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Publisher: Oxford University Press   (Total: 370 journals)

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Showing 1 - 200 of 370 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: 81, 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: 6)
American Historical Review     Hybrid Journal   (Followers: 125, 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: 151, SJR: 3.047, h-index: 201)
American J. of Hypertension     Hybrid Journal   (Followers: 18, 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: 24)
Annals of Botany     Hybrid Journal   (Followers: 35, SJR: 1.912, h-index: 124)
Annals of Occupational Hygiene     Hybrid Journal   (Followers: 26, 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: 8, 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: 19, 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: 26, 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: 47, SJR: 0.144, h-index: 15)
Behavioral Ecology     Hybrid Journal   (Followers: 46, SJR: 1.698, h-index: 92)
Bioinformatics     Hybrid Journal   (Followers: 231, SJR: 4.643, h-index: 271)
Biology Methods and Protocols     Hybrid Journal  
Biology of Reproduction     Full-text available via subscription   (Followers: 9, SJR: 1.646, h-index: 149)
Biometrika     Hybrid Journal   (Followers: 19, 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: 16, SJR: 1.955, h-index: 55)
BJA : British J. of Anaesthesia     Hybrid Journal   (Followers: 134, 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: 45, 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: 33, SJR: 1.267, h-index: 38)
British J. of Aesthetics     Hybrid Journal   (Followers: 25, SJR: 0.217, h-index: 18)
British J. of Criminology     Hybrid Journal   (Followers: 502, SJR: 1.373, h-index: 62)
British J. of Social Work     Hybrid Journal   (Followers: 80, 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: 54, 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: 39, SJR: 4.827, h-index: 192)
CESifo Economic Studies     Hybrid Journal   (Followers: 16, SJR: 0.501, h-index: 19)
Chemical Senses     Hybrid Journal   (Followers: 1, SJR: 1.436, h-index: 76)
Children and Schools     Hybrid Journal   (Followers: 6, 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: 59, 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: 24, SJR: 0.47, h-index: 28)
Computer J.     Hybrid Journal   (Followers: 8, SJR: 0.371, h-index: 47)
Conservation Physiology     Open Access   (Followers: 2)
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: 3)
Early Music     Hybrid Journal   (Followers: 13, SJR: 0.124, h-index: 11)
Economic Policy     Hybrid Journal   (Followers: 52, SJR: 2.052, h-index: 52)
ELT J.     Hybrid Journal   (Followers: 25, SJR: 1.26, h-index: 23)
English Historical Review     Hybrid Journal   (Followers: 46, 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: 2, 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: 47, 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: 147, 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: 26, 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: 20, SJR: 1.126, h-index: 118)
Fems Microbiology Reviews     Hybrid Journal   (Followers: 25, 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: 16, 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: 30, 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: 25, 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: 45, 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: 20, SJR: 0.664, h-index: 60)
History Workshop J.     Hybrid Journal   (Followers: 27, SJR: 0.313, h-index: 20)
Holocaust and Genocide Studies     Hybrid Journal   (Followers: 23, SJR: 0.115, h-index: 13)
Human Molecular Genetics     Hybrid Journal   (Followers: 9, SJR: 4.288, h-index: 233)
Human Reproduction     Hybrid Journal   (Followers: 76, SJR: 2.271, h-index: 179)
Human Reproduction Update     Hybrid Journal   (Followers: 16, SJR: 4.678, h-index: 128)
Human Rights Law Review     Hybrid Journal   (Followers: 58, SJR: 0.7, h-index: 21)
ICES J. of Marine Science: J. du Conseil     Hybrid Journal   (Followers: 54, SJR: 1.233, h-index: 88)
ICSID Review     Hybrid Journal   (Followers: 9)
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: 8, 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. Affairs     Hybrid Journal   (Followers: 51, SJR: 1.264, h-index: 53)
Intl. Data Privacy Law     Hybrid Journal   (Followers: 26)
Intl. Health     Hybrid Journal   (Followers: 4, SJR: 0.835, h-index: 15)
Intl. Immunology     Hybrid Journal   (Followers: 3, 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: 59, SJR: 0.613, h-index: 19)
Intl. J. of Epidemiology     Hybrid Journal   (Followers: 121, 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: 28, 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: 3, 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: 32, 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. Political Sociology     Hybrid Journal   (Followers: 26, 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: 36, 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: 39, 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: 19, 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: 44, SJR: 1.341, h-index: 96)
J. of Chromatographic Science     Hybrid Journal   (Followers: 16, 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: 40, 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: 3)
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: 34, SJR: 2.909, h-index: 69)
J. of Environmental Law     Hybrid Journal   (Followers: 23, SJR: 0.457, h-index: 20)
J. of European Competition Law & Practice     Hybrid Journal   (Followers: 19)
J. of Experimental Botany     Hybrid Journal   (Followers: 14, 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: 20, SJR: 0.399, h-index: 10)
J. of Infectious Diseases     Hybrid Journal   (Followers: 40, 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]   [134 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  [370 journals]
  • Oxford Textbook of Vascular Surgery . M. M. Thompson, R. Fitridge, J.
           Boyle, M. Thompson, K. Brohi, R. J. Hinchliffe, N. Cheshire, A. R. Naylor,
           I. Loftus and A. H. Davies (editors)
    • Authors: Howell SJ.
      Abstract: Oxford Textbook of Vascular Surgery. ThompsonM. M., FitridgeR., BoyleJ., ThompsonM., BrohiK., HinchliffeR. J., CheshireN., NaylorA. R., LoftusI. and DaviesA. H. (editors). eISBN: 9780199658220. Oxford University Press, 800 pp. £44.00 (online), £145.00 (textbook)
      PubDate: 2017-05-15
  • Volatile anaesthetics and organ protection in kidney transplantation:
           finally, a randomized controlled trial!
