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Journal Cover Anaesthesia
  [SJR: 1.404]   [H-I: 88]   [146 followers]  Follow
   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 0003-2409 - ISSN (Online) 1365-2044
   Published by John Wiley and Sons Homepage  [1597 journals]
  • Big data: breaking new ground in airway research
    • Authors: K. B. Greenland; M. G. Irwin
      PubDate: 2018-03-13T11:00:19.577598-05:
      DOI: 10.1111/anae.14248
  • The Airway App: exploring the role of smartphone technology to capture
           emergency front-of-neck airway experiences internationally
    • Authors: L. V. Duggan; S. L. Lockhart, T. M. Cook, E. P. O'Sullivan, T. Dare, P. A. Baker
      Abstract: In this exploratory study we describe the utility of smartphone technology for anonymous retrospective observational data collection of emergency front-of-neck airway management. The medical community continues to debate the optimal technique for emergency front-of-neck airway management. Although individual clinicians infrequently perform this procedure, hundreds are performed annually worldwide. Ubiquitous smartphone technology and internet connectivity have created the opportunity to collect these data. We created the ‘Airway App’, a smartphone application to capture the experiences of healthcare providers involved in emergency front-of-neck airway procedures. In the first 18-month period, 104 emergency front-of-neck airway management reports were received; 99 (95%) were internally valid and unique from 21 countries. Eighty-one (82%) were performed by non-surgeons and 63 (64%) were ‘cannot intubate, cannot oxygenate’ emergencies. Overall first-attempt success varied by technique; 45 scalpel–bougie cricothyroidotomy (37 first-attempt success), 25 surgical cricothyroidotomy (15 first-attempt success), eight cannula cricothyroidotomy (five first-attempt success), six wire-guided cricothyroidotomy (three first-attempt success) and 15 tracheostomy reports (11 first-attempt success). The most commonly reported positive human factors were good communication, good teamwork and/or skilled personnel. The most commonly reported negative human factors were fixation on multiple tracheal intubation attempts, delay in initiating emergency front-of-neck airway and/or the failure to plan for failure. Due to the anonymous nature of reporting, reports are open to recollection bias and spurious reporting. We conclude collection of data using a smartphone application is feasible and has the potential to expand our knowledge of emergency front-of-neck airway management.
      PubDate: 2018-03-13T10:50:28.592298-05:
      DOI: 10.1111/anae.14247
  • Bespoke intra-operative anaesthesia – the end of the formulaic
    • Authors: W. J. Fawcett; C. N. Jones
      PubDate: 2018-03-13T10:45:23.275855-05:
      DOI: 10.1111/anae.14253
  • Sodium-glucose co-transporter type-2 inhibitors: pharmacology and
           peri-operative considerations
    • Authors: D. A. Milder; T. Y. Milder, P. C. A. Kam
      Abstract: Sodium-glucose co-transporter 2 (SGLT2) inhibitors are an emerging class of oral hypoglycaemic agents with therapeutic benefits beyond better glycaemic control. A major concern of the sodium-glucose co-transporter 2 inhibitors is their propensity to cause euglycaemic ketoacidosis in the peri-operative period and the potential for this critical diagnosis to be delayed or missed entirely. This review attempts to collate the case reports of sodium-glucose co-transporter 2 inhibitor ketoacidosis associated with surgery to highlight and put a perspective on this peri-operative issue. Preventive strategies and the management of the ketoacidosis are discussed.
      PubDate: 2018-03-12T12:30:20.941204-05:
      DOI: 10.1111/anae.14251
  • Pre-operative anaemia, intra-operative hepcidin concentration and acute
           kidney injury after cardiac surgery: a retrospective observational study
    • Authors: K. Karkouti; P. Yip, C. Chan, L. Chawla, V. Rao
      Abstract: Acute kidney after cardiac surgery is more common in anaemic patients, whereas haemolysis during cardiopulmonary bypass may lead to iron-induced renal injury. Hepcidin promotes iron sequestration by macrophages: hepcidin concentration is reduced by anaemia and increased by inflammation. We analysed the associations in 525 patients between pre-operative anaemia (haemoglobin < 130 g.l−1 in men and < 120 g.l−1 in women), intra-operative hepcidin concentration and acute kidney injury (dialysis or> 26.4 μmol.l−1 or> 50% creatinine increase during the first two days after cardiac surgery. Rates of pre-operative anaemia and postoperative kidney injury were 109/525 (21%) and 36/525 (7%), respectively. The median (IQR [range]) intra-operative hepcidin concentration was 20 (10–33 [0–125]) μg.l−1 and was lower in anaemic patients than those who were not: 15 (4–28 [0–125]) μg.l−1 vs. 21 (12–33 [0–125]) μg.l−1, respectively, p = 0.002. Four variables were independently associated with postoperative kidney injury, for which the beta-coefficients (SE) were: minutes on cardiopulmonary bypass, 0.016 (0.004), p < 0.001; intra-operative hepcidin concentration, 0.032 (0.008), p < 0.001; pre-operative anaemia, 1.97 (0.56), p < 0.001; and Cleveland clinic risk score, 0.88 (0.35), p = 0.005. Contrary to generally increased rates of kidney injury in patients with higher hepcidin concentrations, rates of kidney injury in anaemic patients were lower in patients with higher hepcidin concentrations, beta-coefficient (SE) −0.037 (0.01), p = 0.007. In cardiac surgical patients the rate of postoperative acute kidney injury predicted by the Cleveland risk score might be adjusted for pre-operative anaemia and intra-operative cardiopulmonary bypass time and hepcidin concentration. Pre-operative correction of anaemia, reduction in intra-operative bypass time and modification of iron homeostasis and hepcidin concentration might reduce acute kidney injury.
      PubDate: 2018-03-12T12:25:21.491633-05:
      DOI: 10.1111/anae.14274
  • Lung ultrasound compared with chest X-ray in diagnosing postoperative
           pulmonary complications following cardiothoracic surgery: a prospective
           observational study
    • Authors: H. R. Touw; K. L. Parlevliet, M. Beerepoot, P. Schober, A. Vonk, J. W. Twisk, P. W. Elbers, C. Boer, P. R. Tuinman
      Abstract: Postoperative pulmonary complications are common after cardiothoracic surgery and are associated with adverse outcomes. The ability to detect postoperative pulmonary complications using chest X-rays is limited, and this technique requires radiation exposure. Little is known about the diagnostic accuracy of lung ultrasound for the detection of postoperative pulmonary complications after cardiothoracic surgery, and we therefore aimed to compare lung ultrasound with chest X-ray to detect postoperative pulmonary complications in this group of patients. We performed this prospective, observational, single-centre study in a tertiary intensive care unit treating adult patients who had undergone cardiothoracic surgery. We recorded chest X-ray findings upon admission and on postoperative days 2 and 3, as well as rates of postoperative pulmonary complications and clinically-relevant postoperative pulmonary complications that required therapy according to the treating physician as part of their standard clinical practice. Lung ultrasound was performed by an independent researcher at the time of chest X-ray. We compared lung ultrasound with chest X-ray for the detection of postoperative pulmonary complications and clinically-relevant postoperative pulmonary complications. We also assessed inter-observer agreement for lung ultrasound, and the time to perform both imaging techniques. Subgroup analyses were performed to compare the time to detection of clinically-relevant postoperative pulmonary complications by both modalities. We recruited a total of 177 patients in whom both lung ultrasound and chest X-ray imaging were performed. Lung ultrasound identified 159 (90%) postoperative pulmonary complications on the day of admission compared with 107 (61%) identified with chest X-ray (p 
      PubDate: 2018-03-12T12:20:25.205104-05:
      DOI: 10.1111/anae.14243
  • The relationship between pre-operative hypertension and intra-operative
           haemodynamic changes known to be associated with postoperative morbidity
    • Authors: M. Crowther; K. Spuy, F. Roodt, M. B. Nejthardt, J. G. Davids, J. Roos, E. Cloete, T. Pretorius, G. L. Davies, J. G. Walt, C. Westhuizen, M. Flint, J. L. C. Swanevelder, B. M. Biccard
      Abstract: Hypertension is not consistently associated with postoperative cardiovascular morbidity and is therefore not considered a major peri-operative risk factor. However, hypertension may predispose to peri-operative haemodynamic changes known to be associated with peri-operative morbidity and mortality, such as intra-operative hypotension and tachycardia. The objective of this study was to determine whether pre-operative hypertension was independently associated with haemodynamic changes known to be associated with adverse peri-operative outcomes. We performed a five-day multicentre, prospective, observational cohort study which included all adult inpatients undergoing elective, non-cardiac, non-obstetric surgery. We recruited 343 patients of whom 164 (47.8%) were hypertensive. An intra-operative mean arterial pressure of < 55 mmHg occurred in 59 (18.2%) patients, of which 25 (42.4%) were hypertensive. Intra-operative tachycardia (heart rate> 100 beats.min−1) occurred in 126 (38.9%) patients, of whom 61 (48.4%) were hypertensive. Multivariable logistic regression did not show an independent association between the stage of hypertension and either clinically significant hypotension or tachycardia, when controlled for ASA physical status, functional status, major surgery, duration of surgery or blood transfusion. There was no association between pre-operative hypertension and peri-operative haemodynamic changes known to be associated with major morbidity and mortality. These data, therefore, support the recommendation of the Joint Guidelines of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the British Hypertension Society to proceed with elective surgery if a patient's blood pressure is < 180/110 mmHg.
