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Publisher: Oxford University Press   (Total: 369 journals)

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Showing 1 - 200 of 369 Journals sorted alphabetically
Acta Biochimica et Biophysica Sinica     Hybrid Journal   (Followers: 6, SJR: 0.881, h-index: 38)
Adaptation     Hybrid Journal   (Followers: 8, SJR: 0.111, h-index: 4)
Aesthetic Surgery J.     Hybrid Journal   (Followers: 6, SJR: 1.538, h-index: 35)
African Affairs     Hybrid Journal   (Followers: 57, SJR: 1.512, h-index: 46)
Age and Ageing     Hybrid Journal   (Followers: 79, SJR: 1.611, h-index: 107)
Alcohol and Alcoholism     Hybrid Journal   (Followers: 14, SJR: 0.935, h-index: 80)
American Entomologist     Full-text available via subscription   (Followers: 5)
American Historical Review     Hybrid Journal   (Followers: 120, SJR: 0.652, h-index: 43)
American J. of Agricultural Economics     Hybrid Journal   (Followers: 41, SJR: 1.441, h-index: 77)
American J. of Epidemiology     Hybrid Journal   (Followers: 146, SJR: 3.047, h-index: 201)
American J. of Hypertension     Hybrid Journal   (Followers: 19, SJR: 1.397, h-index: 111)
American J. of Jurisprudence     Hybrid Journal   (Followers: 15)
American journal of legal history     Full-text available via subscription   (Followers: 4, SJR: 0.151, h-index: 7)
American Law and Economics Review     Hybrid Journal   (Followers: 26, SJR: 0.824, h-index: 23)
American Literary History     Hybrid Journal   (Followers: 12, SJR: 0.185, h-index: 22)
Analysis     Hybrid Journal   (Followers: 23)
Annals of Botany     Hybrid Journal   (Followers: 33, SJR: 1.912, h-index: 124)
Annals of Occupational Hygiene     Hybrid Journal   (Followers: 24, SJR: 0.837, h-index: 57)
Annals of Oncology     Hybrid Journal   (Followers: 48, SJR: 4.362, h-index: 173)
Annals of the Entomological Society of America     Full-text available via subscription   (Followers: 9, SJR: 0.642, h-index: 53)
Annals of Work Exposures and Health     Hybrid Journal  
AoB Plants     Open Access   (Followers: 4, SJR: 0.78, h-index: 10)
Applied Economic Perspectives and Policy     Hybrid Journal   (Followers: 18, SJR: 0.884, h-index: 31)
Applied Linguistics     Hybrid Journal   (Followers: 51, SJR: 1.749, h-index: 63)
Applied Mathematics Research eXpress     Hybrid Journal   (Followers: 1, SJR: 0.779, h-index: 11)
Arbitration Intl.     Full-text available via subscription   (Followers: 19)
Arbitration Law Reports and Review     Hybrid Journal   (Followers: 12)
Archives of Clinical Neuropsychology     Hybrid Journal   (Followers: 25, SJR: 0.96, h-index: 71)
Aristotelian Society Supplementary Volume     Hybrid Journal   (Followers: 2, SJR: 0.102, h-index: 20)
Arthropod Management Tests     Hybrid Journal   (Followers: 2)
Astronomy & Geophysics     Hybrid Journal   (Followers: 46, SJR: 0.144, h-index: 15)
Behavioral Ecology     Hybrid Journal   (Followers: 47, SJR: 1.698, h-index: 92)
Bioinformatics     Hybrid Journal   (Followers: 222, SJR: 4.643, h-index: 271)
Biology Methods and Protocols     Hybrid Journal  
Biology of Reproduction     Full-text available via subscription   (Followers: 10, SJR: 1.646, h-index: 149)
Biometrika     Hybrid Journal   (Followers: 18, SJR: 2.801, h-index: 90)
BioScience     Hybrid Journal   (Followers: 28, SJR: 2.374, h-index: 154)
Bioscience Horizons : The National Undergraduate Research J.     Open Access   (Followers: 1, SJR: 0.213, h-index: 9)
Biostatistics     Hybrid Journal   (Followers: 15, SJR: 1.955, h-index: 55)
BJA : British J. of Anaesthesia     Hybrid Journal   (Followers: 132, SJR: 2.314, h-index: 133)
BJA Education     Hybrid Journal   (Followers: 65, SJR: 0.272, h-index: 20)
Brain     Hybrid Journal   (Followers: 61, SJR: 6.097, h-index: 264)
Briefings in Bioinformatics     Hybrid Journal   (Followers: 43, SJR: 4.086, h-index: 73)
Briefings in Functional Genomics     Hybrid Journal   (Followers: 4, SJR: 1.771, h-index: 50)
British J. for the Philosophy of Science     Hybrid Journal   (Followers: 32, SJR: 1.267, h-index: 38)
British J. of Aesthetics     Hybrid Journal   (Followers: 24, SJR: 0.217, h-index: 18)
British J. of Criminology     Hybrid Journal   (Followers: 489, SJR: 1.373, h-index: 62)
British J. of Social Work     Hybrid Journal   (Followers: 77, SJR: 0.771, h-index: 53)
British Medical Bulletin     Hybrid Journal   (Followers: 7, SJR: 1.391, h-index: 84)
British Yearbook of Intl. Law     Hybrid Journal   (Followers: 26)
Bulletin of the London Mathematical Society     Hybrid Journal   (Followers: 3, SJR: 1.474, h-index: 31)
Cambridge J. of Economics     Hybrid Journal   (Followers: 55, SJR: 0.957, h-index: 59)
Cambridge J. of Regions, Economy and Society     Hybrid Journal   (Followers: 9, SJR: 1.067, h-index: 22)
Cambridge Quarterly     Hybrid Journal   (Followers: 10, SJR: 0.1, h-index: 7)
Capital Markets Law J.     Hybrid Journal  
Carcinogenesis     Hybrid Journal   (Followers: 2, SJR: 2.439, h-index: 167)
Cardiovascular Research     Hybrid Journal   (Followers: 11, SJR: 2.897, h-index: 175)
Cerebral Cortex     Hybrid Journal   (Followers: 37, SJR: 4.827, h-index: 192)
CESifo Economic Studies     Hybrid Journal   (Followers: 15, SJR: 0.501, h-index: 19)
Chemical Senses     Hybrid Journal   (Followers: 1, SJR: 1.436, h-index: 76)
Children and Schools     Hybrid Journal   (Followers: 5, SJR: 0.211, h-index: 18)
Chinese J. of Comparative Law     Hybrid Journal   (Followers: 3)
Chinese J. of Intl. Law     Hybrid Journal   (Followers: 19, SJR: 0.737, h-index: 11)
Chinese J. of Intl. Politics     Hybrid Journal   (Followers: 8, SJR: 1.238, h-index: 15)
Christian Bioethics: Non-Ecumenical Studies in Medical Morality     Hybrid Journal   (Followers: 11, SJR: 0.191, h-index: 8)
Classical Receptions J.     Hybrid Journal   (Followers: 17, SJR: 0.1, h-index: 3)
Clinical Infectious Diseases     Hybrid Journal   (Followers: 58, SJR: 4.742, h-index: 261)
Clinical Kidney J.     Open Access   (Followers: 4, SJR: 0.338, h-index: 19)
Community Development J.     Hybrid Journal   (Followers: 23, SJR: 0.47, h-index: 28)
Computer J.     Hybrid Journal   (Followers: 8, SJR: 0.371, h-index: 47)
Conservation Physiology     Open Access   (Followers: 1)
Contemporary Women's Writing     Hybrid Journal   (Followers: 11, SJR: 0.111, h-index: 3)
Contributions to Political Economy     Hybrid Journal   (Followers: 6, SJR: 0.313, h-index: 10)
Critical Values     Full-text available via subscription  
Current Legal Problems     Hybrid Journal   (Followers: 25)
Current Zoology     Full-text available via subscription   (SJR: 0.999, h-index: 20)
Database : The J. of Biological Databases and Curation     Open Access   (Followers: 11, SJR: 1.068, h-index: 24)
Digital Scholarship in the Humanities     Hybrid Journal   (Followers: 12)
Diplomatic History     Hybrid Journal   (Followers: 18, SJR: 0.296, h-index: 22)
DNA Research     Open Access   (Followers: 4, SJR: 2.42, h-index: 77)
Dynamics and Statistics of the Climate System     Open Access   (Followers: 2)
Early Music     Hybrid Journal   (Followers: 13, SJR: 0.124, h-index: 11)
Economic Policy     Hybrid Journal   (Followers: 47, SJR: 2.052, h-index: 52)
ELT J.     Hybrid Journal   (Followers: 25, SJR: 1.26, h-index: 23)
English Historical Review     Hybrid Journal   (Followers: 45, SJR: 0.311, h-index: 10)