    • Authors: Beck-Schimmer BB; Schadde EE, Schläpfer MM.
      Abstract: Many clinical trials have evaluated whether volatile anaesthetics are protective in scenarios of ischaemia–reperfusion (I/R). Although the majority of studies of I/R injury involve cardiac surgery with cardiopulmonary bypass,12 some have been performed in lung surgery with one-lung ventilation,3 liver resection under inflow occlusion,4 or liver transplantation.5 The study by Niewuwenhuijs-Moeke and colleagues6 in this issue of the BritishJournalof Anaesthesia is the first to evaluate direct effects of volatile anaesthetics on kidneys undergoing I/R injury during transplantation (volatile anaesthetic protection of renal transplants, VAPOR-1 trial). The authors are to be congratulated for their efforts. So far, only animal experiments have addressed the impact of volatile anaesthetics on renal I/R injury, or the kidneys were evaluated only as a secondary outcome in clinical trials.2 Therefore, this study increases our knowledge and experience of organ protection and volatile anaesthetics.
      PubDate: 2017-05-15
  • ‘Failed supraglottic airway’: an algorithm for suboptimally placed
           supraglottic airway devices based on videolaryngoscopy
    • Authors: Van Zundert AJ; Gatt SP, Kumar CM, et al.
      Abstract: Anaesthetists would not accept malpositioned tracheal tubes resulting in leak, inadequate ventilation, high airway pressures, or one-sided lung ventilation. Yet it is our impression that many, if not the majority, of surgeries are conducted with blindly placed and suboptimally sited supraglottic airway devices (SADs). The anaesthetic community appears to accept much lower standards for SAD placement than for tracheal tube placement.
      PubDate: 2017-05-15
  • Critical airways, critical language
    • Authors: Chrimes NN; Cook TM.
      Abstract: The contribution of human factors to adverse outcomes during emergency airway management is well established.1 Effective communication is a core non-technical skill that contributes to minimizing such error.2 The language used must aid rather than hinder communication.
      PubDate: 2017-05-15
  • Engaging in risky business: is it time to rethink risk tolerance in
    • Authors: Ehrenfeld JM; Fleischut PM.
      Abstract: In this issue of the British Journal of Anaesthesia, Greig and colleagues1 describe a new study examining risk tolerance amongst a large and diverse group of anaesthetists from across a single National Health Service Trust. Using a validated electronic questionnaire, the authors presented a group of anaesthetists with 11 risky situations and queried respondents as to whether they would proceed with the procedure or not (a go/no-go decision). Importantly, all of the scenarios were drawn from previous instances where a critical incident had occurred and been reported. Among their key findings, the authors reported that a consultant was significantly more likely to proceed with a given scenario than a trainee. Perhaps even more striking was the finding that in no one scenario was there absolute agreement over whether to proceed or not. Even in situations where national guidelines clearly suggest a procedure should be cancelled (i.e. a faulty gas analyser), several individuals responded that they would proceed. Overall, the authors found wide variability in what anaesthetists consider either acceptable or professional behaviour. One might expect that if the study were expanded to include other trusts, or even anaesthetists from other countries, this variability would be likely to persist.
      PubDate: 2017-05-15
  • It's not about the bike: enhancing oxygen delivery
    • Authors: Minto GG; Struthers RA.
      Abstract: It’s Not About the Bike was the title of Lance Armstrong’s first autobiography, and in the light of subsequent allegations and admissions, it seems indeed that it was not.1 Armstrong’s phenomenal Tour de France cycling success was of course multifactorial, an aggregation of gains in several aspects of performance, but an integral factor in his success appears to have been ‘blood doping’, a fast-track increase in haemoglobin achieved with erythropoietin and autologous blood transfusion.2 In the case of elite athletes, the advantage being sought is an increase in critical power, the highest work rate that can be sustained over a substantial amount of time without an appreciable contribution from anaerobic metabolism.3 Could a similar approach be employed clinically to improve the functional capacity of patients facing major surgery?
      PubDate: 2017-05-15
  • Medication errors in paediatric anaesthesia: the hidden part of the
    • Authors: Welte JF; Desgranges FP, De Queiroz Siqueira MM, et al.
      Abstract: Editor—We read with great interest the recent report by Wahr and colleagues1 about medication safety in the operating room. The authors highlighted several issues, particularly errors attributable to syringe preparation. Paediatric patients are a population particularly exposed to medication errors owing to the fact that drugs on the pharmaceutical market are, for the most part, supplied in adult packaging and dosage. Thus, the drug dilution procedure is a crucial step to obtain accurate concentrations of drugs used for paediatric or neonatal anaesthesia. As few studies have evaluated the accuracy of drug dilution in the paediatric population, we prospectively assessed the content of syringes prepared by nurse anaesthetists in several paediatric operating theatres in France.
      PubDate: 2017-05-15
  • Anaesthetic considerations for hybrid atrial fibrillation surgery
    • Authors: Umbrain VV; Chierchia GB, La Meir MM.
      Abstract: Editor—Hybrid atrial fibrillation surgery consists of simultaneous epicardial and endocardial ablation of the beating heart by thoracoscopy and percutaneous femoral approaches, respectively, without cardiopulmonary bypass support. The epicardial ablation may be bilateral or unilateral. A joint effort of different teams is required: cardiologist, cardiac surgeon, anaesthetists, respiratory therapists, and nurses.1 The cardiopulmonary bypass team is on standby. Anaesthetic considerations for hybrid surgery involve control of perioperative haemodynamic and respiratory stability and postoperative pain control. We review our institutional approach here for the benefit of new programmes.
      PubDate: 2017-05-15
  • Real-time ultrasound-guided paramedian spinal anaesthesia: evaluation of
           the efficacy and the success rate of single needle pass
    • Authors: Chong SE; Mohd Nikman AA, Saedah AA, et al.
