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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: 59, SJR: 1.512, h-index: 46)
Age and Ageing     Hybrid Journal   (Followers: 85, SJR: 1.611, h-index: 107)
Alcohol and Alcoholism     Hybrid Journal   (Followers: 16, SJR: 0.935, h-index: 80)
American Entomologist     Full-text available via subscription   (Followers: 6)
American Historical Review     Hybrid Journal   (Followers: 139, SJR: 0.652, h-index: 43)
American J. of Agricultural Economics     Hybrid Journal   (Followers: 40, SJR: 1.441, h-index: 77)
American J. of Epidemiology     Hybrid Journal   (Followers: 171, SJR: 3.047, h-index: 201)
American J. of Hypertension     Hybrid Journal   (Followers: 23, SJR: 1.397, h-index: 111)
American J. of Jurisprudence     Hybrid Journal   (Followers: 17)
American J. of Legal History     Full-text available via subscription   (Followers: 6, SJR: 0.151, h-index: 7)
American Law and Economics Review     Hybrid Journal   (Followers: 25, 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: 36, SJR: 1.912, h-index: 124)
Annals of Occupational Hygiene     Hybrid Journal   (Followers: 28, SJR: 0.837, h-index: 57)
Annals of Oncology     Hybrid Journal   (Followers: 49, 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: 20)
Arbitration Law Reports and Review     Hybrid Journal   (Followers: 13)
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: 49, SJR: 1.698, h-index: 92)
Bioinformatics     Hybrid Journal   (Followers: 304, 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: 30, 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: 148, SJR: 2.314, h-index: 133)
BJA Education     Hybrid Journal   (Followers: 64, SJR: 0.272, h-index: 20)
Brain     Hybrid Journal   (Followers: 61, SJR: 6.097, h-index: 264)
Briefings in Bioinformatics     Hybrid Journal   (Followers: 44, 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: 34, SJR: 1.267, h-index: 38)
British J. of Aesthetics     Hybrid Journal   (Followers: 26, SJR: 0.217, h-index: 18)
British J. of Criminology     Hybrid Journal   (Followers: 527, SJR: 1.373, h-index: 62)
British J. of Social Work     Hybrid Journal   (Followers: 83, 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: 27)
Bulletin of the London Mathematical Society     Hybrid Journal   (Followers: 3, SJR: 1.474, h-index: 31)
Cambridge J. of Economics     Hybrid Journal   (Followers: 58, SJR: 0.957, h-index: 59)
Cambridge J. of Regions, Economy and Society     Hybrid Journal   (Followers: 11, SJR: 1.067, h-index: 22)
Cambridge Quarterly     Hybrid Journal   (Followers: 11, SJR: 0.1, h-index: 7)
Capital Markets Law J.     Hybrid Journal   (Followers: 1)
Carcinogenesis     Hybrid Journal   (Followers: 2, SJR: 2.439, h-index: 167)
Cardiovascular Research     Hybrid Journal   (Followers: 12, SJR: 2.897, h-index: 175)
Cerebral Cortex     Hybrid Journal   (Followers: 41, 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: 21, SJR: 0.737, h-index: 11)
Chinese J. of Intl. Politics     Hybrid Journal   (Followers: 9, 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: 24, 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: 7, 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: 5, SJR: 0.313, h-index: 10)
Critical Values     Full-text available via subscription  
Current Legal Problems     Hybrid Journal   (Followers: 26)
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: 19, 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: 15, SJR: 0.124, h-index: 11)
Economic Policy     Hybrid Journal   (Followers: 63, SJR: 2.052, h-index: 52)
ELT J.     Hybrid Journal   (Followers: 25, SJR: 1.26, h-index: 23)
English Historical Review     Hybrid Journal   (Followers: 51, SJR: 0.311, h-index: 10)
English: J. of the English Association     Hybrid Journal   (Followers: 13, 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: 26, SJR: 0.197, h-index: 25)
EP-Europace     Hybrid Journal   (Followers: 2, SJR: 2.201, h-index: 71)
Epidemiologic Reviews     Hybrid Journal   (Followers: 10, SJR: 3.917, h-index: 81)
ESHRE Monographs     Hybrid Journal  
Essays in Criticism     Hybrid Journal   (Followers: 16, SJR: 0.1, h-index: 6)
European Heart J.     Hybrid Journal   (Followers: 49, SJR: 6.997, h-index: 227)
European Heart J. - Cardiovascular Imaging     Hybrid Journal   (Followers: 8, 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: 7, SJR: 0.152, h-index: 31)
European J. of Cardio-Thoracic Surgery     Hybrid Journal   (Followers: 8, SJR: 1.568, h-index: 104)
European J. of Intl. Law     Hybrid Journal   (Followers: 160, 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: 11, SJR: 1.549, h-index: 42)
European Review of Economic History     Hybrid Journal   (Followers: 28, SJR: 0.628, h-index: 24)
European Sociological Review     Hybrid Journal   (Followers: 41, SJR: 2.061, h-index: 53)
Evolution, Medicine, and Public Health     Open Access   (Followers: 11)
Family Practice     Hybrid Journal   (Followers: 11, SJR: 1.048, h-index: 77)
Fems Microbiology Ecology     Hybrid Journal   (Followers: 9, 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: 22, 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: 32, SJR: 0.123, h-index: 10)
French Studies     Hybrid Journal   (Followers: 20, 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: 34, 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: 49, 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: 20, SJR: 1.628, h-index: 66)
Health Promotion Intl.     Hybrid Journal   (Followers: 21, 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: 24, SJR: 0.115, h-index: 13)
Human Molecular Genetics     Hybrid Journal   (Followers: 9, SJR: 4.288, h-index: 233)
Human Reproduction     Hybrid Journal   (Followers: 78, SJR: 2.271, h-index: 179)
Human Reproduction Update     Hybrid Journal   (Followers: 17, 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: 54, SJR: 1.233, h-index: 88)
ICSID Review     Hybrid Journal   (Followers: 10)
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: 30, 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: 5, SJR: 0.743, h-index: 35)
Intl. Affairs     Hybrid Journal   (Followers: 52, SJR: 1.264, h-index: 53)
Intl. Data Privacy Law     Hybrid Journal   (Followers: 28)
Intl. Health     Hybrid Journal   (Followers: 5, 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: 33, SJR: 1.593, h-index: 69)
Intl. J. of Constitutional Law     Hybrid Journal   (Followers: 60, SJR: 0.613, h-index: 19)
Intl. J. of Epidemiology     Hybrid Journal   (Followers: 148, SJR: 4.381, h-index: 145)
Intl. J. of Law and Information Technology     Hybrid Journal   (Followers: 4, SJR: 0.247, h-index: 8)
Intl. J. of Law, Policy and the Family     Hybrid Journal   (Followers: 29, 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: 9, SJR: 0.906, h-index: 33)
Intl. J. of Refugee Law     Hybrid Journal   (Followers: 33, 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: 31, SJR: 1.339, h-index: 19)
Intl. Relations of the Asia-Pacific     Hybrid Journal   (Followers: 18, 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: 39, SJR: 2.184, h-index: 68)
Intl. Studies Review     Hybrid Journal   (Followers: 18, 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: 43, 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: 13, 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: 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: 35, 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: 13, SJR: 0.196, h-index: 15)
J. of Consumer Research     Full-text available via subscription   (Followers: 43, SJR: 4.896, h-index: 121)
J. of Crohn's and Colitis     Hybrid Journal   (Followers: 10, SJR: 1.543, h-index: 37)
J. of Cybersecurity     Hybrid Journal   (Followers: 3)
J. of Deaf Studies and Deaf Education     Hybrid Journal   (Followers: 9, SJR: 0.69, h-index: 36)
J. of Design History     Hybrid Journal   (Followers: 16, 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: 39, 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: 23, SJR: 1.314, h-index: 27)
J. of Global Security Studies     Hybrid Journal   (Followers: 3)
J. of Heredity     Hybrid Journal   (Followers: 4, 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: 39, SJR: 4, h-index: 209)
J. of Insect Science     Open Access   (Followers: 8, SJR: 0.388, h-index: 31)

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Journal Cover BJA : British Journal of Anaesthesia
  [SJR: 2.314]   [H-I: 133]   [148 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]
  • 24th Annual Meeting of the Chinese Society of Anesthesiology
    • Abstract: Guangzhou, China, August 25–28, 2016 
      PubDate: 2017-09-28
  • Review: Brown’s Atlas of Regional Anesthesia . E Farag and L
           Mounir-Soliman (editors) & Brown’s Regional Anesthesia Review . E
           Farag and L Mounir-Soliman (editors)
    • Authors: Tedore TT.
      Abstract: Review: Brown’s Atlas of Regional Anesthesia.FaragE and Mounir-SolimanL (editors), 5th edn, 2017. Published by Elsevier. Pp. 376. Price $199.99. ISBN-13: 978-0323354905.
      PubDate: 2017-09-28
  • In the October BJA …
    • Abstract: This issue of the BJA contains a special section on pain medicine that includes articles on acute and chronic pain in the context of anaesthesia. The main section of the Journal includes a number of articles relevant to perioperative outcomes in sepsis and septic shock, and in cardiac, abdominal, and lung resection surgery. There are also articles on the impact of non-depolarising neuromuscular blocking agents, beta-blockers, and statins on perioperative outcomes. The Neurosciences and Neuroanaesthesia section features three articles and three editorials related to anaesthetic effects on neuronal network connectivity as it relates to unconsciousness. And the Quality and Patient Safety section features an article with an editorial on the impact of anaesthetist gender on communication in simulated crisis situations.
