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Background: Delirium is common after hip fracture surgery, affecting up to 50% of patients. The incidence of delirium may be influenced by mode and conduct of anaesthesia. We examined the effect of spinal anaesthesia (with and without sedation) compared with general anaesthesia on early outcomes following hip fracture surgery, including delirium.Methods: We used prospective data on 107,028 patients (2018 to 2019) from the National Hip Fracture Database, which records all hip fractures in patients aged 60 years and over in England, Wales and Northern Ireland. Patients were grouped by anaesthesia: general (58,727; 55%), spinal without sedation (31,484; 29%), and spinal with sedation (16,817; 16%). Outcomes (4AT score on post-operative delirium screening; mobilisation day one post-operatively; length of hospital stay; discharge destination; 30-day mortality) were compared between anaesthetic groups using multivariable logistic and linear regression models.Results: Compared with general anaesthesia, spinal anaesthesia without sedation (but not spinal with sedation) was associated with a significantly reduced risk of delirium (odds ratio (OR)=0.95, 95% confidence interval (CI)=0.92-0.98), increased likelihood of day one mobilisation (OR=1.06, CI=1.02-1.10) and return to original residence (OR=1.04, CI=1.00-1.07). Spinal without sedation (p<0.001) and spinal with sedation (p=0.001) were both associated with shorter hospital stays compared with general anaesthesia. No differences in mortality were observed between anaesthetic groups.Conclusions: Spinal and general anaesthesia achieve similar outcomes for patients with hip fracture. However, this equivalence appears to reflect improved perioperative outcomes (including a reduced risk of delirium, increased likelihood of mobilisation day one post-operatively, shorter length of hospital stay and improved likelihood of returning to previous residence on discharge) among the sub-set of patients who received spinal anaesthesia without sedation. The role and effect of sedation should be studied in future trials of hip fracture patients undergoing spinal anaesthesia. [ABSTRACT FROM AUTHOR]

Background: Days alive and out of hospital (DAOH) is a composite, patient-centred outcome measure describing a patient's postoperative recovery, encompassing hospitalisation and mortality. DAOH is the number of days not in hospital over a defined postoperative period; patients who die have DAOH of zero. The Standardising Endpoints in Perioperative Medicine (StEP) group recommended DAOH as a perioperative outcome. However, DAOH has never been validated in patients undergoing emergency laparotomy. Here, we validate DAOH after emergency laparotomy and establish the optimal duration of observation.Methods: Prospectively collected data of patients having emergency laparotomy in England (December 1, 2013-November 30, 2017) were linked to national hospital admission and mortality records for the year after surgery. We evaluated construct validity by assessing DAOH variation with known perioperative risk factors and predictive validity for 1 yr mortality using a multivariate Bayesian mixed-effects logistic regression. The optimal postoperative DAOH period (30 or 90 days) was judged on distributional and pragmatic properties.Results: We analysed 78 921 records. The median 30-day DAOH (DAOH30) was 16 (inter-quartile range [IQR], 0-22) days and the median DAOH90 was 75 (46-82) days. DAOH was shorter in the presence of known perioperative risk factors. For patients surviving the first 30 postoperative days, shorter DAOH30 was associated with higher 1-yr mortality (odds ratio=0.94; 95% credible interval, 0.94-0.94).Conclusion: DAOH is a valid, patient-centred outcome after emergency laparotomy. We recommend its use in clinical trials, quality assurance, and quality improvement, measured at 30 days as mortality heavily skews DAOH measured at 90 days and beyond. [ABSTRACT FROM AUTHOR]

