study, comparing sevoflurane with propofol for maintenance of general anaesthesia, the choice of anaesthetic had no effect on the requirement of oxycodone or intensity of pain after surgery. [ABSTRACT FROM AUTHOR]

Large observational studies of accurate data can provide similar results to more arduous and expensive randomised controlled trials. In 2012, the National Hip Fracture Database extended its dataset to include 'type of anaesthesia' data fields. We analysed 65 535 patient record sets to determine differences in outcome. Type of anaesthesia was recorded in 59 191 (90%) patients. Omitting patients who received both general and spinal anaesthesia or in whom an uncertain type of anaesthesia was recorded, there was no significant difference in either cumulative five-day (2.8% vs 2.8%, p = 0.991) or 30-day (7.0% vs 7.5%, p = 0.053) mortality between 30 130 patients receiving general anaesthesia and 22 999 patients receiving spinal anaesthesia, even when 30-day mortality was adjusted for age and ASA physical status (p = 0.226). Mortality within 24 hours after surgery was significantly higher among patients receiving cemented compared with uncemented hemiarthroplasty (1.6% vs 1.2%, p = 0.030), suggesting excess early mortality related to bone cement implantation syndrome. If these data are accurate, then either there is no difference in 30-day mortality between general and spinal anaesthesia after hip fracture surgery per se, and therefore future research should focus on how to make both types of anaesthesia safer, or there is a difference, but mortality is not the correct outcome to measure after anaesthesia, and therefore future research should focus on differences between general and spinal anaesthesia. These could include more anaesthesia-sensitive outcomes, such as hypotension, pain, postoperative confusion, respiratory infection and mobilisation. [ABSTRACT FROM AUTHOR]

The elderly have the ethical and legal equivalence of younger adults, yet are treated differently by society. Numerous recent reports have exposed poor inpatient care resulting in part from institutional ageism, which has moral and legal implications for healthcare providers. Morally, there is an argument for positive 'exceptionalism' in elderly peri-operative care, pursuing quality improvement through use of a dignity agenda. Legally, numerous changes in human rights, equality, consent, capacity, and end-of-life laws and professional guidance have consistently re-emphasised the need for greater communication between doctors, patients, their relatives and carers. This review describes current ethical thinking and legal precedent (in England and Wales), and directs readers to consider areas in which the law might change in the near future, particularly with regard to the end-of-life care of elderly surgical patients. [ABSTRACT FROM AUTHOR]

We evaluated the effects of a prolonged inspiratory time on gas exchange in subjects undergoing one-lung ventilation for thoracic surgery. One hundred patients were randomly assigned to Group I:E = 1:2 or Group I:E = 1:1. Arterial blood gas analysis and respiratory mechanics measurements were performed 10 min after anaesthesia induction, 30 and 60 min after initiation of one-lung ventilation, and 15 min after restoration of conventional two-lung ventilation. The mean ( SD) ratio of the partial pressure of arterial oxygen to fraction of inspired oxygen after 60 min of one-lung ventilation was significantly lower in Group I:E = 1:2 compared with Group I:E = 1:1 (27.7 (13.2) kPa vs 35.2 (22.1) kPa, respectively, p = 0.043). Mean ( SD) physiological dead space-to-tidal volume ratio after 60 min of one-lung ventilation was significantly higher in Group I:E = 1:2 compared with Group I:E = 1:1 (0.46 (0.04) vs 0.43 (0.04), respectively, p = 0.008). Median ( IQR [range]) peak inspiratory pressure was higher in Group I:E = 1:2 compared with Group I:E = 1:1 after 60 min of one-lung ventilation (23 (22-25 [18-29]) cmH2O vs 20 (18-21 [16-27]) cmH2O, respectively, p < 0.001) and median ( IQR [range]) mean airway pressure was lower in Group I:E = 1:2 compared with Group I:E = 1:1 (10 (8-11 [5-15]) cmH2O vs 11 (10-13 [5-16]) cmH2O, respectively, p < 0.001). We conclude that, compared with an I:E ratio of 1:2, an I:E ratio of 1:1 resulted in a modest improvement in oxygenation and decreased shunt fraction during one-lung ventilation. [ABSTRACT FROM AUTHOR]