      PubDate: 2018-03-12T12:10:35.050999-05:
      DOI: 10.1111/anae.14239
  • Randomised double-blind comparison of bolus phenylephrine or ephedrine for
           treatment of hypotension in women with pre-eclampsia undergoing caesarean
    • Authors: M. Mohta; S. Duggal, G. T. Chilkoti
      Abstract: Treatment of post-spinal hypotension during caesarean section assumes special concern in pre-eclamptic patients due to a compromised fetoplacental circulation and increased risk of placental hypoperfusion. Phenylephrine and ephedrine are the most commonly used vasopressors, although the best choice is still not clear. We studied 80 pre-eclamptic women with a singleton pregnancy who underwent caesarean section with spinal anaesthesia, and who developed hypotension defined as a decrease in systolic arterial pressure ≥ 20% from baseline or absolute value < 100 mmHg. Women were randomly allocated to receive phenylephrine 50 μg or ephedrine 4 mg boluses for treatment of hypotension. Blood pressure changes following vasopressor administration were similar in both groups, but heart rate remained higher after ephedrine at all time-points. The primary outcome measure of umbilical artery pH was 7.26 (0.11) in the phenylephrine group and 7.25 (0.09) in the ephedrine group (p = 0.86). The incidence of neonatal acidosis (umbilical artery pH < 7.20) was 9 (22.5%) in the phenylephrine group and 11 (27.5%) in the ephedrine group (p = 0.80). Other secondary outcome measures were comparable. In conclusion, phenylephrine 50 μg and ephedrine 4 mg, administered as intravenous boluses to treat post-spinal hypotension during caesarean section in pre-eclamptic patients, resulted in similar fetal acid-base values, were equally effective in treating hypotension and were associated with good maternal and neonatal outcome.
      PubDate: 2018-03-09T01:45:28.850224-05:
      DOI: 10.1111/anae.14268
  • Electrocardiogram failure in the operating room – bench testing to
           prevent bed-side disaster
    • Authors: B. Cowie; L. Baker, B. Shoghi, M. Worner, D. Scott
      Abstract: Electrocardiogram (ECG) false alarms are common in electrically-hostile peri-operative environments. Newer integrated monitoring, with sophisticated hardware and software, has the potential to minimise artefacts. However, monitoring issues continue to occur, with the potential for critical incidents and unnecessary and harmful interventions. We describe the root cause analysis of a series of apparent ECG flatline asystolic events that appeared in the operating room shortly after the introduction of new intra-operative monitoring systems. Clinical events and biomedical laboratory testing revealed complete loss of ECG signal with increasing resistance. The new ECG systems had incorporated both software and hardware changes to improve the fidelity of signal acquisition and display, but had become much more sensitive to impedance changes. After we alerted the manufacturer, they added software and hardware updates that resulted in resolution of all incidents of ECG loss-of-signal.
      PubDate: 2018-03-09T00:30:24.255635-05:
      DOI: 10.1111/anae.14250
  • International Fragility Fracture Network Delphi consensus statement on the
           principles of anaesthesia for patients with hip fracture
    • Authors: S. M. White; F. Altermatt, J. Barry, B. Ben-David, M. Coburn, F. Coluzzi, M. Degoli, D. Dillane, N. B. Foss, A. Gelmanas, R. Griffiths, G. Karpetas, J.-H. Kim, M. Kluger, P.-W. Lau, I. Matot, M. McBrien, S. McManus, L. F. Montoya-Pelaez, I. K. Moppett, M. Parker, O. Porrill, R. D. Sanders, C. Shelton, F. Sieber, A. Trikha, X. Xuebing
      PubDate: 2018-03-06T03:26:19.14466-05:0
      DOI: 10.1111/anae.14225
  • Accuracy of near-patient vs. inbuilt spirometry for monitoring tidal
           volumes in an in-vitro paediatric lung model
    • Authors: S. Morgenroth; J. Thomas, V. Cannizzaro, M. Weiss, A. R. Schmidt
      Abstract: Spirometric monitoring provides precise measurement and delivery of tidal volumes within a narrow range, which is essential for lung-protective strategies that aim to reduce morbidity and mortality in mechanically-ventilated patients. Conventional anaesthesia ventilators include inbuilt spirometry to monitor inspiratory and expiratory tidal volumes. The GE Aisys CS2 anaesthesia ventilator allows additional near-patient spirometry via a sensor interposed between the proximal end of the tracheal tube and the respiratory tubing. Near-patient and inbuilt spirometry of two different GE Aisys CS2 anaesthesia ventilators were compared in an in-vitro study. Assessments were made of accuracy and variability in inspiratory and expiratory tidal volume measurements during ventilation of six simulated paediatric lung models using the ASL 5000 test lung. A total of 9240 breaths were recorded and analysed. Differences between inspiratory tidal volumes measured with near-patient and inbuilt spirometry were most significant in the newborn setting (p < 0.001), and became less significant with increasing age and weight. During expiration, tidal volume measurements with near-patient spirometry were consistently more accurate than with inbuilt spirometry for all lung models (p < 0.001). Overall, the variability in measured tidal volumes decreased with increasing tidal volumes, and was smaller with near-patient than with inbuilt spirometry. The variability in measured tidal volumes was higher during expiration, especially with inbuilt spirometry. In conclusion, the present in-vitro study shows that measurements with near-patient spirometry are more accurate and less variable than with inbuilt spirometry. Differences between measurement methods were most significant in the smallest patients. We therefore recommend near-patient spirometry, especially for neonatal and paediatric patients.
      PubDate: 2018-03-01T03:45:31.945823-05:
      DOI: 10.1111/anae.14245
  • Retraction
    • PubDate: 2018-02-27T07:05:23.00035-05:0
      DOI: 10.1111/anae.14241
  • Retraction
    • PubDate: 2018-02-27T07:00:28.505541-05:
      DOI: 10.1111/anae.14240
  • Associations of postoperative mortality with the time of day, week and
    • Authors: F. Kork; C. Spies, T. Conrad, B. Weiss, T. Roenneberg, K-D. Wernecke, F. Balzer
      Abstract: Studies that have investigated circadian, weekday and seasonal variation in postoperative mortality have been relatively small or have been for scheduled surgery. We retrospectively tested a large mixed surgical cohort from a German tertiary care university hospital for the presence of cyclical variation in all-cause in-hospital mortality after operations performed between 2006 and 2013. We analysed mortality rates after 247,475 operations, adjusted for age, sex, comorbidities, location, urgency and duration of the surgery, and intra-operative blood transfusions. The mortality odds ratio (95%CI) after operations started in the morning (08:00–11:00) were lowest, 0.73 (0.66–0.80), p < 0.001 and highest for operations started in the afternoon (13:00–17:00), 1.29 (1.18–1.40), p < 0.001. Mortality at the weekend was the same as during the week. There was no seasonal variation in mortality, p = 0.12. However, the interference of four-yearly and ten-monthly cycle amplitudes resulted in higher mortality odds ratio (95%CI) in winter 2008–2009, 1.41 (1.18–1.69), p < 0.001, and lower mortality in spring 2011 and 2012, 0.70 (0.56–0.85) and 0.67 (0.53–0.85), p < 0.001 and p = 0.001, respectively. The ability to predict cyclical phenomena would facilitate the design of interventional studies, aimed at reducing mortality following surgery in the afternoon and when cycles interfere constructively.
      PubDate: 2018-02-23T06:35:33.901848-05:
      DOI: 10.1111/anae.14228
  • Cognitive decline in the middle-aged after surgery and anaesthesia:
           results from the Wisconsin Registry for Alzheimer's Prevention cohort
    • Authors: L. C. Bratzke; R. L. Koscik, K. J. Schenning, L. R. Clark, M. A. Sager, S. C. Johnson, B. P. Hermann, K. J. Hogan
      Abstract: Surgery and anaesthesia might affect cognition in middle-aged people without existing cognitive dysfunction. We measured memory and executive function in 964 participants, mean age 54 years, and again four years later, by when 312 participants had had surgery and 652 participants had not. Surgery between tests was associated with a decline in immediate memory by one point (out of a maximum of 30), p = 0.013: memory became abnormal in 77 out of 670 participants with initially normal memory, 21 out of 114 (18%) of whom had had surgery compared with 56 out of 556 (10%) of those who had not, p = 0.02. The number of operations was associated with a reduction in immediate memory on retesting, beta coefficient (SE) 0.08 (0.03), p = 0.012. Working memory decline was also associated with longer cumulative operations, beta coefficient (SE) −0.01 (0.00), p = 0.028. A reduction in cognitive speed and flexibility was associated with worse ASA physical status, beta coefficient (SE) 0.55 (0.22) and 0.37 (0.17) for ASA 1 and 2 vs. 3, p = 0.035. However, a decline in working memory was associated with better ASA physical status, beta coefficient (SE) −0.48 (0.21) for ASA 1 vs. 3, p = 0.01.