      Abstract: Editor—The ideal way to provide spinal anaesthesia is via a single needle pass (i.e. a successful dural puncture, with a single skin puncture and no needle redirection). This was recommended by the Second American Society of Regional Anesthesia Consensus on Neuraxial Anesthesia and Anticoagulation.1 Multiple puncture attempts are associated with a higher chance of complications.2,3 A paramedian approach has been shown to improve the success rate of spinal anaesthesia, especially in patients who are unable to sit up or those with a degenerative spine condition.4–6 The use of ultrasound has been suggested to increase the efficacy of spinal anaesthesia.7
      PubDate: 2017-05-15
  • A different use of visual analytic techniques in anaesthetics
    • Authors: Rice RR; Rice II.
      Abstract: Editor—We are now in a world of big data. In all areas of life, data are collected, stored and interpreted. The potential for big data to improve clinical practice has previously been highlighted.1 Among other ideas, Simpao and colleagues1 suggested that analysis tools could reduce the duration of hospital admissions and provide financial savings tools. We have developed a novel way of viewing clinical data and demonstrate an important use for this.
      PubDate: 2017-05-15
  • The diagnostic challenge of a vitamin K antagonist with dabigatran use
           triggering massive intracranial haemorrhage
    • Authors: Pausch AA; Koch St, Frossard MM, et al.
      Abstract: Editor—We present the case of an 87-year-old patient who was admitted intubated and sedated to our emergency department after traumatic brain injury suspicious of open skull fracture (approved by the Ethical Committee of the Medical University of Vienna; EK Nr.: 1519/2016). The initial computed tomography (CT) scan showed no signs of intracranial haemorrhage or fractures, whereupon the patient was extubated. The anamnestic intake of phenprocoumon was reflected by an international normalized ratio within the therapeutic range. However, neither the considerably increased activated partial thromboplastin time (aPTT) nor the prolonged thrombin time (TT) were consistent with the intake of a vitamin K antagonist (VKA) (Table 1). Table 1Laboratory results, drug administration, and interventions shown in a time-dependent manner in days (d) and hours (h) since the patients admission (T0). aPTT: activated partial thromboplastin time; BUN: blood urea nitrogen; GFR: glomerular filtration rate; INR: international normalized ratio; LMWH: low molecular weight heparin; PPSB: prothrombin complex concentrate; CiCaCVVHD: calcium citrate anticoagulated continuous venovenous haemodialysisVariableUnit (SI unit)T0 + 1 hT0 + 15 hT0 + 20 hT0 + 1 d 14 hT0 + 2 d 12 hT0 + 2 d 18 hT0 + 3 d 3 hT0 + 3 d 14 hT0 + 4 d 13 hT0 + 5 d 14 hT0 + 6 d 13 hT0 + 7 d 13 hT0 + 8 d 13 hThromboplastin time (Owren)%19225562757252545453565653INR times>120>12018.118.635.556.294.890.062.347.827.623.120.3Fibrinogenmg dl -1 (g L-1)353 (3.53)443 (4.43)413 (4.13)435 (4.35)462 (4.62)419 (4.19)314 (3.14)389 (3.89)449 (4.49)498 (4.98)560 (5.60)545 (5.45)610 (6.10)Antithrombin III activity%72946962666857647781837572Dabigatranng ml -1—100<30<30——<3050—————Creatininemg dl -1 (µmol L-1)1.11 (98.24)1.21 (107.09)1.34 (118.59)2.15 (190.28)2.86 (253.11)3.02 (267.27)3.17 (280.55)3.47 (307.10)1.99 (176.12)1.02 (90.27)0.61 (53.99)0.55 (48.68)0.58 (51.33)BUNmg dl-1 (mmol L-1)—15.2 (2.538)15.0 (2.505)23.9 (3.991)29.9 (4.993)33.1 (5.528)34.5 (5.762)39.6 (6.613)29.7 (4.960)18.0 (3.060)11.3 (1.887)11.2 (1.870)10.0 (1.670)GFRml min -1 1.73m -2—56.7350.4229.2221.02————————Serum proteing L -145.354.349.047.948.225.946.050.849.850.351.450.455.3Haemostatic therapy—2000 IU PPSB, 10 mg vitamin K 5 mg Idarucizumab, (∼27.8 IU kg-1)————————LMWHLMWHLMWHIntervention—————Volume, furosemide—Start of CiCaCVVHDCiCaCVVHDCiCaCVVHDCiCaCVVHDCiCaCVVHDCiCaCVVHD
      PubDate: 2017-05-15
  • Reply—stopping antithrombotics during regional anaesthesia and eye
           surgery: crying wolf?
    • Authors: Martin TJ; Kerridge RK.
      Abstract: Editor—We read with interest the recent editorial by Kumar and Seet1 concerning the management of antithrombotics and anticoagulants in relation to regional anaesthesia techniques for ophthalmic surgery. Contrary to the authors’ assertion that there is an absence of guidelines in relation to regional anaesthesia in ophthalmic surgery, we recommend several articles in both the ophthalmic and anaesthesia literature.2–4
      PubDate: 2017-05-15
  • Suturing central venous catheters
    • Authors: Valchanov KK.
      Abstract: Editor—I read with interest the new issue of British Journal of Anaesthesia (volume 118, issue 2). I am concerned that the cover photograph is potentially misleading and perhaps not a good example of best practice for central line suturing. It shows a central venous catheter sutured to the skin of the patient using the holding clips only. The suturing holes of the hub of the device, which are designed to be sutured to the skin, are not in the exposed area, which could mislead the reader into believing that suturing only the clips can safely secure the central venous catheter.
      PubDate: 2017-05-15
  • Classification of videolaryngoscopes is crucial
    • Authors: Cavus EE; Byhahn CC, Dörges VV.
      Abstract: Editor—We read with interest the article by Kleine-Brueggeney and colleagues,1 who compared six videolaryngocopes during routine airway management in patients with simulated difficult airways.