Pilot and feasibility studies are preliminary investigations undertaken before a larger study. We hypothesised that only a small proportion of pilot or feasibility studies published in anaesthesia journals were correctly labelled as such. We searched for papers published between 2007 and 2017 in six anaesthesia journals using the text words 'pilot' OR 'feasibility' and included 266 original articles with 26,682 human participants. Only 34 (12.8%) were correctly labelled as a pilot or feasibility study. They were more likely to: have more median (IQR [range]) participants, 73 (40-130 [4-2716]) vs. 27 (15-60 [2-3305], p < 0.001; report feasibility outcomes, 82.4% vs. 4.3%, p < 0.001; and report an intention to convert, 100% vs. 39.7%, p < 0.001. They were less likely to test the efficacy of the primary outcome, 50% vs. 72.8%, p = 0.009; and report firm clinical conclusions 41.2% vs. 67.7%, p = 0.004. Of the studies published more than 5 years ago, correctly labelled pilot or feasibility studies were more likely to precede a published conversion study, 53.8% vs. 16%, p = 0.004. There was no difference between the number of citations 18 (9-44 [2-216]) vs. 20 (7-47 [0-251]), p = 0.865. These results have important consequences for patients, trialists, researchers and funders. We argue that correctly labelled pilot studies enhance the quality of scientific research by encouraging methodological rigour, ensuring scientific validity and reducing research waste. Authors, reviewers, editors and publishers should ensure they adhere to the contents of the 2016 CONSORT extension for pilot and feasibility studies. [ABSTRACT FROM AUTHOR]

The authors reflect on the recommendation by the Great Britain National Institute for Health and Clinical Excellence (NICE) that a randomized controlled trial (RCT) be performed to assess the clinical and cost effectiveness of regional versus general anaesthesia for hip fracture surgery. They say that the recommendation will like to stimulate research grant applications to the National Institute for Health Research (NIHR). They also explore the problems associated with the design of the RCT.

This study was to estimate the predicted effect-site concentration of propofol administered by a target-controlled infusion (TCI) for maintenance of anesthesia based on the bispectral (BIS) index as a measure of hypnosis in laparoscopic surgery. One-hundred and sixty unpremedicated patients undergoing gynecologic laparoscopy were assigned randomly to receive one of the target effect-site concentrations of propofol 2.0, 2.5, 3.0, 3.5 and 4.0 μg/ml during TCI with propofol and sufentanil. The dose-response relationship of propofol for the maintenance of adequate anesthesia based on BIS, movement and hemodynamic response was investigated using a fixed effect-site concentration of sufentanil (0.2 ng/ml). The BIS values, hemodynamic variables, time course during emergence and intraoperative awareness were also assessed. The predicted effect-site propofol concentrations for adequate anesthesia at the skin incision in 50% (EC) and 95% (EC) of patients undergoing gynecologic laparoscopy were 2.2 and 3.7 μg/ml, respectively. The predicted propofol EC and EC to maintain adequate anesthesia in these patients were 2.6 μg/ml (95% CI 2.3-2.7 μg/ml) and 3.6 μg/ml (95% CI 3.3-4.0 μg/ml), respectively. The BIS values, effect-site concentration of propofol, hemodynamic data and time course during emergence and post-operative adverse events were comparable in each group. There were no reports of intraoperative awareness in the post-anesthetic care unit. Based on the anesthetic depth assessed by the clinical signs and BIS monitoring, the predicted effect-site propofol concentrations for the maintenance of anesthesia in patients undergoing gynecologic laparoscopy were similar in those administered adequate anesthesia at the skin incision during TCI. [ABSTRACT FROM AUTHOR]

