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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: 60, SJR: 1.512, h-index: 46)
Age and Ageing     Hybrid Journal   (Followers: 84, SJR: 1.611, h-index: 107)
Alcohol and Alcoholism     Hybrid Journal   (Followers: 15, SJR: 0.935, h-index: 80)
American Entomologist     Full-text available via subscription   (Followers: 6)
American Historical Review     Hybrid Journal   (Followers: 129, SJR: 0.652, h-index: 43)
American J. of Agricultural Economics     Hybrid Journal   (Followers: 41, SJR: 1.441, h-index: 77)
American J. of Epidemiology     Hybrid Journal   (Followers: 159, 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: 16)
American J. of Legal History     Full-text available via subscription   (Followers: 5, 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: 24)
Annals of Botany     Hybrid Journal   (Followers: 35, SJR: 1.912, h-index: 124)
Annals of Occupational Hygiene     Hybrid Journal   (Followers: 26, SJR: 0.837, h-index: 57)
Annals of Oncology     Hybrid Journal   (Followers: 47, 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: 3, 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: 48, SJR: 1.698, h-index: 92)
Bioinformatics     Hybrid Journal   (Followers: 246, SJR: 4.643, h-index: 271)
Biology Methods and Protocols     Hybrid Journal  
Biology of Reproduction     Full-text available via subscription   (Followers: 9, SJR: 1.646, h-index: 149)
Biometrika     Hybrid Journal   (Followers: 19, SJR: 2.801, h-index: 90)
BioScience     Hybrid Journal   (Followers: 28, SJR: 2.374, h-index: 154)
Bioscience Horizons : The National Undergraduate Research J.     Open Access   (Followers: 1, SJR: 0.213, h-index: 9)
Biostatistics     Hybrid Journal   (Followers: 16, SJR: 1.955, h-index: 55)
BJA : British J. of Anaesthesia     Hybrid Journal   (Followers: 142, SJR: 2.314, h-index: 133)
BJA Education     Hybrid Journal   (Followers: 66, SJR: 0.272, h-index: 20)
Brain     Hybrid Journal   (Followers: 60, SJR: 6.097, h-index: 264)
Briefings in Bioinformatics     Hybrid Journal   (Followers: 45, SJR: 4.086, h-index: 73)
Briefings in Functional Genomics     Hybrid Journal   (Followers: 4, SJR: 1.771, h-index: 50)
British J. for the Philosophy of Science     Hybrid Journal   (Followers: 34, SJR: 1.267, h-index: 38)
British J. of Aesthetics     Hybrid Journal   (Followers: 25, SJR: 0.217, h-index: 18)
British J. of Criminology     Hybrid Journal   (Followers: 524, SJR: 1.373, h-index: 62)
British J. of Social Work     Hybrid Journal   (Followers: 82, 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  
Carcinogenesis     Hybrid Journal   (Followers: 2, SJR: 2.439, h-index: 167)
Cardiovascular Research     Hybrid Journal   (Followers: 11, SJR: 2.897, h-index: 175)
Cerebral Cortex     Hybrid Journal   (Followers: 40, 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: 8, SJR: 1.238, h-index: 15)
Christian Bioethics: Non-Ecumenical Studies in Medical Morality     Hybrid Journal   (Followers: 11, SJR: 0.191, h-index: 8)
Classical Receptions J.     Hybrid Journal   (Followers: 19, SJR: 0.1, h-index: 3)
Clinical Infectious Diseases     Hybrid Journal   (Followers: 58, SJR: 4.742, h-index: 261)
Clinical Kidney J.     Open Access   (Followers: 4, SJR: 0.338, h-index: 19)
Community Development J.     Hybrid Journal   (Followers: 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: 6, 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: 18, SJR: 0.296, h-index: 22)
DNA Research     Open Access   (Followers: 4, SJR: 2.42, h-index: 77)
Dynamics and Statistics of the Climate System     Open Access   (Followers: 3)
Early Music     Hybrid Journal   (Followers: 14, SJR: 0.124, h-index: 11)
Economic Policy     Hybrid Journal   (Followers: 59, SJR: 2.052, h-index: 52)
ELT J.     Hybrid Journal   (Followers: 25, SJR: 1.26, h-index: 23)
English Historical Review     Hybrid Journal   (Followers: 48, 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: 9, SJR: 2.044, h-index: 58)
European Heart J. - Cardiovascular Pharmacotherapy     Full-text available via subscription   (Followers: 1)
European Heart J. - Quality of Care and Clinical Outcomes     Hybrid Journal  
European Heart J. Supplements     Hybrid Journal   (Followers: 8, SJR: 0.152, h-index: 31)
European J. of Cardio-Thoracic Surgery     Hybrid Journal   (Followers: 8, SJR: 1.568, h-index: 104)
European J. of Intl. Law     Hybrid Journal   (Followers: 152, SJR: 0.722, h-index: 38)
European J. of Orthodontics     Hybrid Journal   (Followers: 4, SJR: 1.09, h-index: 60)
European J. of Public Health     Hybrid Journal   (Followers: 22, SJR: 1.284, h-index: 64)
European Review of Agricultural Economics     Hybrid Journal   (Followers: 12, SJR: 1.549, h-index: 42)
European Review of Economic History     Hybrid Journal   (Followers: 28, SJR: 0.628, h-index: 24)
European Sociological Review     Hybrid Journal   (Followers: 40, 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: 8, SJR: 1.687, h-index: 115)
Fems Microbiology Letters     Hybrid Journal   (Followers: 20, SJR: 1.126, h-index: 118)
Fems Microbiology Reviews     Hybrid Journal   (Followers: 25, SJR: 7.587, h-index: 150)
Fems Yeast Research     Hybrid Journal   (Followers: 13, SJR: 1.213, h-index: 66)
Foreign Policy Analysis     Hybrid Journal   (Followers: 21, SJR: 0.859, h-index: 10)
Forestry: An Intl. J. of Forest Research     Hybrid Journal   (Followers: 16, SJR: 0.903, h-index: 44)
Forum for Modern Language Studies     Hybrid Journal   (Followers: 6, SJR: 0.108, h-index: 6)
French History     Hybrid Journal   (Followers: 31, SJR: 0.123, h-index: 10)
French Studies     Hybrid Journal   (Followers: 19, SJR: 0.119, h-index: 7)
French Studies Bulletin     Hybrid Journal   (Followers: 10, SJR: 0.102, h-index: 3)
Gastroenterology Report     Open Access   (Followers: 2)
Genome Biology and Evolution     Open Access   (Followers: 9, 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: 48, 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: 19, 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: 26, SJR: 0.313, h-index: 20)
Holocaust and Genocide Studies     Hybrid Journal   (Followers: 23, SJR: 0.115, h-index: 13)
Human Molecular Genetics     Hybrid Journal   (Followers: 9, SJR: 4.288, h-index: 233)
Human Reproduction     Hybrid Journal   (Followers: 78, SJR: 2.271, h-index: 179)
Human Reproduction Update     Hybrid Journal   (Followers: 18, SJR: 4.678, h-index: 128)
Human Rights Law Review     Hybrid Journal   (Followers: 59, SJR: 0.7, h-index: 21)
ICES J. of Marine Science: J. du Conseil     Hybrid Journal   (Followers: 53, SJR: 1.233, h-index: 88)
ICSID Review     Hybrid Journal   (Followers: 9)
ILAR J.     Hybrid Journal   (Followers: 1, SJR: 1.099, h-index: 51)
IMA J. of Applied Mathematics     Hybrid Journal   (SJR: 0.329, h-index: 26)
IMA J. of Management Mathematics     Hybrid Journal   (Followers: 2, SJR: 0.351, h-index: 20)
IMA J. of Mathematical Control and Information     Hybrid Journal   (Followers: 2, SJR: 0.661, h-index: 28)
IMA J. of Numerical Analysis - advance access     Hybrid Journal   (SJR: 2.032, h-index: 44)