      PubDate: 2017-05-15
  • An unusual sidestream capnogram
    • Authors: Diehl JL; Chamoun CC, Mercat AA, et al.
      Abstract: Editor—We report an unusual record of exhaled CO2 observed during end-expiratory occlusion in a chronic obstructive pulmonary disease patient receiving invasive mechanical ventilation because of a severe acute exacerbation attributable to a bacterial pneumonia. As the patient fulfilled moderate acute respiratory distress syndrome criteria, he was deeply sedated and under neuromuscular block. The 70-yr-old male patient was ventilated (assist-controlled) with a CARESCAPE R860 ventilator (GE Healthcare, Madison, WI, USA). An end-expiratory occlusion manoeuvre was performed to determine the total PEEP level. The duration of the expiratory pause was extended to 15 s, because of the clinical observation of a very unusual record (Fig. 1a). The airway CO2 monitoring system (sidestream sampling, aspiration flow 120 ml min−1 as indicated by the manufacturer) displayed at first a so-called ‘curare cleft’1 and further a short ‘plateau-like’ line, rapidly followed by a decrease in CO2 fraction, associated with an increase in measured airway O2 fraction. Indentations were observed during the decreasing phase at a rate very similar to the cardiac frequency. Such a pattern was repeatedly observed over time, even after switching to another CARESCAPE R860 ventilator. Moreover, prolonged expiration was additionally obtained by disconnection of the respiratory line at the Y-piece level, immediately after the port of the CO2 monitoring device. We then observed the expected pattern, with a slow CO2 fraction ascending rate, but without reaching a true plateau (Fig. 1b). Fig 1Records of respiratory O2 and CO2 fractions obtained during a prolonged (15 s) end-expiratory occlusion manoeuvre (a) and after disconnection of the respiratory line at the Y-piece level (b). Records were obtained using the ventilator sensors and the OhmedaCom Research Tool acquisition system.
      PubDate: 2017-05-15
  • Dead or dying? Pulseless electrical activity during trauma
    • Authors: Bäcker HH; Kyburz AA, Bosshard AA, et al.
      Abstract: Editor—We describe a unique case of a 67-yr-old male with high-energy thoracic trauma who developed pulseless electrical activity (PEA) after tracheal intubation.
      PubDate: 2017-05-15
  • In This Issue
    • PubDate: 2017-05-15
  • Efficacy and safety of inhaled anaesthetic for postoperative sedation
           during mechanical ventilation in adult cardiac surgery patients: a
           systematic review and meta-analysis
    • Authors: Spence JJ; Belley-Côté EE, Ma HK, et al.
      Abstract: The aim was to evaluate the efficacy and safety of volatile anaesthetic for postoperative sedation in adult cardiac surgery patients through a systematic review and meta-analysis. We retrieved randomized controlled trials from MEDLINE, EMBASE, CENTRAL, Web of Science, clinical trials registries, conference proceedings, and reference lists of included articles. Independent reviewers extracted data, including patient characteristics, type of intraoperative anaesthesia, inhaled anaesthetic used, comparator sedation, and outcomes of interest, using pre-piloted forms. We assessed risk of bias using the Cochrane Tool and evaluated the strength of the evidence using the GRADE approach. Eight studies enrolling 610 patients were included. Seven had a high and one a low risk of bias. The times to extubation after intensive care unit (ICU) admission and sedation discontinuation were, respectively, 76 [95% confidence interval (CI) −150 to − 2, I2=79%] and 74 min (95% CI − 126 to − 23, I2=96%) less in patients who were sedated using volatile anaesthetic. There was no difference in ICU or hospital length of stay. Patients who received volatile anaesthetic sedation had troponin concentrations that were 0.71 ng ml−1 (95% CI 0.23–1.2) lower than control patients. Reporting on other outcomes was varied and not suitable for meta-analysis. Volatile anaesthetic sedation may be associated with a shorter time to extubation after cardiac surgery but no change in ICU or hospital length of stay. It is associated with a significantly lower postoperative troponin concentration, but the impact of this on adverse cardiovascular outcomes is uncertain. Blinded randomized trials using intention-to-treat analysis are required. PROSPERO registry number: 2016:CRD42016033874. Available from
      PubDate: 2017-05-15
  • Drug safety in paediatric anaesthesia
    • Authors: Kaufmann JJ; Wolf AR, Becke KK, et al.
      Abstract: Life-threatening drug errors are more common in children than in adults. This is likely to be because of their variations in age and weight, combined with the occasional exposure of most anaesthetists to paediatric patients. Drug administration in anaesthesia is mostly undertaken by a single operator and thus represents a potentially greater risk compared with other areas of medicine. This increased risk is believed to be offset by anaesthetists working with only a limited number of drugs on a very frequent and repetitive basis. However, high rates of errors continue to be reported. Paediatric anaesthesia practice requires individual age- and weight-specific drug dose calculations and is therefore without a ‘familiar’ or ‘usual’ dose. The aim of this narrative systematic review of existing recommendations and current evidence of preventive strategies is to identify measures to enhance the safety and quality of drug administration in paediatric anaesthesia. This review collates and grades the evidence of such interventions and recommendations and assesses their feasibility. Most highly effective available measures require low or limited costs and labour. The presented solutions should, therefore, achieve a high level of acceptance and contribute significantly to safety and quality of care in paediatric anaesthesia.
      PubDate: 2017-05-15
  • Neural network imaging to characterize brain injury in cardiac procedures:
           the emerging utility of connectomics
    • Authors: Indja BB; Fanning JP, Maller JJ, et al.
      Abstract: Cognitive dysfunction is a poorly understood but potentially devastating complication of cardiac surgery. Clinically meaningful assessment of cognitive changes after surgery is problematic because of the absence of a means to obtain reproducible, objective, and quantitative measures of the neural disturbances that cause altered brain function. By using both structural and functional connectivity magnetic resonance imaging data to construct a map of the inter-regional connections within the brain, connectomics has the potential to increase the specificity and sensitivity of perioperative neurological assessment, permitting rational individualized assessment and improvement of surgical techniques.