John Davies Thomas (1844-1893) described a two-ounce drop-bottle for chloroform in 1872 while he was a resident medical officer at University College Hospital, London. After working as a ship's surgeon, he settled in Australia. In May 1875, Thomas presented a paper on the mortality from ether and chloroform at a meeting of the Medical Society of Victoria in Melbourne, Victoria. Surveys conducted in Europe and North America had established that the mortality from chloroform was eight to ten times higher than that from ether. At that time, chloroform was the most widely administered anaesthetic in Australia. Thomas' paper was published in The Australian Medical Journal and reprinted by the Medical Society of Victoria for distribution to hospitals in the Colony of Victoria. Later that year, Thomas moved to Adelaide, South Australia, where he may have been influential at the Adelaide Hospital in ensuring that ether was administered more often than chloroform. It does not appear that Thomas' papers on anaesthesia had a significant effect on the conduct of anaesthesia in Victoria or New South Wales. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic has heavily impacted elective and emergency surgery around the world. We aimed to confirm the incidence of perioperative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and associated mortality after surgery.Methods: Analysis of routine electronic health record data from NHS hospitals in England. We extracted data from Hospital Episode Statistics in England describing adult patients undergoing surgery between January 1, 2020 and February 28, 2021. The exposure was SARS-CoV-2 infection defined by International Classification of Diseases (ICD)-10 codes. The primary outcome measure was 90 day in-hospital mortality. Data were analysed using multivariable logistic regression adjusted for age, sex, Charlson Comorbidity Index, Index of Multiple Deprivation, presence of cancer, surgical procedure type and admission acuity. Results are presented as n (%) and odds ratios (OR) with 95% confidence intervals (CI).Results: We identified 2 666 978 patients undergoing surgery of whom 28 777 (1.1%) had SARS-CoV-2 infection. In total, 26 364 (1.0%) patients died in hospital. SARS-CoV-2 infection was associated with a much greater risk of death (SARS-CoV-2: 6153/28 777 [21.4%] vs no SARS-CoV-2: 20 211/2 638 201 [0.8%]; OR=5.7 [95% CI, 5.5-5.9]; P<0.001). Amongst patients undergoing elective surgery, 2412/1 857 586 (0.1%) had SARS-CoV-2, of whom 172/2412 (7.1%) died, compared with 1414/1 857 586 (0.1%) patients without SARS-CoV-2 (OR=25.8 [95% CI, 21.7-30.9]; P<0.001). Amongst patients undergoing emergency surgery, 22 918/582 292 (3.9%) patients had SARS-CoV-2, of whom 5752/22 918 (25.1%) died, compared with 18 060/559 374 (3.4%) patients without SARS-CoV-2 (OR=5.5 [95% CI, 5.3-5.7]; P<0.001).Conclusions: The low incidence of SARS-CoV-2 infection in NHS surgical pathways suggests current infection prevention and control policies are highly effective. However, the high mortality amongst patients with SARS-CoV-2 suggests these precautions cannot be safely relaxed. [ABSTRACT FROM AUTHOR]

Background: A significant proportion of healthcare resource has been diverted to the care of those with COVID-19. This study reports the volume of surgical activity and the number of cancelled surgical procedures during the COVID-19 pandemic.Methods: We used hospital episode statistics for all adult patients undergoing surgery between January 1, 2020 and December 31, 2020 in England and Wales. We identified surgical procedures using a previously published list of procedure codes. Procedures were stratified by urgency of surgery as defined by NHS England. We calculated the deficit of surgical activity by comparing the expected number of procedures from 2016 to 2019 with the actual number of procedures in 2020. Using a linear regression model, we calculated the expected cumulative number of cancelled procedures by December 31, 2021.Results: The total number of surgical procedures carried out in England and Wales in 2020 was 3 102 674 compared with the predicted number of 4 671 338 (95% confidence interval [CI]: 4 218 740-5 123 932). This represents a 33.6% reduction in the national volume of surgical activity. There were 763 730 emergency surgical procedures (13.4% reduction) compared with 2 338 944 elective surgical procedures (38.6% reduction). The cumulative number of cancelled or postponed procedures was 1 568 664 (95% CI: 1 116 066-2 021 258). We estimate that this will increase to 2 358 420 (95% CI: 1 667 587-3 100 808) up to December 31, 2021.Conclusions: The volume of surgical activity in England and Wales was reduced by 33.6% in 2020, resulting in more than 1.5 million cancelled operations. This deficit will continue to grow in 2021. [ABSTRACT FROM AUTHOR]