Industrial and Corporate Change     Hybrid Journal   (Followers: 8, SJR: 1.37, h-index: 81)
Industrial Law J.     Hybrid Journal   (Followers: 29, SJR: 0.184, h-index: 15)
Information and Inference     Free  
Integrative and Comparative Biology     Hybrid Journal   (Followers: 8, SJR: 1.911, h-index: 90)
Interacting with Computers     Hybrid Journal   (Followers: 10, SJR: 0.529, h-index: 59)
Interactive CardioVascular and Thoracic Surgery     Hybrid Journal   (Followers: 5, SJR: 0.743, h-index: 35)
Intl. Affairs     Hybrid Journal   (Followers: 51, SJR: 1.264, h-index: 53)
Intl. Data Privacy Law     Hybrid Journal   (Followers: 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: 32, SJR: 1.593, h-index: 69)
Intl. J. of Constitutional Law     Hybrid Journal   (Followers: 59, SJR: 0.613, h-index: 19)
Intl. J. of Epidemiology     Hybrid Journal   (Followers: 134, 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: 32, SJR: 0.231, h-index: 21)
Intl. J. of Transitional Justice     Hybrid Journal   (Followers: 13, SJR: 0.833, h-index: 12)
Intl. Mathematics Research Notices     Hybrid Journal   (Followers: 1, SJR: 2.052, h-index: 42)
Intl. Political Sociology     Hybrid Journal   (Followers: 31, SJR: 1.339, h-index: 19)
Intl. Relations of the Asia-Pacific     Hybrid Journal   (Followers: 17, SJR: 0.539, h-index: 17)
Intl. Studies Perspectives     Hybrid Journal   (Followers: 7, SJR: 0.998, h-index: 28)
Intl. Studies Quarterly     Hybrid Journal   (Followers: 38, 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: 40, 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: 12, 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: 34, SJR: 0.442, h-index: 16)
J. of Complex Networks     Hybrid Journal   (Followers: 1, SJR: 1.165, h-index: 5)
J. of Conflict and Security Law     Hybrid Journal   (Followers: 12, SJR: 0.196, h-index: 15)
J. of Consumer Research     Full-text available via subscription   (Followers: 41, SJR: 4.896, h-index: 121)
J. of Crohn's and Colitis     Hybrid Journal   (Followers: 9, SJR: 1.543, h-index: 37)
J. of Cybersecurity     Hybrid Journal   (Followers: 3)
J. of Deaf Studies and Deaf Education     Hybrid Journal   (Followers: 9, SJR: 0.69, h-index: 36)
J. of Design History     Hybrid Journal   (Followers: 15, SJR: 0.166, h-index: 14)
J. of Economic Entomology     Full-text available via subscription   (Followers: 6, SJR: 0.894, h-index: 76)
J. of Economic Geography     Hybrid Journal   (Followers: 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: 18)
J. of Experimental Botany     Hybrid Journal   (Followers: 14, SJR: 2.798, h-index: 163)
J. of Financial Econometrics     Hybrid Journal   (Followers: 21, SJR: 1.314, h-index: 27)
J. of Global Security Studies     Hybrid Journal   (Followers: 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: 40, SJR: 4, h-index: 209)
J. of Insect Science     Open Access   (Followers: 9, SJR: 0.388, h-index: 31)

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Journal Cover BJA : British Journal of Anaesthesia
  [SJR: 2.314]   [H-I: 133]   [142 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]
  • Abstracts from the BJA Research Forum Glasgow, November 10–11, 2016
    • Abstract: (The authors of all the following abstracts have confirmed that their research received ethics committee approval or was conducted under the Animal (Scientific Procedures) Act (1986) or equivalent.)
      PubDate: 2017-07-27
  • Abstracts for Spring BJA Research Forum meeting, Royal College of
           Anaesthetists, London, 5th and 6th April 2017
    • Abstract: (The authors of all the following abstracts have confirmed that their research received ethics committee approval or was conducted under the Animal (Scientific Procedures) Act (1986) or equivalent.)
      PubDate: 2017-07-27
  • How powerful is failure to rescue as a global metric' Not as powerful
           as a commitment to measurement
    • Authors: Weiser TG.
      Abstract: In a much-discussed study published in 2009, Dr Ghaferi and colleagues1 revived the concept, originally described in the early 1990s by Jeffrey Silber and colleagues,2 of ‘failure to rescue’. Ghaferi and colleagues1 used a prospective, multicentre clinical registry organized by the American College of Surgeons (ACS-NSQIP) to rank hospitals by mortality quintiles. They then evaluated adverse events and noted that across the different mortality quintiles the risk of an adverse event was remarkably consistent. What differed with respect to mortality was not so much the likelihood of a complication, but the ability of a hospital to ‘save’ a patient who experienced a complication. Hospitals in the lowest mortality quintile had very similar rates of both minor and major complications to those in the highest mortality quintile, yet had half the rates of death. They concluded that ‘failure to rescue’ patients with complications in the higher mortality quintiles represented an opportunity for improvement; it was not the complications per se that killed patients, but the inability to quickly recognize and respond to their deterioration.
      PubDate: 2017-07-27
  • Delirium, what’s in a name'
    • Authors: Slooter AC.
      Abstract: Delirium has been known since ancient times. Hippocrates [460–370 Before Common Era (BCE)] may have been the first to describe the syndrome that he called ‘phrenitis’, marked by confusion and restlessness that fluctuated unpredictably and that was associated with physical illness.1 Many other names have been used, including acute mental status change, confusional state, confusion, acute brain dysfunction, brain failure, encephalopathy, postoperative psychosis and acute organic syndrome.1 Of these, the term delirium (derived from the Latin word delirare, deviate from a straight track) has gained acceptance. Besides a more uniform terminology, an important recent achievement includes publication of criteria to define delirium. Although criticized,23 the criteria of the Diagnostic and Statistical Manual of Mental Disorders (5th edition, DSM-5) have become standard.4 According to these criteria, a patient can be considered delirious when all items listed in Table 1 are present at the same time.4 In essence, this means that a patient has acutely developed disturbed attention with other cognitive deficits, which is not solely due to underlying dementia and is caused by a physical condition. Table 1Criteria for delirium according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5)4A. A disturbance in attention (i.e. reduced ability to direct, focus, sustain and shift attention) and awareness (reduced orientation to the environment).B. The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.C. An additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability or perception).D. The disturbances in Criteria A and C are not better explained by another pre-existing, established or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma.E. There is evidence from the history, physical examination or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e. due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple aetiologies.