      PubDate: 2017-09-28
  • Diastolic dysfunction and sepsis: the devil is in the detail
    • Authors: Poelaert JJ.
      Abstract: Diastolic dysfunction is the consequence of impaired left ventricular relaxation, decreased recoil and decreased ventricular compliance.1 Before the era of tissue Doppler imaging (TDI), pulmonary vein Doppler imaging in conjunction with transmitral Doppler, was a major tool in identifying diastolic dysfunction, also in septic shock patients.2 Pulmonary vein Doppler assessment with a systolic (S) < diastolic (D) flow velocity supports the finding of elevated left ventricular filling pressures in a euvolaemic patient.
      PubDate: 2017-09-28
  • Readmission after surgery: are neuromuscular blocking drugs a cause'
    • Authors: Blobner MM; Ulm KK, Hunter J.
      Abstract: Neuromuscular blocking drugs (NMBDs) play an integral role in balanced anaesthesia. They improve intubating conditions, reduce iatrogenic damage to the upper airway and decrease postoperative hoarseness.1 They also improve surgical operating conditions.2 But use of NMBDs always carries the risk of residual neuromuscular block postoperatively. About 30% of all patients who receive NMBDs intraoperatively show signs of residual neuromuscular block when arriving in the post-anaesthesia care unit.3–5 It has been suggested that residual neuromuscular block can cause postoperative pulmonary complications.6–8
      PubDate: 2017-09-28
  • Age and inflammation after cardiac surgery
    • Authors: Hernandez AA; Shaw AD.
      Abstract: The cardiac surgical population is aging and these patients have increased expectations with respect to quantity and quality of postoperative survival. Some of the physiological changes related to aging that impact surgical outcomes are better understood than others, and recently we are also beginning to gain a better understanding of the impact of aging on immunity and the immune response to surgery.12
      PubDate: 2017-09-28
  • Hierarchy in disruption of large-scale networks across altered arousal
    • Authors: Lewis LD; Akeju OO.
      Abstract: Understanding how anaesthetics act within neural circuits to induce altered arousal states that range from sedation to general anaesthesia is an important question in neuroscience. Studies in laboratory animals demonstrate that anaesthetics including propofol, ether derivatives, and dexmedetomidine induce activity patterns in brainstem arousal nuclei that are similar to natural sleep.1–3 However, anaesthetic drug action in brainstem arousal nuclei may provide only a partial answer to explain the behavioural and neurophysiological distinctions between anaesthesia-induced states and sleep, because anaesthetics also significantly modulate neuronal activity in other brain regions such as the thalamus and cortex.45 Insights into how anaesthetics disrupt networks that sustain consciousness have been constrained by the practical and ethical challenges involved in noninvasively studying human brain activity. Guldenmund and colleagues6 used human neuroimaging to study large-scale network disruptions that are associated with dexmedetomidine and propofol sedation, two anaesthetic drugs with different receptor level targets.
      PubDate: 2017-09-28
  • Fading whispers down the lane: signal propagation in anaesthetized
           cortical networks
    • Authors: Mashour GA; Hudetz AG.
      Abstract: An active area of enquiry in the neuroscientific investigation of general anaesthesia is the question of whether anaesthetic-induced unconsciousness is mediated by bottom-up or top-down mechanisms in the brain. Candidates for the bottom-up approach include suppression of arousal centres in the brainstem and diencephalon,12 activation of sleep-promoting neurones or nuclei in similar locations,13 blockade of sensory information en route from the thalamus to the cortex,4 and a disabled thalamic conductor for the neuronal orchestra of the cortex.5 Candidates for the top-down approach include direct effects on long-latency activity in cortical networks,6 with a consequent disruption of higher-order information synthesis that occurs beyond the level of the primary sensory cortex.7–9 This bottom-up vs top-down distinction is almost surely artificial given the integrated circuits required for the normal function of neural systems and the widespread effects of general anaesthetics on the brain. We recently proposed that anaesthetics alter the level of consciousness (e.g. awake vs somnolent) through bottom-up mechanisms while degrading the contents of consciousness (e.g. the particular qualities of experience) through top-down mechanisms.10 Developing a clearer understanding of these processes is important because it can inform (i) the neurobiology of consciousness, a fundamental question in science, and (ii) our approach to brain monitoring, a fundamental and unmet challenge in clinical anaesthesia. However, it is difficult to address this question by investigating individual brain areas or molecular targets in the laboratory and also difficult to distinguish cortical and subcortical mechanisms through human neuroimaging and neurophysiology. In this issue of the British Journal of Anaesthesia, Hentschke and colleagues11 examine an intermediate level of neuroanatomy and neurophysiology in a cortical slice model, finding more profound effects of isoflurane on signal propagation through the cortex than to the cortex.
      PubDate: 2017-09-28
  • Speaking up: does anaesthetist gender influence teamwork and
    • Authors: Garden AL; Weller JM.
      Abstract: Speaking up can be defined as explicitly communicating observations or concerns, requesting clarification or explanation, or explicitly challenging a colleague’s decision or action.1 Speaking up provides an opportunity to intervene before patient harm occurs, or to mitigate actual harm, and is a key element in effective teamwork and collaboration.2 The importance of speaking up is most evident in its absence, where colleagues remain silent or make ineffectual attempts at speaking up, and erroneous actions proceed to cause patient harm. There are many prominent examples where failing to speak up in an effective manner has contributed to accidents and catastrophes in aviation,3 space exploration4 and in healthcare.5
      PubDate: 2017-09-28
  • Special section on pain: progress in pain assessment and management
    • Authors: Colvin LL.
      Abstract: This issue of the British Journal of Anaesthesia has a special section on pain, featuring a number of editorials, reviews and original articles across a range of areas in pain medicine. The last BJA special issue on pain medicine was in July 2013, entitled “Managing pain: recent advances and new challenges”, as summarized in the lead editorial of that issue.1 A similar title could be used for this month's special section. Pain medicine continues to evolve, with advances in acute, chronic and cancer pain understanding and management. However, the challenges remain, and arguably, increase, as our population ages: Pain is one of the biggest causes of disability globally, with musculoskeletal pain being the leading cause of disability in most countries in 2015.23 Managing pain successfully - acute, chronic or cancer - is an area where there is potential major clinical benefit both at an individual and societal level.
      PubDate: 2017-09-28
  • Guidelines for perioperative pain management: need for re-evaluation
    • Authors: Joshi GP; Kehlet HH, , et al.
      Abstract: Optimal perioperative pain management facilitates postoperative ambulation and rehabilitation, and is considered a prerequisite to enhancing recovery after surgery.12 Despite well-documented benefits, postoperative pain continues to be inadequately treated.3–5 Although the reasons for the lack of appropriate pain management are not precisely known, conflicting and confusing evidence as well as lack of clear guidance could be contributing factors.
      PubDate: 2017-09-28
  • NeuPSIG: investing in solutions to the growing global challenge of
           neuropathic pain
    • Authors: Smith BH; Raja SN.
      Abstract: This issue of the British Journal of Anaesthesia (BJA) includes two excellent review papers discussing epidemiology, mechanisms and management of pain after cancer.12 These were presented in a workshop at the 6th International Congress on Neuropathic Pain, in June 2017, sponsored by the BJA. Cancer pain is a distressing, chronic painful condition, which is generally under-recognized yet whose importance in society is increasing as cancer survivorship improves and people live longer with lasting side-effects of treatment.3
      PubDate: 2017-09-28
  • Monitoring nociception—getting ‘ there yet’ might be
           easier with a road map
    • Authors: Ledowski TT.
      Abstract: General anaesthesia can be described simplistically as a combination of hypnosis, anti-nociception and muscle relaxation. To allow a goal-directed approach to each component, validated and user-friendly monitoring solutions are essential. However, although the measurement of neuromuscular paralysis, as well as depth of anaesthesia, has been established for decades,12 the reliable assessment of (anti-)nociception appears to remain an elusive goal. The lack of such a tool is of specific interest as it relates to the current debate about the ideal (if any) doses of intraoperative opioids, because of the growing understanding of their potentially significant non-analgesic side-effects, such as immunosuppression.3 Traditionally, clinicians utilize symptoms of the physiological stress response to nociceptive stimuli (i.e. increase of heart rate, blood pressure or lacrimation) to guide analgesic administration. However, as the incidence of significant postoperative pain is still as high as 20–80%,4 administration of intraoperative analgesics guided by clinical symptoms alone appears to be of very limited value for the prevention of acute postoperative pain.
      PubDate: 2017-09-28
  • The dilemma of interventional pain trials: thinking beyond the box
    • Authors: Poply KK; Mehta VV.
      Abstract: “I want a parachute that is based on good research”1Interventional pain medicine is rapidly growing, yet it is lacking in robust evidence. The problem is not limited to a particular geography, rather it is ubiquitous across the globe, with uniform dearth of good-quality data. The increasing numbers of intervention procedures speak for themselves; as per 2014–15 UK Hospital Episodes Statistics (HES) data, there were 82 188 therapeutic epidurals, 13 796 facet joint denervations, and 83 308 ‘other procedures’ around the spine.2 The narrative is similar in the USA, with a ∼11% annual increase in select Medicare service beneficiaries, whereas facet joint and sacroiliac joint interventions increased by 313% in the last decade.3 Understandably, this presents a challenge to commissioners, funding organizations, and prescribers alike. Considering the competing interests of funding authorities and health policy-makers to execute cost-saving measures, whilst ensuring sustainability of the delivery of the health-care system, it is more imperative than before that we address this issue, so as to allow a congenial conclusion to this rather needless rigmarole.