      PubDate: 2017-05-15
  • Randomized trial of red cell washing for the prevention of
           transfusion-associated organ injury in cardiac surgery
    • Authors: Woźniak MJ; Sullo NN, Qureshi SS, et al.
      Abstract: Background. Experimental studies suggest that mechanical cell washing to remove pro-inflammatory components that accumulate in the supernatant of stored donor red blood cells (RBCs) might reduce inflammation and organ injury in transfused patients.Methods. Cardiac surgery patients at increased risk of large-volume RBC transfusion were eligible. Participants were randomized to receive either mechanically washed allogenic RBCs or standard care RBCs. The primary outcome was serum interleukin-8 measured at baseline and at four postsurgery time points. A mechanism substudy evaluated the effects of washing on stored RBCs in vitro and on markers of platelet, leucocyte, and endothelial activation in trial subjects.Results. Sixty adult cardiac surgery patients at three UK cardiac centres were enrolled between September 2013 and March 2015. Subjects received a median of 3.5 (interquartile range 2–5.5) RBC units, stored for a mean of 21 (sd 5.2) days, within 48 h of surgery. Mechanical washing reduced concentrations of RBC-derived microvesicles but increased cell-free haemoglobin concentrations in RBC supernatant relative to standard care RBC supernatant. There was no difference between groups with respect to perioperative serum interleukin-8 values [adjusted mean difference 0.239 (95% confidence intervals −0.231, 0.709), P=0.318] or concentrations of plasma RBC microvesicles, platelet and leucocyte activation, plasma cell-free haemoglobin, endothelial activation, or biomarkers of heart, lung, or kidney injury.Conclusions. These results do not support a hypothesis that allogenic red blood cell washing has clinical benefits in cardiac surgery.Clinical trial registration. ISRCTN 27076315.
      PubDate: 2017-05-15
  • Comparison of preoperative and intraoperative assessment of aortic
           stenosis severity by echocardiography
    • Authors: Uda YY; Cowie BB, Kluger RR.
      Abstract: Background. General anaesthesia and surgically induced changes in cardiac loading conditions may alter flow across the aortic valve. This study examined how echocardiographic assessment of the severity of aortic stenosis (AS) changes during surgery.Methods. Patients who underwent aortic valve replacement for any severity of AS between July 2007 and June 2015 were identified. Peak velocities, mean gradients, and dimensionless indices (DI) measured with preoperative transthoracic echocardiography (TTE) were compared with those measured with intraoperative transoesophageal echocardiography (TOE). Additionally, agreement of preoperative and intraoperative grading of AS based on these measurements was assessed.Results. Data from 319 patients were analysed. On average, intraoperative TOE peak velocity and mean gradient were lower by 0.59 m s−1 and 12.5 mm Hg, respectively (P<0.0001), compared with preoperative TTE measurements, whereas the difference in mean DI was minimal at 0.008. Preoperative and intraoperative grades of AS severity (mild, moderate, and severe) by peak velocity, mean gradient, and DI agreed in 53.3, 53.7, and 83.3% of patients, respectively. The TOE grade of AS severity by peak velocity and mean gradient was at least one lower than the TTE grade in 45.1 and 42.7% of patients, respectively. Significantly fewer patients had their severity of AS reclassified based on DI (P<0.0001).Conclusions. Intraoperative TOE peak velocities and mean gradients are often significantly lower than preoperative TTE measurements, leading to underestimation of AS severity in nearly half of our study patients. The DI is a more reliable measurement of AS severity in the intraoperative setting.
      PubDate: 2017-05-15
  • Pharmacokinetic/pharmacodynamic model for unfractionated heparin dosing
           during cardiopulmonary bypass
    • Authors: Delavenne XX; Ollier EE, Chollet SS, et al.
      Abstract: Background. High-dose heparin is used during cardiopulmonary bypass (CPB) to prevent thrombosis in the circuits used for extracorporeal circulation. The aim of this study was, initially, to develop a population pharmacokinetic/pharmacodynamic (PK/PD) model to assess the variability of PK/PD parameters and their correlation with the results of the routine haemostatic test activated clotting time (ACT) and thereafter to develop a Bayesian estimator enabling an individualized dosing strategy.Methods. Fifty consecutive patients undergoing cardiac surgery with CPB were included in the study. Heparin was administered as an initial bolus of 300 IU kg−1 followed by additional boluses of 5000 IU to maintain ACT <400 s. In total, 361 blood samples were collected. The PK and PD data were analysed using a non-linear mixed effect model.Results. A two-compartment model with a linear elimination link to an Emax model best described heparin anti-factor Xa activities and ACT. Covariate analysis showed that body weight was positively correlated with clearance and central compartment volume. Inclusion of body weight with these parameters decreased their variability by 11 and 15%, respectively. The Bayesian estimator performed well in predicting individual parameters in an independent group of patients.Conclusions. A population PK/PD analysis of heparin during CPB, using a routine haemostatic test, shows that Bayesian estimation might help to predict ACT on the basis of only one or two blood samples.
      PubDate: 2017-05-15
  • Altered preoperative coagulation and fibrinolysis are associated with
           myocardial injury after non-cardiac surgery
    • Authors: Górka JJ; Polok KK, Iwaniec TT, et al.