English: J. of the English Association     Hybrid Journal   (Followers: 12, SJR: 0.144, h-index: 3)
Environmental Entomology     Full-text available via subscription   (Followers: 11, SJR: 0.791, h-index: 66)
Environmental Epigenetics     Open Access   (Followers: 1)
Environmental History     Hybrid Journal   (Followers: 25, SJR: 0.197, h-index: 25)
EP-Europace     Hybrid Journal   (Followers: 1, SJR: 2.201, h-index: 71)
Epidemiologic Reviews     Hybrid Journal   (Followers: 9, SJR: 3.917, h-index: 81)
ESHRE Monographs     Hybrid Journal  
Essays in Criticism     Hybrid Journal   (Followers: 15, SJR: 0.1, h-index: 6)
European Heart J.     Hybrid Journal   (Followers: 46, SJR: 6.997, h-index: 227)
European Heart J. - Cardiovascular Imaging     Hybrid Journal   (Followers: 9, SJR: 2.044, h-index: 58)
European Heart J. - Cardiovascular Pharmacotherapy     Full-text available via subscription   (Followers: 1)
European Heart J. - Quality of Care and Clinical Outcomes     Hybrid Journal  
European Heart J. Supplements     Hybrid Journal   (Followers: 8, SJR: 0.152, h-index: 31)
European J. of Cardio-Thoracic Surgery     Hybrid Journal   (Followers: 7, SJR: 1.568, h-index: 104)
European J. of Intl. Law     Hybrid Journal   (Followers: 141, SJR: 0.722, h-index: 38)
European J. of Orthodontics     Hybrid Journal   (Followers: 4, SJR: 1.09, h-index: 60)
European J. of Public Health     Hybrid Journal   (Followers: 22, SJR: 1.284, h-index: 64)
European Review of Agricultural Economics     Hybrid Journal   (Followers: 12, SJR: 1.549, h-index: 42)
European Review of Economic History     Hybrid Journal   (Followers: 25, SJR: 0.628, h-index: 24)
European Sociological Review     Hybrid Journal   (Followers: 37, SJR: 2.061, h-index: 53)
Evolution, Medicine, and Public Health     Open Access   (Followers: 11)
Family Practice     Hybrid Journal   (Followers: 13, SJR: 1.048, h-index: 77)
Fems Microbiology Ecology     Hybrid Journal   (Followers: 8, SJR: 1.687, h-index: 115)
Fems Microbiology Letters     Hybrid Journal   (Followers: 19, SJR: 1.126, h-index: 118)
Fems Microbiology Reviews     Hybrid Journal   (Followers: 24, SJR: 7.587, h-index: 150)
Fems Yeast Research     Hybrid Journal   (Followers: 13, SJR: 1.213, h-index: 66)
Foreign Policy Analysis     Hybrid Journal   (Followers: 21, SJR: 0.859, h-index: 10)
Forestry: An Intl. J. of Forest Research     Hybrid Journal   (Followers: 17, SJR: 0.903, h-index: 44)
Forum for Modern Language Studies     Hybrid Journal   (Followers: 6, SJR: 0.108, h-index: 6)
French History     Hybrid Journal   (Followers: 29, SJR: 0.123, h-index: 10)
French Studies     Hybrid Journal   (Followers: 19, SJR: 0.119, h-index: 7)
French Studies Bulletin     Hybrid Journal   (Followers: 10, SJR: 0.102, h-index: 3)
Gastroenterology Report     Open Access   (Followers: 2)
Genome Biology and Evolution     Open Access   (Followers: 10, SJR: 3.22, h-index: 39)
Geophysical J. Intl.     Hybrid Journal   (Followers: 31, SJR: 1.839, h-index: 119)
German History     Hybrid Journal   (Followers: 24, SJR: 0.437, h-index: 13)
GigaScience     Open Access   (Followers: 3)
Global Summitry     Hybrid Journal  
Glycobiology     Hybrid Journal   (Followers: 14, SJR: 1.692, h-index: 101)
Health and Social Work     Hybrid Journal   (Followers: 46, SJR: 0.505, h-index: 40)
Health Education Research     Hybrid Journal   (Followers: 12, SJR: 0.814, h-index: 80)
Health Policy and Planning     Hybrid Journal   (Followers: 21, SJR: 1.628, h-index: 66)
Health Promotion Intl.     Hybrid Journal   (Followers: 19, SJR: 0.664, h-index: 60)
History Workshop J.     Hybrid Journal   (Followers: 25, SJR: 0.313, h-index: 20)
Holocaust and Genocide Studies     Hybrid Journal   (Followers: 22, SJR: 0.115, h-index: 13)
Human Molecular Genetics     Hybrid Journal   (Followers: 10, SJR: 4.288, h-index: 233)
Human Reproduction     Hybrid Journal   (Followers: 74, SJR: 2.271, h-index: 179)
Human Reproduction Update     Hybrid Journal   (Followers: 15, SJR: 4.678, h-index: 128)
Human Rights Law Review     Hybrid Journal   (Followers: 60, SJR: 0.7, h-index: 21)
ICES J. of Marine Science: J. du Conseil     Hybrid Journal   (Followers: 53, SJR: 1.233, h-index: 88)
ICSID Review     Hybrid Journal   (Followers: 8)
ILAR J.     Hybrid Journal   (Followers: 1, SJR: 1.099, h-index: 51)
IMA J. of Applied Mathematics     Hybrid Journal   (SJR: 0.329, h-index: 26)
IMA J. of Management Mathematics     Hybrid Journal   (Followers: 2, SJR: 0.351, h-index: 20)
IMA J. of Mathematical Control and Information     Hybrid Journal   (Followers: 2, SJR: 0.661, h-index: 28)
IMA J. of Numerical Analysis - advance access     Hybrid Journal   (SJR: 2.032, h-index: 44)
Industrial and Corporate Change     Hybrid Journal   (Followers: 8, SJR: 1.37, h-index: 81)
Industrial Law J.     Hybrid Journal   (Followers: 29, SJR: 0.184, h-index: 15)
Information and Inference     Free  
Integrative and Comparative Biology     Hybrid Journal   (Followers: 7, SJR: 1.911, h-index: 90)
Interacting with Computers     Hybrid Journal   (Followers: 10, SJR: 0.529, h-index: 59)
Interactive CardioVascular and Thoracic Surgery     Hybrid Journal   (Followers: 4, SJR: 0.743, h-index: 35)
Intl. Data Privacy Law     Hybrid Journal   (Followers: 27)
Intl. Health     Hybrid Journal   (Followers: 4, SJR: 0.835, h-index: 15)
Intl. Immunology     Hybrid Journal   (Followers: 4, SJR: 1.613, h-index: 111)
Intl. J. for Quality in Health Care     Hybrid Journal   (Followers: 32, SJR: 1.593, h-index: 69)
Intl. J. of Constitutional Law     Hybrid Journal   (Followers: 50, SJR: 0.613, h-index: 19)
Intl. J. of Epidemiology     Hybrid Journal   (Followers: 115, SJR: 4.381, h-index: 145)
Intl. J. of Law and Information Technology     Hybrid Journal   (Followers: 3, SJR: 0.247, h-index: 8)
Intl. J. of Law, Policy and the Family     Hybrid Journal   (Followers: 18, SJR: 0.307, h-index: 15)
Intl. J. of Lexicography     Hybrid Journal   (Followers: 8, SJR: 0.404, h-index: 18)
Intl. J. of Low-Carbon Technologies     Open Access   (Followers: 1, SJR: 0.457, h-index: 12)
Intl. J. of Neuropsychopharmacology     Open Access   (Followers: 4, SJR: 1.69, h-index: 79)
Intl. J. of Public Opinion Research     Hybrid Journal   (Followers: 8, SJR: 0.906, h-index: 33)
Intl. J. of Refugee Law     Hybrid Journal   (Followers: 34, SJR: 0.231, h-index: 21)
Intl. J. of Transitional Justice     Hybrid Journal   (Followers: 13, SJR: 0.833, h-index: 12)
Intl. Mathematics Research Notices     Hybrid Journal   (Followers: 1, SJR: 2.052, h-index: 42)
Intl. Mathematics Research Surveys - advance access     Hybrid Journal  
Intl. Political Sociology     Hybrid Journal   (Followers: 24, SJR: 1.339, h-index: 19)
Intl. Relations of the Asia-Pacific     Hybrid Journal   (Followers: 17, SJR: 0.539, h-index: 17)
Intl. Studies Perspectives     Hybrid Journal   (Followers: 7, SJR: 0.998, h-index: 28)
Intl. Studies Quarterly     Hybrid Journal   (Followers: 33, SJR: 2.184, h-index: 68)
Intl. Studies Review     Hybrid Journal   (Followers: 17, SJR: 0.783, h-index: 38)
ISLE: Interdisciplinary Studies in Literature and Environment     Hybrid Journal   (Followers: 1, SJR: 0.155, h-index: 4)
ITNOW     Hybrid Journal   (Followers: 2, SJR: 0.102, h-index: 4)
J. of African Economies     Hybrid Journal   (Followers: 15, SJR: 0.647, h-index: 30)
J. of American History     Hybrid Journal   (Followers: 38, SJR: 0.286, h-index: 34)