      PubDate: 2017-07-27
  • Postoperative delirium portends descent to dementia
    • Authors: Aranake-Chrisinger AA; Avidan MS.
      Abstract: Many elderly patients worry that their thinking will be impaired after surgery. Concerns include acute confusion in the days to weeks following surgery, as well as persistent cognitive deficits lasting months to years.1 Both postoperative delirium (POD) and delayed neurocognitive recovery lasting months after surgery are common in older adults, but reports of non-resolving cognitive decline or neurocognitive disorders (NCDs) are inconsistent.23 The acute onset inattention and disorganized thinking characteristic of POD often manifest between one and four days after surgery.4 Delayed neurocognitive recovery is a subtle NCD that typically lasts weeks to months following surgery. Although transient, both disorders can significantly impact recovery. Patients with POD have increased morbidity and mortality, longer Intensive Care Unit (ICU) stays, decreases in quality of life and are likely to be vulnerable to delayed neurocognitive recovery.56 While the pathophysiology of delirium remains unclear, it has been linked with NCDs and dementia in non-surgical patients,7 and several studies have suggested that POD may be a risk factor for non-resolving minor and even major NCD (or incident dementia).89 In this issue of the British Journal of Anaesthesia, the retrospective cohort studies by Sauër and colleagues10 and Sprung and colleagues11 investigate the association between POD and persistent NCDs; the conflicting results highlight the difficulties in studying postoperative cognition.
      PubDate: 2017-07-27
  • Post-anaesthesia care unit delirium: incidence, risk factors and
           associated adverse outcomes
    • Authors: Hernandez BA; Lindroth HH, Rowley PP, et al.
      Abstract: Delirium is a sudden disturbance in attention and orientation to the environment that develops over a short period of time and tends to fluctuate in severity during the course of the day.1 The acute confusional state of delirium occurs in 50–80% of critically ill patients and postoperatively (from the day after surgery onwards) in up to 54% of elective major non-cardiac surgical patients.1 It incurs a huge societal burden, because of, in part, a result of its association with increased morbidity and mortality; each additional day of delirium has been independently associated with a 10% increased risk of death.2 Increased morbidity contributes to prolonged hospital length of stay and significant financial implications: delirium is estimated to total $4–16 billion annually.3 Its association with long-term neuropsychological and cognitive deficits4–7 mandates a better understanding of the pathogenesis of delirium8 and the mechanisms underlying the prolonged disruption of cognitive processing.9 Despite these apparent strong associations, it remains unclear whether delirium identified in the post-anaesthetic care unit (PACU) or recovery unit is associated with similar outcomes. For anaesthetists, this is a critical question that remains unanswered. Indeed at least some of these events are of limited duration and hence it could be assumed they would be associated with less severe consequences. In this context, PACU delirium is differentiated from postoperative delirium as the latter occurs from the day after surgery onwards whereas the former occurs in the PACU on the day of surgery.
      PubDate: 2017-07-27
  • Predicting postoperative brain function from the blood: is there a role
           for biomarkers'
    • Authors: Vutskits LL.
      Abstract: Loss of consciousness upon exposure to general anaesthetics reflects the powerful influence of these drugs on brain physiology. While this phenomenon is usually transient and rapidly resolves upon discontinuation of drug administration, an overwhelming number of both clinical and experimental observations suggest that even relatively short periods of anaesthesia can trigger a myriad of biochemical pathways which, in turn, can give rise to temporary or even lasting changes in neurobehavioural and cognitive function after emergence from anaesthesia.1 Most of these functional alterations have been described as postoperative delirium or impaired cognitive performance and, therefore, have negative connotations. It is nevertheless important to note that exposure to anaesthetics can also improve both cognition and mood in some specific clinical states, such as in major depressive disorders. This context-dependent impact of anaesthetics on neuronal function probably reflects the major context-dependent modulatory influence of these drugs on neuronal plasticity.1
      PubDate: 2017-07-27
  • Using a worldwide in-app survey to explore sugammadex usage patterns: a
           prospective observational study
    • Authors: O’Reilly-Shah VN; Wolf FA, Jabaley CS, et al.
      Abstract: Editor—Via encapsulation, sugammadex can rapidly and completely reverse even profound neuromuscular block induced by rocuronium or vecuronium, which is not possible to achieve with cholinesterase inhibitors.1–4 Although approved for use in Europe in 20085 and available for several years elsewhere,6 the United States Food and Drug Administration (US FDA) delayed approval due to concerns regarding potential hypersensitivity reactions and effects on coagulation tests,7 which were ultimately satisfied.8–10 We are interested in better understanding global experience with sugammadex and the impact, if any, of pharmacoeconomics on post-marketing policies. The present data were analysed from an ongoing, Institutional Review Board (IRB)-approved (Emory University, Atlanta, GA, USA, IRB# 00082571) study of a globally utilized anaesthesia calculator app for the Android platform (‘Anesthesiologist’)1112 fitted with a module capable of collecting survey data and app analytics.13 We used this tool to deploy a survey assessing global patterns of clinical practice and experience with sugammadex.
      PubDate: 2017-07-27
  • Availability of critical care services in Taiwan under National Health
    • Authors: Lai CC; Ho CH, Chang CL, et al.
      Abstract: Editor—Since the implementation of Taiwan’s National Health Insurance (NHI) programme in 1995, use of health-care services has significantly increased.1 This is also true for the use of mechanical ventilation and extracorporeal membrane oxygenation.23 In contrast, information is limited about use of intensive care unit (ICU) beds.4 We conducted this study to investigate the availability of the critical care service in Taiwan under the NHI programme.
      PubDate: 2017-07-27
  • Ultrasound-guided central venous catheterization in the prone position
    • Authors: Chen GY; Cheng KI, Hsu HT, et al.
      Abstract: Editor—Central venous catheterization for patients positioned prone poses challenges to the anaesthesiologist, such as anatomical restrictions in head and neck position, lack of anatomical landmark points to approach, and difficult right internal jugular vein (RIJV) needle advancement with the left hand. Here we present an approach for RIJV catheterization in a patient positioned prone using in-plane needle ultrasound guidance.
      PubDate: 2017-07-27
  • Acute kidney injury following enhanced recovery for orthopaedic joint
           replacement surgery—role of preoperative kidney disease'
    • Authors: Medlock GG; Berg AA, Stevenson IM.
      Abstract: Editor—Enhanced recovery after surgery (ERAS), a multifaceted approach to anaesthesia and surgery, has been implemented widely throughout orthopaedic lower limb arthroplasty.1 The aim is to discontinue i.v. fluids by midday on postoperative day one;2 however, there is marked variation in practice between centres. We sought to determine the incidence of acute kidney injury (AKI) in patients undergoing hip or knee arthroplasty under ERAS principles particular to our unit, where fluids are discontinued before leaving the recovery room. All patients who had undergone primary unilateral lower limb arthroplasty as part of an ERAS programme over a three month period were analysed retrospectively. Patients received cefuroxime as antibiotic prophylaxis or clarithromycin if history of penicillin allergy. Dalteparin or fondaparinux was given for venothromboembolic prophylaxis based on consultant preference. Unfractionated heparin (mini-hep) was used for estimated glomerular filtration rate (eGFR) <45 ml min−1. Multimodal analgesia including paracetamol, gabapentin and modified release morphine was given perioperatively with dosing adjusted for patient weight, renal function and preoperative medications. Diagnosis of AKI was based on the modified acute kidney injury network (AKIN) criteria as described by National Institute for Health and Care Excellence (NICE) Guidelines:3 rise in creatinine of 26 mmol litre−1 or greater within 48 h or a 50% or more rise in creatinine known or presumed to have occurred in the past 7 days. Due to the small sample size, Fisher’s exact χ2 test was used to determine whether there was an association between preoperative eGFR and development of AKI. The Mann–Whitney U-test was used to determine whether there was an association between development of AKI and length of hospital stay.