General anaesthesia for obstetric surgery has distinct characteristics that may contribute towards a higher risk of accidental awareness during general anaesthesia. The primary aim of this study was to investigate the incidence, experience and psychological implications of unintended conscious awareness during general anaesthesia in obstetric patients. From May 2017 to August 2018, 3115 consenting patients receiving general anaesthesia for obstetric surgery in 72 hospitals in England were recruited to the study. Patients received three repetitions of standardised questioning over 30 days, with responses indicating memories during general anaesthesia that were verified using interviews and record interrogation. A total of 12 patients had certain/probable or possible awareness, an incidence of 1 in 256 (95%CI 149-500) for all obstetric surgery. The incidence was 1 in 212 (95%CI 122-417) for caesarean section surgery. Distressing experiences were reported by seven (58.3%) patients, paralysis by five (41.7%) and paralysis with pain by two (16.7%). Accidental awareness occurred during induction and emergence in nine (75%) of the patients who reported awareness. Factors associated with accidental awareness during general anaesthesia were: high BMI (25-30 kg.m-2 ); low BMI (<18.5 kg.m-2 ); out-of-hours surgery; and use of ketamine or thiopental for induction. Standardised psychological impact scores at 30 days were significantly higher in awareness patients (median (IQR [range]) 15 (2.7-52.0 [2-56]) than in patients without awareness 3 (1-9 [0-64]), p = 0.010. Four patients had a provisional diagnosis of post-traumatic stress disorder. We conclude that direct postoperative questioning reveals high rates of accidental awareness during general anaesthesia for obstetric surgery, which has implications for anaesthetic practice, consent and follow-up. [ABSTRACT FROM AUTHOR]

This article describes how a personal smartphone and an online video-sharing platform were used to produce and then disseminate an interactive training resource to staff working in a contraception and sexual health service in England. This interactive training resource was one element of a larger staff training package developed to support the introduction of vapocoolant anaesthetic spray as the main method of pain relief offered to women being fitted with contraceptive subdermal implants. Contextual challenges demanded an approach to training that was highly flexible and training materials that could be made readily accessible to a large and diverse clinical team. Photographs and videos were used to convey important learning points. Three months after implementation of the initiative, a small staff survey indicated the approach had been successful and a change in practice effectively implemented. The paper shares some learning points, most pertinently, how everyday technologies can improve patient care. [ABSTRACT FROM AUTHOR]

The National Institute of Academic Anaesthesia (NIAA) was founded in 2008 to lead a UK strategy for developing academic anaesthesia. We aimed to assess the distribution of applications and quantify the academic returns of NIAA-supported research grants, as this has hitherto not been analysed. We sought data on the baseline characteristics of all grant applicants and recipients. Every grant recipient from 2008 to 2015 was contacted to ascertain the status of their supported research projects. We also examined Google Scholar, Scopus® database and InCites Journal Citation Reports for citation, author and journal metrics, respectively. In total, 495 research project applications were made, with 150 grants being awarded. Data on 121 out of 150 (80.7%) grant awards, accounting for £3.5 million, were collected, of which 91 completed studies resulted in 140 publications and 2759 citations. The median (IQR [range]) time to first or only publication was 3 (2-4 [0-9]) years. The overall cost per publication was £14,970 (£7457-£24,998 [£2212-£73,755]) and the cost per citation was £1515 (£323-£3785 [£70-£36,182]), with 1 (0-2 [0-8]) publication and 4 (0-25 [0-265]) citations resulting per grant. The impact factor of journals in which publications arose was 4.7 (2.5-6.2 [0-47.8]), with the highest impact arising from clinical and basic science studies, particularly in the fields of pain and peri-operative medicine. Grants were most frequently awarded to clinical and basic science categories of study, but in terms of specialty, critical care medicine and peri-operative medicine received the greatest number of grants. Superficially, there seemed a geographical disparity, with 123 (82%) grants being awarded to researchers in England, London receiving 48 (32%) of these. However, this was in proportion to the number of grant applications received by country or city of application, such that there was no significant difference in overall success rates. There was no significant difference in productivity in terms of publications and citations from grants awarded to each city. The 150 grants were awarded to 107 recipients (identified as the most senior applicant for each grant), 27 of whom received ≥ two grants. Recipients had a median career total of 21 (8-76 [0-254]) publications and 302 (44-1320 [0-8167]) citations, with an h-index of 8 (3-22 [0-54]). We conclude that a key determinant of grant success is simply applying. This is the first study to report the distribution and scholarly output of individual anaesthesia research grants, particularly from a collaborative body such as the NIAA, and can be used as a benchmark to further develop academic anaesthesia in the UK and beyond. [ABSTRACT FROM AUTHOR]