      Abstract: Background. Myocardial injury after non-cardiac surgery (MINS), a complication with unclear pathogenesis, occurs within the first 30 days after surgery and worsens prognosis. Hypercoagulability induced by surgery might contribute to plaque rupture, with subsequent thrombosis and myocardial injury. This study assessed haemostatic markers before surgery and evaluated their association with MINS.Methods. This is a substudy of VISION, a prospective cohort study of perioperative cardiovascular events. Of 475 consecutive vascular surgery patients, 47 (9.9%) developed MINS, defined as postoperative high-sensitivity troponin  ≥50 ng litre−1, with ≥20% elevation from the preoperative concentration. The control group consisted of 84 non-MINS patients matched for patient characteristics and co-morbidities. The following preoperative markers of hypercoagulability and fibrinolysis were measured: antithrombin, factor VIII activity, von Willebrand factor concentration and activity, fibrinogen, D-dimer, plasmin–antiplasmin complex, and tissue plasminogen activator. Moreover, C-reactive protein and CD40L concentrations were measured to assess inflammatory activity.Results. Patients with MINS compared with the non-MINS group had a significantly higher concentration of factor VIII (186 vs 155%, P=0.006), von Willebrand factor activity (223 vs 160%, P<0.001), von Willebrand factor concentration (317 vs 237%, P=0.02), concentrations of fibrinogen (5.6 vs 4.2 g litre−1, P=0.03), D-dimer (1680.0 vs 1090.0 ng ml−1, P=0.04), plasmin–antiplasmin complex (747 vs 512 ng ml−1, P=0.002) and C-reactive protein (10 vs 4.5 mg litre−1, P=0.02) but not antithrombin (95 vs 94%, P=0.89), tissue plasminogen activator (11 vs 9.7 ng ml−1, P=0.06) and CD40L (8790 vs 8580 pg ml−1, P=0.73).Conclusions. Preoperative elevation of blood markers of hypercoagulability in patients undergoing vascular surgery is associated with a higher risk of MINS.Clinical trial registration. NCT00512109.
      PubDate: 2017-05-15
  • Propofol-based anaesthesia versus sevoflurane-based anaesthesia for living
           donor kidney transplantation: results of the VAPOR-1 randomized controlled
    • Authors: Nieuwenhuijs-Moeke GJ; Nieuwenhuijs VB, Seelen MJ, et al.
      Abstract: Background. Kidney transplantation is associated with harmful processes affecting the viability of the graft. One of these processes is associated with the phenomenon of ischaemia–reperfusion injury. Anaesthetic conditioning is a widely described strategy to attenuate ischaemia–reperfusion injury. We therefore conducted the Volatile Anaesthetic Protection of Renal Transplants-1 trial, a pilot project evaluating the influence of two anaesthetic regimens, propofol- vs sevoflurane-based anaesthesia, on biochemical and clinical outcomes in living donor kidney transplantation.Methods. Sixty couples were randomly assigned to the following three groups: PROP (donor and recipient propofol), SEVO (donor and recipient sevoflurane), and PROSE (donor propofol and recipient sevoflurane). The primary outcome was renal injury reflected by urinary biomarkers. The follow-up period was 2 yr.Results. Three couples were excluded, leaving 57 couples for analysis. Concentrations of kidney injury molecule-1 (KIM-1), N-acetyl-β-d-glucosaminidase (NAG), and heart-type fatty acid binding protein (H-FABP) in the first urine upon reperfusion showed no differences. On day 2, KIM-1 concentrations were higher in SEVO [952.8 (interquartile range 311.8–1893.0) pg mmol−1] compared with PROP [301.2 (202.0–504.7) pg mmol−1]. This was the same for NAG: SEVO, 1.835 (1.162–2.457) IU mmol−1vs PROP, 1.078 (0.819–1.713) IU mmol−1. Concentrations of H-FABP showed no differences. Measured glomerular filtration rate at 3, 6, and 12 months showed no difference. After 2 yr, there was a difference in the acute rejection rate (P=0.039). Post hoc testing revealed a difference between PROP (35%) and PROSE (5%; P=0.020). The difference between PROP and SEVO (11%) was not significant (P=0.110).Conclusions. The SEVO group showed higher urinary KIM-1 and NAG concentrations in living donor kidney transplantation on the second day after transplantation. This was not reflected in inferior graft outcome.Clinical trial registration. NCT01248871.
      PubDate: 2017-05-15
  • Measuring the anaesthesia clinical learning environment at the department
           level is feasible and reliable
    • Authors: Castanelli DJ; Smith NA.
      Abstract: Background. The learning environment describes the context and culture in which trainees learn. In order to establish the feasibility and reliability of measuring the anaesthetic learning environment in individual departments we implemented a previously developed instrument in hospitals across New South Wales.Methods. We distributed the instrument to trainees from 25 anaesthesia departments and supplied summarized results to individual departments. Exploratory and confirmatory factor analyses were performed to assess internal structure validity and generalizability theory was used to calculate reliability. The number of trainees required for acceptable precision in results was determined using the standard error of measurement.Results. We received 172 responses (59% response rate). Suitable internal structure validity was confirmed. Measured reliability was acceptable (G-coefficient 0.69) with nine trainees per department. Eight trainees were required for a 95% confidence interval of plus or minus 0.25 in the mean total score. Eight trainees as assessors also allow a 95% confidence interval of approximately plus or minus 0.3 in the subscale mean scores. Results for individual departments varied, with scores below the expected level recorded on individual subscales, particularly the ‘teaching’ subscale.Conclusions. Our results confirm that, using this instrument, individual departments can obtain acceptable precision in results with achievable trainee numbers. Additionally, with the exception of departments with few trainees, implementation proved feasible across a training region. Repeated use would allow departments or accrediting bodies to monitor their individual learning environment and the impact of changes such as the introduction of new curricular elements, or local initiatives to improve trainee experience.
      PubDate: 2017-05-15
  • Go/no-go decision in anaesthesia: wide variation in risk tolerance amongst
    • Authors: Greig PR; Higham HE, Darbyshire JL, et al.