      PubDate: 2017-07-27
  • Approach affects injectate spread in ultrasound-guided thoracic
           paravertebral block: a cadaveric trial
    • Authors: Taketa YY; Fujitani TT.
      Abstract: Editor—Ultrasound-guided thoracic paravertebral block has made much progress, and various approaches have been developed in the past decade.1 However, the differences in local anaesthetic distribution patterns are unknown. We adopted two patterns of injections, namely the intercostal approach (IC approach)2 and the paralaminar in-plane approach (PL approach),34 and compared their injectate spreading patterns in three Thiel-embalmed human cadavers using a dye injection method.56 For the IC approach, a 6–13 MHz linear array transducer was placed at the T4, T5 and T9 intercostal levels to visualize the transverse process. An 18-gauge Tuohy needle was inserted from lateral to medial beside the probe to penetrate the internal intercostal membrane next to the tip of the transverse process. For the PL approach, the needle was inserted from medial to lateral using a 5–8 MHz microconvex array transducer to visualize the lateral edge of the vertebral lamina at the T6, T7 and T10 levels. We investigated five injections by the IC approach and four injections by the PL approach using 10 ml of dye of various colours. One injection in each group included real-time, direct observation of the distribution pattern after dissection via a pre-inserted catheter 2.5 cm beyond the needle tip. Paravertebral spread was confirmed in all procedures. In the IC approach group, dye covered the respective intercostal space and the adjacent paravertebral space (PVS) (Fig. 1A), consistent with previous reports.7 The injected dye in the PL approach group covered the more longitudinal and medial PVS rather than the lateral intercostal space (Fig. 1B).8 Real-time dye injections from the catheter showed that in the IC approach dye first spread to the respective intercostal level following PVS whereas in the PL approach dye first covered the area around the sympathetic trunk followed by the intercostal area.
      PubDate: 2017-07-27
  • Simulated emergency cricothyroid incision length
    • Authors: Miller TC; Comara JJ, Groom PP.
      Abstract: Editor—The revised 2015 Difficult Airway Society (DAS) guidelines for the ‘unanticipated difficult airway’ include a standardized approach to performance of emergency front-of-neck access in the ‘can’t intubate, can’t oxygenate’ (CICO) scenario.1 We have subsequently changed how we educate colleagues in the management of a CICO scenario using the surgical technique as part of our airway update days and on the Aintree Difficult Airway Management course.
      PubDate: 2017-07-27
  • Mind the gap when performing emergency front-of-neck access
    • Authors: Marimuthu MM; Dunn CC, Hodzovic II.
      Abstract: Editor—Plan D of the Difficult Airway Society guidelines1 on managing the can’t intubate can’t oxygenate (CICO) scenario states that a 6.0 mm cuffed tracheal tube should be railroaded over the bougie when performing scalpel cricothyroidotomy. During our departmental CICO training sessions, conducted on sheep larynxes, we have noticed that candidates have difficulties railroading the tube over the bougie (Frova Intubating Introducer, Cook Medical Ltd. Limerick, Ireland) when using a 6 mm cuffed tracheal tube. This appears to be caused by the tip of the tube catching on the airway as it is being advanced, because of the large gap between the bougie and the tube (Fig. 1A). We noted that when using a smaller 5 mm tube, railroading appeared to be easier, perhaps because the gap between the bougie and the tube is smaller (Fig. 1B). The resistance to advancing the tube over the bougie was almost negligible when using a size 5 mm Melker cuffed emergency cricothyrotomy catheter (Cook Medical Ltd, Limerick, Ireland), as this tube has a tapered tip that fits snugly over the bougie (Fig. 1C).
      PubDate: 2017-07-27
  • Management of perioperative laryngospasm by French paediatric
    • Authors: Michelet DD; Skhiri AA, Greff BB, et al.
      Abstract: Editor—Perioperative laryngospasm is a life-threating emergency in paediatric patients. A recent multicentre study of children undergoing surgery1 found a high rate of severe critical events during the perioperative period (5.2%), with an incidence of respiratory critical events of 3.1%. Laryngospasm was one of most frequent respiratory complications (0.2–6.7%). Its effective management requires appropriate diagnosis, followed by prompt and aggressive management. The use of a structured algorithm would lead to earlier recognition and better management.2 We undertook a survey in order to explore the practical management of laryngospasm by French paediatric anaesthetists.
      PubDate: 2017-07-27
  • The Princes of Serendip
    • Authors: Moppett IK; Moonesinghe SR, Grocott MP.
      Abstract: Editor—We thank Professor Wildsmith1 for his interest in our editorial2 and for clarifying aspects of the process around NAP3.3
      PubDate: 2017-07-27
  • Topics for the national audit projects of the Royal College of
    • Authors: Wildsmith JW.
      Abstract: Editor—Moppett and colleagues1 provide a very fair assessment of the value of the national audit projects (NAPs) performed in the UK during the last decade. However, I would question their statement that the choice of topics for the third and fourth projects performed by the Royal College of Anesthetists (NAP3 and NAP4) was ‘in part serendipitous, as a result of the coincidence of the desires of the specialist societies (Pain and Difficult Airway) and the Royal College of Anaesthetists’. The subjects for both audits were discussed at meetings of College Council and, as a member of that group at the time, I remember no input from any society.
      PubDate: 2017-07-27
  • Dexmedetomidine pharmacodynamics in healthy volunteers: 2. Haemodynamic
    • Authors: Colin PJ; Hannivoort LN, Eleveld DJ, et al.
      Abstract: AbstractBackground. Dexmedetomidine, a selective α2-adrenoreceptor agonist, has unique characteristics, with little respiratory depression and rousability during sedations. We characterized the haemodynamic properties of dexmedetomidine by developing a pharmacokinetic–pharmacodynamic (PKPD) model with a focus on changes in mean arterial blood pressure (MAP) and heart rate.Methods. Dexmedetomidine was delivered i.v. to 18 healthy volunteers in a step-up fashion by target-controlled infusion using the Dyck model. Exploratory PKPD modelling and covariate analysis were conducted in NONMEM.Results. Our model adequately describes dexmedetomidine-induced hypotension, hypertension, and bradycardia, with a greater effective concentration for the hypertensive effect. Changes in MAP were best described by a double-sigmoidal Emax model with hysteresis. Covariate analysis revealed no significant covariates apart from age on the baseline MAP in the population pharmacokinetic model used to develop this PKPD model. Simulations revealed good general agreement with published descriptive studies of haemodynamics after dexmedetomedine infusion.Conclusions. The present integrated PKPD model should allow tighter control over the desired level of sedation, while limiting potential haemodynamic side-effects.Clinical trial registration. NCT01879865.