      PubDate: 2017-09-28
  • Should we use hypotonic or isotonic maintenance intravenous fluids in sick
           patients' Why a study in healthy volunteers will not provide the
           answer Response to: Effect of isotonic versus hypotonic maintenance fluid
           therapy on urine output, fluid balance, and electrolyte homeostasis: a
           crossover study in fasting adult volunteers
    • Authors: Leroy PL; Hoorn EJ.
      Abstract: Editor—Sick patients who are unable to ingest oral fluids usually receive i.v. maintenance fluid therapy (IVMFT). The main goal of IVMFT is to temporarily meet water, electrolyte and glucose needs pending a more sustainable (par)enteral solution for feeding and hydration. Despite routine application, IVMFT is often based on dogmatic principles rather than high quality empirical research.1 Furthermore, macro- and micronutrient deficiencies, fluid overload, hyperchloraemic acidosis and hyponatraemia have all been reported as potentially detrimental complications. Fortunately, well-designed high quality studies performed over the last decade have substantially improved our insights into safe and effective IVMFT. Recently, Van Regenmortel and colleagues2 contributed additional data to this growing body of evidence by comparing the effects of isotonic and hypotonic IVMFT in healthy adult volunteers. They conclude that a hypotonic IVMFT (NaCl 0.32%) increased diuresis and resulted in significantly less intravascular fluid retention compared with isotonic IVMFT (NaCl 0.9%). In line with a previous report by this group, the authors argue that IVMFT should be hypotonic in order to avoid fluid overload.3
      PubDate: 2017-09-28
  • Cardiopulmonary exercise testing in preoperative risk assessment and
           patient management
    • Authors: Older PP; Hall AA.
      Abstract: Editor—The article by Swart and colleagues1 aroused our interest. In 1999 our group published a paper in which we used cardiopulmonary exercise testing (CPX) to stratify surgical risk in 548 consecutive patients >60 years of age (or younger with known cardiopulmonary disease).2 We found that, to quote, ‘In elderly patients undergoing major intra-abdominal surgery, the AT (anaerobic threshold), as determined by CPX testing, is an excellent predictor of mortality from cardiopulmonary causes in the postoperative period. Preoperative screening using CPX testing allowed the identification of high-risk patients and the appropriate selection of perioperative management’.
      PubDate: 2017-09-28
  • Does surrounding temperature influence the rate of hypothermia during
           Caesarean section'
    • Authors: Siedentopf JP.
      Abstract: Editor—I read the meta-analysis by Sultan and colleagues1 and the comment thereon by Nair2 with great interest. Although the duration of a Caesarean section is short, the exposed abdomen loses warmth by radiation and convection, leading to a reportedly high rate of hypothermia after surgery. In addition to the size of the exposed area, temperature loss is proportional to the difference in temperature (Fourier’s law). I am astonished that neither the review by Sultan and colleagues1, nor other reviews like the one by Munday and colleagues,3 mention the temperature of the operation theatre as an influential factor to the parturitients’ and neonates’ body temperature. Unfortunately this leaves me clueless as to which temperature I should recommend for setting the operation theatre air-conditioning system.
      PubDate: 2017-09-28
  • Ambient operating room temperature: mother, baby or surgeon'
    • Authors: Sultan PP; Habib AS, Carvalho BB.
      Abstract: Editor—We thank Siedentopf1 for raising an important point regarding ambient operating theatre temperature and its potential influence upon maternal and neonatal hypothermia during and after Caesarean delivery. The World Health Organization (WHO) recommends a delivery room temperature of 25–28 °C to reduce the incidence of neonatal hypothermia.2 These guidelines do not, however, specifically recommend ideal operating theatre ambient temperatures nor the optimal temperature required to prevent maternal hypothermia. A recently published study by Duryea and colleagues3 specifically explored the impact of operating theatre temperature on maternal and neonatal outcomes. The authors performed a cluster randomization schedule to either 20°C (standard operating room ambient temperature) or 23 °C (maximum ambient temperature allowed by hospital policy). Results from 791 mothers (and 825 neonates) undergoing elective or emergency Caesarean delivery under either regional or general anaesthesia demonstrated a significantly lower incidence of mild (<36.5 °C) and moderate-to-severe neonatal hypothermia (<36 °C) when ambient operating theatre temperature was 23 °C, with concomitant use of warmed fluids in all parturients. Although neonatal morbidity did not differ between groups, the study was not powered to detect such differences. Maternal hypothermia on arrival to the postoperative care area was only modestly reduced with increased operating theatre temperature (36.1 ± 0.6 °C vs 36.2 ± 0.6 °C) with no clinical differences between groups.
      PubDate: 2017-09-28
  • Response to: Emergency front-of-neck access: scalpel or cannula—and the
           parable of Buridan’s ass
    • Authors: Cook TM.
      Abstract: Editor—I was interested to read the editorial by Greenland and colleagues1 that contributes further to the debate that has raged for some time over whether a cannot intubate, cannot oxygenate (CICO) situation should be managed with a fine needle or scalpel cricothyroidotomy approach.
      PubDate: 2017-09-28
  • The paradox in the current use of videolaryngoscopes in the UK
    • Authors: Marathe SS; Poncia JJ, Kasivisvanathan RR.
      Abstract: Editor—The recent national survey by Cook and Kelly1 is the first to provide a comprehensive overview of the current usage and practices of videolaryngoscopes (VLs) in UK clinical practice. We feel we can add to this area and would like to present some of the results of a regional survey on VLs that we conducted to gain an understanding of current practices and decision-making in the use of VLs in general airway management in the operating theatre (OT). The survey was conducted electronically via SurveyMonkey (San Mateo, CA, USA) and was distributed to 10 departments of anaesthesia in the London Deanery (London, UK) in December 2016. There were 171 responses collected between December 2016 and January 2017 with a response rate of about 51%, including 44% consultants, 21% specialty Registrar (StR) yr 7–yr 5, 14% StR yr 4–yr 3, and 7% core trainees. Selected findings from the survey were as follows: When asked whether VLs should be first line management strategy for anticipated difficult intubation (where bag mask ventilation was not predicted difficult), when given the choice between a VL and a Macintosh laryngoscope short/long blade +/–bougie, 51% of those surveyed preferred to use a VL.When asked whether VLs should be used routinely for intubation in all patients, regardless of predicted difficulty of intubation, 14% of respondents thought that VLs should be used routinely.When asked how many uses it approximately required to gain subjective competence in the use of any VL, 68% of respondents felt it required over 10 uses, 32% felt it required over 20 uses and 13% felt it required over 30 uses.When asked whether anaesthetists should begin their core training with VLs alongside the Macintosh laryngoscope as first line for all intubations, 10% of respondents were of the opinion that this should be the case.
      PubDate: 2017-09-28
  • Routine videolaryngoscopy is likely to improve skills needed to use a
           videolaryngoscope when laryngoscopy is difficult
    • Authors: Kelly FE; Cook TM.
      Abstract: Editor–We read Dr Marathe and colleagues’1 comments with great interest. Their survey, though small, is interesting as it explores current attitudes to videolaryngoscopy (VL). In our department, we are familiar with individual reticence to use VL and identified the same before introduction of universal availability of VL in 2014. In our hospital, 92% of trainee anaesthetists were opposed to a trial of universal VL in 2014, primarily because of training concerns. Within eight months this reticence was replaced with widespread enthusiasm and uptake: 95% then reported that VL had enhanced their training and their development as an anaesthetist (data submitted for publication). This enthusiasm was mirrored in our anaesthetic assistants.
      PubDate: 2017-09-28
  • An algorithm for suboptimally placed supraglottic airway devices: the
           choice of videolaryngoscope
    • Authors: Tobin SP; Maloney DG, Walker JD.
      Abstract: Editor—We agree with Zundert and colleagues1 that anaesthetists sometimes accept lower standards for supraglottic airway device (SAD) placement than for tracheal tube placement. They advocate the use of videolaryngoscopy to correct a suboptimal SAD position using an algorithm, however they do not make any specific recommendation about which type of videolaryngoscope to use. A variety of classifications of videolaryngoscopes exist,2–5 and some classes (for example, channelled videolaryngoscopes) might prove to be very difficult to use in this situation; some may even cause trauma in the reduced space available when an SAD is present. Zundert and colleagues 6 have previously referenced the C-MAC videolaryngoscope (Karl Storz, Tuttlingen, Germany) in this situation, but presumably other Macintosh-type bladed scopes would be acceptable. We would be keen to learn whether they have experience of other videolaryngoscopes, and we also wondered whether they had considered the place of the optical stylet.
      PubDate: 2017-09-28
  • Reply to Tobin and colleagues
    • Authors: Van Zundert AJ; Gatt SP, Kumar CM, et al.
      Abstract: Editor—We thank Tobin and colleagues1 for their constructive remarks on our Editorial.2
      PubDate: 2017-09-28
  • Is the bougie redundant in direct laryngoscopic grade 3 intubations'
    • Authors: Craig TT; Bird SS.
      Abstract: A 51-year-old woman presented for major elective colorectal surgery with predicted difficult intubation (Mallampati score 3, small mouth opening) and a video laryngoscope was prepared as a ‘plan B’. After induction, the patient’s lungs were easily ventilated with a bag valve mask. Direct laryngoscopy was performed that demonstrated a grade 3 view. An experienced operator intubated successfully using a bougie, which was carefully advanced in one attempt blindly behind the epiglottis into the trachea.