General anaesthesia is the fastest method for anaesthetising a category-1 caesarean section but is associated with increased maternal morbidity and mortality. We describe the ‘rapid sequence spinal’ to minimise anaesthetic time. This consists of a no-touch spinal technique, consideration of omission of the spinal opioid, limiting spinal attempts, allowing the start of surgery before full establishment of the spinal block, and being prepared for conversion to general anaesthesia if there are delays or problems. We present a case series of 25 rapid sequence spinal anaesthetics for category-1 caesarean section. The mean (SD [range]) decision-delivery interval was 23 (6 [14–41]) min. After excluding cases where there was an identified delay, the median (IQR [range]) time to prepare and perform the spinal was 2 (2–3 [1–7]) min, and time to develop a ‘satisfactory’ block was 4 (3–5 [2–7]) min. The total time to induce spinal anaesthesia was 8 (7–8 [6–8]) min. There were three pre-operative conversions to general anaesthesia and three women had pain during surgery that did not require treatment. Our data indicate that one might expect to establish anaesthesia in 6–8 min using a rapid sequence spinal. Careful case selection is crucial. While rapid anaesthesia is important, the reduction of the decision-delivery interval also requires attention to other stages in the pre-operative process. [ABSTRACT FROM AUTHOR]

The aim of this audit was to investigate process, personnel and anaesthetic factors in relation to mortality among patients with proximal femoral fractures. A questionnaire was used to record standardised data about 1195 patients with proximal femoral fracture admitted to 22 hospitals contributing to the Hip Fracture Anaesthesia Network over a 2-month winter period. Patients were demographically similar between hospitals (mean age 81 years, 73% female, median ASA grade 3). However, there was wide variation in time from admission to operation (24–108 h) and 30-day postoperative mortality (2–25%). Fifty percent of hospitals had a mean admission to operation time < 48 h. Forty-two percent of operations were delayed: 51% for organisational; 44% for medical; and 4% for ‘anaesthetic’ reasons. Regional anaesthesia was administered to 49% of patients (by hospital, range = 0–82%), 51% received general anaesthesia and 19% of patients received peripheral nerve blockade. Consultants administered 61% of anaesthetics (17–100%). Wide national variations in current management of patients sustaining proximal femoral fracture reflect a lack of research evidence on which to base best practice guidance. Collaborative audits such as this provide a robust method of collecting such evidence. [ABSTRACT FROM AUTHOR]

Following two deaths from respiratory failure secondary to opioid toxicity in patients admitted for surgical repair of fractured neck of femur, we retrospectively studied the serum urea and electrolyte concentrations of 1511 consecutive patients requiring surgery for proximal femoral fracture, and calculated their glomerular filtration rate. Five hundred and forty-five (36.1%) patients had renal dysfunction on admission (glomerular filtration rate < 60 ml.min−1.1.73 m−2); 435 (28.8%) had grade 3 chronic kidney disease (moderate; glomerular filtration rate 30–59 ml.min−1.1.73 m−2), 82 (5.4%) had grade 4 disease (severe; glomerular filtration rate 15–29 ml.min−1.1.73 m−2) and 28 (1.9%) had grade 5 (renal failure; glomerular filtration rate < 15 ml min−1.1.73 m−2). The 30-day mortality for patients with renal dysfunction (62/536; 11.6%) was significantly greater (p = 0.004) than for patients with normal renal function (68/958; 7.1%), although median (IQR [range]) postoperative lengths of stay were similar 15 (10–22 [1–125]) vs 14 (9–22 [1–120]) days respectively; p = 0.06). Renal impairment is common in patients admitted for fixation of fractured neck of femur, who are consequently at risk of opioid toxicity. [ABSTRACT FROM AUTHOR]