      PubDate: 2018-02-21T23:15:32.936613-05:
      DOI: 10.1111/anae.14216
  • The effect of anaesthetic technique during primary breast cancer surgery
           on neutrophil–lymphocyte ratio, platelet–lymphocyte ratio and return
           to intended oncological therapy
    • Authors: A. Ní Eochagáin; D. Burns, B. Riedel, D. I. Sessler, D. J. Buggy
      Abstract: Inflammation and immunosuppression contribute to the pathogenesis of cancer. An increased neutrophil–lymphocyte ratio reflects these processes and is associated with adverse cancer outcomes. Whether anaesthetic technique for breast cancer surgery influences these factors, and potentially cancer recurrence, remains unknown. We conducted a secondary analysis in patients enrolled in an ongoing trial of anaesthetic technique on breast cancer recurrence. The primary hypothesis was that postoperative neutrophil–lymphocyte ratio is lower in patients allocated to receive propofol-paravertebral rather than inhalational agent-opioid anaesthesia for primary breast cancer surgery. Among 397 patients, 116 had differential white cell counts performed pre-operatively and postoperatively. Pre-operative neutrophil–lymphocyte ratio was similar in the propofol-paravertebral 2.3 (95%CI 1.8–2.8) and inhalational agent-opioid anaesthesia 2.2 (1.9–3.2) groups, p = 0.72. Postoperative neutrophil–lymphocyte ratio was lower (3.0 (2.4–4.2) vs. 4.0 (2.9–5.4), p = 0.001) in the propofol-paravertebral group. Propofol-paravertebral anaesthesia attenuated the postoperative increase in the neutrophil-lymphocyte ratio.
      PubDate: 2018-02-19T00:45:23.230288-05:
      DOI: 10.1111/anae.14207
  • Comparison of laryngeal morbidities with modified reinforced silicone tube
           intubation guided over a bougie vs. a guidewire: novel assessment with
           voice analysis
    • Authors: T. Ponnusamy; P. Kundra, P. Rudingwa, S. Gopalakrishnan
      Abstract: Semi-rigid flexible introducer-guided tracheal intubation is associated with pharyngolaryngeal morbidities. We compared the practice of railroading a newly described modified reinforced silicone tracheal tube with a built-in guide channel in its wall over a non-kinking guidewire with railroading the same tube over a disposable bougie, with respect to pharyngolaryngeal morbidities. One hundred and twenty-four ASA 1 and 2 adults were randomly assigned to undergo bougie-guided (n = 62) or wire-guided (n = 62) intubation under general anaesthesia. All patients were assessed for postoperative pharyngolaryngeal complaints. In addition, voice parameters (fundamental frequency, shimmer, jitter and harmonic noise ratio) with vowels ‘a’ and ‘i’ were analysed pre-operatively and 24 h postoperatively. The success of first-attempt intubation and the associated haemodynamic response were also recorded. A higher incidence of pharyngolaryngeal complaints was seen in the bougie group, 48.3%, 95%CI (35.9–60.9%) when compared with wire-guided group 28.3%, 95%CI (18.0–40.6%), p = 0.01. Postoperatively, all the voice parameters were significantly more affected when compared with their pre-operative value in the bougie-guided group (p < 0.05) but not in the wire-guided group. The success of first-attempt intubation was similar in both groups. Wire-guided orotracheal intubation was associated with a lower incidence of pharyngolaryngeal complaints and effect on voice when compared with bougie-guided intubation.
      PubDate: 2018-02-07T01:15:26.509074-05:
      DOI: 10.1111/anae.14236
  • Optimisation of the dosage of tranexamic acid in trauma patients with
           population pharmacokinetic analysis
    • Authors: S. Grassin-Delyle; O. M. Theusinger, R. Albrecht, S. Mueller, D. R. Spahn, S. Urien, P. Stein
      Abstract: Tranexamic acid is used both pre-hospital and in-hospital as an antifibrinolytic drug to treat or prevent hyperfibrinolysis in trauma patients; dosing, however, remains empirical. We aimed to measure plasma levels of tranexamic acid in patients receiving pre-hospital anti-hyperfibrinolytic therapy and to build a population pharmacokinetic model to propose an optimised dosing regimen. Seventy-three trauma patients were enrolled and each received tranexamic acid 1 g intravenously pre-hospital. A blood sample was drawn after arrival in the emergency department, and we measured the plasma tranexamic acid concentration using liquid chromatography-mass spectrometry, and modelled the data using non-linear mixed effect modelling. Tranexamic acid was administered at a median (IQR [range]) time of 43 (30–55 [5–135]) min after trauma. Plasma tranexamic acid levels were determined on arrival at hospital, 57 (43–70 [20–148]) min after pre-hospital administration of the drug. The measured concentration was 28.7 (21.5–38.5 [8.7–89.0]) μ−1. Our subjects had sustained severe trauma; injury severity score 20 (16–29 [5–75]), including penetrating injury in 2.8% and isolated traumatic brain injury in 19.7%. The pharmacokinetics were ascribed a two-compartment open model with body-weight as the main covariate. As tranexamic acid concentrations may fall below therapeutic levels during initial hospital treatment, we propose additional dosing schemes to maintain a specific target blood concentration for as long as required. This is the first study to investigate plasma level and pharmacokinetics of tranexamic acid after pre-hospital administration in trauma patients. Our proposed dosing regimen could be used in subsequent clinical trials to better study efficacy and tolerance profiles with controlled blood concentrations.
      PubDate: 2018-02-07T01:00:27.104531-05:
      DOI: 10.1111/anae.14184
  • Videolaryngoscopy vs. Macintosh laryngoscopy for double-lumen tube
           intubation in thoracic surgery: a systematic review and meta-analysis
    • Authors: T. T. Liu; L. Li, L. Wan, C. H. Zhang, W. L. Yao
      Abstract: Double-lumen intubation is more difficult than single-lumen tracheal intubation. Videolaryngoscopes have many advantages in airway management. However, the advantages of videolaryngoscopy for intubation with a double-lumen tube remain controversial compared with traditional Macintosh laryngoscopy. In this study, we searched MEDLINE, Embase, Cochrane Library and the Web of Science for randomised controlled trials comparing videolaryngoscopy with Macintosh laryngoscopy for double-lumen tube intubation. We found that videolaryngoscopy provided a higher success rate at first attempt for double-lumen tube intubation, with an odds ratio (95%CI) of 2.77 (1.92–4.00) (12 studies, 1215 patients, moderate-quality evidence, p < 0.00001), as well as a lower incidence of oral, mucosal or dental injuries during double-lumen tube intubation, odds ratio (95%CI) 0.36 (0.15–0.85) (11 studies, 1145 patients, low-quality evidence, p = 0.02), and for postoperative sore throat, odds ratio (95%CI) 0.54 (0.36–0.81) (7 studies, 561 patients, moderate-quality evidence, p = 0.003), compared with Macintosh laryngoscopy. There were no significant differences in intubation time, with a standardised mean difference (95%CI) of −0.10 (−0.62 to 0.42) (14 studies, 1310 patients, very low-quality evidence, p = 0.71); and the incidence of postoperative voice change, odds ratio (95%CI) 0.53 (0.21–1.31) (7 studies, 535 patients, low-quality evidence, p = 0.17). Videolaryngoscopy led to a higher incidence of malpositioned double-lumen tube, with an odds ratio (95%CI) of 2.23 (1.10–4.52) (six studies, 487 patients, moderate-quality evidence, p = 0.03).
      PubDate: 2018-02-06T02:35:29.026742-05:
      DOI: 10.1111/anae.14226
  • Anomalies in target-controlled infusion: an analysis after 20 years
           of clinical use
    • Authors: F. H. M. Engbers; A. Dahan
      Abstract: Although target-controlled infusion has been in use for more than two decades, its benefits are being obscured by anomalies in clinical practice caused by a number of important problems. These include: a variety of pharmacokinetic models available in open target-controlled infusion systems, which often confuse the user; the extrapolation of anthropomorphic data which provokes anomalous adjustments of dosing by such systems; and the uncertainty of regulatory requirements for the application of target-controlled infusion which causes uncontrolled exploitation of drugs and pharmacokinetic models in target-controlled infusion devices. Comparison of performance of pharmacokinetic models is complex and mostly inconclusive. However, a specific behaviour of a model in a target-controlled infusion system that is neither intended nor supported by scientific data can be considered an artefact or anomaly. Several of these anomalies can be identified in the current commercially available target-controlled infusion systems and are discussed in this review.