      PubDate: 2017-09-28
  • Treatment of chronic venous ulcers with topical sevoflurane: a
           retrospective clinical study
    • Authors: Imbernon-Moya AA; Ortiz-de Frutos FJ, Sanjuan-Alvarez MM, et al.
      Abstract: Editor—Chronic venous ulcers are a common problem with a significant repercussion on quality of life.1 Eighty-five per cent of venous or mixed aetiology chronic ulcers are painful, with one group reporting a mean pain visual analogue scale (VAS) of 4.6.2 Chronic pain usually reduces adherence to treatment and impairs healing.3
      PubDate: 2017-09-28
  • Humour therapy intervention to reduce stress and anxiety in paediatric
           anaesthetic induction, a pilot study
    • Authors: Romero Leguizamon CC; Osorio Castaño AA, Guarin Morales CC, et al.
      Abstract: Editor—Hospitalization is a particularly negative experience for the paediatric population. Infants experiencing surgery can develop problematic behaviour, such as preoperative anxiety (50–75%)1 and postoperative negative behavioural changes (75%), sleep and eating disorders, cognitive alterations, enuresis and disobedience. These complications can persist for several months after the surgical procedure.2 In addition, it is well known that stress slows the healing process, decreases inflammatory responses, and likewise increases fear and anxiety. From a pathophysiological point of view, the increase in levels of circulating cortisol, secondary to an increase in the production of corticotropin releasing hormone and the action of the autonomic nervous system, can create harmful effects in different organs and tissues.3 Salivary cortisol has been used in several studies to measure levels of stress in children, as an index of the amount in blood, but which is a noninvasive procedure ideal for use in the paediatric population.
      PubDate: 2017-09-28
  • Age and other perioperative risk factors for postoperative systemic
           inflammatory response syndrome after cardiac surgery
    • Authors: Dieleman JM; Peelen LM, Coulson TG, et al.
      Abstract: AbstractBackgroundThe inflammatory response to surgery varies considerably between individual patients. Age might be a substantial factor in this variability. Our objective was to examine the association of patient age and other potential risk factors with the occurrence of a postoperative systemic inflammatory response syndrome, during the first 24 h after cardiac surgery.MethodsThis was a retrospective cohort study, using linked data from the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) Database and the Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database. Data from patients who underwent coronary artery bypass grafting and/or valve surgery were used. The association between age and postoperative SIRS was analysed using Poisson regression, and corrected for other risk factors. Restricted cubic splines were used to determine relevant age categories. Results are expressed as risk ratios (RR) with 95% confidence intervals (CI).ResultsData from 28 513 patients were used. In both univariable and multivariable models, increased patient age was strongly associated with reduced postoperative SIRS prevalence. Using 73–83 yr as the reference category, the RRs (95% CI) for the age categories were 1.38 (1.28–1.49) for ≤43 yr, 1.15 (1.09–1.20) for 44–63 yr, 1.05 (1.00–1.09) for 64–72 yr, and 1.03 (0.94–1.12) for >83 yr, respectively. The predictive value for postoperative SIRS of the final model, however, was moderate (c-statistic: 0.61).ConclusionsWe have demonstrated that advanced patient age is associated with a decreased risk of postoperative SIRS among cardiac surgery patients, where patients aged over 72 yr had the lowest risk.
      PubDate: 2017-09-28
  • Preadmission statin use improves the outcome of less severe sepsis
           patients - a population-based propensity score matched cohort study
    • Authors: Lee MG; Lee CC, Lai CC, et al.
      Abstract: AbstractBackgroundRandomized controlled trials on the post-admission use of statins in sepsis patients have not shown a survival benefit. Whether preadmission use of statins would confer any beneficial effects in sepsis patients has not been well studied.MethodsWe conducted a population-based cohort study on a national health insurance claims database between 1999 and 2011. Sepsis patients were identified by ICD-9 codes compatible with the third International consensus definitions for sepsis. Use of statin was defined as the cumulative use of any statin for more than 30 days before the indexed sepsis admission. We determined the association between statin use and sepsis outcome by multivariate-adjusted Cox proportional hazard models and propensity score matched analysis. To minimize baseline imbalance between statin users and non-statin users, we matched/adjusted for social economic status, comorbidities, proxies for healthy lifestyle, health care facility utilization, and use of medications.ResultsWe identified 52 737 sepsis patients, of which 3599 received statin treatment. Statins use was associated with a reduced 30-day mortality after multivariable adjustment (HR 0.86, 95% CI, 0.78–0.94) and propensity score matching (HR, 0.88; 95% CI, 0.78–0.99). On subgroup analysis, the beneficial effects of statins were not significant in patients receiving ventilator support or requiring ICU admission.ConclusionsIn this national cohort study, preadmission statin therapy before sepsis development was associated with a 12% reduction in mortality when compared with patients who never received a statin. There were no consistent beneficial effects of statins in all patient subgroups.
      PubDate: 2017-09-28
  • Brain functional connectivity differentiates dexmedetomidine from propofol
           and natural sleep
    • Authors: Guldenmund PP; Vanhaudenhuyse AA, Sanders RD, et al.
      Abstract: AbstractBackgroundWe used functional connectivity measures from brain resting state functional magnetic resonance imaging to identify human neural correlates of sedation with dexmedetomidine or propofol and their similarities with natural sleep.MethodsConnectivity within the resting state networks that are proposed to sustain consciousness generation was compared between deep non-rapid-eye-movement (N3) sleep, dexmedetomidine sedation, and propofol sedation in volunteers who became unresponsive to verbal command. A newly acquired dexmedetomidine dataset was compared with our previously published propofol and N3 sleep datasets.ResultsIn all three unresponsive states (dexmedetomidine sedation, propofol sedation, and N3 sleep), within-network functional connectivity, including thalamic functional connectivity in the higher-order (default mode, executive control, and salience) networks, was significantly reduced as compared with the wake state. Thalamic functional connectivity was not reduced for unresponsive states within lower-order (auditory, sensorimotor, and visual) networks. Voxel-wise statistical comparisons between the different unresponsive states revealed that thalamic functional connectivity with the medial prefrontal/anterior cingulate cortex and with the mesopontine area was reduced least during dexmedetomidine-induced unresponsiveness and most during propofol-induced unresponsiveness. The reduction seen during N3 sleep was intermediate between those of dexmedetomidine and propofol.ConclusionsThalamic connectivity with key nodes of arousal and saliency detection networks was relatively preserved during N3 sleep and dexmedetomidine-induced unresponsiveness as compared to propofol. These network effects may explain the rapid recovery of oriented responsiveness to external stimulation seen under dexmedetomidine sedation.Trial registry numberCommittee number: ‘Comité d’Ethique Hospitalo-Facultaire Universitaire de Liège’ (707); EudraCT number: 2012-003562-40; internal reference: 20121/135; accepted on August 31, 2012; Chair: Prof G. Rorive. As it was considered a phase I clinical trial, this protocol does not appear on the EudraCT public website.
      PubDate: 2017-09-28
  • Disruption of cortical network activity by the general anaesthetic
    • Authors: Hentschke HH; Raz AA, Krause BM, et al.
      Abstract: AbstractBackgroundActions of general anaesthetics on activity in the cortico-thalamic network likely contribute to loss of consciousness and disconnection from the environment. Previously, we showed that the general anaesthetic isoflurane preferentially suppresses cortically evoked synaptic responses compared with thalamically evoked synaptic responses, but how this differential sensitivity translates into changes in network activity is unclear.MethodsWe investigated isoflurane disruption of spontaneous and stimulus-induced cortical network activity using multichannel recordings in murine auditory thalamo-cortical brain slices.ResultsUnder control conditions, afferent stimulation elicited short latency, presumably monosynaptically driven, spiking responses, as well as long latency network bursts that propagated horizontally through the cortex. Isoflurane (0.05–0.6 mM) suppressed spiking activity overall, but had a far greater effect on network bursts than on early spiking responses. At isoflurane concentrations >0.3 mM, network bursts were almost entirely blocked, even with increased stimulation intensity and in response to paired (thalamo-cortical + cortical layer 1) stimulation, while early spiking responses were <50% blocked. Isoflurane increased the threshold for eliciting bursts, decreased their propagation speed and prevented layer 1 afferents from facilitating burst induction by thalamo-cortical afferents.ConclusionsDisruption of horizontal activity spread and of layer 1 facilitation of thalamo-cortical responses likely contribute to the mechanism by which suppression of cortical feedback connections disrupts sensory awareness under anaesthesia.
      PubDate: 2017-09-28
  • Gender, power and leadership: the effect of a superior’s gender on
           respiratory therapists’ ability to challenge leadership during a
           life-threatening emergency
    • Authors: Pattni NN; Bould MD, Hayter MA, et al.
      Abstract: AbstractBackground. Effective communication within teams is crucial, especially in crisis situations. Hierarchy gradients between team members can contribute to communication failures and are influenced by many factors. The effect of gender on team performance has not been well studied. The objective of this study was to examine the effect of the physician's gender on respiratory therapists’ ability to effectively challenge clearly incorrect clinical decisions during a life-threatening crisis.Methods. Respiratory therapists were recruited to take part in a high-fidelity simulation of can’t-intubate can’t-oxygenate scenarios. They were randomized into two groups, either assisting a male or a female anaesthetist in managing an airway crisis during which the anaesthetist made incorrect clinical decisions. Two independent raters scored the performances using the modified Advocacy-Inquiry Score (min 1, max 6).Results. Twenty-nine subjects completed the study. The median best challenge score when the staff anaesthetist was female was 4 (3–5 IQR [2–6 range]) compared with 3 (3–3[0–3]) for challenges to a male anaesthetist (P=0.017). The median of the total challenges against a female staff member 11 (7.3–14.8 [2–18]) was significantly higher compared with 4 (3.5–7 [2–11.5]) for a male staff (P=0.006).Conclusions. The study showed a significant effect of superiors’ gender on a respiratory therapist’s ability to challenge leadership. A female staff anaesthetist was challenged more often and with greater assertiveness and effectiveness. This has implications for an educational intervention targeting the ability to challenge a wrong decision by a supervisor and emphasizing the effect of gender on the willingness to speak up.
