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Journal Cover Anaesthesia
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   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  [1579 journals]
  • Publisher's Note
    • PubDate: 2017-10-16T03:46:29.535951-05:
      DOI: 10.1111/anae.14117
  • Nitrous oxide-based vs. nitrous oxide-free general anaesthesia and
           accidental awareness in surgical patients: an abridged Cochrane systematic
    • Authors: J. Hounsome; J. Greenhalgh, O. J. Schofield-Robinson, S. R. Lewis, T. M. Cook, A. F. Smith
      Abstract: Accidental awareness during general anaesthesia can arise from a failure to deliver sufficient anaesthetic agent, or from a patient's resistance to an expected sufficient dose of such an agent. Awareness is ‘explicit’ if the patient is subsequently able to recall the event. We conducted a systematic review into the effect of nitrous oxide used as part of a general anaesthetic on the risk of accidental awareness in people over the age of five years undergoing general anaesthesia for surgery. We included 15 randomised controlled trials, 14 of which, representing a total of 3439 participants, were included in our primary analysis of the frequency of accidental awareness events. The awareness incidence rate was rare within these studies, and all were considered underpowered with respect to this outcome. The risk of bias across all studies was judged to be high, and 76% of studies failed adequately to conceal participant allocation. We considered the available evidence to be of very poor quality. There were a total of three accidental awareness events reported in two studies, one of which reported that the awareness was the result of a kink in a propofol intravenous line. There were insufficient data to conduct a meta- or sub-group analysis and there was insufficient evidence to draw outcome-related conclusions. We can, however, recommend that future studies focus on potentially high-risk groups such as obstetric or cardiac surgery patients, or those receiving neuromuscular blocking drugs or total intravenous anaesthesia.
      PubDate: 2017-10-16T02:25:35.412489-05:
      DOI: 10.1111/anae.14065
  • Real-time ultrasound-guided axillary vein cannulation in children: a
           randomised controlled trial
    • Authors: E.-H. Kim; J.-H. Lee, I.-K. Song, H.-S. Kim, Y.-E. Jang, S.-N. Choi, J.-T. Kim
      Abstract: The axillary vein is a good site for ultrasound-guided central venous cannulation in terms of infection rate, patient comfort and its anatomical relationship with the clavicle and lungs. We compared real-time ultrasound-guided axillary vein cannulation with conventional infraclavicular landmark-guided subclavian vein cannulation in children. A total of 132 paediatric patients were randomly allocated to either ultrasound-guided axillary vein (axillary group) or landmark-guided subclavian vein (landmark group). The outcomes measured were success rate after two attempts, first-attempt success rate, time to cannulation and complication rate. The success rate after two attempts was 83% in the axillary group compared with 63% in the landmark group (odds ratio 2.85, 95%CI 1.25–6.48, p = 0.010). The first-attempt success rate was 46% for the axillary group and 40% for the landmark group (p = 0.274) and median time to cannulation was 156 s for the axillary group and 180 s for the landmark group (p = 0.286). There were no differences in complication rates between the two groups, although three episodes of subclavian artery puncture occurred in the landmark group (p = 0.08). We conclude that axillary vein cannulation using a real-time ultrasound-guided in-plane technique is useful and effective in paediatric patients.
      PubDate: 2017-10-09T00:29:46.094139-05:
      DOI: 10.1111/anae.14086
  • Can point-of-care ultrasound predict spinal hypotension during caesarean
           section' A prospective observational study
    • Authors: L. Zieleskiewicz; A. Noel, G. Duclos, M. Haddam, A. Delmas, C. Bechis, A. Loundou, J. Blanc, A. Mignon, L. Bouvet, S. Einav, A. Bourgoin, M. Leone
      Abstract: Spinal anaesthesia for elective caesarean section is associated with maternal hypotension, secondary to alteration of sympathetic tone and hypovolemia, in up to 70% of cases. Measurement of the subaortic variation in the velocity time integral (VTI) after passive leg raising allows prediction of fluid responsiveness. Our objective, in this prospective single-centre observational study, was to assess the ability of change in VTI after 45° passive leg raising to predict hypotension after spinal anaesthesia. Ultrasound measurements were performed just before elective caesarean section. Anaesthesia, intravenous coloading and prophylactic vasopressor treatment were standardised according to current guidelines. We studied 40 women. Hypotension occurred in 17 (45%) women. The area (95%CI) under the receiver operating characteristics (ROC) curve for the prediction of spinal hypotension was 0.8 (0.6–0.9; p = 0.0001). Seventeen women had a change in VTI with leg elevation ≤ 8%, which was predictive for not developing hypotension, and 11 had a change ≥ 21%, predictive for hypotension. The grey zone between 8% and 21%, with inconclusive values, included 12 women. We suggest that cardiac ultrasound provides characterisation of the risk of hypotension following spinal anaesthesia at elective caesarean section, and therefore may allow individualised strategies for prevention and management.