J. of Analytical Toxicology     Hybrid Journal   (Followers: 13, SJR: 1.038, h-index: 60)
J. of Antimicrobial Chemotherapy     Hybrid Journal   (Followers: 20, SJR: 2.157, h-index: 149)
J. of Antitrust Enforcement     Hybrid Journal   (Followers: 1)
J. of Applied Poultry Research     Hybrid Journal   (Followers: 3, SJR: 0.563, h-index: 43)
J. of Biochemistry     Hybrid Journal   (Followers: 43, SJR: 1.341, h-index: 96)
J. of Chromatographic Science     Hybrid Journal   (Followers: 18, SJR: 0.448, h-index: 42)
J. of Church and State     Hybrid Journal   (Followers: 11, SJR: 0.167, h-index: 11)
J. of Competition Law and Economics     Hybrid Journal   (Followers: 34, SJR: 0.442, h-index: 16)
J. of Complex Networks     Hybrid Journal   (Followers: 1, SJR: 1.165, h-index: 5)
J. of Conflict and Security Law     Hybrid Journal   (Followers: 11, SJR: 0.196, h-index: 15)
J. of Consumer Research     Full-text available via subscription   (Followers: 38, SJR: 4.896, h-index: 121)
J. of Crohn's and Colitis     Hybrid Journal   (Followers: 9, SJR: 1.543, h-index: 37)
J. of Cybersecurity     Hybrid Journal   (Followers: 2)
J. of Deaf Studies and Deaf Education     Hybrid Journal   (Followers: 8, SJR: 0.69, h-index: 36)
J. of Design History     Hybrid Journal   (Followers: 15, SJR: 0.166, h-index: 14)
J. of Economic Entomology     Full-text available via subscription   (Followers: 6, SJR: 0.894, h-index: 76)
J. of Economic Geography     Hybrid Journal   (Followers: 32, SJR: 2.909, h-index: 69)
J. of Environmental Law     Hybrid Journal   (Followers: 25, SJR: 0.457, h-index: 20)
J. of European Competition Law & Practice     Hybrid Journal   (Followers: 19)
J. of Experimental Botany     Hybrid Journal   (Followers: 13, SJR: 2.798, h-index: 163)
J. of Financial Econometrics     Hybrid Journal   (Followers: 21, SJR: 1.314, h-index: 27)
J. of Global Security Studies     Hybrid Journal   (Followers: 2)
J. of Heredity     Hybrid Journal   (Followers: 3, SJR: 1.024, h-index: 76)
J. of Hindu Studies     Hybrid Journal   (Followers: 7, SJR: 0.186, h-index: 3)
J. of Hip Preservation Surgery     Open Access  
J. of Human Rights Practice     Hybrid Journal   (Followers: 21, SJR: 0.399, h-index: 10)
J. of Infectious Diseases     Hybrid Journal   (Followers: 39, SJR: 4, h-index: 209)
J. of Insect Science     Open Access   (Followers: 9, SJR: 0.388, h-index: 31)

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Journal Cover BJA : British Journal of Anaesthesia
  [SJR: 2.314]   [H-I: 133]   [132 followers]  Follow
   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 0007-0912 - ISSN (Online) 1471-6771
   Published by Oxford University Press Homepage  [369 journals]
  • Revision Notes in Intensive Care Medicine . S Gillon, C Wright, C Knott, M
           McPhail and L Camporota.
    • Authors: Beed M.
      Abstract: Revision Notes in Intensive Care Medicine. GillonS, WrightC, KnottC, McPhailM and CamporotaL. 2016. Published by Oxford University Press. Pp. 480 Price £49.99. ISBN: 978-0-19-875461-9.
      PubDate: 2017-02-16
  • Drugs in Anaesthesia and Intensive Care . E. Scarth and S. Smith
           (editors). 5th Edn.
    • Authors: Tempe DK.
      Abstract: Drugs in Anaesthesia and Intensive Care. ScarthE. and SmithS. (editors). 5th Edn. Published by Oxford University Press. Pp. 427. Price $59.95. ISBN 978-0-19-876881-4
      PubDate: 2017-02-16
  • 25 years: looking back to going forward
    • Authors: Langton JA; Brennan LL.
      Abstract: 2017 is a momentous year for the Royal College of Anaesthetists (RCoA) as we celebrate the 25th Anniversary of receiving our Royal Charter. The past quarter of a century has seen anaesthesia make tremendous advances, many of which were first documented in the pages of the British Journal of Anaesthesia (BJA). Interacting with more than two-thirds of hospital in-patients,1 anaesthesia is now the UK’s largest single secondary care speciality supported by a College, that has quadrupled in size with growing political influence to match. Anaesthetists are vital to the delivery of safe, high quality patient care and we know from a recent survey that our efforts are highly valued by patients.2
      PubDate: 2017-02-16
  • Stranger danger—mortality after transfusions
    • Authors: Webster NR.
      Abstract: In the 1960s and 1970s hepatitis as a result of blood transfusion was relatively common, but at a recent talk on recent advances in the treatment of hepatitis I was surprised to learn just how high the mortality was after blood transfusion during this time period. In the USA an epidemiological study reported that 6% of nearly 30,000 patients with viral hepatitis had received one or more transfusions of blood or blood product within two weeks to six months before the onset of symptoms and the mortality in these patients was around 10%.1 In the yrs to come there were also new and emerging viruses and prions to add to the problem. On searching the more recent literature however, there are many reports which still highlight higher mortality in patients who have had blood transfusions. Two immediate questions spring to mind: 1. Are there problems associated with the transfusion itself or 2. Does the original need for a transfusion result in increased mortality'
      PubDate: 2017-02-16
  • Facing acute hypoxia: from the mountains to critical care medicine
    • Authors: Berger MM; Grocott MW.
      Abstract: It was not until 1978 that, after many unsuccessful attempts, the summit of Mount Everest (8850 m) was reached by climbers breathing only ambient air. This challenge was first accomplished by Peter Habeler and Reinhold Messner. Their intriguing success renewed interest in high-altitude physiology and medicine, especially because in the preceding 60 yr a number of physiologists and high-altitude climbers had predicted that it would never be possible to conquer this peak without the aid of supplemental oxygen. This view was based on the assumption that the inspired oxygen partial pressure (PO2) of ∼43 mm Hg1 at the summit of Mount Everest was at, or even below, the limit of human tolerance to hypoxia at rest, leaving no oxygen available for physical work.
      PubDate: 2017-02-16
  • Medical research and the ethics of medical treatments: disability-free
    • Authors: Lönnqvist PA.
      Abstract: Interest in relevant patient-centred outcomes, instead of surrogate outcomes, continues to increase, and for good reason. An example in the setting of anaesthesia and intensive care is that therapeutic measures that improve oxygenation in the setting of acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) (“blood gas cosmetics”), do not translate into improved survival as might be expected. Other measures (e.g. ICU mortality or even 30-day post-ICU discharge survival) do not really reflect what many medical staff and laypeople believe represents valid outcome parameters. Using surrogate end-points or mortality rates can also lead to spurious results when it comes to clinical research.
      PubDate: 2017-02-16
  • Remote ischaemic preconditioning: an intervention for anaesthetists'
    • Authors: Mouton RR; Soar JJ.
      Abstract: The great tragedy of science—the slaying of a beautiful hypothesis by an ugly fact.Thomas Huxley
      PubDate: 2017-02-16
  • Think drink! Current fasting guidelines are outdated
    • Authors: Thomas MM; Engelhardt TT.