      PubDate: 2017-07-27
  • Frequency of surgical treatment and related hospital procedures in the UK:
           a national ecological study using hospital episode statistics
    • Authors: Abbott TF; Fowler AJ, Dobbs TD, et al.
      Abstract: AbstractBackground: Despite evidence of high activity, the number of surgical procedures performed in UK hospitals, their cost and subsequent mortality remain unclear.Methods: Time-trend ecological study using hospital episode data from England, Scotland, Wales and Northern Ireland. The primary outcome was the number of in-hospital procedures, grouped using three increasingly specific categories of surgery. Secondary outcomes were all-cause mortality, length of hospital stay and healthcare costs according to standard National Health Service tariffs.Results: Between April 1, 2009 and March 31, 2014, 39 631 801 surgical patient episodes were recorded. There was an annual average of 7 926 360 procedures (inclusive category), 5 104 165 procedures (intermediate category) and 1 526 421 procedures (restrictive category). This equates to 12 537, 8073 and 2414 procedures per 100 000 population per year, respectively. On average there were 85 181 deaths (1.1%) within 30 days of a procedure each year, rising to 178 040 deaths (2.3%) after 90 days. Approximately 62.8% of all procedures were day cases. Median length of stay for in-patient procedures was 1.7 (1.3–2.0) days. The total cost of surgery over the 5 yr period was £54.6 billion ($104.4 billion), representing an average annual cost of £10.9 billion (inclusive), £9.5 billion (intermediate) and £5.6 billion (restrictive). For each category, the number of procedures increased each year, while mortality decreased. One-third of all mortalities in national death registers occurred within 90 days of a procedure (inclusive category).Conclusions: The number of surgical procedures in the UK varies widely according to definition. The number of procedures is slowly increasing whilst the number of deaths is decreasing.
      PubDate: 2017-07-27
  • Association between delirium and cognitive change after cardiac surgery
    • Authors: Sauër AC; Veldhuijzen DS, Ottens TH, et al.
      Abstract: AbstractBackground. Previous studies provide inconsistent data on whether postoperative delirium (POD) is a risk factor for postoperative cognitive decline (POCD). We thus investigated the relationship between POD and cognitive change after cardiac surgery and assessed the relationship between preoperative cognitive domain scores and POD.Methods. Postoperative delirium was assessed with the Confusion Assessment Method (CAM) adapted for the intensive care unit and the conventional CAM accompanied by chart review. Cognitive function was assessed with a neuropsychological test battery before elective cardiac surgery and 1 month and 1 yr afterwards. Cognitive change was calculated using the Reliable Change Index (RCI). Multiple linear regression was used to adjust for confounding.Results. Of the 184 patients who completed baseline assessment, 23 (12.5%) developed POD. At 1 month, the decline in cognitive performance was worse in patients with POD [median composite RCI −1.00, interquartile range (IQR) −1.67 to 0.28] than in patients without POD (RCI −0.04, IQR −0.70 to 0.63, P=0.02). At 1 yr, both groups showed cognitive improvement on average compared with baseline (POD patients median composite RCI 0.25, IQR −0.42 to 1.31, vs non-POD patients RCI 0.92, IQR 0.18–1.53; P=0.08). Correction for differences in age and level of education did not change the results. Patients with POD performed less well than patients without POD on the preoperative Trailmaking test part A (P=0.03).Conclusions. Postoperative delirium is independently associated with cognitive decline 1 month after surgery, but cognitive performance generally recovers in 1 yr. Patients with a predisposition to POD can be identified before surgery by worse performance in an attention task.Clinical trial registration. NCT00293592.
      PubDate: 2017-07-27
  • In This Issue
    • PubDate: 2017-07-27
  • Efficacy of perineural vs systemic dexamethasone to prolong analgesia
           after peripheral nerve block: a systematic review and meta-analysis
    • Authors: Baeriswyl MM; Kirkham KR, Jacot-Guillarmod AA, et al.
      Abstract: AbstractPerineural dexamethasone has gained popularity in regional anaesthesia to prolong the duration of analgesia, but its advantage over systemic administration is disputed. The objective of this meta-analysis was to compare the analgesic efficacy of both routes of administration during peripheral nerve block. The methodology followed the PRISMA statement guidelines. The primary outcome was the duration of analgesia analysed according to the type of local anaesthetic administered (bupivacaine or ropivacaine). Secondary outcomes included cumulative opioid consumption in morphine i.v. equivalents, pain scores, and complication rates (neurological complications, infection, or hyperglycaemia). Eleven controlled trials, including 914 patients, were identified. The duration of analgesia was significantly increased with perineural dexamethasone vs systemic dexamethasone by a mean difference of 3 h [95% confidence interval (CI): 1.4, 4.5 h; P=0.0001]. Subgroup analysis revealed that the duration of analgesia was increased by 21% with bupivacaine (mean difference: 4.0 h; 95% CI: 2.8, 5.2 h; P<0.00001) and 12% with ropivacaine (mean difference: 2.0 h; 95% CI: −0.5, 4.5 h; P=0.11). The quality of evidence for our primary outcome was moderate according to the GRADE system. There were no significant differences in other secondary outcomes. No neurological complications or infections were reported. Glucose concentrations were not increased when dexamethasone was injected systemically, but this outcome was reported by only two trials. There is, therefore, moderate evidence that perineural dexamethasone combined with bupivacaine, but not ropivacaine, slightly prolongs the duration of analgesia, without an impact on other pain-related outcomes, when compared with systemic dexamethasone. Injection of perineural dexamethasone should be cautiously balanced in light of the off-label indication for this route of administration.
      PubDate: 2017-07-27
  • Electroencephalography and delirium in the postoperative period
    • Authors: Palanca BA; Wildes TS, Ju YS, et al.
      Abstract: AbstractDelirium commonly manifests in the postoperative period as a clinical syndrome resulting from acute brain dysfunction or encephalopathy. Delirium is characterized by acute and often fluctuating changes in attention and cognition. Emergence delirium typically presents and resolves within minutes to hours after termination of general anaesthesia. Postoperative delirium hours to days after an invasive procedure can herald poor outcomes. Easily recognized when patients are hyperactive or agitated, delirium often evades diagnosis as it most frequently presents with hypoactivity and somnolence. EEG offers objective measurements to complement clinical assessment of this complex fluctuating disorder. Although EEG features of delirium in the postoperative period remain incompletely characterized, a shift of EEG power into low frequencies is a typical finding shared among encephalopathies that manifest with delirium. In aggregate, existing data suggest that serial or continuous EEG in the postoperative period facilitates monitoring of delirium development and severity and assists in detecting epileptic aetiologies. Future studies are needed to clarify the precise EEG features that can reliably predict or diagnose delirium in the postoperative period, and to provide mechanistic insights into this pathologically diverse neurological disorder.
      PubDate: 2017-07-27
  • Predicting successful supraclavicular brachial plexus block using pulse
           oximeter perfusion index
    • Authors: Abdelnasser AA; Abdelhamid BB, Elsonbaty AA, et al.