      PubDate: 2017-09-28
  • Low-dose buprenorphine infusion to prevent postoperative hyperalgesia in
           patients undergoing major lung surgery and remifentanil infusion: a
           double-blind, randomized, active-controlled trial
    • Authors: Mercieri M; Palmisani S, De Blasi RA, et al.
      Abstract: AbstractBackground. Postoperative secondary hyperalgesia arises from central sensitization due to pain pathways facilitation and/or acute opioid exposure. The latter is also known as opioid-induced hyperalgesia (OIH). Remifentanil, a potent μ-opioid agonist, reportedly induces postoperative hyperalgesia and increases postoperative pain scores and opioid consumption. The pathophysiology underlying secondary hyperalgesia involves N-methyl-D-aspartate (NMDA)-mediated pain pathways. In this study, we investigated whether perioperatively infusing low-dose buprenorphine, an opioid with anti-NMDA activity, in patients receiving remifentanil infusion prevents postoperative secondary hyperalgesia.Methods. Sixty-four patients, undergoing remifentanil infusion during general anaesthesia and major lung surgery, were randomly assigned to receive either buprenorphine i.v. infusion (25 μg h−1 for 24 h) or morphine (equianalgesic dose) perioperatively. The presence and extent of punctuate hyperalgesia were assessed one day postoperatively. Secondary outcome variables included postoperative pain scores, opioid consumption and postoperative neuropathic pain assessed one and three months postoperatively.Results. A distinct area of hyperalgesia or allodynia around the surgical incision was found in more patients in the control group than in the treated group. Mean time from extubation to first morphine rescue dose was twice as long in the buprenorphine-treated group than in the morphine-treated group: 18 vs 9 min (P=0.002). At 30 min postoperatively, patients receiving morphine had a higher hazard ratio for the first analgesic rescue dose than those treated with buprenorphine (P=0.009). At three months, no differences between groups were noted.Conclusions. Low-dose buprenorphine infusion prevents the development of secondary hyperalgesia around the surgical incision but shows no long-term efficacy at three months follow-up.
      PubDate: 2017-09-28
  • Are perioperative therapeutic doses of statins associated with
           postoperative pain and opioid consumption after hip surgery under spinal
    • Authors: Saasouh WW; Leung SS, Yilmaz HO, et al.
      Abstract: AbstractBackground. The anti-inflammatory effects of statins have been suggested to relieve postoperative pain. This retrospective study tested the association between the perioperative routine use of statins in therapeutic doses, and opioid requirements and pain scores, after hip replacement surgery.Methods. With IRB approval, data was obtained for adult patients who had elective hip replacement surgery under spinal anaesthesia at Cleveland Clinic between 2005 and 2015. Patients were compared using a joint hypothesis framework. We used the inverse probability of treatment weighting method to control for observed confounding factors (a total of 26).Results. We included 611 statin users and 780 non-statin users. Pain score during the initial 72 h after surgery was 0.07 higher (95% CI: −0.02, 0.17) in statin users (noninferiority test in both directions P<0.001). The estimated ratio of geometric means in the cumulative i.v. morphine equivalent opioid consumption was 1.01 (95% CI: 0.93, 1.10) for statin vs non-statin users (noninferiority test P=0.001 in the hypothesized direction and<0.001 in the other direction) during the initial 72 h after surgery. The statin and non-statin patients were deemed equivalent on postoperative opioid consumption and pain score.Conclusions. This is the first large retrospective clinical study that investigates the effects of statin use on postoperative pain and opioid consumption. We observed no difference between statin users and non-users during the initial 72 h after hip surgery. Our findings do not support the routine use of statins as part of an analgesic regimen.
      PubDate: 2017-09-28
  • Prediction of persistent post-surgery pain by preoperative cold pain
    • Authors: Lötsch JJ; Ultsch AA, Kalso EE.
      Abstract: AbstractBackgroundTo prevent persistent post-surgery pain, early identification of patients at high risk is a clinical need. Supervised machine-learning techniques were used to test how accurately the patients’ performance in a preoperatively performed tonic cold pain test could predict persistent post-surgery pain.MethodsWe analysed 763 patients from a cohort of 900 women who were treated for breast cancer, of whom 61 patients had developed signs of persistent pain during three yr of follow-up. Preoperatively, all patients underwent a cold pain test (immersion of the hand into a water bath at 2–4 °C). The patients rated the pain intensity using a numerical ratings scale (NRS) from 0 to 10. Supervised machine-learning techniques were used to construct a classifier that could predict patients at risk of persistent pain.ResultsWhether or not a patient rated the pain intensity at NRS=10 within less than 45 s during the cold water immersion test provided a negative predictive value of 94.4% to assign a patient to the “persistent pain” group. If NRS=10 was never reached during the cold test, the predictive value for not developing persistent pain was almost 97%. However, a low negative predictive value of 10% implied a high false positive rate.ConclusionsResults provide a robust exclusion of persistent pain in women with an accuracy of 94.4%. Moreover, results provide further support for the hypothesis that the endogenous pain inhibitory system may play an important role in the process of pain becoming persistent.
      PubDate: 2017-09-28
  • Human neural correlates of sevoflurane-induced unconsciousness
    • Authors: Palanca BA; Avidan MS, Mashour GA.
      Abstract: AbstractSevoflurane, a volatile anaesthetic agent well-tolerated for inhalation induction, provides a useful opportunity to elucidate the processes whereby halogenated ethers disrupt consciousness and cognition. Multiple molecular targets of sevoflurane have been identified, complementing imaging and electrophysiologic markers for the mechanistically obscure progression from wakefulness to unconsciousness. Recent investigations have more precisely detailed scalp EEG activity during this transition, with practical clinical implications. The relative timing of scalp potentials in frontal and parietal EEG signals suggests that sevoflurane might perturb the propagation of neural information between underlying cortical regions. Spatially distributed brain activity during general anaesthesia has been further investigated with positron emission tomography (PET) and resting-state functional magnetic resonance imaging (fMRI). Combined EEG and PET investigations have identified changes in cerebral blood flow and metabolic activity in frontal, parietal, and thalamic regions during sevoflurane-induced loss of consciousness. More recent fMRI investigations have revealed that sevoflurane weakens the signal correlations among brain regions that share functionality and specialization during wakefulness. In particular, two such resting-state networks have shown progressive breakdown in intracortical and thalamocortical connectivity with increasing anaesthetic concentrations: the Default Mode Network (introspection and episodic memory) and the Ventral Attention Network (orienting of attention to salient feature of the external world). These data support the hypotheses that perturbations in temporally correlated activity across brain regions contribute to the transition between states of sevoflurane sedation and general anaesthesia.
      PubDate: 2017-09-28
  • Tissue Doppler assessment of diastolic function and relationship with
           mortality in critically ill septic patients: a systematic review and
    • Authors: Sanfilippo FF; Corredor CC, Arcadipane AA, et al.
      Abstract: AbstractBackgroundMyocardial dysfunction may contribute to circulatory failure in sepsis. There is growing evidence of an association between left ventricular diastolic dysfunction (LVDD) and mortality in septic patients. Utilizing echocardiography, we know that tissue Doppler imaging (TDI) variables e′ and E/e′ are reliable predictors of LVDD and are useful measurements to estimate left ventricular (LV) filling pressures.MethodsWe conducted a systematic review and meta-analysis to investigate the association of e′ and E/e′ with mortality of patients with severe sepsis or septic shock. In the primary analysis, we included studies providing transthoracic TDI data for e′ and E/e′ and their association with mortality. Subgroup analyses were conducted according to myocardial regional focus of TDI assessment (septal, lateral or averaged). Three secondary analyses were performed: one included data from a transoesophageal study, another excluded studies reporting data at a very early (<6 h) or late (>48 h) stage following diagnosis, and the third pooled data only from studies excluding patients with heart valve disease.ResultsThe primary analysis included 16 studies with 1507 patients with severe sepsis and/or septic shock. A significant association was found between mortality and both lower e′ [standard mean difference (SMD) 0.33; 95% confidence interval (CI): 0.05, 0.62; P=0.02] and higher E/e′ (SMD –0.33; 95% CI: –0.57, –0.10; P=0.006). In the subgroup analyses, only the lateral TDI values showed significant association with mortality (lower e′ SMD 0.45; 95% CI: 0.11, 0.78; P=0.009; higher E/e′ SMD –0.49; 95% CI: –0.76, –0.22; P=0.0003). The findings of the primary analysis were confirmed by all secondary analyses.ConclusionsThere is a strong association between both lower e′ and higher E/e′ and mortality in septic patients.
      PubDate: 2017-09-28
  • Beta-blockers in sepsis: time to reconsider current constraints'
    • Authors: Boerma EC; Singer MM.