      Abstract: Ever since the formative work of Curtis Mendelson1 in peripartum women, the need for preoperative fasting has been propagated to help to minimize the risk of pulmonary aspiration of gastric content during anaesthesia. That early work described the catastrophic consequences of particulate matter aspiration but also reported all those who aspirated non-particulate matter (40 patients out of 44 016) survived. This is notable considering the lack of sophisticated postoperative monitoring and care more than seven decades ago. Fasting guidelines and recommendations have been produced as a consequence of this early work, with the majority advocating a 6 h fast for solids, 4 h for breast milk, and 2 h for clear fluids for elective surgery in both adults and children,2 3 the so-called 6–4–2 rule. Uncertainty remains for trauma patients, whereas obstetric patients are considered to have a full stomach.
      PubDate: 2017-02-16
  • Tranexamic acid: still far to go
    • Authors: Goobie SM.
      Abstract: Tranexamic acid (TXA), a synthetic lysine analogue, is a potent antifibrinolytic agent that inhibits both plasminogen and plasmin. Tranexamic acid gained worldwide recognition in the 2010 Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage (CRASH- 2) trial, a multinational randomized placebo-controlled trial of TXA in adult trauma patients with significant bleeding.1 TXA significantly reduced the risk of death as a result of bleeding by about a sixth and reduced the risk of all cause mortality by about a tenth. In 2011, TXA was recommended by the World Health Organization as an essential medicine for the treatment of acute bleeding in patients with trauma, cardiopulmonary bypass or postpartum haemorrhage.2 The 2013 European guidelines recommended TXA in the prophylactic treatment of bleeding in major surgery to reduce perioperative blood loss and allogeneic blood transfusion.3 The 2015 ASAs practice guidelines for perioperative blood management recommended consideration of TXA in surgical patients with excessive bleeding.4 Tranexamic acid has consistently been shown to play an important role in blood conservation and to reduce perioperative blood loss in various settings, from trauma to cardiac, orthopaedic, neurological, craniofacial, obstetrical and gynaecological surgery.5
      PubDate: 2017-02-16
  • Meta-analyses of Bland–Altman-style cardiac output validation studies:
           good, but do they provide answers to all our questions'
    • Authors: Critchley LH.
      Abstract: No one would deny the need for safe, reliable, and non-invasive cardiac output (CO) monitoring in anaesthesia and acute medicine. Measuring CO, or better still stroke volume (SV), adds a further dimension to haemodynamic monitoring as it completes the circulatory equation BP=CO×PR, where BP is blood pressure, PR is peripheral resistance, CO=SV×HR, and HR is heart rate. Clinical use of the pulmonary artery thermodilution catheter has been in decline since the 1990s,1 and newer, less invasive technologies have been developed that still need clinical evaluation.2 Since its first description in 1986, the Bland–Altman method of determining accuracy and precision against a reference method, such as thermodilution, has become the gold standard in validation statistics.3 In this month’s edition of the Journal, one finds a ‘state-of-the-art’ systematic review and meta-analysis by Joosten and colleagues4 that focuses on totally non-invasive and continuous CO monitoring technology and analyses published data extracted from Bland–Altman-style CO validation studies. It is one of a number of recent reviews published by this group that uses ‘state-of-the-art’ literature searches, paper selection, and statistical analysis technics to determine the overall accuracy and precision of the monitoring methods they review.5–7
      PubDate: 2017-02-16
  • Clinical decision versus thromboelastometry based fresh frozen plasma
           transfusion in cardiac surgery
    • Authors: Meesters MI; Koning NJ, Romijn JA, et al.
      Abstract: Editor—The prompt decision to transfuse fresh frozen plasma (FFP) after cardiopulmonary bypass (CPB) is frequently based on clinical signs of coagulopathy, patient characteristics, duration of cardiopulmonary bypass and experience of the surgical team, all united in the clinical view of the anaesthetist.1,2 We investigated whether FFP transfusion based on this clinical judgment in the absence of haemostatic test results was appropriate when retrospectively validated by a thromboelastometry-based algorithm.
      PubDate: 2017-02-16
  • Antagonism of moderate neuromuscular block with sugammadex versus
    • Authors: Muggleton EE; Muggleton TT.
      Abstract: Editor—Boon and colleagues1 conclude in their study that “the selection of antagonistic agent has a significant effect on postoperative respiratory conditions”. We suggest, however, that what they have demonstrated is that neuromuscular monitoring is essential in clinical practice and that patients should not be extubated before adequate recovery of neuromuscular function. Residual neuromuscular block has been demonstrated to interfere with pulmonary dynamics and to impair the ventilatory response to hypoxia.2
      PubDate: 2017-02-16
  • Sugammadex leads to improved oxygen saturations in recovery
    • Authors: Sethi RR; Sethi SS, Beech AA.
      Abstract: Editor—We read with interest the paper by Boon and colleagues1 comparing the effect of antagonism of moderate grade of neuromuscular block (NMB) with neostigmine vs sugammadex on oxygen saturations after extubation in ‘blinded neuromuscular block conditions’. The incidence of residual NMB is around 20–50% and can pose a threat to patient safety and contribute to overall health care costs.2 The train of four (TOF) method of peripheral nerve stimulation, introduced in the 1970s, used a previously agreed threshold ratio of > 0.7 derived from studies aimed to establish an “acceptable level of recovery”. This ratio was derived based on clinical signs such as tongue protrusion, eye opening, ability to cough and attain vital capacity breaths. Currently, residual NMB is defined as a TOF ratio 
      PubDate: 2017-02-16
  • Location of persistent pharyngeal pain after general anaesthesia
    • Authors: Konishi YY; Komasawa NN, Sano HH, et al.
      Abstract: Editor—Tracheal intubation can induce postoperative sore throat (POST) and/or hoarseness after general anaesthesia as a result of mucosal injury in the trachea or vocal cord injury.1 Various reports suggest that POST, for the most part, improves by the next morning after extubation. However, a non-negligible number of patients suffer from persistent POST after postoperative day one. POST does not always occur in the same region of the pharyngeal and laryngeal anatomy. In other words, the definition of POST is vague from an anatomical perspective.
      PubDate: 2017-02-16
  • Vision-guided placement of supraglottic airway device prevents airway
           obstruction: a prospective audit
    • Authors: Van Zundert AJ; Gatt SP, Kumar CM, et al.
      Abstract: Editor—It is well established that blind insertion of Supraglottic Airway Devices (SADs) often results in malposition or suboptimal position within the desired segment of oro/hypopharynx.1–6 An ideal or optimally-positioned, correct-sized SAD should (i) sit snugly within in the hypopharynx with (ii) its distal tip abutting (comprehensively blocking) the oesophagus, (iii) with the tip of the epiglottis aligned with the rim of the proximal cuff of a correctly inflated mask and (iv) epiglottis resting on the outer side of the cuff such that (v) the SAD-tube opening opposes the glottic opening and the entrance to the trachea.7 Sub-optimal positioning of SADs is known to occur as a result of: cuff hyperinflation/hypoinflation; too small- or too large-size SAD; and too deeply or too superficially-positioned SADs. A well-sealed entrance to the trachea is expected to facilitate spontaneous breathing or mechanical ventilation. This prospective audit aimed to assess the extent of suboptimal positioning of SADs seen under direct vision and to apply measures to correct malpositioned SADs to facilitate an unobstructed airway.
      PubDate: 2017-02-16
  • Preoxygenation using the Optiflow™ system
    • Authors: Ang KS; Green AA, Ramaswamy KK, et al.
      Abstract: Editor—The use of transnasal humidified oxygen delivery system (Optiflow™, Fisher and Paykel Healthcare Limited, Auckland, New Zealand) has been described to provide preoxygenation and to extend the apnoea time of patients with difficult airways in the THRIVE study.1 The purpose of preoxygenation is to increase alveolar oxygen fraction,2 which is inferred by the measurement of end tidal oxygen concentration (EtO2). We conducted an observational pilot study to evaluate the performance of the Optiflow™ system in preoxygenating patients.
      PubDate: 2017-02-16
  • Acute postoperative hypoxemic respiratory failure as a result of
           Chilaiditi’s syndrome: contribution of high flow oxygen through nasal
    • Authors: Poignant SS; Moënne-loccoz JJ, Cohen BB, et al.
      Abstract: Editor—A 56 yr old man was admitted in our intensive care unit for acute hypoxaemic respiratory failure after orthopaedic surgery for an infected hygroma of the right knee.