      Abstract: AbstractBackground. Supraclavicular nerve block is a popular approach for anaesthesia for upper limb surgeries. Conventional methods for evaluation of block success are time consuming and need patient cooperation. The aim of this study was to evaluate whether the perfusion index (PI) can be used to predict and provide a cut-off value for ultrasound-guided supraclavicular nerve block success.Methods. The study included 77 patients undergoing elective orthopaedic procedures under ultrasound-guided supraclavicular nerve block. After local anaesthetic injection, sensory block success was assessed every 3 min by pinprick, and motor block success was assessed every 5 min by the ability to flex the elbow and the hand against resistance. The PI was recorded at baseline and at 10, 20, and 30 min after anaesthetic injection in both blocked and non-blocked limbs. The PI ratio was calculated as the PI after 10 min divided by the PI at the baseline. Receiver operating characteristic curves were constructed for the accuracy of the PI in detection of block success.Results. The PI was higher in the blocked limb at all time points, and this was paralleled by a higher PI ratio compared with the unblocked limb. Both the PI and the PI ratio at 10 min after injection showed a sensitivity and specificity of 100% for block success at cut-off values of 3.3 and 1.4, respectively.Conclusions. The PI is a useful tool for evaluation of successful supraclavicular nerve block. A PI ratio of > 1.4 is a good predictor for block success.
      PubDate: 2017-07-17
  • Dexmedetomidine pharmacokinetic–pharmacodynamic modelling in healthy
           volunteers: 1. Influence of arousal on bispectral index and sedation
    • Authors: Colin PJ; Hannivoort LN, Eleveld DJ, et al.
      Abstract: AbstractBackground. Dexmedetomidine, a selective α2-adrenoreceptor agonist, has unique characteristics, such as maintained respiratory drive and production of arousable sedation. We describe development of a pharmacokinetic–pharmacodynamic model of the sedative properties of dexmedetomidine, taking into account the effect of stimulation on its sedative properties.Methods. In a two-period, randomized study in 18 healthy volunteers, dexmedetomidine was delivered in a step-up fashion by means of target-controlled infusion using the Dyck model. Volunteers were randomized to a session without background noise and a session with pre-recorded looped operating room background noise. Exploratory pharmacokinetic–pharmacodynamic modelling and covariate analysis were conducted in NONMEM using bispectral index (BIS) monitoring of processed EEG.Results. We found that both stimulation at the time of Modified Observer’s Assessment of Alertness/Sedation (MOAA/S) scale scoring and the presence or absence of ambient noise had an effect on the sedative properties of dexmedetomidine. The stimuli associated with MOAA/S scoring increased the BIS of sedated volunteers because of a transient 170% increase in the effect-site concentration necessary to reach half of the maximal effect. In contrast, volunteers deprived of ambient noise were more resistant to dexmedetomidine and required, on average, 32% higher effect-site concentrations for the same effect as subjects who were exposed to background operating room noise.Conclusions. The new pharmacokinetic–pharmacodynamic models might be used for effect-site rather than plasma concentration target-controlled infusion for dexmedetomidine in clinical practice, thereby allowing tighter control over the desired level of sedation.Clinical trial registration. NCT01879865.
      PubDate: 2017-07-14
  • Prognostic significance of central venous-to-arterial carbon dioxide
           difference during the first 24 hours of septic shock in patients with and
           without impaired cardiac function
    • Authors: Muller GG; Mercier EE, Vignon PP, et al.
      Abstract: AbstractObjective: To investigate the prognostic significance of central venous-to-arterial carbon dioxide difference (cv-art CO2 gap) during septic shock in patients with and without impaired cardiac function.Methods: We performed a prospective cohort study in 10 French intensive care units. Patients suffering from septic shock were assigned to the impaired cardiac function group (‘cardiac group’, n=123) if they had atrial fibrillation (AF) and/or left ventricular ejection fraction (LVEF) <50% at study entry and to the non-cardiac group (n=240) otherwise.Results: Central venous and arterial blood gases were sampled every 6 h during the first 24 h to calculate cv-art CO2 gap. Patients in the cardiac group had a higher cv-art CO2 gap [at study entry and 6 and 12 h (all P<0.02)] than the non-cardiac group. Patients in the cardiac group with a cv-art CO2 gap >0.9 kPa at 12 h had a higher risk of day 28 mortality (hazard ratio=3.18; P=0.0049). Among the 59 patients in the cardiac group with mean arterial pressure (MAP) ≥65 mm Hg, central venous pressure (CVP) ≥8 mm Hg and central venous oxygen saturation (ScvO2) ≥70% at 12 h, those with a high cv-art CO2 gap (>0.9 kPa; n=19) had a higher day 28 mortality (37% vs. 13%; P=0.042). In the non-cardiac group, a high cv-art CO2 gap was not linked to a higher risk of day 28 death, whatever the threshold value of the cv-art CO2 gap.Conclusion: Patients with septic shock and with AF and/or low LVEF were more prone to a persistent high cv-art CO2 gap, even when initial resuscitation succeeded in normalizing MAP, CVP, and ScvO2. In these patients, a persistent high cv-art CO2 gap at 12 h was significantly associated with higher day 28 mortality.
      PubDate: 2017-07-14
  • Duty of candour: a statutory obligation or just the right thing to do'
    • Authors: Wijesuriya JD; Walker DD.
      Abstract: In 1990 the case of Robbie Powell catalogued a story of medical errors and neglect that ultimately lead to his untimely death from Addison’s disease at 10 years of age. In this high-profile case, the child’s father felt that events were made even more unbearable by failures of health care providers to offer credible explanations for what had occurred and subsequently by the detrimental actions of investigatory bodies.1 Despite tireless and tenacious legal challenges, Robbie Powell’s father was denied the truth for nearly 2 decades. It is now established that forgery and falsification of patient medical records occurred and investigations were plagued by conflict of interest and dishonesty, including cabinet ministers providing false parliamentary answers.2 Indeed, two Police Complaints Authority investigations into the handling of the case named the Dyfed-Powys police force as ‘institutionally incompetent’ and identified 35 separate potential criminal offences including falsification of documents and perverting the course of justice.3 No criminal prosecutions were brought and in May 2000 the European Court of Human Rights stated in a judgement on the case that: As the law stands now … doctors have no duty to give parents of a child who died as a result of their negligence a truthful account of the circumstances of the death, nor even refrain from deliberately falsifying records.4 Although this case must be considered rare and indeed extreme, it is important to take a moment to reflect on a purely human level how one would feel if a loved one suffered serious harm or death as the result of a medical incident. Add to that emotional turmoil the distress of not being told what had happened or the insult of being deceived by those with whom care and support had been entrusted. In the 27 years since this tragic case, the National Health Service (NHS) has slowly moved towards a culture of transparency and openness. This article discusses the UK statutory Duty of Candour (DoC) and the implications for enacting the legislation with respect to perioperative and intensive care medicine.
      PubDate: 2017-07-08
  • Intraoperative dexamethasone alters immune cell populations in patients
           undergoing elective laparoscopic gynaecological surgery
    • Authors: Corcoran TT; Paech MM, Law DD, et al.