      PubDate: 2018-01-31T07:00:42.117945-05:
      DOI: 10.1111/anae.14212
  • A triple-blind, placebo-controlled randomised trial of the
           ilioinguinal-transversus abdominis plane (I-TAP) nerve block for elective
           caesarean section
    • Authors: J. J. Staker; D. Liu, R. Church, D. J. Carlson, M. Panahkhahi, A. Lim, T. LeCong
      Abstract: This study investigated the efficacy of a new ilioinguinal-transversus abdominis plane block when used as a component of multimodal analgesia. We conducted a prospective, triple-blind, placebo-controlled randomised study of 100 women undergoing elective caesarean section. All women had spinal anaesthesia with hyperbaric bupivacaine, 15 μg fentanyl and 150 μg morphine, as well as 100 mg diclofenac and 1.5 g paracetamol rectally. Women were randomly allocated to receive the ilioinguinal-transversus abdominis plane block or a sham block at the end of surgery. The primary outcome was the difference in fentanyl patient-controlled analgesia dose at 24 h. Secondary outcomes included postoperative pain scores, adverse effects and maternal satisfaction. The cumulative mean (95%CI) fentanyl dose at 24 h was 71.9 (55.6–92.7) μg in the ilioinguinal-transversus abdominis group compared with 179.1 (138.5–231.4) μg in the control group (p < 0.001). Visual analogue scale pain scores averaged across time-points were 1.9 (1.5–2.3) mm vs. 5.0 (4.3–5.9) mm (p = 0.006) at rest, and 4.7 (4.1–5.5) mm vs. 11.3 (9.9–13.0) mm (p = 0.001) on movement, respectively. Post-hoc analysis showed that the ilioinguinal-transversus abdominis group was less likely to use ≥ 1000 μg fentanyl compared with the control group (2% vs. 16%; p = 0.016). There were no differences in opioid-related side-effects or maternal satisfaction with analgesia. The addition of the ilioinguinal-transversus abdominis plane block provides superior analgesia to our usual multimodal analgesic regimen.
      PubDate: 2018-01-29T01:50:49.779603-05:
      DOI: 10.1111/anae.14222
  • Topical benzydamine hydrochloride for prevention of postoperative sore
           throat in adults undergoing tracheal intubation for elective surgery: a
           systematic review and meta-analysis
    • Authors: A. Kuriyama; M. Aga, H. Maeda
      Abstract: Postoperative sore throat has a negative impact on patient satisfaction and recovery. Benzydamine hydrochloride is a non-steroidal anti-inflammatory drug available for topical use. We performed a systematic review and meta-analysis to assess the efficacy and safety of topical application of benzydamine to prevent postoperative sore throat in adults undergoing elective surgery under general anaesthesia. We searched PubMed, EMBASE, Web of Science and the Cochrane Central Register of Controlled Trials to identify relevant randomised controlled trials and pooled the data using a random effects model. The primary outcomes were the incidence and severity of sore throat 24 h after surgery/extubation, and adverse events. The quality of evidence was assessed using the grading of recommendations, assessment, development and evaluation (GRADE) criteria. Thirteen randomised controlled trials involving 1842 patients were included. Compared with control patients who did not receive analgesia, benzydamine was associated with a decreased incidence of postoperative sore throat, with a risk ratio (95%CI) of 0.31 (0.20–0.47), but not with significantly reduced severity, the standardised mean difference (95%CI) being −0.27 (−0.63 to 0.08). There were no significant adverse events related to benzydamine. Benzydamine was also associated with a reduced incidence of postoperative sore throat when compared with lidocaine, with a risk ratio (95%CI) of 0.18 (0.07–0.43). We judged the evidence for the outcome ‘incidence of postoperative sore throat’ as high quality.
      PubDate: 2018-01-29T01:40:46.841386-05:
      DOI: 10.1111/anae.14224
  • A good pilot to navigate troubled waters
    • Authors: S. W. Choi; M. Charlesworth, G. T. C. Wong
      PubDate: 2018-01-24T04:10:20.001316-05:
      DOI: 10.1111/anae.14223
  • Effect of palpable vs. impalpable cricothyroid membranes in a simulated
           emergency front-of-neck access scenario
    • Authors: C. F. Pairaudeau; C. Mendonca, C. Hillermann, I. Qazi, P. A. Baker, R. E. Hodgson, S. Radhakrishna
      Abstract: The Difficult Airway Society 2015 guidelines recommend and describe in detail a surgical cricothyroidotomy technique for the can't intubate, can't oxygenate (CICO) scenario, but this can be technically challenging for anaesthetists with no surgical training. Following a structured training session, 104 anaesthetists took part individually in a simulated can't intubate, can't oxygenate event using simulation and airway models to evaluate how well they could perform these front-of-neck access techniques. Main outcomes measures were: ability to correctly perform the technical steps; procedural time; and success rate. Outcomes were compared between palpable and impalpable cricothyroid membrane scenarios. Anaesthetists’ technical abilities were good, as assessed by a video analysis checklist score. Mean (SD) procedural time was 44 (16) s and 65 (17) s for the palpable and impalpable cricothyroid membrane models, respectively (p ≤ 0.001). First-pass tracheal tube placement was obtained in 103 out of the 104 palpable cricothyroidotomies and in 101 out of the 104 impalpable cricothyroidotomies (p = 0.31). We conclude that anaesthetists can be trained to perform surgical front-of-neck access to an acceptable level of competence and speed when assessed using a simulator.
      PubDate: 2018-01-19T01:50:30.825169-05:
      DOI: 10.1111/anae.14218
  • The association between borderline pre-operative anaemia in women and
           outcomes after cardiac surgery: a cohort study
    • Authors: G. Blaudszun; K. E. Munting, A. Butchart, C. Gerrard, A. A. Klein
      Abstract: Anaemia is common before cardiac surgery and is associated with increased morbidity and mortality. The World Health Organization (WHO) definition of anaemia is lower for women than for men by 10 g.l−1, potentially putting women at a disadvantage compared with men with regard to pre-operative optimisation. Our hypothesis was that women with borderline anaemia (defined by us as haemoglobin concentration 120–129 g.l−1) would have a higher rate of red cell transfusion, morbidity and mortality than non-anaemic women (haemoglobin ≥ 130 g.l−1). This retrospective observational study included all adult patients admitted for elective cardiac surgery from January 2013 to April 2016. During the study period, 1388 women underwent cardiac surgery. Pre-operatively, 333 (24%) had a haemoglobin level < 120 g.l−1; 408 (29%) 120–129 g.l−1; and 647 (47%) ≥ 130 g.l−1. Compared with non-anaemic women, women with borderline anaemia were more likely to be transfused (68.6% vs. 44.5%; RR 1.5, 95%CI 1.4–1.7; p < 0.0001) and were transfused with more units of red cells, mean (SD) 1.8 (2.8) vs. 1.3 (3.0); p < 0.0001. Hospital length of stay was significantly longer in the borderline anaemia group compared with non-anaemic women, median (IQR [range]) 8 (6–12 [3–45]) vs. 7 (6–11 [4–60]); p = 0.0159. Short- and long-term postoperative survival was comparable in both groups. Borderline anaemia is associated with increased red cell transfusion and prolonged hospital stay. Future research should address whether correction of borderline anaemia results in improved outcomes.
      PubDate: 2018-01-19T01:50:26.498911-05:
      DOI: 10.1111/anae.14185
  • A new retrograde transillumination technique for videolaryngoscopic
           tracheal intubation
    • Authors: P. Biro; E. Fried, M. Schlaepfer, M. S. Kristensen
      Abstract: This single-centre, prospective trial was designed to assess the efficacy of a new retrograde transillumination device called the ‘Infrared Red Intubation System’ (IRRIS) to aid videolaryngoscopic tracheal intubation. We included 40 adult patients, who were undergoing elective urological surgery under general anaesthesia. We assessed the ability to differentiate the transilluminated glottis from other structures and found a median (IQR [range]) larynx recognition time of 8 (5–14 [3–28]) s. The difference in laryngeal visibility on the screen between the deactivated vs. activated device expressed on a visual analogue scale was significant (6 (4–7 [2–10]) vs. 10 (8–10 [4–10]); p < 0.001). The number of laryngoscope insertions was 1 (1–2 [1–3]) and the device showed high values on a visual analogue scale ranging from 0 (lowest score) to 10 (highest score) for helpfulness (6 (5–7 [2–10])), credibility (10 (8–10 [5–10])) and ease of use (10 (9–10 [8–10])). Tracheal intubation with the system lasted 26 (16–32 [6–89]) s. No alternative technique of securing the airway was necessary. The lowest SpO2 during intubation was 98 (97–99 [91–100])%. We conclude that this method of retrograde transillumination can assist videolaryngoscopy.