      PubDate: 2017-02-16
  • Human factors can’t intubate can’t oxygenate (CICO) bundle is more
           important than needle versus scalpel debate
    • Authors: Booth AG; Vidhani KK.
      Abstract: Editor—We believe best practice for front-of-neck access will be achieved when using human factors engineering principles, optimizing the interaction between people (most skilled airway manager available) and clinical decision-making (using Help to overcome cognitive bias and perform the task) in an environment using standardized equipment following a practised algorithm regardless of the technical approach taken.1
      PubDate: 2017-02-16
  • Front-of-neck access: a practical viewpoint, from experience
    • Authors: Henderson MA.
      Abstract: Editor—The cogent editorial by Timmermann and colleagues1 deeply resonated with me. As an anaesthetic core trainee, I was called upon to obtain front-of-neck access in an emergency, using a scalpel and Mini-Trach kit (Portex, Smiths Medical, USA). The scenario was a cardiac arrest attributable to anaphylaxis and upper airway obstruction in the Emergency Department of a District General Hospital. Despite receiving excellent airway teaching and previous practice in simulation, I was psychologically unprepared for the practicalities. With no surgical training, it was unlike any task that I had previously performed, and I had no confidence in performing it proficiently. I was surprised by the bleeding, which inevitably occurred, and when the procedure proved to be difficult, I had no real-life experience with which to troubleshoot.
      PubDate: 2017-02-16
  • When are ‘human factors’ not ‘human factors’ in can't intubate
           can't oxygenate scenarios' When they are ‘human’ factors
    • Authors: Moneypenny MJ.
      Abstract: Editor—Timmermann and colleagues1 raise valid concerns about the recommendation by the Difficult Airway Society (DAS) to use a scalpel cricothyroidotomy as the sole technique in a can’t intubate can’t oxygenate (CICO) scenario.2 However, their argument falls short on a number of levels. First, although the Fourth National Audit Project (NAP4) has its drawbacks, it is the best snapshot ever created of current anaesthetic practice with respect to complications of airway management.3 NAP4 tells us what is happening now, in the real world, not in a hypothetical reality where ‘dedicated training programme(s)’ have been instituted. In the real world, anaesthetists cause morbidity and mortality with a cannula technique. In addition, advocating cannula use because it can be practised on real patients is to obfuscate the issue. Awake fibreoptic intubations, which in some institutions are relatively rare themselves, do not need transtracheal blocks because the airway can be anaesthetized with less invasive means. Nor is the pre-emptive use of cannula cricothyroidotomy likely to catch on. Second, a ‘human factors’ approach to the CICO problem needs to move beyond the human/anaesthetist viewpoint and look at the wider picture. The authors concentrate on the anaesthetic practitioner in terms of familiarity, training, and pre-emptive use. Human factors is the science of improving human performance and well-being by examining all the effectors of human performance. A ‘scalpel only’ technique, when viewed using a human factors approach, has a number of benefits, as follows. Task. Equipment can be minimized and standardized, with no need to decide between ‘the Enk Oxygen Flow Modulator (Cook Medical, Bloomington, IN, USA), the Rapid-O2 (Meditech Systems Ltd, Shaftesbury, UK), or the Ventrain (Dolphys Medical BV, Eindhoven, The Netherlands)’.Person. In the crisis, there is no need for the anaesthetist to waste time making a decision between cannula and surgical cricothyroidotomy. Precious training time can be focused on the one technique.Team. In the crisis, the team will know what equipment to get. There is no need to wonder whether the anaesthetist has chosen the correct technique for this patient. Precious team training time can be focused on the one techniqueOrganization. The organization can use implementation of the DAS guidelines as part of its governance procedures. The anaesthetic department can use the DAS guidelines to make a case for equipment and training.Socio-cultural. The adoption of a sole technique means that future reviews of difficult airway management can focus on best practice with the scalpel technique.
      PubDate: 2017-02-16
  • Videolaryngoscopy: the more I practise, the luckier I get
    • Authors: Evans SW; McCahon RR.
      Abstract: Editor—We would like to comment on two recent manuscripts that compared the performance of videolaryngoscopes in manikins and simulated difficult laryngoscopy in patients.12 Both manuscripts provided useful steps in our understanding of the variability of intubation performance using videolaryngoscopes. Ultimately, they suggested that differences in performance between devices relate to their design, the nature of the airway difficulty, or indeed, the type of user. Anaesthetists quite rightly consider themselves expert in all matters airway. However, as a result we believe there is an unsupported assumption that somehow expertise in Macintosh laryngoscopy equates to similar levels of performance with novel laryngoscopes. Indeed, Kleine-Brueggeney and colleagues1 allowed their group of airway experts to self-assess their competence with videolaryngoscopes before study commencement. However, it is known that self-assessment of performance is subject to many confounders and is unreliable.3 Therefore, we believe that a major consideration in device performance is the current expertise of the user and the efficacy of any teaching intervention on skill acquisition. If we consider the two studies in question, the recruits had little opportunity to learn and practise with videolaryngoscopes, which they had seldom if ever used, thus maintaining an expertise gap. It is unsurprising then, that airway experts performed best with non-channelled, Macintosh-like videolaryngoscopes.1
      PubDate: 2017-02-16
  • Videolaryngoscopy is not a panacea for difficult airway management
    • Authors: Rajendram RR.
      Abstract: Editor—I read with great interest the excellent study of six videolaryngoscopes (VLs) in 720 patients by Kleine-Brueggeney and colleagues.1 Many more studies of this calibre are required because the data available to guide the purchase and use of airway devices remain far from robust. Despite this, many devices that have not and may never be subjected to rigorous clinical trials have already been purchased and are being used in patients. Indeed, Kleine-Brueggeney and colleagues1 report the first trial data on the use of the A.P. Advance VL (Venner Medical, Singapore) in clinical practice. Unfortunately, it appears to perform poorly in the airway with limited mouth opening and reduced neck movement created by using a hard neck collar (Stifneck; Laerdal, Orpington, Kent, UK). However, in routine practice there are many potential causes of difficulty. Thus, as the authors suggest, their data cannot be generalized to other difficult airway scenarios. To obtain data on genuinely difficult patients, rather than extrapolating results from cohorts of patients who are predicted to be difficult, the study of large numbers of unselected patients is recommended.2
      PubDate: 2017-02-16
  • Videolaryngoscopy and the search for the Holy Grail
    • Authors: Sgalambro FF; Sorbello MM.
      Abstract: Editor—Kleine-Brueggeney and colleagues1 compared the performance of six videolaryngoscopes (VLs) in 720 patients in a methodologically excellent multicentre study. The context for a difficult airway was simulated by application of a cervical collar, and the results, with all limitations underlined by the authors, raise serious doubts about our (maybe abused) trust in VLs for difficult airways. The most important finding, in our opinion, is that VLs do fail; the success rate was 98% after some data exclusion, while the total success range was 37–98%. Including all VLs, the view was excellent in only 60% of patients, and the time for intubation ranged from 47 to 93 s, including the ‘I can see but I can’t intubate’ scenario. Injury to soft tissue and bleeding occurred in 5–36% of the patients.
      PubDate: 2017-02-16
  • Surgery of the axilla with combined brachial plexus and intercostobrachial
           nerve block in the subpectoral intercostal plane
    • Authors: Seidel RR; Gray AT, Wree AA, et al.
      Abstract: Editor—The axilla has the shape of a pyramid, with walls formed by muscles (and the axillary fascia) innervated by the brachial plexus (myotomes). The base of the pyramid is formed by the skin above the armpit (dermatomes). Both the brachial plexus and the lateral cutaneous branches of the upper intercostal nerves (intercostobrachial nerve T2–T3) are involved in the sensory innervation.1–4 This requires a combined regional anaesthesia technique for more extensive surgical interventions in the axillary region. We present an ultrasound-guided subpectoral intercostal plane block as a simple and promising technique to anaesthetize the intercostobrachial nerve selectively. This is documented by an anatomical case series. In combination with a brachial plexus block (segments C5–T1), the anaesthetic field is expanded to include segments T2–T3.
      PubDate: 2017-02-16
  • Erector spinae plane block for pain relief in rib fractures
    • Authors: Hamilton DL; Manickam BB.
      Abstract: Editor—We report a case of successful erector spinae plane (ESP) block using a continuous catheter technique for pain relief in a patient with multiple unilateral rib fractures.