      Abstract: New insights into the mechanisms of action of beta-blockers, and the potential consequences for clinical practice, are continually evolving. Originally, this class of drugs was targeted towards treatment or prevention of hypertension, arrhythmias and myocardial ischaemia. Their therapeutic potential then expanded towards the reduction of mortality after myocardial infarction and heart failure.1 Although these indications are now widely accepted, they were not immediately apparent. So why may the use of beta-blockers be beneficial in patients already suffering from impaired myocardial contractility' Clinical observations suggested that the beneficial effect of beta-blockers was greater in patients with the worst cardiac performance.2 Concurrent findings that chronic use of an oral beta-agonist was associated with increased mortality led to re-evaluation of the paradigm,34 fuelled new research that unravelled the concept of maladaptive sympathetic overstimulation in heart failure,5 and changed clinical practice towards the use of beta-blockade.
      PubDate: 2017-09-12
  • Pectoral nerve block1 versus modified pectoral nerve block2 for
           postoperative pain relief in patients undergoing modified radical
           mastectomy: a randomized clinical trial †
    • Authors: Goswami SS; Kundra PP, Bhattacharyya JJ.
      Abstract: AbstractBackgroundPectoral nerve block1 (PEC1) given between pectoralis major and minor, and modified pectoral nerve block2 (mPEC2) performed between pectoralis minor and serratus anterior, can provide continuous analgesia after modified radical mastectomy (MRM) when catheters are placed before skin closure. This study was designed to compare PEC1 and mPEC2 block for providing postoperative pain relief after MRM.MethodsSixty-two physically fit patients undergoing MRM were assigned into two groups (Group PEC1, n=31 and Group mPEC2, n=31). Before wound closure, epidural catheter was placed in the group designated muscle plane and 30ml of 0.25% bupivacaine was injected through the catheter after wound closure. Bupivacaine 15ml of 0.25% top up was given on patient’s demand or whenever visual analogue scale (VAS) score was>4. Time for first analgesia (TFA), number of top ups and VAS was recorded at 0.5, 6, 12, 18, 24 h after surgery. Sensory blockade was assessed 30 min after extubation.ResultsAnalgesia was significantly prolonged in group mPEC2 [mean(SD)] 313.45(43.05) vs 258.87(34.71) min in group PEC1, P<0.001. Total pain experienced over 24 h was significantly less in group mPEC2 [mean(SD)] 9.77(6.93) than in group PEC1 24.19(10.81), P<0.0001. Consequently, top up requirements were significantly reduced in group mPEC2 than in group PEC1 [median(range)] 3(2-4) vs 4(3-5) respectively, P<0.001. Lateral pectoral (77.42% and 35.48%) and thoracodorsal nerves (93.55% and 48.39%) had higher incidence of sensory block in group mPEC2 than group PEC1, P<0.001.ConclusionsmPEC2 provides better postoperative analgesia than PEC1 when catheters are placed under direct vision after MRM.Clinical trial registrationCTRI/2017/02/007811 (REF/2015/11/010185).
      PubDate: 2017-09-12
  • Pain in cancer survivors; filling in the gaps
    • Authors: Brown MM; Farquhar-Smith PP.
      Abstract: AbstractCancer survivorship represents a growing clinical challenge for pain clinicians. The population of cancer survivors is rapidly expanding and many of these patients experience pain as a sequelae of their disease and its treatment. The features, pathophysiology and natural history of some painful conditions observed in cancer survivors, such as direct tumour effects, cancer induced bone pain (CIBP) or chronic post-surgical pain have received extensive exposure elsewhere in the literature. In this narrative review, we attempt to ‘fill in the gaps’ in the knowledge, by providing a succinct outline of a range of less well known pain states encountered in the cancer survivor population. These include neuropathies as a result of graft versus host disease (GVHD), novel chemotherapeutic agents and monoclonal antibodies (mAb), and radiation induced pain states. The increasing prevalence of visceral post-surgical pain and aromatase inhibitor-induced arthralgia (AIA) is also detailed. Additionally an overview of suggested approaches to the assessment of pain in cancer survivors is provided and potential treatment strategies, with a focus on novel approaches are discussed.
      PubDate: 2017-09-11
  • Perioperative statins surgery and postoperative pain
    • Authors: Sneyd JR; Colvin LA, Columb MO, et al.
      Abstract: In this issue of the BritishJournalof Anaesthesia, Saasouh and colleagues1 evaluated whether statins influence postoperative pain and opioid consumption after hip surgery.1 Using a large and long-established Cleveland Clinic database a group of patients already taking statins were matched with otherwise similar patients who were not. The authors conclude that there was no significant relationship between statin taking and postoperative pain and opioid consumption during the initial 72 h after hip surgery.
      PubDate: 2017-09-08
  • Association between intraoperative non-depolarising neuromuscular blocking
           agent dose and 30-day readmission after abdominal surgery
    • Authors: Thevathasan TT; Shih SL, Safavi KC, et al.
      Abstract: AbstractBackgroundWe hypothesised that intraoperative non-depolarising neuromuscular blocking agent (NMBA) dose is associated with 30-day hospital readmission.MethodsData from 13,122 adult patients who underwent abdominal surgery under general anaesthesia at a tertiary care hospital were analysed by multivariable regression, to examine the effects of intraoperatively administered NMBA dose on 30-day readmission (primary endpoint), hospital length of stay, and hospital costs.ResultsClinicians used cisatracurium (mean dose [SD] 0.19 mg kg−1 [0.12]), rocuronium (0.83 mg kg−1 [0.53]) and vecuronium (0.14 mg kg−1 [0.07]). Intraoperative administration of NMBAs was dose-dependently associated with higher risk of 30-day hospital readmission (adjusted odds ratio 1.89 [95% Confidence Interval (CI) 1.26–2.84] for 5th quintile vs 1st quintile; P for trend: P<0.001), prolonged hospital length of stay (adjusted incidence rate ratio [aIRR] 1.20 [95% CI 1.11–1.29]; P for trend: P<0.001) and increased hospital costs (aIRR 1.18 [95% CI 1.13-1.24]; P for trend: P<0.001). Admission type (same-day vs inpatient surgery) significantly modified the risk (interaction term: aOR 1.31 [95% CI 1.05–1.63], P=0.02), and the adjusted odds of readmission in patients undergoing ambulatory surgical procedures who received high-dose NMBAs vs low-dose NMBAs amounted to 2.61 [95% CI 1.11–6.17], P for trend: P<0.001. Total intraoperative neostigmine dose increased the risk of 30-day readmission (aOR 1.04 [1.0–1.08], P=0.048).ConclusionsIn a retrospective analysis, high doses of NMBAs given during abdominal surgery was associated with an increased risk of 30-day readmission, particularly in patients undergoing ambulatory surgery.
      PubDate: 2017-09-06
  • Analgesia nociception index for the assessment of pain in critically ill
           patients: a diagnostic accuracy study
    • Authors: Chanques GG; Tarri TT, Ride AA, et al.
      Abstract: AbstractBackgroundBehavioural pain tools are used in Intensive Care Unit (ICU) patients unable to self-report their pain-intensity but need sustained efforts to educate and train the ICU team because of the subjective nature of these clinical tools. This study measured the validity and performance of an electrophysiological monitoring tool based on the spectral analysis of heart rate variability, the Analgesia Nociception Index (ANI) which varies from 0 (minimal parasympathetic tone, maximal stress-response and pain) to 100 (maximal parasympathetic tone, minimal stress-response and pain).MethodsMean-ANI (ANIm) and Instant-ANI (ANIi) were continuously recorded then compared with the Behavioral Pain Scale (BPS) before, during and after routine care procedures in critically-ill non-comatose patients.Results969 assessments were performed in 110 patients. ANIi was the most discriminative pain tool. It was significantly correlated with BPS (r=–0.30; 95%CI –0.37 to –0.25; P<0.001). For an ANIi threshold of 42.5, the sensitivity, specificity, positive and negative predictive values were respectively 61.4%, 77.4%, 37.0%, and 90.4%. Compared with the BPS, ANIi had no significantly different ability to change during turning and tracheal-suctioning but changed significantly more during dressing change. ANIi increased independently with age, obesity and severity of illness, and controlled mechanical-ventilation, vasopressors use and analgesia. ANIi decreased independently when vigilance status and respiratory rate increased. ANIm demonstrated poor psychometric properties to detect pain.ConclusionsDespite low sensitivity/specificity, ANIi≥43 had a Negative-Predictive-Value of 90%. Hence ANIi may be of highest benefit for excluding significant pain. A randomized controlled trial should compare sedation-analgesia protocols based on ANIi to presently recommended behavioural-pain-tools.
      PubDate: 2017-09-06
  • Benefit and harm of pregabalin in acute pain treatment: a systematic
           review with meta-analyses and trial sequential analyses
    • Authors: Fabritius ML; Strøm CC, Koyuncu SS, et al.
      Abstract: AbstractPregabalin has demonstrated anti-hyperalgesic properties and was introduced into acute pain treatment in 2001. Our aim was to evaluate the beneficial and harmful effects of pregabalin in postoperative pain management. We included randomized clinical trials investigating perioperative pregabalin treatment in adult surgical patients. The review followed Cochrane methodology, including Grading of Recommendations Assessment, Development, and Evaluation (GRADE), and used trial sequential analyses (TSAs). The primary outcomes were 24 h morphine i.v. consumption and the incidence of serious adverse events (SAEs) defined by International Conference of Harmonisation Good Clinical Practice guidelines. Conclusions were based primarily on trials with low risk of bias. Ninety-seven randomized clinical trials with 7201 patients were included. The 24 h morphine i.v. consumption was reported in 11 trials with overall low risk of bias, finding a reduction of 5.8 mg (3.2, 8.5; TSA adjusted confidence interval: 3.2, 8.5). Incidence of SAEs was reported in 21 trials, with 55 SAEs reported in 12 of these trials, and 22 SAEs reported in 10 trials with overall low risk of bias. In trials with overall low risk of bias, Peto’s odds ratio was 2.9 (1.2, 6.8; TSA adjusted confidence interval: 0.1, 97.1). Based on trials with low risk of bias, pregabalin may have a minimal opioid-sparing effect, but the risk of SAEs seems increased. However, the GRADE-rated evaluations showed only moderate to very low quality of evidence. Consequently, a routine use of pregabalin for postoperative pain treatment cannot be recommended.