      Abstract: Background. The variability in risk tolerance in medicine is not well understood. Parallels are often drawn between aviation and anaesthesia. The aviation industry is perceived as culturally risk averse, and part of preflight checks involves a decision on whether the flight can operate. This is sometimes termed a go/no-go decision. This questionnaire study was undertaken to explore the equivalent go/no-go decision in anaesthesia. We presented anaesthetists with a range of situations in which additional risk might be expected and asked them to decide whether they would proceed with the case.Methods. An electronic questionnaire was distributed to anaesthetic colleagues of all grades in one National Health Service Trust. Eleven scenarios, all drawn from critical incident data, were presented. Participants were invited to consider whether they would proceed, how they would modify their anaesthetic technique, and to predict whether a colleague with similar experience would make the same decision. Textual responses were analysed qualitatively.Results. The scenario response rate was 28%. Consultants were significantly more likely to proceed than trainees. In no scenario was there absolute agreement over whether to proceed, even in scenarios where national guidelines would suggest a case should be cancelled. Thematic analysis suggested a wide variability in what anaesthetists consider acceptable or professional behaviour.Conclusions. It is clear that safety decisions cannot be made in isolation and that clinicians must consider operational requirements, such as throughput, when making a go/no-go decision. The level of variability in decision-making was surprising, particularly for scenarios that appeared to go against guidelines.
      PubDate: 2017-05-15
  • Total haemoglobin mass, but not haemoglobin concentration, is associated
           with preoperative cardiopulmonary exercise testing-derived
           oxygen-consumption variables
    • Authors: Otto JM; Plumb JM, Wakeham DD, et al.
      Abstract: Background. Cardiopulmonary exercise testing (CPET) measures peak exertional oxygen consumption (V˙O2peak) and that at the anaerobic threshold (V˙O2 at AT, i.e. the point at which anaerobic metabolism contributes substantially to overall metabolism). Lower values are associated with excess postoperative morbidity and mortality. A reduced haemoglobin concentration ([Hb]) results from a reduction in total haemoglobin mass (tHb-mass) or an increase in plasma volume. Thus, tHb-mass might be a more useful measure of oxygen-carrying capacity and might correlate better with CPET-derived fitness measures in preoperative patients than does circulating [Hb].Methods. Before major elective surgery, CPET was performed, and both tHb-mass (optimized carbon monoxide rebreathing method) and circulating [Hb] were determined.Results. In 42 patients (83% male), [Hb] was unrelated to V˙O2 at AT and V˙O2peak (r=0.02, P=0.89 and r=0.04, P=0.80, respectively) and explained none of the variance in either measure. In contrast, tHb-mass was related to both (r=0.661, P<0.0001 and r=0.483, P=0.001 for V˙O2 at AT and V˙O2peak, respectively). The tHb-mass explained 44% of variance in V˙O2 at AT (P<0.0001) and 23% in V˙O2peak (P=0.001).Conclusions. In contrast to [Hb], tHb-mass is an important determinant of physical fitness before major elective surgery. Further studies should determine whether low tHb-mass is predictive of poor outcome and whether targeted increases in tHb-mass might thus improve outcome.
      PubDate: 2017-05-15
  • Burst-suppression ratio underestimates absolute duration of
           electroencephalogram suppression compared with visual analysis of
           intraoperative electroencephalogram
    • Authors: Muhlhofer WG; Zak RR, Kamal TT, et al.
      Abstract: Background. Machine-generated indices based on quantitative electroencephalography (EEG), such as the patient state index (PSI™) and burst-suppression ratio (BSR), are increasingly being used to monitor intraoperative depth of anaesthesia in the endeavour to improve postoperative neurological outcomes, such as postoperative delirium (POD). However, the accuracy of the BSR compared with direct visualization of the EEG trace with regard to the prediction of POD has not been evaluated previously.Methods. Forty-one consecutive patients undergoing non-cardiac, non-intracranial surgery with general anaesthesia wore a SedLine® monitor during surgery and were assessed after surgery for the presence of delirium with the Confusion Assessment Method. The intraoperative EEG was scanned for absolute minutes of EEG suppression and correlated with the incidence of POD. The BSR and PSI™ were compared between patients with and without POD.Results. Visual analysis of the EEG by neurologists and the SedLine®-generated BSR provided a significantly different distribution of estimated minutes of EEG suppression (P=0.037). The Sedline® system markedly underestimated the amount of EEG suppression. The number of minutes of suppression assessed by visual analysis of the EEG was significantly associated with POD (P=0.039), whereas the minutes based on the BSR generated by SedLine® were not associated with POD (P=0.275).Conclusions. Our findings suggest that SedLine® (machine)-generated indices might underestimate the minutes of EEG suppression, thereby reducing the sensitivity for detecting patients at risk for POD. Thus, the monitoring of machine-generated BSR and PSI™ might benefit from the addition of a visual tracing of the EEG to achieve a more accurate and real-time guidance of anaesthesia depth monitoring and the ultimate goal, to reduce the risk of POD.
      PubDate: 2017-05-15
  • Patient choice compared with no choice of intrathecal morphine dose for
           caesarean analgesia: a randomized clinical trial
    • Authors: Carvalho BB; Mirza FF, Flood PP.