      PubDate: 2017-02-16
  • Accuracy and precision of non-invasive cardiac output monitoring devices
           in perioperative medicine: a systematic review and meta-analysis †
    • Authors: Joosten AA; Desebbe OO, Suehiro KK, et al.
      Abstract: AbstractCardiac output (CO) measurement is crucial for the guidance of therapeutic decisions in critically ill and high-risk surgical patients. Newly developed completely non-invasive CO technologies are commercially available; however, their accuracy and precision have not recently been evaluated in a meta-analysis. We conducted a systematic search using PubMed, Cochrane Library of Clinical Trials, Scopus, and Web of Science to review published data comparing CO measured by bolus thermodilution with commercially available non-invasive technologies including pulse wave transit time, non-invasive pulse contour analysis, thoracic electrical bioimpedance/bioreactance, and CO2 rebreathing. The non-invasive CO technology was considered acceptable if the pooled estimate of percentage error was
      PubDate: 2017-02-16
  • Primary blast lung injury - a review
    • Authors: Scott TE; Kirkman EE, Haque MM, et al.
      Abstract: AbstractBomb or explosion-blast injuries are likely to be increasingly encountered as terrorist activity increases and pre-hospital medical care improves. We therefore reviewed the epidemiology, pathophysiology and treatment of primary blast lung injury.In addition to contemporary military publications and expert recommendation, an EMBASE and MEDLINE search of English speaking journals was undertaken using the medical subject headings (MeSHs) ‘blast injury’ and ‘lung injury’. Review articles, retrospective case series, and controlled animal modelling studies published since 2000 were evaluated.6-11% of military casualties in recent conflicts have suffered primary blast lung injury but the incidence increases to more than 90% in terrorist attacks occurring in enclosed spaces such as trains. The majority of victims require mechanical ventilation and intensive care management. Specific therapies do not exist and treatment is supportive utilizing current best practice.Understanding the consequences and supportive therapies available to treat primary blast lung injury are important for anaesthetists.
      PubDate: 2017-02-16
  • Paediatric emergence delirium: a comprehensive review and interpretation
           of the literature
    • Authors: Mason KP; .
      Abstract: AbstractThere remain unanswered questions and implications related to emergence delirium in children. Although we know that there are some predisposing factors to emergence delirium, we still are unable to predict accurately those who are at greatest risk. Emergence delirium should be considered as a ‘vital sign’, which should be followed and documented in every child in the postanaesthesia recovery period. Standardized screening tools should be adopted for paediatric emergence delirium.
      PubDate: 2017-02-16
  • When fasted is not empty: a retrospective cohort study of gastric content
           in fasted surgical patients †
    • Authors: Van de Putte PP; Vernieuwe LL, Jerjir AA, et al.
      Abstract: AbstractBackground. Perioperative aspiration leads to significant morbidity and mortality. Point-of-care gastric ultrasound is an emerging tool to assess gastric content at the bedside.Methods. We performed a retrospective cohort study of baseline gastric content on fasted elective surgical patients. The primary outcome was the incidence of full stomach (solid content or >1.5 ml kg−1 of clear fluid). Secondary outcomes included: gastric volume distribution (entire cohort, each antral grade); the association between gastric fullness, fasting intervals, and co-morbidities; anaesthetic management changes and incidence of aspiration.Results. We identified 538 patients. Thirty-two patients (6.2%) presented with a full stomach. Nine of these (1.7%) had solid content and 23 (4.5%) had clear fluid >1.5 ml kg−1. An empty stomach was documented in 480 (89.8%) patients. The examination was inconclusive in the remaining 20 patients (5.0%). As expected, increasing antral grade was correlated with larger antral cross-sectional area and higher gastric volume (P
      PubDate: 2017-02-16
  • Prevalence and factors predictive of full stomach in elective and
           emergency surgical patients: a prospective cohort study
    • Authors: Bouvet LL; Desgranges FP, Aubergy CC, et al.
      Abstract: AbstractBackground. This prospective observational study sought to assess the rate of full and empty stomach in elective and emergency patients and to determine the factors associated with full stomach.Methods. Non-premedicated patients were consecutively included between May 2014 and October 2014. Ultrasound examination of the gastric antrum was performed by an operator blinded to the history of the patient. It included measurement of the antral cross-sectional area, performed in the supine position with the head of the bed elevated to 45°, and qualitative assessment of the gastric antrum, performed in both semirecumbent and right lateral decubitus positions. Full stomach was defined by the appearance of any gastric content in both positions (Grade 2). Empty stomach was defined either by empty antrum in both positions (Grade 0) or by empty antrum in the semirecumbent position only (Grade 1) with measured antral area 340 mm2 defined intermediate stomach. Logistic regression analyses were performed for the identification of factors associated with full stomach.Results. Four hundred and forty patients were analysed. The prevalence of full stomach was 5% (95% confidence interval: 2–9) in elective patients and 56% (95% confidence interval: 50–62) in emergency patients (P
      PubDate: 2017-02-16
  • Intraoperative tranexamic acid use in major spine surgery in adults: a
           multicentre, randomized, placebo-controlled trial †
    • Authors: Colomina MJ; Koo MM, Basora MM, et al.
      Abstract: AbstractBackground. Perioperative tranexamic acid (TXA) use can reduce bleeding and transfusion requirements in several types of surgery, but level I evidence proving its effectiveness in major spine surgery is lacking. This study was designed to investigate the hypothesis that TXA reduces perioperative blood loss and transfusion requirements in patients undergoing major spine procedures.Methods. We conducted a multicentre, prospective, randomized double-blind clinical trial, comparing TXA with placebo in posterior instrumented spine surgery. Efficacy was determined based on the total number of blood units transfused and the perioperative blood loss. Other variables such as the characteristics of surgery, length of hospital stay, and complications were also analysed.Results. Ninety-five patients undergoing posterior instrumented spine surgery (fusion of >3 segments) were enrolled and randomized: 44 received TXA (TXA group) and 51 received placebo (controls). The groups were comparable for duration of surgery, number of levels fused, and length of hospitalization. Transfusion was not required in 48% of subjects receiving TXA compared with 33% of controls (P = 0.05). Mean number of blood units transfused was 0.85 in the TXA group and 1.42 with placebo (P = 0.06). TXA resulted in a significant decrease in intraoperative bleeding (P = 0.01) and total bleeding (P = 0.01) relative to placebo. The incidence of adverse events was similar in the two groups.Conclusions. TXA did not significantly reduce transfusion requirements, but significantly reduced perioperative blood loss in adults undergoing major spinal surgery.Clinical trial registration. NCT01136590.
      PubDate: 2017-02-16
  • Early postoperative oral fluid intake in paediatric day case surgery
           influences the need for opioids and postoperative vomiting: a controlled
           randomized trial †
    • Authors: Chauvin CC; Schalber-Geyer AS, Lefebvre FF, et al.
      Abstract: AbstractBackground. In children younger than 4 yr, it is difficult to distinguish the cause of postoperative distress, such as thirst, pain, and emergence delirium. This may lead to inappropriate treatment, such as administration of opioids. The aim of this study was to evaluate the influence of early postoperative oral fluid intake on the use of opioid analgesics and the incidence of postoperative vomiting (POV) after paediatric day case surgery.Methods. After ethics committee approval and with parental informed consent, planned day surgery patients aged 6 months to 4 yr were randomized to the liberal group (LG), in which apple juice (10 ml kg−1) was offered first if the Face Legs Activity Cry COnsolability (FLACC) score was ≥4 in the PACU, or to the control group (CG), in which children were treated after surgery according to the institutional opioid protocol, and drinking was allowed only upon the return to the ward. Bayesian statistical analysis was used to compare POV incidence and opioid use across groups.Results. Data from 231 patients were analysed. The incidence of POV in the LG and the CG was 11.40 and 23.93%, respectively. An opioid was needed in 14.04% (mean total dose: 0.18 mg kg−1) and 35.89% (mean total dose: 0.20 mg kg−1) of the patients in the LG and the CG. The PACU stay was 53.45 and 65.05 min in the LG and the CG, respectively (all differences were statistically significant).Conclusions. In our paediatric outpatient setting, early postoperative oral fluid intake was associated with a reduction in opioid use and POV incidence. These results deserve confirmation in other settings.Clinical trial registration. NCT02288650.
      PubDate: 2017-02-16
  • Ultrasound-guided lumbar plexus block in volunteers; a randomized
           controlled trial
    • Authors: Strid JC; Sauter AR, Ullensvang KK, et al.