Anaesthesia for Caesarean section was audited over a 5 year period: 5080 cases were performed using spinal 63%, epidural top-up 26%, combined spinal-epidural 5% and primary general anaesthesia 5%. The rate of general anaesthesia conversion of regional anaesthesia was 0.8% for elective and 4.9% for emergency Caesarean section compared to Royal College of Anaesthetists targets of 1% and 3%. The rate of conversion of regional to general anaesthesia in category 1 Caesarean section was 20%. A total of 8% of women had general anaesthesia when both primary general and conversion of regional anaesthesia were combined. The rate of failure to achieve a pain-free operation was 6% with spinals, 24% with epidural top-up and 18% with combined spinal-epidural. Besides the type of anaesthesia and operative urgency, other factors associated with pre-operative failure of regional anaesthesia included body mass index, no previous Caesareans, and indication for Caesarean of acute fetal distress or maternal medical condition. Inadequacy of pre-operative anaesthetic block and duration of surgery were important risk factors for intra-operative failure. For spinal anaesthesia, use of a spinal opioid was associated with less pre-operative failure. For epidural top-up anaesthesia, lower epidural top-up volume was associated with less pre-operative failure, and use of adrenaline was associated with both less pre-operative and intra-operative failure. The rate of serious adverse incidents was 1 : 126 with general anaesthesia and 1 : 501 with regional anaesthesia. [ABSTRACT FROM AUTHOR]

A PAXpress™ (Vital Signs Inc., Barnham, UK) airway device was placed in 50 adult ASA grade I and II patients undergoing elective surgery under general anaesthesia. The alignment of the PAXpress to the larynx was scored fibreoptically. The patients were then intubated blindly through the PAXpress and the adjusting manoeuvres required for successful intubation and complications of intubation observed. Insertion of the PAXpress was successful in all patients, and intubation was successful in 42 (84%) patients. Eleven patients were intubated in the neutral position, seven with a flexion manoeuvre and 24 with an extension manoeuvre. Intubation was successful in 17/20, 18/20, 6/8 and 1/2 of patients with a fibreoptic alignment score of 1, 2, 3 and 4, respectively. When the fibreoptic alignment score was between 2 and 4 intubation was achieved predominantly with the extension manoeuvre (20/30, 66%) rather than the flexion manoeuvre (1/30, 3%) or the neutral position (5/30, 16%). Blood staining was observed in 20 patients. We conclude that blind tracheal intubation through PAXpress has a moderately good success rate and a high incidence of mucosal trauma. ‘Extension’ is the predominant adjusting manoeuvre required for blind tracheal intubation, especially when the alignment of the PAXpress to the larynx is poor. [ABSTRACT FROM AUTHOR]

During neonatal resuscitation, the routine use of capnography to verify correct placement of the endotracheal tube is not an established international practice. We present four cases that illustrate the successful use of immediate capnography to verify correct tracheal tube placement even in extremely low birthweight (ELBW) prematures (< 1000 g) during resuscitation. Based on this limited experience, we reached institutional consensus among paediatricians and anaesthesiologists that capnography should become standard monitoring during all endotracheal intubations in premature babies. [ABSTRACT FROM AUTHOR]

Traditional medical decision making is unstructured and incorporates evidence haphazardly. I present a more structured approach based on decision analysis, a model that considers all relevant options and outcomes informed by evidence where appropriate. This method is useful both for planning clinical management and for analysing decisions already taken. [ABSTRACT FROM AUTHOR]

This paper evaluates the effectiveness of nasopharyngeal oxygen insufflation following preoxygenation using the four deep breath technique within 30 s, on the onset of haemoglobin desaturation during the subsequent apnoea. Thirty ASA I or II patients were randomly allocated to one of two groups. In the study group ( n = 15), pre-oxygenation was followed by insufflation of oxygen at a flow of 5 l.min−1 via a nasopharyngeal catheter commenced at the onset of apnoea. In the control group, pre-oxygenation was not followed by nasopharyngeal oxygen insufflation ( n = 15). In the control group, Spo2 fell to 95% within a mean (SD) apnoea time of 3.65 (1.15) min, whereas in the study group, Spo2 was maintained in all patients at 100% throughout the 6 min of apnoea, at which point apnoea was terminated and positive pressure ventilation commenced. We conclude that nasopharyngeal oxygen insufflation following pre-oxygenation using the four deep breath technique can delay the onset of haemoglobin desaturation for a significant period of time during the subsequent apnoea. [ABSTRACT FROM AUTHOR]