      PubDate: 2017-09-06
  • Non-steroidal anti-inflammatory drugs in the oncological surgical
           population: beneficial or harmful' A systematic review of the
    • Authors: Cata JP; Guerra CE, Chang GJ, et al.
      Abstract: AbstractBackgroundNon-steroidal anti-inflammatory drugs (NSAIDs) are effective analgesic drugs. Recent studies have indicated a potential beneficial effect on long-term survival outcomes after cancer surgery but a negative impact on anastomotic leaks. The objective of this study was to objectively assess the implications of the perioperative NSAIDs use on anastomotic leaks and cancer recurrence.MethodsWe searched PubMed, MEDLINE, Embase and Cochrane Library for publications up to mid-January 2017. Randomized controlled trials (RCTs) and observational studies in adults undergoing cancer surgery were included for quality assessment. We excluded animal studies, in vitro experiments and case reports. The selected sudies were graded using the Jadad score or Newcastle–Ottawa scale for RCTs and observational retrospective studies, respectively.ResultsThe systematic review identified 25 trials that explored the impact of NSAIDs on anastomotic leaks and 16 trials that assessed the association between perioperative NSAIDs and cancer recurrence. Meta-analyses were not performed because of high heterogeneity and low quality of the included studies.ConclusionsThe literature is not conclusive on whether the use of NSAIDs is associated with anastomotic leaks after gastrointestinal cancer surgery. Also, the current evidence is equivocal regarding the effects of short-term NSAIDs on cancer recurrence after major cancer surgery. Three RCTs are being conducted to assess the impact of NSAIDs on cancer recurrence. There are no registered RCTs that are testing the hypothesis of whether the perioperative use of NSAIDs increases the rate of anastomotic leaks.
      PubDate: 2017-09-04
  • Neuropathic pain in cancer: systematic review, performance of screening
           tools and analysis of symptom profiles
    • Authors: Mulvey MR; Boland EG, Bouhassira DD, et al.
      Abstract: AbstractBackgroundThe objectives of this study were to evaluate the methodological quality of rigorous neuropathic pain assessment tools in applicable clinical studies, and determine the performance of screening tools for identifying neuropathic pain in patients with cancer.MethodsSystematic literature search identified studies reporting use of Leeds Assessment of Neuropathic Symptoms and Signs (LANSS), Douleur Neuropathique en 4 (DN4) or painDETECT (PDQ) in cancer patients with a clinical diagnosis of neuropathic or not neuropathic pain. Individual patient data were requested to examine descriptor item profiles.ResultsSix studies recruited a total of 2301 cancer patients of which 1564 (68%) reported pain. Overall accuracy of screening tools ranged from 73 to 94%. There was variation in description and rigour of clinical assessment, particularly related to the rigour of clinical judgement of pain as the reference standard. Individual data from 1351 patients showed large variation in the selection of neuropathic pain descriptor items by cancer patients with neuropathic pain. LANSS and DN4 items characterized a significantly different neuropathic pain symptom profile from non-neuropathic pain in both tumour- and treatment-related cancer pain aetiologies.ConclusionsWe identified concordance between the clinician diagnosis and screening tool outcomes for LANSS, DN4 and PDQ in patients with cancer pain. Shortcomings in relation to standardized clinician assessment are likely to account for variation in screening tool sensitivity, which should include the use of the neuropathic pain grading system. Further research is needed to standardize and improve clinical assessment in patients with cancer pain. Until the standardization of clinical diagnosis for neuropathic cancer pain has been validated, screening tools offer a practical approach to identify potential cases of neuropathic cancer pain.
      PubDate: 2017-09-04
  • Postoperative pulmonary complications, pulmonary and systemic inflammatory
           responses after lung resection surgery with prolonged one-lung
           ventilation. Randomized controlled trial comparing intravenous and
           inhalational anaesthesia
    • Authors: de la Gala FF; Piñeiro PP, Reyes AA, et al.
      Abstract: AbstractBackgroundRecent studies report the immunomodulatory lung-protective role of halogenated anaesthetics during lung resection surgery (LRS) but have not investigated differences in clinical postoperative pulmonary complications (PPCs). The main goal of the present study was to compare the effect of sevoflurane and propofol on the incidence of PPCs in patients undergoing LRS. The second aim was to compare pulmonary and systemic inflammatory responses to LRS.MethodsOf 180 patients undergoing LRS recruited, data from 174 patients were analysed. Patients were randomized to two groups (propofol or sevoflurane) and were managed otherwise using the same anaesthetic protocol. Bronchoalveolar lavage (BAL) was performed in both lungs before and after one-lung ventilation for analysis of cytokines. Arterial blood was drawn for measurement of the cytokines analysed in the BAL fluid at five time points. Intraoperative haemodynamic and respiratory parameters, PPCs (defined following the ARISCAT study), and mortality during the first month and yr were recorded.ResultsMore PPCs were detected in the propofol group (28.4% vs 14%, OR 2.44 [95% CI, 1.14–5.26]). First-yr mortality was significantly higher in the propofol group (12.5% vs 2.3%, OR 5.37 [95% CI, 1.23–23.54]). Expression of lung and systemic pro-inflammatory cytokines was greater in the propofol group than in the sevoflurane group. Pulmonary and systemic IL-10 release was less in the propofol group.ConclusionsOur results suggest that administration of sevoflurane during LRS reduces the frequency of the PPCs recorded in our study and attenuates the pulmonary and systemic inflammatory response.Clinical trial registrationNCT 02168751; EudraCT 2011-002294-29.
      PubDate: 2017-08-31
  • Effects of intraoperative and early postoperative normal saline or
           Plasma-Lyte 148 ® on hyperkalaemia in deceased donor renal
           transplantation: a double-blind randomized trial
    • Authors: Weinberg LL; Harris LL, Bellomo RR, et al.
      Abstract: AbstractBackgroundAdministration of saline in renal transplantation is associated with hyperchloraemic metabolic acidosis, but the effect of normal saline (NS) on the risk of hyperkalaemia or postoperative graft function is uncertain.MethodsWe compared NS with Plasma-Lyte 148® (PL) given during surgery and for 48 h after surgery in patients undergoing deceased donor renal transplantation. The primary outcome was hyperkalaemia within 48 h after surgery. Secondary outcomes were need for hyperkalaemia treatment, change in acid–base status, and graft function.ResultsTwenty-five subjects were randomized to NS and 24 to PL. The incidence of hyperkalaemia in the first 48 h after surgery was higher in the NS group; 20 patients (80%) vs 12 patients (50%) in the PL group (risk difference: 0.3; 95% confidence interval: 0.05, 0.55; P=0.037). The mean (sd) peak serum potassium was NS 6.1 (0.8) compared with PL 5.4 (0.9) mmol litre−1 (P=0.009). Sixteen participants (64%) in the NS group required treatment for hyperkalaemia compared with five (21%) in the PL group (P=0.004). Participants receiving NS were more acidaemic [pH 7.32 (0.06) vs 7.39 (0.05), P=0.001] and had higher serum chloride concentrations (107 vs 101 mmol litre−1, P<0.001) at the end of surgery. No differences in the rate of delayed graft function were observed. Subjects receiving PL who did not require dialysis had a greater reduction in creatinine on day 2 (P=0.04).ConclusionsCompared with PL, participants receiving NS had a greater incidence of hyperkalaemia and hyperchloraemia and were more acidaemic. These biochemical differences were not associated with adverse clinical outcomes.Clinical trial registrationAustralian New Zealand Clinical Trials Registry: ACTRN12612000023853.
      PubDate: 2017-08-30
  • Clinical and preclinical perspectives on Chemotherapy-Induced Peripheral
           Neuropathy (CIPN): a narrative review
    • Authors: Flatters SL; Dougherty PM, Colvin LA.
      Abstract: AbstractThis review provides an update on the current clinical and preclinical understanding of chemotherapy induced peripheral neuropathy (CIPN). The overview of the clinical syndrome includes a review of its assessment, diagnosis and treatment. CIPN is caused by several widely-used chemotherapeutics including paclitaxel, oxaliplatin, bortezomib. Severe CIPN may require dose reduction, or cessation, of chemotherapy, impacting on patient survival. While CIPN often resolves after chemotherapy, around 30% of patients will have persistent problems, impacting on function and quality of life. Early assessment and diagnosis is important, and we discuss tools developed for this purpose. There are no effective strategies to prevent CIPN, with limited evidence of effective drugs for treating established CIPN. Duloxetine has moderate evidence, with extrapolation from other neuropathic pain states generally being used to direct treatment options for CIPN. The preclinical perspective includes a discussion on the development of clinically-relevant rodent models of CIPN and some of the potentially modifiable mechanisms that have been identified using these models. We focus on the role of mitochondrial dysfunction, oxidative stress, immune cells and changes in ion channels from summary of the latest literature in these areas. Many causal mechanisms of CIPN occur simultaneously and/or can reinforce each other. Thus, combination therapies may well be required for most effective management. More effective treatment of CIPN will require closer links between oncology and pain management clinical teams to ensure CIPN patients are effectively monitored. Furthermore, continued close collaboration between clinical and preclinical research will facilitate the development of novel treatments for CIPN.