      PubDate: 2018-01-18T07:00:41.42022-05:0
      DOI: 10.1111/anae.14217
  • Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) vs.
           facemask breathing pre-oxygenation for rapid sequence induction in adults:
           a prospective randomised non-blinded clinical trial
    • Authors: Å. Lodenius; J. Piehl, A. Östlund, J. Ullman, M. Jonsson Fagerlund
      Abstract: Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) can prolong apnoea time in adults. Therefore, THRIVE used for pre-oxygenation in rapid sequence induction of anaesthesia could extend safe apnoea time during prolonged laryngoscopy and intubation. In this randomised controlled trial, we compared the lowest peripheral oxygen saturation (SpO2) during intubation when pre-oxygenating with either traditional facemask or THRIVE. Eighty adult patients, undergoing rapid sequence induction of anaesthesia for emergency surgery, were randomly allocated to pre-oxygenation with 100% oxygen with facemask or with THRIVE. Median (IQR [range]) lowest SpO2 until 1 min after intubation was 99% (97–100 [70–100]%) for the facemask group vs. 99% (99–100 [96–100]%) for the THRIVE group (p = 0.097). Five patients (12.5%) desaturated below 93% when pre-oxygenated with the facemask vs. none in the THRIVE group (p = 0.019). There were no differences in intubation time or apnoea time between the groups. Median intubation time was 51 (34–66 [22–261]) s in the facemask group vs. 48 (38–63 [10–146]) s in the THRIVE group (p = 0.99). Median apnoea time was 109 (86–142 [37–291]) s and 116 (92–146 [63–249]) s when using facemask and THRIVE, respectively (p = 0.49). No signs of regurgitation of gastric content were detected. The data on desaturation indicate potential benefits of oxygenation with THRIVE for rapid sequence induction compared with facemask pre-oxygenation.
      PubDate: 2018-01-13T00:30:28.081307-05:
      DOI: 10.1111/anae.14215
  • Clinical guideline and recommendations on pre-operative exercise training
           in patients awaiting major non-cardiac surgery
    • Authors: G. A. Tew; R. Ayyash, J. Durrand, G. R. Danjoux
      Abstract: Despite calls for the routine implementation of pre-operative exercise programmes to optimise patient fitness before elective major surgery, there is no practical guidance for providing safe and effective exercise in this specific context. The following clinical guideline was developed following a review of the evidence on the effects of pre-operative exercise interventions. We developed a series of best-practice and, where possible, evidence-based statements to advise on patient care with respect to exercise training in the peri-operative period. These statements cover: patient selection for exercise training in surgical patients; integration of exercise training into multi-modal prehabilitation programmes; and advice on exercise prescription factors and follow-up. Although we acknowledge that further research is needed to identify the optimal exercise prescription in different clinical scenarios, we urge peri-operative teams to make use of these recommendations.
      PubDate: 2018-01-13T00:25:47.729131-05:
      DOI: 10.1111/anae.14177
  • Combined spinal-epidural vs. spinal anaesthesia for caesarean section:
           meta-analysis and trial-sequential analysis
    • Authors: M. Klimek; R. Rossaint, M. Velde, M. Heesen
      Abstract: Combined spinal-epidural and single-shot spinal anaesthesia are both used for caesarean section. It has been claimed in individual trials that combined spinal-epidural is associated with higher sensory spread and greater cardiovascular stability. We set out to gather all available evidence. We performed: a systematic literature search to identify randomised controlled trials comparing combined spinal-epidural with spinal anaesthesia for caesarean section: conventional meta-analysis; trial-sequential analysis; and assessment of trial quality using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Fifteen trials with high heterogeneity, including 1015 patients, were analysed. There was no significant difference between combined spinal-epidural and spinal anaesthesia for our primary outcomes maximum sensory height and vasopressor use (mg ephedrine equivalents). However, trial-sequential analysis suggested insufficient data and the GRADE scores showed ‘very low’ quality of evidence for these outcomes. The secondary outcomes hypotension, time for sensory block to recede to the level of T10, and the combined outcome of nausea and vomiting, did not differ significantly between the interventions. The block times were statistically significantly longer for combined spinal-epidural in individual trials, but only one trial showed a clinically meaningful difference (11 min). Based on this analysis, and taking into consideration all comparisons irrespective of whether drugs had been applied via the epidural route, there is not enough evidence to postulate any advantage compared with the spinal technique. Future analyses and studies need to examine the potential advantages of the combined spinal-epidural technique by using the epidural route intra- and/or postoperatively.
      PubDate: 2018-01-13T00:00:42.270609-05:
      DOI: 10.1111/anae.14210
  • Combined thoracic paravertebral and pectoral nerve blocks for breast
           surgery under sedation: a prospective observational case series
    • Authors: A. Pawa; J. Wight, D. N. Onwochei, R. Vargulescu, I. Reed, L. Chrisman, E. Pushpanathan, A. Kothari, K. El-Boghdadly
      Abstract: Avoidance of general anaesthesia for breast surgery may be because of clinical reasons or patient choice. There is emerging evidence that the use of regional anaesthesia and the avoidance of volatile anaesthetics and opioid analgesia may have beneficial effects on oncological outcomes. We conducted a prospective observational case series of 16 breast cancer surgeries performed under thoracic paravertebral plus pectoral nerve block with propofol sedation to demonstrate feasibility of technique, patient acceptability and surgeon satisfaction. Fifteen out of 16 cases were successfully completed under sedation and regional anaesthesia, with one conversion to general anaesthesia. Eleven out of 16 cases required low-dose intra-operative opioid analgesia. Out of the 15 surgical procedures completed under regional anaesthesia with sedation, all patients experienced either no or minimal intra-operative pain, and all would choose this anaesthetic technique again. Surgeon-reported operating conditions were ‘indistinguishable from general anaesthesia’ in most cases, and surgeons were ‘extremely satisfied’ or ‘satisfied’ with the technique after every procedure. Combined thoracic paravertebral plus pectoral nerve block with intra-operative sedation is a feasible technique for breast surgery.
      PubDate: 2018-01-12T01:35:26.284365-05:
      DOI: 10.1111/anae.14213
  • Has analgesia changed for lung resection surgery'
    • Authors: H. L. Short; K. Kamalanathan
      PubDate: 2018-01-12T01:15:39.863702-05:
      DOI: 10.1111/anae.14188
  • Propensity score-matched outcomes after thoracic epidural or paravertebral
           analgesia for thoracotomy
    • Authors: W. J. Blackshaw; A. Bhawnani, S. H. Pennefather, O. Al-Rawi, S. Agarwal, M. Shaw
      Abstract: It is not known which regional analgesic technique is most effective or safest after open lung resection. We retrospectively examined outcomes in 828 patients who received thoracic epidural analgesia and 791 patients who received paravertebral block after lung resection between 2008 and 2012. We analysed outcomes for 648 patients, 324 who had each analgesic technique, matched by propensity scores generated with peri-operative data. There were 22 out of 324 (7%) postoperative respiratory complications after thoracic epidural and 23 out of 324 (7%) after paravertebral block, p = 0.88. For any postoperative complication, there were 80 out of 324 (25%) and 78 out of 324 (24%) complications, respectively, p = 0.85. There were 17 out of 324 (5%) re-admissions to intensive care after thoracic epidural and 17 out of 324 (5%) after paravertebral block, p> 0.99, and the number of deaths before discharge were 6 out of 324 (2%) and 4 out of 324 (1%), respectively, p = 0.53. There was no significant difference in median (IQR [range]) hospital stay after thoracic epidural or paravertebral block, 6 (5–9 [2–94]) days vs. 6 (5–9 [2–122]), respectively, p = 0.83. Our study suggests that rates of complications as well as length of hospital stay after thoracic epidural analgesia and paravertebral blockade are similar. We were unable to compare analgesic efficacy due to incomplete data.
      PubDate: 2018-01-12T01:10:28.724902-05:
      DOI: 10.1111/anae.14205
  • Have we reached the end for throat packs inserted by anaesthetists'
    • Authors: C. R. Bailey; R. Nouraie, J. M. Huitink
      PubDate: 2018-01-10T23:55:25.939992-05:
      DOI: 10.1111/anae.14168
  • Systematic review of benefits or harms of routine anaesthetist-inserted
           throat packs in adults: practice recommendations for inserting and
           counting throat packs
    • Authors: V. Athanassoglou; A. Patel, B. McGuire, A. Higgs, M. S. Dover, P. A. Brennan, A. Banerjee, B. Bingham, J. J. Pandit
      Abstract: Throat packs are commonly inserted by anaesthetists after induction of anaesthesia for dental, maxillofacial, nasal or upper airway surgery. However, the evidence supporting this practice as routine is unclear, especially in the light of accidentally retained throat packs which constitute ‘Never Events’ as defined by NHS England. On behalf of three relevant national organisations, we therefore conducted a systematic review and literature search to assess the evidence base for benefit, and also the extent and severity of complications associated with throat pack use. Other than descriptions of how to insert throat packs in many standard texts, we could find no study that sought to assess the benefit of their insertion by anaesthetists. Instead, there were many reports of minor and major complications (the latter including serious postoperative airway obstruction and at least one death), and many descriptions of how to avoid complications. As a result of these findings, the three national organisations no longer recommend the routine insertion of throat packs by anaesthetists but advise caution and careful consideration. Two protocols for pack insertion are presented, should their use be judged necessary.