      Abstract: AbstractBackground. The currently best-established ultrasound-guided lumbar plexus block (LPB) techniques use a paravertebral location of the probe, such as the lumbar ultrasound trident (LUT). However, paravertebral ultrasound scanning can provide inadequate sonographic visibility of the lumbar plexus in some patients. The ultrasound-guided shamrock LPB technique allows real-time sonographic viewing of the lumbar plexus, various anatomical landmarks, advancement of the needle, and spread of local anaesthetic injectate in most patients. We aimed to compare block procedure outcomes, effectiveness, and safety of the shamrock vs LUT.Methods. Twenty healthy men underwent ultrasound-guided shamrock and LUT LPBs (2% lidocaine–adrenaline 20 ml, with 1 ml diluted contrast added) in a blinded randomized crossover study. The primary outcome was block procedure time. Secondary outcomes were procedural discomfort, number of needle insertions, injectate spread assessed with magnetic resonance imaging, sensorimotor effects, and lidocaine pharmacokinetics.Results. The shamrock LPB procedure was faster than LUT (238 [sd 74] vs 334 [156] s; P=0.009), more comfortable {numeric rating scale 0–10: 3 [interquartile range (IQR) 2–4] vs 4 [3–6]; P=0.03}, and required fewer needle insertions (2 [IQR 1–3] vs 6 [2–12]; P=0.003). Perineural injectate spread seen with magnetic resonance imaging was similar between the groups and consistent with motor and sensory mapping. Zero/20 (0%) and 1/19 (5%) subjects had epidural spread after shamrock and LUT (P=1.00), respectively. The lidocaine pharmacokinetics were similar between the groups.Conclusions. Shamrock was faster, more comfortable, and equally effective compared with LUT.Clinical trial registration. NCT02255591.
      PubDate: 2017-02-16
  • Addition of transversus thoracic muscle plane block to pectoral nerves
           block provides more effective perioperative pain relief than pectoral
           nerves block alone for breast cancer surgery
    • Authors: Ueshima HH; Otake HH, .
      Abstract: AbstractBackground. The pectoral nerves (PECS) block cannot block the most internal mammary region, whereas a transversus thoracic muscle plane (TTP) block can. The combination of PECS and TTP blocks may be suitable for anterior chest surgery. We studied patients undergoing mastectomy to assess whether the combination of PECS and TTP blocks provides better analgesia than PECS block alone.Methods. Seventy adult female patients undergoing unilateral mastectomy under general anaesthesia were randomly allocated to receive either the combination of PECS and TTP blocks (PT group, n=35) or the PECS block only (C group, n=35). The primary outcome measure was visual analog scale pain score. Secondary outcomes were the sensory level loss confirmed by cold tests and additional analgesic drugs within 24 h after the operation.Results. The visual analog scale pain scores were lower in the PT group than the C group. The use of postoperative additional analgesic drugs was also lower lower in the PT group than that in the C group. In the majority of patients in the PT group, sensory loss was confirmed in both the anterior and the lateral branches of thoracic nerves (Th2–6).Conclusion. Compared with PECS block, the combination of PECS and TTP blocks provides effective perioperative pain relief for breast cancer surgery.Clinical trial registration. University Hospital Medical Information Network (UMIN) ID number 000018299.
      PubDate: 2017-02-16
  • SponTaneous Respiration using IntraVEnous anaesthesia and Hi-flow nasal
           oxygen (STRIVE Hi) maintains oxygenation and airway patency during
           management of the obstructed airway: an observational study
    • Authors: Booth AG; Vidhani KK, Lee PK, et al.
      Abstract: AbstractBackground. High-flow nasal oxygen (HFNO) has been shown to benefit oxygenation, ventilation and upper airway patency in a range of clinical scenarios, however its use in spontaneously breathing patients during general anaesthesia has not been described. Spontaneous respiration using i.v. anaesthesia is the primary technique used at our institution for tubeless airway surgery. We hypothesized that the addition of HFNO would increase our margin of safety, particularly during management of an obstructed airway.Methods. A retrospective observational study was conducted using a SponTaneous Respiration using IntraVEnous anaesthesia and High-flow nasal oxygen (STRIVE Hi) technique to manage 30 adult patients undergoing elective laryngotracheal surgery.Results. Twenty-six patients (87%) presented with significant airway and/or respiratory compromise (16 were stridulous, 10 were dyspnoeic). No episodes of apnoea or complete airway obstruction occurred during the induction of anaesthesia using STRIVE Hi. The median [IQR (range)] lowest oxygen saturation during the induction period was 100 [99–100 (97–100)] %. The median [IQR (range)] overall duration of spontaneous ventilation was 44 [40–49.5 (18–100)] min. The median [IQR (range)] end-tidal carbon dioxide (ETCO2) level at the end of the spontaneous ventilation period was 6.8 [6.4–7.1 (4.8–8.9)] kPa. The mean rate of increase in ETCO2 was 0.03 kPa min−1.Conclusions. STRIVE Hi succeeded in preserving adequate oxygen saturation, end-tidal carbon dioxide and airway patency. We suggest that the upper and lower airway benefits attributed to HFNO, are ideally suited to a spontaneous respiration induction, increasing its margin of safety. STRIVE Hi is a modern alternative to the traditional inhalation induction.
      PubDate: 2017-02-16
  • Influence of head and neck position on ventilation using the air-Q ® SP
           airway in anaesthetized paralysed patients: a prospective randomized
           crossover study
    • Authors: Kim HJ; Lee KK, Bai SS, et al.
      Abstract: AbstractBackground. The influence of different head and neck positions on the effectiveness of ventilation with the air-Q® self-pressurizing airway remains unevaluated. This study aimed to evaluate the influence of different head and neck positions on ventilation with the air-Q® SP airway.Methods. In this prospective, randomized crossover study, we enrolled 51 female patients who were to undergo elective gynaecological or breast surgery under general anaesthesia. An air-Q® SP airway was placed in all patients, and mechanical ventilation was performed using a volume-controlled mode with a tidal volume of 10 ml kg−1 and a respiratory rate of 12 bpm. The expiratory tidal volume, peak inspiratory pressure, oropharyngeal leak pressure, and ventilation score were assessed first for the neutral head position and then for the extended, flexed, and rotated head positions in a random order.Results. All parameters were similar for the rotated head and neck position and the neutral position. Compared with the neutral position, the oropharyngeal leak pressure and peak inspiratory pressure decreased in the extended position but increased significantly in the flexed position (P
      PubDate: 2017-02-16
  • In the March BJA …
    • PubDate: 2017-02-16
  • Postoperative pulmonary complications
    • Authors: Miskovic AA; Lumb AB, .
      Abstract: AbstractPostoperative pulmonary complications (PPCs) are common, costly, and increase patient mortality. Changes to the respiratory system occur immediately on induction of general anaesthesia: respiratory drive and muscle function are altered, lung volumes reduced, and atelectasis develops in > 75% of patients receiving a neuromuscular blocking drug. The respiratory system may take 6 weeks to return to its preoperative state after general anaesthesia for major surgery. Risk factors for PPC development are numerous, and clinicians should be aware of non-modifiable and modifiable factors in order to recognize those at risk and optimize their care. Many validated risk prediction models are described. These have been useful for improving our understanding of PPC development, but there remains inadequate consensus for them to be useful clinically. Preventative measures include preoperative optimization of co-morbidities, smoking cessation, and correction of anaemia, in addition to intraoperative protective ventilation strategies and appropriate management of neuromuscular blocking drugs. Protective ventilation includes low tidal volumes, which must be calculated according to the patient’s ideal body weight. Further evidence for the most beneficial level of PEEP is required, and on-going randomized trials will hopefully provide more information. When PEEP is used, it may be useful to precede this with a recruitment manoeuvre if atelectasis is suspected. For high-risk patients, surgical time should be minimized. After surgery, nasogastric tubes should be avoided and analgesia optimized. A postoperative mobilization, chest physiotherapy, and oral hygiene bundle reduces PPCs.
      PubDate: 2017-02-10
  • Pulmonary aspiration during procedural sedation: a comprehensive
           systematic review
    • Authors: Green SM; Mason KP, Krauss BS, et al.