Background and objectives: A recent survey in the British Medical Journal reported the attitudes of orthopaedic surgeons towards the intraoperative death of a patient. Several replies to this article were from anaesthetists, who pointed out that other staff might be affected by ‘death on the table’. We designed a questionnaire survey to assess the attitudes of anaesthetists, concerning intraoperative death. Methods: Three hundred anonymized questionnaires were distributed to 12 anaesthetic departments throughout England. Results: Two hundred and fifty-one replies were received (84% response rate); 92% of respondents had experienced an intraoperative death, the majority of deaths being expected (60%) and non-preventable (77%), occurring mainly during emergency surgery (80%), particularly involving vascular surgery (41% of cases); 87% had administered another general anaesthetic in the following 24 h, most without their professional ability being compromised (77%). Conclusions: This survey shows that anaesthetists are highly likely to experience intraoperative death, the consequences of which can be extremely stressful. Although the majority of anaesthetists (71%) agreed that it was reasonable for medical staff not to take part in operations for 24 h after an intraoperative death, fewer (25%) thought the proposal practicable. Nevertheless, all departments should provide for the discontinuation of further operations, if the circumstances require it. Consideration should be given by all departments of anaesthesia towards the prevention of intraoperative death, and the management of its aftermath, including the provision of support for psychologically traumatized staff. [ABSTRACT FROM AUTHOR]

Abstract: The proportion of operations performed as day cases in England has risen from 34% for the period 1989-1990 to 65% for 1998-1999. This trend is set to continue owing to financial considerations, lack of hospital beds, patient request and established benefit. To provide a good and safe service, a well-selected patient must receive an appropriate anaesthetic for a suitable procedure that takes place in a tailored environment. This process, if done well, reduces mortality, prevents complications (e.g. prolonged stay, unanticipated admission) and increases patient satisfaction. [Copyright &y& Elsevier]

Summary The anaesthetic incident reporting scheme in Leicester has been running for 11 years and 1000 incidents have now been reported. The scheme has successfully highlighted weaknesses where a procedural change has been able to prevent repetition. It has provided advance notification of problems which could be overcome by publicity and has been a source of educational cases. The experience of this scheme supports the use of a definition which does not include blame and allows the possibility of anonymous reporting. The scheme has evolved, driven by hospital decisions on reporting risk management cases, by inclusion of the Royal College of Anaesthetists' incident categories and by progressive refinements. Summary figures are given for the different categories of incident. These show marked similarities with previous studies. [ABSTRACT FROM AUTHOR]

Summary In order to determine the current level of support provided to anaesthetists on the labour suite, a postal questionnaire was sent to the lead consultants of the 257 obstetric units in England and Wales. One hundred and ninety-five replied, a response rate of 76%. Of those who replied, only 1% of units experienced frequent delays to elective obstetric lists due to lack of an anaesthetic assistant and 141 units (72%) had a designated assistant for the labour ward. However, 58 units experienced delays waiting for an anaesthetic assistance in emergency situations (29%). One hundred and sixty-eight units (86%) had an operating department practitioner/nurse (ODP/N) resident on call for the hospital, but not exclusively for the maternity unit. In 76% of units, midwives assisted the anaesthetist when inserting regional blocks in labour. More than one-third of respondents thought that it would be appropriate to have a dedicated ODP/N resident on call for the labour ward who would also assist with labour analgesia blocks. [ABSTRACT FROM AUTHOR]