      PubDate: 2017-08-17
  • Continuing chronic beta-blockade in the acute phase of severe sepsis and
           septic shock is associated with decreased mortality rates up to 90 days
    • Authors: Fuchs CC; Wauschkuhn SS, Scheer CC, et al.
      Abstract: AbstractBackgroundThere is growing evidence that beta-blockade may reduce mortality in selected patients with sepsis. However, it is unclear if a pre-existing, chronic oral beta-blocker therapy should be continued or discontinued during the acute phase of severe sepsis and septic shock.MethodsThe present secondary analysis of a prospective observational single centre trial compared patient and treatment characteristics, length of stay and mortality rates between adult patients with severe sepsis or septic shock, in whom chronic beta-blocker therapy was continued or discontinued, respectively. The acute phase was defined as the period ranging from two days before to three days after disease onset. Multivariable Cox regression analysis was performed to compare survival outcomes in patients with pre-existing chronic beta-blockade.ResultsA total of 296 patients with severe sepsis or septic shock and pre-existing, chronic oral beta-blocker therapy were included. Chronic beta-blocker medication was discontinued during the acute phase of sepsis in 129 patients and continued in 167 patients. Continuation of beta-blocker therapy was significantly associated with decreased hospital (P=0.03), 28-day (P=0.04) and 90-day mortality rates (40.7% vs 52.7%; P=0.046) in contrast to beta-blocker cessation. The differences in survival functions were validated by a Log-rank test (P=0.01). Multivariable analysis identified the continuation of chronic beta-blocker therapy as an independent predictor of improved survival rates (HR = 0.67, 95%-CI (0.48, 0.95), P=0.03).ConclusionsContinuing pre-existing chronic beta-blockade might be associated with decreased mortality rates up to 90 days in septic patients.
      PubDate: 2017-08-16
  • Epidemiology of sepsis and septic shock in critical care units: comparison
           between sepsis-2 and sepsis-3 populations using a national critical care
    • Authors: Shankar-Hari MM; Harrison DA, Rubenfeld GD, et al.
      Abstract: AbstractBackgroundNew sepsis and septic shock definitions could change the epidemiology of sepsis because of differences in criteria. We therefore compared the sepsis populations identified by the old and new definitions.MethodsWe used a high-quality, national, intensive care unit (ICU) database of 654 918 consecutive admissions to 189 adult ICUs in England, from January 2011 to December 2015. Primary outcome was acute hospital mortality. We compared old (Sepsis-2) and new (Sepsis-3) incidence, outcomes, trends in outcomes, and predictive validity of sepsis and septic shock populations.ResultsFrom among 197 724 Sepsis-2 severe sepsis and 197 142 Sepsis-3 sepsis cases, we identified 153 257 Sepsis-2 septic shock and 39 262 Sepsis-3 septic shock cases. The extrapolated population incidence of Sepsis-3 sepsis and Sepsis-3 septic shock was 101.8 and 19.3 per 100 000 person-years, respectively, in 2015. Sepsis-2 severe sepsis and Sepsis-3 sepsis had similar incidence, similar mortality and showed significant risk-adjusted improvements in mortality over time. Sepsis-3 septic shock had a much higher Acute Physiology And Chronic Health Evaluation II (APACHE II) score, greater mortality and no risk-adjusted trends in mortality improvement compared with Sepsis-2 septic shock. ICU admissions identified either as Sepsis-3 sepsis or septic shock and as Sepsis-2 severe sepsis or septic shock had significantly greater risk-adjusted odds of death compared with non-sepsis admissions (P<0.001). The predictive validity was greatest for Sepsis-3 septic shock.ConclusionsIn an ICU database, compared with Sepsis-2, Sepsis-3 identifies a similar sepsis population with 92% overlap and much smaller septic shock population with improved predictive validity.
      PubDate: 2017-08-16
  • Frontal alpha-delta EEG does not preclude volitional response during
           anaesthesia: prospective cohort study of the isolated forearm technique
    • Authors: Gaskell AL; Hight DF, Winders JJ, et al.
      Abstract: AbstractBackgroundThe isolated forearm test (IFT) is the gold standard test of connected consciousness (awareness of the environment) during anaesthesia. The frontal alpha-delta EEG pattern (seen in slow wave sleep) is widely held to indicate anaesthetic-induced unconsciousness. A priori we proposed that one responder with the frontal alpha-delta EEG pattern would falsify this concept.MethodsFrontal EEG was recorded in a subset of patients from three centres participating in an international multicentre study of IFT responsiveness following tracheal intubation. Raw EEG waveforms were analysed for power–frequency spectra, depth-of-anaesthesia indices, permutation entropy, slow wave activity saturation and alpha-delta amplitude-phase coupling.ResultsVolitional responses to verbal command occurred in six out of 90 patients. Three responses occurred immediately following intubation in patients (from Sites 1 and 2) exhibiting an alpha-delta dominant (delta power >20 dB, alpha power >10 dB) EEG pattern. The power–frequency spectra obtained during these responses were similar to those of non-responders (P>0.05) at those sites. A further three responses occurred in (Site 3) patients not exhibiting the classic alpha-delta EEG pattern; these responses occurred later relative to intubation, and in patients had been co-administered ketamine and less volatile anaesthetic compared with Site 1 and 2 patients. None of the derived depth-of-anaesthesia indices could robustly discrimate IFT responders and non-responders.ConclusionsConnected consciousness can occur in the presence of the frontal alpha-delta EEG pattern during anaesthesia. Frontal EEG parameters do not readily discriminate volitional responsiveness (a marker of connected consciousness) and unresponsiveness during anaesthesia.Clinical trial registrationNCT02248623
      PubDate: 2017-08-09
  • Ultrasound-guided percutaneous cryoneurolysis for treatment of acute pain:
           could cryoanalgesia replace continuous peripheral nerve blocks'
    • Authors: Ilfeld BM; Gabriel RA, Trescot AM.
      Abstract: Local anaesthetics, delivered percutaneously through a needle, have been used for over a century to provide perioperative anaesthesia and analgesia. However, the duration of a single-injection peripheral nerve block is usually limited to less than 24 hr, leaving untreated surgical pain that may last for weeks—or in some cases months. While prolonged analgesia may be provided using a perineural catheter and repeated/continuous administration of local anaesthetic, the duration of this modality is still usually limited to less than one week because of the risk of infection, rapid consumption of the local anaesthetic, and the burden of carrying an infusion pump and anaesthetic reservoir.1 An analgesic modality with a prolonged duration of action could be advantageous for various surgical procedures that are associated with a typically prolonged postoperative period of pain.
      PubDate: 2017-07-14
  • Black swans: challenging the relationship of anaesthetic-induced
           unconsciousness and electroencephalographic oscillations in the frontal
    • Authors: Mashour GA; Avidan MS.
      Abstract: The study of general anaesthesia and electroencephalographic oscillations in the frontal cortex spans at least four decades, with several notable findings: In 1977, Tinker and colleagues1 proposed, based on studies of the nonhuman primate, that anteriorization—the shift of electroencephalographic power from posterior cortex to frontal cortex—correlated with unresponsiveness during general anaesthesia.In the early 1990s, Steriade contributed to our understanding of the neurophysiology of sleep and general anaesthesia in animals, including descriptions of three distinct oscillations involving corticothalamic networks: a slow rhythm at < 1 Hz, a delta rhythm at 1-4 Hz, and a faster theta/alpha rhythm at 7-14 Hz.23In the mid-1990s, the shift of alpha oscillations to more anterior structures was identified during both propofol sedation4 and isoflurane/nitrous oxide anaesthesia.5In 2001, anteriorized alpha and slow-wave activity was posited by John and colleagues6 to be an agent-invariant marker of anaesthetic-induced unconsciousness, based on a study of 176 surgical patients.In 2004, the disappearance of occipital alpha oscillations and shift to high-power frontal alpha oscillations was found to be associated with propofol-induced unconsciousness in healthy human participants.7In 2013, Purdon and colleagues8 found, using high-density electroencephalography in human volunteers, that anteriorization of alpha and phase-amplitude coupling patterns correlated with propofol-induced unconsciousness.In 2014, both propofol and sevoflurane anaesthesia were found to be associated with anterior alpha and slow oscillations in surgical patients.9
      PubDate: 2017-07-06
  • Chronic postsurgical pain in the Evaluation of Nitrous Oxide in the Gas
           Mixture for Anaesthesia (ENIGMA)-II trial
    • Abstract: British Journal of Anaesthesia, 2016; 117(6): 801–11,
      DOI 10.1093/bja/aew338
      PubDate: 2017-05-23
  • Modern hydroxyethyl starch and acute kidney injury after cardiac surgery:
           a prospective multicentre cohort
    • Abstract: British Journal of Anaesthesia, 2016; 117(4): 458–63,
      DOI 10.1093/bja/aew258
      PubDate: 2017-05-23
  • Preoperative platelet function predicts perioperative bleeding
           complications in ticagrelor-treated cardiac surgery patients: a
           prospective observational study
    • Abstract: British Journal of Anaesthesia, 2016; 117(3): 309–15,
      DOI 10.1093/bja/aew189
      PubDate: 2017-05-23
  • Dexmedetomidine: a valuable sedative currently not widely available in the
    • Abstract: British Journal of Anaesthesia, 2016; 117(2): 263–264,
      DOI 10.1093/bja/aew202
      PubDate: 2017-05-22
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