      PubDate: 2018-01-10T23:40:29.293658-05:
      DOI: 10.1111/anae.14197
  • A randomised controlled trial comparing needle movements during combined
           spinal-epidural anaesthesia with and without ultrasound assistance
    • Authors: A. Chin; B. Crooke, L. Heywood, R. Brijball, A. M. Pelecanos, W. Abeypala
      Abstract: Ultrasound assistance for neuraxial techniques may improve technical performance; however, it is unclear which populations benefit most. Our study aimed to investigate the efficacy of neuraxial ultrasound in women having caesarean section with combined spinal-epidural anaesthesia, and to identify factors associated with improved technical performance. Two-hundred and eighteen women were randomly allocated to ultrasound-assisted or control groups. All the women had a pre-procedure ultrasound, but only women in the ultrasound group had this information conveyed to the anaesthetist. Primary outcomes were first-pass success (a single needle insertion with no redirections) and procedure difficulty. Secondary outcomes were block quality, patient experience and complications. Exploratory sub-group analysis and regression analysis were used to identify factors associated with success. Data from 215 women were analysed. First-pass success was achieved in 67 (63.8%) and 42 (38.2%) women in the ultrasound and control groups, respectively (adjusted p = 0.001). Combined spinal-epidural anaesthesia was ‘difficult’ in 19 (18.1%) and 33 (30.0%) women in the ultrasound and control groups, respectively (adjusted p = 0.09). Secondary outcomes did not differ significantly. Anaesthetists misidentified the intervertebral level by two or more spaces in 23 (10.7%) women. Sub-group analysis demonstrated a benefit for ultrasound in women with easily palpable spinous processes (adjusted p = 0.027). Regression analysis identified use of ultrasound and easily palpable spinous processes to be associated with first-pass success.
      PubDate: 2018-01-10T23:30:25.586817-05:
      DOI: 10.1111/anae.14206
  • Prospective clinical trial registration: not sufficient, but always
    • Authors: S. M. Smith; R. H. Dworkin
      PubDate: 2018-01-02T00:05:28.809092-05:
      DOI: 10.1111/anae.14189
  • Journal response: prospective clinical trial registration –
           desirable, but not necessary
    • Authors: J. J. Pandit; A. A. Klein
      PubDate: 2018-01-01T23:05:28.927651-05:
      DOI: 10.1111/anae.14198
  • Adherence to guidance on registration of randomised controlled trials
           published in Anaesthesia
    • Authors: K. El-Boghdadly; M. D. Wiles, S. Atton, C. R. Bailey
      Abstract: The International Committee of Medical Journal Editors recommends the prospective registration of interventional clinical trials. We aimed to assess the compliance with these guidelines for manuscripts submitted to and published by a single anaesthetic journal. We examined the rates of prospective trial registration, the incidence of discrepancies in primary outcome measure(s) and sample sizes, and the citation metrics of all randomised controlled trials published in Anaesthesia over a 3-year period (2014–2016). Of the 422 randomised controlled trials submitted during the study period, 115 (27.3%) were accepted for publication, of which 90 (78.3%) were patient studies, with the remaining 25 comprising manikin, simulation, volunteer, bench, cadaver and other non-patient intervention studies. Of the accepted patient studies, 64 (71.1%) were prospectively registered with a clinical trials registry, 20 (22.2%) were not registered and 6 (6.7%) were retrospectively registered after manuscript submission. There was no difference in the frequency of registration between accepted and rejected manuscripts (77.8% vs. 84.5%, respectively, p = 0.143). The median (IQR [range]) time from registration of accepted manuscripts to journal submission was 701 (331–1341 [99–2436]) days. There was no correlation between number of patients recruited to a study and time to submission. Fifty-two (81.3%) of the prospectively registered studies reported the same primary outcomes in both registration and submission, and 34 (53.1%) studies were published with the same powered sample size as that described in the registry. Eleven (12.2%) studies recruited more patients and 19 (21.1%) recruited fewer patients than described in the registration protocol. There was no difference in the median (IQR [range]) number of citations per month since publication between prospectively (0.27 (0.15–0.46 [0.00–1.59]), and retrospectively (0.39 (0.15–0.62 [0.10–0.67]); p = 0.502) or unregistered (0.33 (0.10–0.52 [0.00–0.67]); p = 0.867) studies. Our results suggest that prospective clinical trial registration has no influence on acceptance for publication by Anaesthesia or subsequent citation metrics. The international recommendation for prospective trial registration appears to have not been universally incorporated into anaesthetic-related research practice.
      PubDate: 2018-01-01T22:25:34.691-05:00
      DOI: 10.1111/anae.14103
  • Issue Information – Editorial Board
    • Pages: 405 - 405
      PubDate: 2018-03-14T00:07:20.217451-05:
      DOI: 10.1111/anae.14069
  • UK Confidential Enquiry into Maternal Deaths – still learning to
           save mothers’ lives
    • Authors: D. N. Lucas; J. H. Bamber
      Pages: 416 - 420
      PubDate: 2018-03-14T00:07:19.516858-05:
      DOI: 10.1111/anae.14246
  • Optimising analgesia for day-case cruciate ligament reconstruction
    • Authors: S. Mughal; S. Jagannathan
      Pages: 515 - 515
      PubDate: 2018-03-14T00:07:22.173737-05:
      DOI: 10.1111/anae.14264
  • Optimising day-case analgesia for anterior cruciate ligament
           reconstruction – a reply
    • Authors: E. Albrecht; K. R. Kirkham
      Pages: 515 - 516
      PubDate: 2018-03-14T00:07:21.77571-05:0
      DOI: 10.1111/anae.14266
  • Enfit™ system nasogastric tube failure
    • Authors: R. J. Berwick; Z. Damani
      Pages: 516 - 517
      PubDate: 2018-03-14T00:07:22.283457-05:
      DOI: 10.1111/anae.14194
  • Enfit™ system nasogastric tube failure – manufacturer's reply
    • Authors: A. Cushman
      Pages: 518 - 518
      PubDate: 2018-03-14T00:07:23.53885-05:0
      DOI: 10.1111/anae.14255
  • Asking key questions in the consent process
    • Authors: S. Kannan
      Pages: 518 - 519
      PubDate: 2018-03-14T00:07:19.058227-05:
      DOI: 10.1111/anae.14265
  • Asking key questions in the consent process – a reply
    • Authors: N. C. Chrimes; S. M. Marshall
      Pages: 519 - 520
      PubDate: 2018-03-14T00:07:18.818216-05:
      DOI: 10.1111/anae.14254
  • Entropy interference from operating tables
    • Authors: R. May; I. Bailes, J. Myatt
      Pages: 520 - 521
      PubDate: 2018-03-14T00:07:22.710001-05:
      DOI: 10.1111/anae.14256
  • Patient satisfaction and quality of recovery
    • Authors: V. Berning; T. Heidegger, M. Laupheimer, M. Nübling
      Pages: 521 - 522
      PubDate: 2018-03-14T00:07:23.634149-05:
      DOI: 10.1111/anae.14258
  • Computed tomography scanner dimensions
    • Authors: C. King; A. Barry
      Pages: 521 - 521
      PubDate: 2018-03-14T00:07:20.79784-05:0
      DOI: 10.1111/anae.14257
  • Consent and operating list efficiency
    • Authors: D. Leslie; V. Salota
      Pages: 522 - 523
      PubDate: 2018-03-14T00:07:20.866959-05:
      DOI: 10.1111/anae.14259
  • Standardised recording of neuromuscular block reversal
    • Authors: S. Arshed; A. Philip
      Pages: 523 - 523
      PubDate: 2018-03-14T00:07:23.737105-05:
      DOI: 10.1111/anae.14260
  • Airway management – an extracorporeal ‘fifth way’'
    • Authors: L. Wang; W. Xu, X. Deng
      Pages: 523 - 524
      PubDate: 2018-03-14T00:07:20.971599-05:
      DOI: 10.1111/anae.14261
  • Learning bias when teaching fibreoptic intubation
    • Authors: D. Price
      Pages: 524 - 524
      PubDate: 2018-03-14T00:07:23.69741-05:0
      DOI: 10.1111/anae.14262
  • The educational value of night shifts
    • Authors: D. M. Williams; A. Calo
      Pages: 524 - 524
      PubDate: 2018-03-14T00:07:22.226611-05:
      DOI: 10.1111/anae.14263
  • Alternative electrocardiography electrode placement
    • Authors: S. Gupta; B. Paliwal, M. Kumar, P. Bhatia
      Pages: 525 - 525
      PubDate: 2018-03-14T00:07:22.650056-05:
      DOI: 10.1111/anae.14271
  • The comparative efficacy and safety of sugammadex and neostigmine in
           reversing neuromuscular blockade in adults. A Cochrane systematic review
           with meta-analysis and trial sequential analysis
    • Authors: A.-M. Hristovska; P. Duch, M. Allingstrup, A. Afshari
      Abstract: We compared the efficacy and safety of sugammadex and neostigmine in reversing neuromuscular blockade in adults. Our outcomes were: recovery time from second twitch to train-of-four ratio> 0.9; recovery time from post-tetanic count 1–5 to train-of-four ratio> 0.9; and risk of composite adverse and serious adverse events. We searched for randomised clinical trials irrespective of publication status and date, blinding status, outcomes reported or language. We included 41 studies with 4206 participants. Time to reversal of neuromuscular blockade from second twitch to a train-of-four ratio> 0.9 was 2.0 min with sugammadex 2−1 and 12.9 min with neostigmine 0.05−1, with a mean difference (MD) (95%CI)) of 10.2 (8.5–12.0) (I2 = 84%, 10 studies, n = 835, Grades of Recommendation, Assessment, Development and Evaluation (GRADE): moderate quality). Time to reversal of neuromuscular blockade from a post-tetanic count of 1–5 to a train-of-four ratio> 0.9 was 2.9 min with sugammadex 4−1 and 48.8 min with neostigmine 0.07−1, with a MD (95%CI) of 45.8 (39.4–52.2) (I2 = 0%, 2 studies, n = 114, GRADE: low quality). There were significantly fewer composite adverse events in the sugammadex group compared with neostigmine, with a risk ratio (95%CI) of 0.60 (0.49–0.74) (I2 = 40%, 28 studies, n = 2298, number needed to treat (NNT): 8, GRADE: moderate quality). Specifically, the risk of bradycardia (RR (95%CI) 0.16 (0.07–0.34), n = 1218, NNT: 14, GRADE: moderate quality), postoperative nausea and vomiting (RR (95%CI) 0.52 (0.28–0.97), n = 389, NNT: 16, GRADE: low quality) and overall signs of postoperative residual paralysis (RR (95%CI) 0.40 (0.28–0.57), n = 1474, NNT: 13, GRADE: moderate quality) were all reduced. There was no significant difference regarding the risk of serious adverse events (RR 0.54, 95%CI 0.13–2.25, I2 = 0%, n = 959, GRADE: low quality). Sugammadex reverses neuromuscular blockade more rapidly than neostigmine and is associated with fewer adverse events.