      Abstract: AbstractBackground. Although pulmonary aspiration complicating operative general anaesthesia has been extensively studied, little is known regarding aspiration during procedural sedation.Methods. We performed a comprehensive, systematic review to identify and catalogue published instances of aspiration involving procedural sedation in patients of all ages. We sought to report descriptively the circumstances, nature, and outcomes of these events.Results. Of 1249 records identified by our search, we found 35 articles describing one or more occurrences of pulmonary aspiration during procedural sedation. Of the 292 occurrences during gastrointestinal endoscopy, there were eight deaths. Of the 34 unique occurrences for procedures other than endoscopy, there was a single death in a moribund patient, full recovery in 31, and unknown recovery status in two. We found no occurrences of aspiration in non-fasted patients receiving procedures other than endoscopy.Conclusions. This first systematic review of pulmonary aspiration during procedural sedation identified few occurrences outside of gastrointestinal endoscopy, with full recovery typical. Although diligent caution remains warranted, our data indicate that aspiration during procedural sedation appears rare, idiosyncratic, and typically benign.
      PubDate: 2017-02-10
  • Change in end-tidal carbon dioxide outperforms other surrogates for change
           in cardiac output during fluid challenge
    • Authors: Lakhal KK; Nay MA, Kamel TT, et al.
      Abstract: AbstractBackground. During fluid challenge, volume expansion (VE)-induced increase in cardiac output (ΔVECO) is seldom measured.Methods. In patients with shock undergoing strictly controlled mechanical ventilation and receiving VE, we assessed minimally invasive surrogates for ΔVECO (by transthoracic echocardiography): fluid-induced increases in end-tidal carbon dioxide (ΔVEE′CO2); pulse (ΔVEPP), systolic (ΔVESBP), and mean systemic blood pressure (ΔVEMBP); and femoral artery Doppler flow (ΔVEFemFlow). In the absence of arrhythmia, fluid-induced decrease in heart rate (ΔVEHR) and in pulse pressure respiratory variation (ΔVEPPV) were also evaluated. Areas under the receiver operating characteristic curves (AUCROCs) reflect the ability to identify a response to VE (ΔVECO ≥15%).Results. In 86 patients, ΔVEE′CO2 had an AUCROC=0.82 [interquartile range 0.73–0.90], significantly higher than the AUCROC for ΔVEPP, ΔVESBP, ΔVEMBP, and ΔVEFemFlow (AUCROC=0.61–0.65, all P 1 mm Hg (>0.13 kPa) had good positive (5.0 [2.6–9.8]) and fair negative (0.29 [0.2–0.5]) likelihood ratios. The 16 patients with arrhythmia had similar relationships between ΔVEE′CO2 and ΔVECO to patients with regular rhythm (r2=0.23 in both subgroups). In 60 patients with no arrhythmia, ΔVEE′CO2 (AUCROC=0.84 [0.72–0.92]) outperformed ΔVEHR (AUCROC=0.52 [0.39–0.66], P0.13 kPa) indicated a likely response to VE.
      PubDate: 2017-02-10
  • Risk prediction models for delirium in the intensive care unit after
           cardiac surgery: a systematic review and independent external validation
    • Authors: Lee AA; Mu JL, Joynt GM, et al.
      Abstract: AbstractNumerous risk prediction models are available for predicting delirium after cardiac surgery, but few have been directly compared with one another or been validated in an independent data set. We conducted a systematic review to identify validated risk prediction models of delirium (using the Confusion Assessment Method-Intensive Care Unit tool) after cardiac surgery and assessed the transportability of the risk prediction models on a prospective cohort of 600 consecutive patients undergoing cardiac surgery at a university hospital in Hong Kong from July 2013 to July 2015. The discrimination (c-statistic), calibration (GiViTI calibration belt), and clinical usefulness (decision curve analysis) of the risk prediction models were examined in a stepwise manner. Three published high-quality intensive care unit delirium risk prediction models (n=5939) were identified: Katznelson, the original PRE-DELIRIC, and the international recalibrated PRE-DELIRIC model. Delirium occurred in 83 patients (13.8%, 95% CI: 11.2–16.9%). After updating the intercept and regression coefficients in the Katznelson model, there was fair discrimination (0.62, 95% CI: 0.58–0.66) and good calibration. As the original PRE-DELIRIC model was already validated externally and recalibrated in six countries, we performed a logistic calibration on the recalibrated model and found acceptable discrimination (0.75, 95% CI: 0.72–0.79) and good calibration. Decision curve analysis demonstrated that the recalibrated PRE-DELIRIC risk model was marginally more clinically useful than the Katznelson model. Current models predict delirium risk in the intensive care unit after cardiac surgery with only fair to moderate accuracy and are insufficient for routine clinical use.
      PubDate: 2017-02-10
  • Detection and differentiation of cerebral microemboli in patients
           undergoing major orthopaedic surgery using transcranial Doppler ultrasound
    • Authors: Kietaibl CC; Engel AA, Horvat Menih II, et al.
      Abstract: AbstractBackground. Cerebral microemboli (ME) are frequently generated during orthopaedic surgery and may impair cerebral integrity. However, the nature of cerebral ME, being either of solid or gaseous origin, is poorly investigated. Our primary aim was to determine both the frequency and nature of cerebral ME in generally anaesthetised patients undergoing major orthopaedic surgery.Methods. Fifty patients (hip/knee/shoulder prosthesis, spine surgery) were enrolled. Cerebral ME and cerebral blood flow velocity (CBFV) were determined in both middle cerebral arteries for 15 min preoperatively and postoperatively, using transcranial Doppler ultrasound. Cerebral tissue oxygen index, determined by near-infrared spectroscopy, was further examined. Statistical analysis was carried out using the Wilcoxon matched-pairs signed-ranks test (median (25th; 75th percentile), P 
      PubDate: 2017-02-10
  • Predictive performance of eleven pharmacokinetic models for propofol
           infusion in children for long-duration anaesthesia
    • Authors: Hara MM; Masui KK, Eleveld DJ, et al.
      Abstract: AbstractBackground. Predictive performance of eleven published propofol pharmacokinetic models was evaluated for long-duration propofol infusion in children.Methods. Twenty-one aged three–11 yr ASA I–II patients were included. Anaesthesia was induced with propofol or sevoflurane, and maintained with propofol, remifentanil, and fentanyl. Propofol was continuously infused at rates of 4–14 mg kg −1 h−1 after an initial bolus of 1.5–2.0 mg kg −1. Venous blood samples were obtained every 30–60 min for five h and then every 60–120 min after five h from the start of propofol administration, and immediately after the end of propofol administration. Model performance was assessed with prediction error (PE) derivatives including divergence PE, median PE (MDPE), and median absolute PE (MDAPE) as time-related PE shift, measures for bias, and inaccuracy, respectively.Results. We collected 85 samples over 270 (130) (88–545), mean (SD) (range), min. The Short model for children, and the Schüttler general-purpose model had acceptable performance (–20%≤MDPE ≤ 20%, MDAPE ≤ 30%, –4% h−1 ≤ divergence PE ≤ 4% h−1). The Short model showed the best performance with the maximum predictive performance metric. Two models developed only using bolus dosing (Shangguan and Saint-Maurice models) and the Paedfusor of the remaining nine models had significant negative divergence PE (≤–6.1% h−1).Conclusions. The Short model performed well during continuous infusion up to 545 min. This model might be preferable for target-controlled infusion for long-duration anaesthesia in children.
      PubDate: 2017-02-10
  • Measuring acute postoperative pain using the visual analog scale: the
           minimal clinically important difference and patient acceptable symptom
    • Authors: Myles PS; Myles DB, Galagher WW, et al.
      Abstract: AbstractBackground. The 100 mm visual analog scale (VAS) score is widely used to measure pain intensity after surgery. Despite this widespread use, it is unclear what constitutes the minimal clinically important difference (MCID); that is, what minimal change in score would indicate a meaningful change in a patient’s pain status.Methods. We enrolled a sequential, unselected cohort of patients recovering from surgery and used a VAS to quantify pain intensity. We compared changes in the VAS with a global rating-of-change questionnaire using an anchor-based method and three distribution-based methods (0.3 sd, standard error of the measurement, and 5% range). We then averaged the change estimates to determine the MCID for the pain VAS. The patient acceptable symptom state (PASS) was defined as the 25th centile of the VAS corresponding to a positive patient response to having made a good recovery from surgery.Results. We enrolled 224 patients at the first postoperative visit, and 219 of these were available for a second interview. The VAS scores improved significantly between the first two interviews. Triangulation of distribution and anchor-based methods resulted in an MCID of 9.9 for the pain VAS, and a PASS of 33.Conclusions. Analgesic interventions that provide a change of 10 for the 100 mm pain VAS signify a clinically important improvement or deterioration, and a VAS of 33 or less signifies acceptable pain control (i.e. a responder), after surgery.
      PubDate: 2017-02-10
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