Extrahepatic biliary atresia (EHBA) is an uncommon condition presenting in the first few weeks of life. It has an incidence of 0.5–1 per 10 000 live births and is the end result of a destructive inflammatory process involving the extrahepatic biliary system of unknown aetiology occurring in utero. The net result is neonatal jaundice due to bile stasis, with subsequent hepatocellular damage and cirrhosis. In the untreated, patient death is inevitable within 2 years. Precise diagnosis (or exclusion) of EHBA in the persistently jaundiced infant must be made urgently and major surgery (hepatic portoenterostomy: Kasai procedure) carried out as soon as possible, preferably before 6–8 weeks of age. This review is concerned with anaesthesia for correction of EHBA in 50 consecutive patients and also outlines the experience gained in the largest European centre for correction of EHBA where the number of cases now approaches 500. [ABSTRACT FROM AUTHOR]

In the South Thames (West) region of the United Kingdom, during a 6-year period from 1993 to 1998, there was a significant increase in the Caesarean section rate accompanied by a significant decrease in the use of general anaesthesia for operative delivery. During this time, there were 36 failed tracheal intubations occurring in 8970 obstetric general anaesthetics (incidence 1/249). There was no significant difference in the incidence of failed tracheal intubation in each of the six years. In 24 of the 26 cases for which the patients' notes could be examined, there was either no recording of pre-operative assessment, a failure to follow an accepted protocol for failed tracheal intubation, or no follow-up. [ABSTRACT FROM AUTHOR]

Objectives: In the UK, 20% of patients with severe traumatic brain injury (TBI) receive prehospital emergency anaesthesia (PHEA). Current guidance recommends an end-tidal carbon dioxide (ETCO 2 ) of 4.0-4.5 kPa (30.0-33.8 mm Hg) to achieve a low-normal arterial partial pressure of CO 2 (PaCO 2 ), and reduce secondary brain injury. This recommendation assumes a 0.5 kPa (3.8 mm Hg) ETCO 2 -PaCO 2 gradient. However, the gradient in the acute phase of TBI is unknown. The primary aim was to report the ETCO 2 -PaCO 2 gradient of TBI patients at hospital arrival., Methods: A retrospective cohort study of adult patients with serious TBI, who received a PHEA by a prehospital critical care team in the East of England between 1 April 2015 and 31 December 2017. Linear regression was performed to test for correlation and reported as R-squared (R 2 ). A Bland-Altman plot was used to test for paired ETCO 2 and PaCO 2 agreement and reported with 95% CI. ETCO 2 -PaCO 2 gradient data were compared with a two-tailed, unpaired, t-test., Results: 107 patients were eligible for inclusion. Sixty-seven patients did not receive a PaCO 2 sample within 30 min of hospital arrival and were therefore excluded. Forty patients had complete data and were included in the final analysis; per protocol. The mean ETCO 2 -PaCO 2 gradient was 1.7 (±1.0) kPa (12.8 mm Hg), with moderate correlation (R 2 =0.23, p=0.002). The Bland-Altman bias was 1.7 (95% CI 1.4 to 2.0) kPa with upper and lower limits of agreement of 3.6 (95% CI 3.0 to 4.1) kPa and -0.2 (95% CI -0.8 to 0.3) kPa, respectively. There was no evidence of a larger gradient in more severe TBI (p=0.29). There was no significant gradient correlation in patients with a coexisting serious thoracic injury (R 2 =0.13, p=0.10), and this cohort had a larger ETCO 2 -PaCO 2 gradient, 2.0 (±1.1) kPa (15.1 mm Hg), p=0.01. Patients who underwent prehospital arterial blood sampling had an arrival PaCO 2 of 4.7 (±0.2) kPa (35.1 mm Hg)., Conclusion: There is only moderate correlation of ETCO 2 and PaCO 2 at hospital arrival in patients with serious TBI. The mean ETCO 2 -PaCO 2 gradient was 1.7 (±1.0) kPa (12.8 mm Hg). Lower ETCO 2 targets than previously recommended may be safe and appropriate, and there may be a role for prehospital PaCO 2 measurement., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The London surgeon and anaesthetist, Joseph Thomas Clover (1825-1882), and the Birmingham surgeon, Joseph Sampson Gamgee (1828-1886), are well known figures in the history of medicine. Draft letters among the surviving papers of Joseph Clover have been transcribed and reveal new information about their friendship, their financial affairs and Clover's motivation to become a full-time anaesthetist. They have also led to the discovery that Gamgee was briefly imprisoned in Warwick County Goal for debt in 1859.