      PubDate: 2017-12-27T06:43:09.867117-05:
      DOI: 10.1111/anae.14160
  • Definitions of anaesthetic technique and the implications for clinical
    • Authors: R. A. Armstrong; R. Mouton
      PubDate: 2017-12-27T00:40:24.813376-05:
      DOI: 10.1111/anae.14200
  • Exploring performance of, and attitudes to, Stop- and
           Mock-Before-You-Block in preventing wrong side anaesthetic blocks
    • Authors: M. Hopping; A. F. Merry, J. J. Pandit
      Abstract: We conducted an online survey to assess the career experiences of wrong side blocks, the practice of Stop-Before-You-Block, the recently described method of Mock-Before-You-Block and attitudes to these. Respondents were 208 anaesthetists across nine hospitals (173 consultants or Staff and Associate Specialist doctors'), representing 3623 years of collective anaesthetic practice. There had been a total of 62 wrong side blocks (by 51 anaesthetists and one current trainee). Predisposing factors for this were commonly ascribed to distractions (35 (69%), for example due to rushing or teaching), patient positioning (9 (18%)) or miscommunication (6 (12%)). Two (4%) respondents felt they had performed Stop-Before-You-Block too early; 62 (41%) of all respondents stated they performed Stop-Before-You-Block as early as preparing the skin or on arrival of the patient in the anaesthetic room, and not any later. Twenty (10%) respondents admitted to not performing Stop-Before-You-Block at all or only occasionally (including 5 (2%) who had performed a wrong side block). Mock-Before-You-Block was easily understood (by 169 out of 197 (86%)) and 14 out of 61 (23%) respondents felt it would have prevented the wrong side error in their case. However, free-text comments indicated that many anaesthetists were reluctant to use a method that interrupted their performance of the block. We conclude that considerable work is needed to achieve full compliance with Stop-Before-You-Block at the correct time.
      PubDate: 2017-12-27T00:20:40.104668-05:
      DOI: 10.1111/anae.14167
  • Working out wrong-site blocks
    • Authors: I. K. Moppett; S. T. Shorrock
      PubDate: 2017-12-27T00:20:27.266401-05:
      DOI: 10.1111/anae.14165
  • Regional nerve blockade for early analgesic management of elderly patients
           with hip fracture – a narrative review
    • Authors: A. Scurrah; C. T. Shiner, J. A. Stevens, S. G. Faux
      Abstract: Elderly patients with hip fracture experience high morbidity and mortality, and are often undertreated for pain. Acute pain management in the elderly is challenging, with physiological frailty, medical comorbidities and cognitive impairment commonly compounding pain assessment and treatment. Guidelines outlining current best practice for acute pain management in the elderly now exist, but evidence suggests that practice remains variable and there continues to be scope for improvement. We conducted a narrative review of the literature to examine the challenges of acute pain management in the elderly, and to evaluate evidence for the role of regional nerve blocks for acute pain associated with hip fracture in the elderly. There is consistent evidence that regional nerve blocks can effectively reduce pain associated with hip fracture, providing rapid-onset, site-specific analgesia that is more effective than standard systemic analgesia alone. There is also moderate evidence that nerve blocks may contribute to reduced rates of delirium, and some suggestion of reduced length of inpatient stay, morbidity and mortality, although limited evidence is available. Fascia iliaca blocks are emerging as a block of choice, with evidence they can be safely and rapidly administered under ultrasound guidance in the acute setting, by both trained medical and nursing staff, with good effect. Ideally, comprehensive pain protocols for elderly hip fracture patients are required, that integrate evidence-based fascia iliaca block use, timely and repeated pain assessment, and multidisciplinary orthogeriatric patient care.
      PubDate: 2017-12-26T06:00:22.839395-05:
      DOI: 10.1111/anae.14178
  • The association of pre-operative home accelerometry with cardiopulmonary
           exercise variables
    • Authors: H. W. Cui; G. S. Kirby, K. Surmacz, C. Hargrove, J. Griffiths, B. W. Turney
      Abstract: We investigated the association of pre-operative activity, reported by the Duke Activity Score Index, Short Form-12 and measured by an accelerometer worn at home, with five cardiopulmonary exercise variables: peak power; peak oxygen consumption; anaerobic threshold; and ventilatory equivalents for oxygen and carbon dioxide. Fifty patients scheduled for major surgery underwent a standard pre-operative cardiopulmonary exercise test and wore a chest-mounted triaxial accelerometer for a mean (SD) duration of 3.2 (0.4) days. The Duke Activity Score Index and six accelerometer variables were significantly correlated with all five cardiopulmonary exercise variables, Pearson correlation coefficients 0.5–0.7, p = 0.02 to p 
      PubDate: 2017-12-12T00:46:03.838557-05:
      DOI: 10.1111/anae.14181
  • Intravenous dexamethasone for prophylaxis of postoperative nausea and
           vomiting after administration of long-acting neuraxial opioids: a
           systematic review and meta-analysis
    • Authors: S. Grape; I. Usmanova, K. R. Kirkham, E. Albrecht
      Abstract: Long-acting neuraxial opioids provide excellent analgesia after surgery, but are associated with higher rates of postoperative nausea and vomiting. Dexamethasone effectively prevents postoperative nausea and vomiting after general anaesthesia, but its value in patients receiving long-acting neuraxial opioids is undetermined. Therefore, the objective of this meta-analysis was to assess the prophylactic anti-emetic efficacy of intravenous (i.v.) dexamethasone in this population. The study methodology followed the PRISMA statement guidelines. The primary outcome was the need for rescue anti-emetics during the first 24 postoperative hours, analysed according to the dose of dexamethasone (low-dose 2.5–5.0 mg; intermediate dose 6.0–10.0 mg), timing of administration (beginning or end of surgery) and route of long-acting opioid administration (intrathecal or epidural). Additionally, the rates of complications (restlessness, infection, hyperglycaemia) were sought. Thirteen trials were identified, representing a total of 1111 patients. When compared with placebo, intravenous dexamethasone reduced the need for rescue anti-emetics (risk ratio (95%CI) 0.44 (0.35–0.56); I2 = 43%; p < 0.00001; quality of GRADE evidence: moderate), without differences between dexamethasone doses (p for sub-group difference = 0.67), timing of administration (p for sub-group difference = 0.32) or route of long-acting opioid (p for sub-group difference = 0.10). No patients developed infection or restlessness among trials that sought these complications. No trial measured blood glucose levels. In conclusion, there is enough evidence to state that intravenous dexamethasone provides effective anti-emetic prophylaxis during the first 24 postoperative hours in patients who receive long-acting neuraxial opioids.