      Abstract: Background: The study aimed to determine whether a patient’s choice for their intrathecal morphine (ITM) dose reflects their opioid requirements and pain after caesarean delivery and if giving women a choice of ITM dose would reduce opioid use and improve pain scores compared with women who did not have a choice.Methods: A total of 120 women undergoing caesarean delivery with spinal anaesthesia were enrolled in this randomized, double-blind study. Patients were randomly assigned to a choice of 100 or 200 μg ITM or no choice. The study involved deception, such that all participants were still randomly assigned 100 or 200 μg ITM regardless of choice. Rescue opioid use over the 48-h study period was the primary outcome measure. Pain at rest and movement and side effect (pruritus, nausea, and vomiting) data were collected 3, 6, 12, 24, 36 and 48 h postoperatively. Data are presented as median [95% confidence interval (CI)].Results: Women who requested the larger ITM dose required more supplemental opioid [median 0.8 (95% CI 0.4–1.3)] mg morphine equivalents at each assessment interval; P < 0.001] and reported more pain with movement [median 1.2 (95% CI 0.5–1.9)] verbal numerical rating score of 0–10 points] than patients who requested the smaller ITM dose (P = 0.0008), regardless of the ITM dose given. There was no difference in opioid use whether the patient was offered a perceived choice or not.Conclusions: Women who were given a choice and chose the larger ITM dose correctly anticipated a greater postoperative opioid requirement and more pain compared with women who chose the smaller dose. Simply being offered a choice did not impact opioid use or pain scores after caesarean delivery.Trial Registration: (NCT01425762).
      PubDate: 2017-05-15
  • Efficacy and safety of carbetocin given as an intravenous bolus compared
           with short infusion for Caesarean section - double-blind, double-dummy,
           randomized controlled non-inferiority trial
    • Authors: Dell-Kuster SS; Hoesli II, Lapaire OO, et al.
      Abstract: Background. Carbetocin is a synthetic oxytocin-analogue, which should be administered as bolus according to manufacturer’s recommendations. A higher speed of oxytocin administration leads to increased cardiovascular side-effects. It is unclear whether carbetocin administration as short infusion has the same efficacy on uterine tone compared with bolus administration and whether haemodynamic parameters differ.Methods. In this randomized, double-blind, non-inferiority trial, women undergoing planned or unplanned Caesarean section (CS) under regional anaesthesia received a bolus and a short infusion, only one of which contained carbetocin 100 mcg (double dummy). Obstetricians quantified uterine tone two, three, five and 10 min after cord-clamping by manual palpation using a linear analogue scale from 0 to 100. We evaluated whether the lower limit of the 95% CI of the difference in maximum uterine tone within the first five min after cord-clamping did not include the pre-specified non-inferiority limit of −10.Results. Between December 2014 and November 2015, 69 patients were randomized to receive carbetocin as bolus and 71 to receive it as short infusion. Maximal uterine tone was 89 in the bolus and 88 in the short infusion group (mean difference −1.3, 95% CI −5.7 to 3.1). Bp, calculated blood loss, use of additional uterotonics, and side-effects were comparable.Conclusions. Administration of carbetocin as short infusion does not compromise uterine tone and has similar cardiovascular side-effects as a slow i.v. bolus. In accordance with current recommendations for oxytocin, carbetocin can safely be administered as short -infusion during planned or unplanned CS.Clinical trial registration. NCT02221531 and SNCTP000001197.
      PubDate: 2017-05-15
  • Effect of caudal block using different volumes of local anaesthetic on
           optic nerve sheath diameter in children: a prospective, randomized trial
    • Authors: Lee BB; Koo BN, Choi YS, et al.
      Abstract: Background: Caudal block is commonly administered for postoperative analgesia in children. Although caudal block with 1.5 ml kg−1 local anaesthetic has been reported to reduce cerebral oxygenation in infants, the effect of caudal block on intracranial pressure (ICP) in children has not been well investigated. Optic nerve sheath diameter (ONSD) correlates with degree of ICP. This study aimed to estimate the effects of caudal block on ICP according to volume of local anaesthetic using ultrasonographic measurement of ONSD in children.Methods: Eighty patients, 6- to 48-months-old, were randomly allocated to the high-volume (HV) or low-volume (LV) groups for caudal block with ropivacaine 0.15%, 1.5 ml kg−1 or 1.0 ml kg−1, respectively. Measurement of ONSD was performed before (T0), immediately after (T1), and 10 min (T2) and 30 min (T3) after caudal block.Results: The two groups exhibited significant differences in ONSD according to time (PGroup x Time=0.003). The HV group exhibited significantly greater changes in ONSD from T0 to T2 and T3 than the LV group. However, in both groups, ONSDs at T1, T2 and T3 were significantly greater compared with those at T0, with the highest values at T2.Conclusions: Caudal block with a high volume of local anaesthetic can cause a greater increase in ICP than caudal block with a low volume of local anaesthetic. However, caudal block with 1.0 ml kg−1 of local anaesthetic can also result in a significant increase in ICP.Clinical trial registration. NCT02768493.
      PubDate: 2017-05-15
  • Early or late fresh frozen plasma administration in newborns and small
           infants undergoing cardiac surgery: the APPEAR randomized trial
    • Authors: Bianchi PP; Cotza MM, Beccaris CC, et al.
      Abstract: Background. In newborns and small infants undergoing cardiac surgery with cardiopulmonary bypass (CPB) and blood priming, it is unclear whether there is reduced blood loss if fresh frozen plasma (FFP) is added to the CPB priming volume. This single-centre, randomized trial tested the hypothesis that the administration of FFP after CPB (late FFP group) is superior to FFP priming (early FFP group) in terms of postoperative bleeding and overall red blood cell (RBC) transfusion.Methods. Seventy-three infants weighing <10 kg were randomly allocated to receive FFP to supplement RBCs in the CPB priming solution (n=36) or immediately after CPB (n=37). The primary endpoint was a difference in postoperative blood loss; secondary endpoints included the amount of RBCs and FFP transfused through the first 48 postoperative hours.Results. All patients were included in the analysis. Patients in the late FFP arm had greater postoperative mean blood loss than patients in the early FFP arm [33.1 (sd 20.6) vs 24.1 (12.9) ml kg−1; P=0.028], but no differences in transfusions were found. The subgroup of cyanotic heart disease patients had comparable results, but with greater use of RBCs in the late FFP group.Conclusions. In infants undergoing cardiac surgery, FFP in the priming solution appears slightly superior to late administration in terms of postoperative bleeding.Clinical trial, NCT02738190.
      PubDate: 2017-05-15
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