The Mental Capacity Act 2005 is due to come into force in April 2007. The Act provides a protective statutory framework for decision-making on behalf of incompetent adults, representing, in the main, a codification of the common law that had already developed in this area. For example, ‘advance decisions’ are now given formal statutory recognition. Importantly, the Act creates a new specialist ‘Court of Protection’ to manage the Act's enforcement, and an office of ‘Public Guardian’ to act as registering authority for new ‘Lasting Powers of Attorney’ and ‘court-appointed deputies’, both of which will be able to make proxy decisions about medical treatment for adult patients without capacity. There is also considerable regulation concerning the participation of adults without capacity in research. Given that their practice routinely involves the medical treatment of adults who lack legal capacity, anaesthetists and intensivists should familiarise themselves with the Act's key precepts. [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate the changes in plasma concentrations of propofol in three phases (the paleohepatic, anhepatic, and neohepatic phases) during orthotopic liver transplantation (OLT) using target-controlled infusion (TCI). Ten patients undergoing OLT without venovenous bypass were studied (age 29–53 years, weight 56–79 kg). After intubation, a non-hypnotic target concentration of propofol 0.5 µg ml−1 using a Diprifusor® pump (Zeneca Pharmaceuticals, Macclesfield, UK) was administered as a supplement anesthesia throughout the procedure. Plasma samples were obtained in each phase for propofol assay, respectively. Performance parameters for the Diprifusor® system in each phase, the percentage median performance error (MDPE), the percentage median absolute performance error (MDAPE), and the percentage median absolute constancy error (MDACE) were evaluated. In all patients, measured plasma propofol concentrations were several times higher than Diprifusor® values in each phase during the procedure. In nine patients, propofol concentrations in the anhepatic phase were higher than those in the paleohepatic or neohepatic phase ( P < 0.05). There were no significant differences between the paleohepatic and neohepatic phases. Interindividual variation of the plasma propofol concentrations was significant ( P < 0.05). Percentage median performance error of Diprifusor® in each phase, as well as MDAPE, was large (>300%) and was significantly higher in the anhepatic phase ( P < 0.01), whereas MDACE was relatively small and there was no significant difference between phases. Models used by Diprifusor® are not suitable for liver transplantation patients. A further study should be performed in order to determine all pharmacokinetic parameters of propofol in these patients. [ABSTRACT FROM AUTHOR]

Summary The Human Rights Act 1998 was incorporated into UK statutory law on October 2, 2000. The 18 Articles of the Act are likely to have a significant impact on the practice of medicine in the UK, particularly in reference to consent, disclosure of medical information and patient access to healthcare. This article examines the implications of the new legislation for anaesthetic and intensive care practice. [ABSTRACT FROM AUTHOR]

Background: The intravenous anaesthetic propofol inhibits the neuronal uptake of noradrenaline (uptake1) from the vascular sympathetic neuromuscular junction, resulting in an enhancement of the sympathetic neurotransmission. This could be important for maintenance of blood pressure during propofol anaesthesia. The aim of the present study was to determine how propofol influences the kinetics of uptake1.Methods: Isolated segments of rat femoral arteries were incubated with [3H]-noradrenaline in the presence or absence of propofol and the radioactivity taken up was measured in a scintillation counter. The uptake1 inhibitor, desipramine, was used to delineate the specific neuronal uptake.Results: Desipramine and 10 microM propofol significantly reduced the uptake in segments incubated with 0.1 microM [3H]-noradrenaline. Propofol at 1 microM and 100 microM did not affect the uptake. Non-linear regression analysis of specific uptake yielded Km 0.50 microM, Vmax 1.6 pmol mg(-1) 15 min(-1) and Hill coefficient 1.1. Propofol (1-10 microM) increased the Km value and propofol (10-100 microM) increased the Vmax value concentration-dependently, while the Hill coefficient was not affected.Conclusion: Propofol seems to have a biphasic effect on the uptake of noradrenaline in the vascular sympathetic neuromuscular junction. At lower propofol concentrations there is a decrease in the affinity of the noradrenaline transporters. The resulting uptake inhibition is counteracted at higher propofol concentrations by an increase in the efficacy of the uptake. [ABSTRACT FROM AUTHOR]