      PubDate: 2017-12-11T06:35:38.847399-05:
      DOI: 10.1111/anae.14166
  • Pilot multi-centre randomised trial of the impact of pre-operative focused
           cardiac ultrasound on mortality and morbidity in patients having surgery
           for femoral neck fractures (ECHONOF-2 pilot)
    • Authors: D. J. Canty; J. Heiberg, Y. Yang, A. G. Royse, S. Margale, N. Nanjappa, D. Scott, A. Maier, D. I. Sessler, A. Chuan, A. Palmer, A. Bucknill, C. French, C. F. Royse
      Abstract: Hip fracture surgery is common, usually occurs in elderly patients who have multiple comorbidities, and is associated with high morbidity and mortality. Pre-operative focused cardiac ultrasound can alter diagnosis and management, but its impact on outcome remains uncertain. This pilot study assessed feasibility and group separation for a proposed large randomised clinical trial of the impact of pre-operative focused cardiac ultrasound on patient outcome after hip fracture surgery. Adult patients requiring hip fracture surgery in four teaching hospitals in Australia were randomly allocated to receive focused cardiac ultrasound before surgery or not. The primary composite outcome was any death, acute kidney injury, non-fatal myocardial infarction, cerebrovascular accident, pulmonary embolism or cardiopulmonary arrest within 30 days of surgery. Of the 175 patients screened, 100 were included as trial participants (screening:recruitment ratio 1.7:1), 49 in the ultrasound group and 51 as controls. There was one protocol failure among those recruited. The primary composite outcome occurred in seven of the ultrasound group patients and 12 of the control group patients (relative group separation 39%). Death, acute kidney injury and cerebrovascular accident were recorded, but no cases of myocardial infarction, pulmonary embolism or cardiopulmonary arrest ocurred. Focused cardiac ultrasound altered the management of 17 participants, suggesting an effect mechanism. This pilot study demonstrated that enrolment and the protocol are feasible, that the primary composite outcome is appropriate, and that there is a treatment effect favouring focused cardiac ultrasound – and therefore supports a large randomised clinical trial.
      PubDate: 2017-12-11T06:30:26.736736-05:
      DOI: 10.1111/anae.14130
  • Postoperative outcomes following cardiac surgery in non-anaemic
           iron-replete and iron-deficient patients – an exploratory study
    • Authors: L. F. Miles; S. A. Kunz, L. H. Na, S. Braat, K. Burbury, D. A. Story
      Abstract: Iron deficiency anaemia is strongly associated with poor outcomes after cardiac surgery. However, pre-operative non-anaemic iron deficiency (a probable anaemia precursor) has not been comprehensively examined in patients undergoing cardiac surgery, despite biological plausibility and evidence from other patient populations of negative effect on outcome. This exploratory retrospective cohort study aimed to compare an iron-deficient group of patients undergoing cardiac surgery with an iron-replete group. Consecutive non-anaemic patients undergoing elective coronary artery bypass grafting or single valve replacement in our institution between January 2013 and December 2015 were considered for inclusion. Data from a total of 277 patients were analysed, and were categorised by iron status and blood haemoglobin concentration into iron-deficient (n = 109) and iron-replete (n = 168) groups. Compared with the iron-replete group, patients in the iron-deficient group were more likely to be female (43% vs. 12%, iron-replete, respectively); older, mean (SD) age 64.4 (9.7) vs. 63.2 (10.3) years; and to have a higher pre-operative EuroSCORE (median IQR [range]) 3 (2–5 [0–10]) vs. 3 (2–4 [0–9]), with a lower preoperative haemoglobin of 141.6 (11.6) vs. 148.3 (11.7) g.l−1. Univariate analysis suggested that iron-deficient patients had a longer hospital length of stay (7 (6–9 [2–40]) vs. 7 (5–8 [4–23]) days; p = 0.013) and fewer days alive and out of hospital at postoperative day 90 (83 (80–84 [0–87]) vs. 83 (81–85 [34–86]), p = 0.009). There was no evidence of an association between iron deficiency and either lower nadir haemoglobin or higher requirement for blood products during inpatient stay. After adjusting the model for pre-operative age, sex, renal function, EuroSCORE and haemoglobin, the mean increase in hospital length of stay in the iron-deficient group relative to the iron-replete group was 0.86 days (bootstrapped 95%CI −0.37 to 2.22, p = 0.098). This exploratory study suggests there is weak evidence of an association between non-anaemic iron deficiency and outcome after cardiac surgery after controlling for potentially confounding variables.
      PubDate: 2017-12-02T01:30:44.211401-05:
      DOI: 10.1111/anae.14115
  • Determination of the optimal programmed intermittent epidural bolus volume
           of bupivacaine 0.0625% with fentanyl 2 μ−1 at a fixed interval of
           forty minutes: a biased coin up-and-down sequential allocation trial
    • Authors: P. Zakus; C. Arzola, R. Bittencourt, K. Downey, X. Y. Ye, J. C. Carvalho
      Abstract: The optimum time interval for 10 ml boluses of bupivacaine 0.0625% + fentanyl 2 μ−1 as part of a programmed intermittent epidural bolus regimen has been found to be 40 min. This regimen was shown to be effective without the use of supplementary patient-controlled epidural analgesia boluses in 90% of women during the first stage of labour, although with a rate of sensory block to ice above T6 in 34% of women. We aimed to determine the optimum programmed intermittent epidural bolus volume at a 40 min interval to provide effective analgesia in 90% of women (EV90) during the first stage of labour, without the use of patient-controlled epidural analgesia. We performed a prospective double-blind dose-finding study using the biased coin up-and-down sequential allocation method in 40 women. The estimated EV90 was 11.0 (95%CI 10.0–11.7) ml with the isotonic regression method and 10.7 (95%CI 10.3–11.0) ml with the truncated Dixon and Mood method. Overall, 18 women had a sensory block above T6, and 37 women exhibited no motor block. No women required treatment for hypotension. In conclusion, it is not possible to reduce the programmed intermittent epidural bolus volume from 10 ml, used in our current regimen, without compromising the quality of analgesia. Using this regimen, a high proportion of women will develop a sensory block above T6.
      PubDate: 2017-12-02T01:25:33.884372-05:
      DOI: 10.1111/anae.14159
  • A systematic review of the incidence of and risk factors for postoperative
           atrial fibrillation following general surgery
    • Authors: R. Chebbout; E. G. Heywood, T. M. Drake, J. R. L. Wild, J. Lee, M. Wilson, M. J. Lee
      Abstract: Atrial fibrillation is a common cardiac arrhythmia and can occur de novo following a surgical procedure. It is associated with increased inpatient and long-term mortality. There is limited evidence concerning new-onset atrial fibrillation following abdominal surgery. This study aimed to identify the prevalence of and risk factors for postoperative atrial fibrillation in the general surgical population. A systematic search of the Embase, MEDLINE and Cochrane (CENTRAL) databases was conducted. Studies were included in the review if they reported cases of new-onset atrial fibrillation within 30 days of the index operation. Results were evaluated qualitatively due to substantial clinical heterogeneity. Incidence rates were pooled using a weighted random-effects meta-analysis model. A total of 835 records were initially identified, from which 32 full texts were retrieved. Following review, 13 studies were included that involved 52,959 patients, of whom 10.94% (95%CI 7.22–15.33) developed atrial fibrillation. Five studies of patients undergoing oesophagectomy (n = 376/1923) had a weighted average rate of 17.66% (95%CI 12.16–21.47), compared with 7.63% (95%CI 4.39–11.98) from eight studies of non-oesophageal surgery (n = 2927/51,036). Identified risk factors included: increasing age; history of cardiac disease; postoperative complications, particularly, sepsis, pneumonia and pleural effusions. New-onset postoperative atrial fibrillation is common, and is more frequent after surgery involving the thorax. Future work should focus on stratifying risk to allow targeted prophylaxis of atrial fibrillation and other peri-operative complications.
      PubDate: 2017-11-04T01:45:24.069355-05:
      DOI: 10.1111/anae.14118
  • Hyperbaric vs. isobaric bupivacaine for spinal anaesthesia for elective
           caesarean section: a Cochrane systematic review
    • Authors: B. L. Sng; N. L. R. Han, W. L. Leong, R. Sultana, F. J. Siddiqui, P. N. Assam, E. S. Chan, K. H. Tan, A. T. Sia
      Abstract: Both isobaric and hyperbaric bupivacaine have been used for spinal anaesthesia for elective caesarean section, but it is not clear if one is better than the other. The primary objective of this systematic review was to determine the effectiveness and safety of hyperbaric bupivacaine compared with isobaric bupivacaine administered during spinal anaesthesia for elective caesarean section. We included 10 studies with 614 subjects in the analysis. There was no evidence of differences either in the risk of conversion to general anaesthesia, with a relative risk (95%CI) of 0.33 (0.09–1.17) (very low quality of evidence), or in the need for supplemental analgesia, the relative risk (95%CI) being 0.61 (0.26–1.41) (very low quality of evidence). There was also no evidence of a difference in the use of ephedrine, the amount of ephedrine used, nausea and vomiting, or headache. Hyperbaric bupivacaine took less time to reach a sensory block height of T4, with a mean difference (95%CI) of −1.06 min (−1.80 to −0.31). Due to the rarity of some outcomes, dose variability, use of adjuvant drugs and spinal technique used, future clinical trials should look into using adequate sample size to investigate the primary outcome of the need for supplemental analgesia.
      PubDate: 2017-10-17T01:55:42.771013-05:
      DOI: 10.1111/anae.14084
  • ‘Your lack of planning does not constitute my emergency’ – caring
           for obstetric patients with mental illness
    • Authors: K. McCombe
      PubDate: 2017-10-05T23:25:20.650529-05:
      DOI: 10.1111/anae.14098
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