      Abstract: AbstractBackground. Anaesthetists use dexamethasone principally for its anti-emetic effect. The purpose of this study was to characterize the effects of a single intraoperative dose of dexamethasone on cellular and metabolic components of the immune system in patients undergoing laparoscopic surgical procedures.Methods. In this prospective double-blind trial, female patients undergoing elective major laparoscopic surgery were randomized to receive saline (Control group, n=16) or dexamethasone 4 mg (Dexamethasone group, n=16) i.v. after the induction of anaesthesia. Inflammatory markers and immune cell counts were examined at 24 and 48 h and 6 weeks after surgery. The changes from baseline preoperative values were compared between groups using a Mann–Whitney U-test, and linear mixed models were used to validate the findings.Results. No differences in concentrations of serum glucose and interleukin-6 were observed between groups after surgery. The increase in C-reactive protein concentration at 24 h after surgery was greater in the control group [median (interquartile range), 33 (25–65) vs 17 (7–26) mg dl−1; P=0.018]. Extensive changes in the counts of white cells, including most lymphocyte subsets, were observed 24 h after surgery, and dexamethasone appeared to attenuate most of these changes. Changes at 48 h and 6 weeks did not differ between groups.Conclusions. In female patients undergoing elective laparoscopic gynaecological surgery, dexamethasone administration appears to attenuate inflammation and to alter immune cell counts at 24 h, with no effects identified after this time. The importance of these changes for postoperative immune function is unknown.Trial registration. Australia and New Zealand Clinical Trials Registry (ACTRN12608000340336).
      PubDate: 2017-07-08
  • Use of failure-to-rescue to identify international variation in
           postoperative care in low-, middle- and high-income countries: a 7-day
           cohort study of elective surgery
    • Authors: Ahmad TT; Bouwman RA, Grigoras II, et al.
      Abstract: AbstractBackground. The incidence and impact of postoperative complications are poorly described. Failure-to-rescue, the rate of death following complications, is an important quality measure for perioperative care but has not been investigated across multiple health care systems.Methods. We analysed data collected during the International Surgical Outcomes Study, an international 7-day cohort study of adults undergoing elective inpatient surgery. Hospitals were ranked by quintiles according to surgical procedural volume (Q1 lowest to Q5 highest). For each quintile we assessed in-hospital complications rates, mortality, and failure-to-rescue. We repeated this analysis ranking hospitals by risk-adjusted complication rates (Q1 lowest to Q5 highest).Results. A total of 44 814 patients from 474 hospitals in 27 low-, middle-, and high-income countries were available for analysis. Of these, 7508 (17%) developed one or more postoperative complication, with 207 deaths in hospital (0.5%), giving an overall failure-to-rescue rate of 2.8%. When hospitals were ranked in quintiles by procedural volume, we identified a three-fold variation in mortality (Q1: 0.6% vs Q5: 0.2%) and a two-fold variation in failure-to-rescue (Q1: 3.6% vs Q5: 1.7%). Ranking hospitals in quintiles by risk-adjusted complication rate further confirmed the presence of important variations in failure-to-rescue, indicating differences between hospitals in the risk of death among patients after they develop complications.Conclusions. Comparison of failure-to-rescue rates across health care systems suggests the presence of preventable postoperative deaths. Using such metrics, developing nations could benefit from a data-driven approach to quality improvement, which has proved effective in high-income countries.
      PubDate: 2017-07-08
  • Safety aspects of preoperative high-dose glucocorticoid in primary total
           knee replacement
    • Authors: Jørgensen CC; Pitter FT, Kehlet HH, et al.
      Abstract: AbstractBackground: Preoperative single high-dose glucocorticoid may have early outcome benefits in total hip arthroplasty (THA) and knee arthroplasty (TKA), but long-term safety aspects have not been evaluated.Methods: From October 2013, the departments reporting to the prospective Lundbeck Foundation Database for Fast-track Hip and Knee Replacement introduced preoperative methylprednisolone (MP) 125 mg as part of a multimodal analgesic protocol in TKA. We analysed the risk of length of hospital stay (LOS) >4 days, 30 and 90 day readmissions in patients with MP vs patients having TKA before the use of MP and adjusted for comorbidity and place of surgery. An unadjusted comparison was specifically done to evaluate deep prosthetic infections.Results: Of a total of 3927 TKA procedures, 1442 received MP. Median LOS was 2 days in both groups, but the fraction with LOS >4 days was 6.0% vs 11.5% (P<0.001) in patients with MP vs those without, and with a reduced risk of LOS >4 days in adjusted analysis [odds ratio (OR) 0.51; confidence interval (CI) 0.39–0.68; P<0.001]. Readmission rates were 5.6% (CI 4.5–6.9) vs 4.4% (P=0.095) and 7.8% vs 7.3% (P=0.53) at 30 and 90 days with and without MP, respectively.Adjusted analysis did not identify MP to be associated with 30 day (OR 1.18; CI 0.89–1.56; P=0.25) or 90 day (OR 1.12; CI 0.86–1.46; P=0.39) readmissions. The incidence of deep infections requiring surgical intervention was 0.8% vs 0.7% with MP vs without, respectively (P=0.78).Conclusions: In this detailed prospective cohort study, preoperative high-dose glucocorticoid administration was not associated with LOS >4 days, readmissions or infectious complications in TKA patients without contraindications.Clinical trial registration: NCT01515670.
      PubDate: 2017-07-01
  • Predicting delirium: are we there yet'
    • Authors: Evered LA.
      Abstract: Postoperative delirium is an extremely common complication after all types of surgery in the elderly, with an incidence as high as 65% in patients admitted for hip fracture repair.1 The implications of an episode of delirium are serious and include an increased risk of dementia, increased length of stay, increased costs, and increased risk of mortality.1 Delirium is associated with progression of cognitive decline even in those with normal baseline cognition.2 It is widely acknowledged that delirium is a preventable complication, with the Australian Council for Safety and Quality in Health Care (ACSQHC), the National Institute for Health and Clinical Excellence (NICE, UK),3 and the American Society of Anesthesiologists (ASA) defining risk-prevention models for implementation in all hospitals. In Australia, the ACSQHC ‘Cognitive Care’ package4 has been distributed as a set of Clinical Care Standards highlighting the importance of preoperative cognitive assessment; NICE in the UK includes similar Clinical Guidelines; while in the USA, the ASA has commenced the ‘Brain Health Initiative’.5 These organizations have developed guidelines for identifying at-risk patients, strategies for prevention, and for targeting research areas specific to reducing delirium.
      PubDate: 2017-06-30
  • Association of intraoperative changes in brain-derived neurotrophic factor
           and postoperative delirium in older adults
    • Authors: Wyrobek JJ; LaFlam AA, Max LL, et al.