We examined the prevalence of novel acronyms in the titles of anaesthetic and related studies and the response of anaesthetists to them. We separately analysed trainee-led research projects in the UK supported by the Research and Audit Federation of Trainees (RAFT), and a 10-year cohort of papers identified using the PubMed literature search tool. We also conducted a survey of 20 anaesthetists within our institution regarding the utility and impact of titles containing acronyms, and their recall of the associated topics. Finally, we developed a scoring system for acronym accuracy and complexity, the ORigin of AcroNym letterinG Used Term AppropriateNess (ORANGUTAN) score, and measured the progression of acronym usage over the 10-year period studied. Our results show that while acronyms themselves are sometimes considered memorable, they do not aid recall of topics and are, in general, not considered helpful. There has been an increase in the prevalence of acronymic titles over 10 years, and in the complexity of acronyms used, suggesting that there is currently a selective pressure favouring the use of acronyms even if they are of limited benefit. [ABSTRACT FROM AUTHOR]

The article offers information on a study concerning bone cement implantation syndrome (BCIS) that occurs in patients undergoing cemented prosthesis insertion for hip fracture repair. Topics discussed include a hypothesis on the association of anesthesia involving tracheal intubation with a reduced prevalence of clinically apparent BCIS; and the need to develop a cost-equivalent non-cemented prostheses to provide similar re-operation and mortality rates, and pain free mobility after surgery.

Background: Regional anaesthesia may have advantages in preserving immune function. Tumor-infiltrating lymphocytes (TILs) are considered indicators of immune response in the tumor microenvironment and used as a prognostic marker in patients after cancer surgery. This study investigated the effects of combined epidural anaesthesia on the number of TILs in patients undergoing surgery for lung adenocarcinoma.Methods: Patients undergoing radical resection for primary lung cancer were randomized to receive either combined epidural-general anaesthesia (Epi-GA) or general anaesthesia (GA) in an ongoing randomized controlled trial (ChiCTR-TRC-14004136). Excised adenocarcinoma specimens from patients enrolled between 1 June 2015 and 30 November 2015 were selected for immunohistochemical staining of CD8 and FOXP3 molecules. The numbers of positive lymphocytes were counted and expressed as the number of cells per mm2 tumor area.Results: One hundred and twenty-eight patients were recruited and randomized; 64 patients were included in immunohistochemistry analysis (37 received Epi-GA vs. 27 received GA). The number of CD8+ T cells was higher in the Epi-GA group than in the GA group (median [interquartile range]: 292.8 [198.0-418.3] vs. 204.7 [131.1-305.8], P = 0.036); whereas the number of FOXP3+ T cells was less in the Epi-GA group than in the GA group (37.6 [14.7-92.3] vs. 99.8 [68.9-168.3], P < 0.001).Conclusions: For patients undergoing surgery for lung adenocarcinoma under general anesthesia, use of epidural anaesthesia increased CD8+ T cells infiltration but decreased FOXP3+ T cells accumulation in tumor tissues. Epidural anaesthesia may affect TILs in a manner that preserves immune function. [ABSTRACT FROM AUTHOR]

We analysed data from the electronic rota system CLWRota, covering 2,689,962 anaesthetic sessions between 01/01/2014 and 31/12/2015, in 91 UK Trusts, in order to investigate trainees' supervision. There were 8209 trainee attachments analysed, during which 618,695 sessions were undertaken by trainees. The number of supervised sessions per week that trainees worked varied considerably (median (IQR [range]) 2.6 (1.6-3.6 [0-10]) for all grades combined), with senior trainees more likely than junior trainees to be supervised for fewer than the three sessions per week mandated by the Royal College of Anaesthetists. The number of supervised sessions was unrelated to Trusts' size, suggesting that trainees in smaller hospitals receive the same level of supervision as in larger teaching hospitals. Analysis of a dataset of this size should be a good reflection of the delivery of anaesthesia training in the UK. [ABSTRACT FROM AUTHOR]

Serious neurological lesions such as vertebral canal haematoma are rare after obstetric regional analgesia/anaesthesia, but early detection may be crucial to avoid permanent damage. This may be hampered by the variable and sometimes prolonged recovery following 'normal' neuraxial block, such that an underlying lesion may easily be missed. These guidelines make recommendations for the monitoring of recovery from obstetric neuraxial block, and escalation should recovery be delayed or new symptoms develop, with the aim of preventing serious neurological morbidity. [ABSTRACT FROM AUTHOR]

Discusses the utilization of nitrous oxide in neuroanesthesia. Potential disadvantages of nitrous oxide in neuroanesthesia; Advantages of using nitrous oxide; Effects of nitrous oxide on the cerebral vasculature and the brain tissue; Factors involved in the estimation of cerebral perfusion pressure.

Summary Sixty adult patients undergoing minor peripheral surgery under general anaesthesia were randomly allocated to receive either the laryngeal mask airway (laryngeal mask airway; size 4 for females and size 5 for males) or the PAXpress TM (adult size), inserted by a single operator with experience of > 50 insertions of each device. The laryngeal mask airway was correctly placed on the first attempt in 27 patients (90%) compared with 20 patients (67%) when using the PA Xpress (p < 0.01). No patient required more than two attempts at insertion and there were no failures with the laryngeal mask airway, compared with four (13%) who needed three attempts and two failures (7%) with the PA Xpress (p < 0.001 and p < 0.01, respectively). Mean (SD) total placement time was shorter with the laryngeal mask airway [24.6 (3.1) s] than with the PA Xpress [35.4 (2.5) s; p < 0.01]. The most common complication was sore throat, which occurred less frequently with the laryngeal mask airway (8 patients; 26%) than with the PA Xpress (15 patients; 53.5%; p < 0.001). [ABSTRACT FROM AUTHOR]

Neuraxial anaesthesia is widely used in obstetrics and neurological complications are rare. However, when they occur, subsequent investigation and management are time-critical and correlate with the extent of neurological recovery. The Third National Audit Project recommended the implementation of guidelines in obstetric epidural management, including advice on monitoring for early signs of problems and acting upon concerns. However, no national guideline exists for postoperative management in the obstetric population. We conducted a national survey of monitoring after obstetric neuraxial blockade and the management of an abnormally prolonged block. We received responses from 112/189 (59.3%) obstetric anaesthetic leads invited to participate. We determined that post-neuraxial blockade monitoring in the UK is highly variable: only 63/112 (56.3%) respondents' units had a monitoring policy in place, although most of these did not undertake formal neurological monitoring, and a range of different monitoring methods and schedules were employed. In 12/63 (19%) local policies, the first review of neurology was performed at the standard postoperative visit the following day, and 66/112 (58.9%) units had no protocol in place to address emergency management of abnormally prolonged neuraxial blockade. Where a policy was in place, the initial recommended action and the type of imaging used were variable. [ABSTRACT FROM AUTHOR]

Breastfeeding has many health benefits for the mother and infant. Women who are breastfeeding may require anaesthesia or sedation. Concerns regarding the passage of drugs into breast milk may lead to inconsistent advice from professionals. This can sometimes result in the interruption of feeding for 24 hours or longer after anaesthesia, or expressing and discarding ('pumping and dumping') breast milk; this may contribute to early cessation of breastfeeding. However, there are data regarding the transfer of most anaesthetic drugs into breast milk. We advise that breastfeeding is acceptable to continue after anaesthesia and should be supported as soon as the woman is alert and able to feed, without the need to discard breast milk. We provide evidence-based information on the pharmacokinetics of drugs commonly used during anaesthesia so that professionals can undertake a risk-benefit discussion with the woman. We advise the development of local policies that aid logistical planning and guide staff to facilitate breastfeeding during the woman's hospital stay. [ABSTRACT FROM AUTHOR]

A reply by the author on comments on his article on ultra-low dose intrathecal anaesthesia for hip fracture surgery is presented.