      Abstract: AbstractBackground. Delirium is common after surgery, although the aetiology is poorly defined. Brain-derived neurotrophic factor (BDNF) is a neurotrophin important in neurotransmission and neuroplasticity. Decreased levels of BDNF have been associated with poor cognitive outcomes, but few studies have characterized the role of BDNF perioperatively. We hypothesized that intraoperative decreases in BDNF levels are associated with postoperative delirium.Methods. Patients undergoing spine surgery were enrolled in a prospective cohort study. Plasma BDNF was collected at baseline and at least hourly intraoperatively. Delirium was assessed using rigorous methods, including the Confusion Assessment Method (CAM) and CAM for the intensive care unit. Associations of changes in BDNF and delirium were examined using regression models.Results. Postoperative delirium developed in 32 of 77 (42%) patients. The median baseline BDNF level was 7.6 ng ml−1 [interquartile range (IQR) 3.0–11.2] and generally declined intraoperatively [median decline 61% (IQR 31–80)]. There was no difference in baseline BDNF levels by delirium status. However, the percent decline in BDNF was greater in patients who developed delirium [median 74% (IQR 51–82)] vs in those who did not develop delirium [median 50% (IQR 14–79); P=0.03]. Each 1% decline in BDNF was associated with increased odds of delirium in unadjusted {odds ratio [OR] 1.02 [95% confidence interval (CI) 1.00–1.04]; P=0.01}, multivariable-adjusted [OR 1.02 (95% CI 1.00–1.03); P=0.03], and propensity score–adjusted models [OR 1.02 (95% CI 1.00–1.04); P=0.03].Conclusions. We observed an association between intraoperative decline in plasma BDNF and delirium. These preliminary results need to be confirmed but suggest that plasma BDNF levels may be a biomarker for postoperative delirium.
      PubDate: 2017-06-30
  • Intelligent dynamic clinical checklists improved checklist compliance in
           the intensive care unit
    • Authors: De Bie AR; Nan SS, Vermeulen LE, et al.
      Abstract: AbstractBackground. Checklists can reduce medical errors. However, the effectiveness of checklists is hampered by lack of acceptance and compliance. Recently, a new type of checklist with dynamic properties has been created to provide more specific checklist items for each individual patient. Our purpose in this simulation-based study was to investigate a newly developed intelligent dynamic clinical checklist (DCC) for the intensive care unit (ICU) ward round.Methods. Eligible clinicians were invited to participate as volunteers. Highest achievable scores were established for six typical ICU scenarios to determine which items must be checked. The participants compared the DCC with the local standard of care. The primary outcomes were the caregiver satisfaction score and the percentages of checked items overall and of critical items requiring a direct intervention.Results. In total, 20 participants were included, who performed 116 scenarios. The median percentage of checked items was 100.0% with the DCC and 73.6% for the scenarios completed with local standard of care (P<0.001). Critical items remained unchecked in 23.1% of the scenarios performed with local standard of care and 0.0% of the scenarios where the DCC was available (P<0.001). The mean satisfaction score of the DCC was 4.13 out of 5.Conclusions. This simulation study indicates that an intelligent DCC significantly increases compliance with best practice by reducing the percentage of unchecked items during ICU ward rounds, while the user satisfaction rate remains high. Real-life clinical research is required to evaluate this new type of checklist further.
      PubDate: 2017-06-28
  • Postoperative delirium in elderly patients is associated with subsequent
           cognitive impairment
    • Authors: Sprung JJ; Roberts RO, Weingarten TN, et al.
      Abstract: AbstractBackground. We examined the risk for postoperative delirium (POD) in patients with mild cognitive impairment (MCI) or dementia, and the association between POD and subsequent development of MCI or dementia in cognitively normal elderly patients.Methods. Patients ≥65 yr of age enrolled in the Mayo Clinic Study of Aging who were exposed to any type of anaesthesia from 2004 to 2014 were included. Cognitive status was evaluated before and after surgery by neuropsychological testing and clinical assessment, and was defined as normal or MCI/dementia. Postoperative delirium was detected with the Confusion Assessment Method for the intensive care unit. Logistic regression analyses were performed.Results. Among 2014 surgical patients, 74 (3.7%) developed POD. Before surgery, 1667 participants were cognitively normal, and 347 met MCI/dementia criteria. The frequency of POD was higher in patients with pre-existing MCI/dementia compared with no MCI/dementia {8.7 vs 2.6%; odds ratio (OR) 2.53, [95% confidence interval (CI) 1.52–4.21]; P<0.001}. Postoperative delirium was associated with lower education [OR, 3.40 (95% CI, 1.60–7.40); P=0.002 for those with <12 vs ≥16 yr of schooling]. Of the 1667 patients cognitively normal at their most recent assessment, 1152 returned for postoperative evaluation, and 109 (9.5%) met MCI/dementia criteria. The frequency of MCI/dementia at the first postoperative evaluation was higher in patients who experienced POD compared with those who did not [33.3 vs 9.0%; adjusted OR, 3.00 (95% CI, 1.12–8.05); P=0.029].Conclusions. Mild cognitive impairment or dementia is a risk for POD. Elderly patients who have not been diagnosed with MCI or dementia but experience POD are more likely to be diagnosed subsequently with MCI or dementia.
      PubDate: 2017-06-28
  • Checklists, cognitive aids, and the future of patient safety
    • Authors: Webster CS.
      Abstract: On Wednesday, October 30, 1935, an evaluation flight of the Boeing Model 299 was undertaken at Wright Field, northeast of Dayton, OH, USA. The Model 299 was the most technologically sophisticated aircraft of its time and was nicknamed the Flying Fortress because of the extent of its armaments. Major Ployer P. Hill was the pilot, and it was his first flight in the new aircraft. The aircraft appeared to ascend normally, but suddenly stalled, turned on one wing, and crashed, killing two of the aircraft’s five crew, including Major Hill. The investigation into the crash discovered that Major Hill had omitted a crucial step during the preflight preparation; he forgot to release a catch, which on the ground locked the aircraft’s control flaps.1 Once in the air, this mistake rendered the aircraft uncontrollable. The crash investigators knew that there was probably no one better qualified to fly the new aircraft than Major Hill—his co-pilot was also highly qualified—yet despite this, the fatal error was still made. The investigators concluded that given the experience of the pilots, further training would not be an effective response to prevent such an event from happening again; a response that is very different from that which often occurs in health care when a mistake is made.2 Some commentators initially believed that this meant the new aircraft was simply too complicated to fly reliably. A new approach was needed, and it took the form of a simple list of crucial tasks that must be completed before the aircraft could leave the ground. The first aviation checklist had been devised.1 With the checklist in use, despite the aircraft’s sophistication, the Model 299 (and later versions of it) performed safely for many years.
      PubDate: 2017-06-26
  • Catheter-related right internal jugular vein thrombosis after chest
    • Authors: Chen PT; Chang KC, Hu KL, et al.
      Abstract: AbstractBackground: Central venous catheters (CVCs) are frequently used for monitoring haemodynamic status and rapidly delivering fluid therapy during the peri- and postoperative periods. Indwelling CVCs are typically used 7–14 days postoperatively for additional monitoring and treatment, but patients may develop asymptomatic catheter-related thrombosis, leading to life-threatening pulmonary embolism and death. Early detection helps to avoid such complications.Methods: This prospective observational study investigated the risk factors associated with catheter-related right internal jugular vein thrombosis in patients undergoing chest surgery. The study enrolled 24 patients who were scheduled to receive chest surgeries during which catheters were needed. To detect thrombus formation, Doppler ultrasound examinations from the thyroid cartilage level to the supraclavicular region were used after CVC placement and on each of the following days until the catheter was removed.Results: No thrombosis was found in patients before surgery, but it appeared in 75% (18/24) after surgery. The risks of thrombosis increased with a longer duration of anaesthesia, greater amounts of bleeding, and use of postoperative ventilator support.Conclusions: Earlier catheter removal may reduce the risk of catheter-related thrombosis and avoid possibly fatal complications after catheter-related thrombosis.
      PubDate: 2017-06-26
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