      PubDate: 2017-10-07T01:20:36.794559-05:
      DOI: 10.1111/anae.14063
  • Dynamic ultrasound-guided short-axis needle tip navigation technique vs.
           landmark technique for difficult saphenous vein access in children: a
           randomised study
    • Authors: S. Hanada; M. T. Van Winkle, S. Subramani, K. Ueda
      Abstract: Dynamic ultrasound-guided short-axis needle tip navigation is a novel technique for vascular access. After venipuncture, the needle and catheter are further advanced within the vessel lumen under real-time ultrasound guidance with constant visualisation of the needle tip in the short-axis view. This can minimise the risk of transfixing the cannulated vessel. We compared two techniques for non-visible saphenous vein cannulation under general anaesthesia in children weighing ≥ 3 kg and less than four years of age: dynamic ultrasound-guided short-axis needle tip navigation technique (ultrasound group) vs. landmark technique. Venous cannulation was performed by three experienced anaesthetists. The primary outcome measure was first-attempt success rate. Success rate within 10 min was a secondary outcome. A total of 102 patients were randomly allocated to either the ultrasound group or the landmark group. First-attempt success rate was 90% in the ultrasound group compared with 51% in the landmark group, p
      PubDate: 2017-10-06T00:00:38.291154-05:
      DOI: 10.1111/anae.14082
  • ‘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
  • Pre-operative variables including fitness associated with complications
           after oesophagectomy
    • Authors: R. C. F. Sinclair; A. W. Phillips, M. Navidi, S. M. Griffin, C. P. Snowden
      Abstract: Oesophagectomy is a technically-demanding operation associated with a high level of morbidity. We analysed the association of pre-operative variables, including those from cardiopulmonary exercise testing, with complications (logistic regression) and survival and length of stay (Cox regression) after scheduled transthoracic oesophagectomy in 273 adults, in isolation and on multivariate testing (maximum Akaike information criterion). On multivariate analysis, any postoperative complication was associated with ventilatory equivalents for carbon dioxide, odds ratio (95%CI) 1.088 (1.02–1.17), p = 0.018. Cardiorespiratory complications were associated with FEV1 and pre-operative background survival (in an analogous group without cancer), odds ratios (95%CI) 0.55 (0.37–0.80), p = 0.002 and 0.89 (0.82–0.96), p = 0.004, respectively. Survival was associated with the ratio of expected-to-observed ventilatory equivalents for carbon dioxide and predicted postoperative survival, hazard ratios (95%CI) 0.17 (0.03–0.91), p = 0.039 and 0.96 (0.90–1.01), p = 0.076. Length of hospital stay was associated with FVC, hazard ratio (95%CI) 1.38 (1.17–1.63), p < 0.0001.
      PubDate: 2017-10-05T23:20:39.592206-05:
      DOI: 10.1111/anae.14085
  • Whose fault are wrong predictions: the clinician, the patient or the
    • Authors: J. B. Carlisle
      PubDate: 2017-10-04T01:20:26.956705-05:
      DOI: 10.1111/anae.14087
  • Restrictive or responsive' Outcome classification and unplanned
           sub-group analyses in meta-analyses
    • Authors: M. Heesen; M. Klimek, S. E. Hoeks
      PubDate: 2017-10-04T01:15:20.811598-05:
      DOI: 10.1111/anae.14078
  • A retrospective study of ketamine administration and the development of
           acute or post-traumatic stress disorder in 274 war-wounded soldiers
    • Authors: G. Mion; J. Le Masson, C. Granier, C. Hoffmann
      Abstract: The objective of this study was to explore whether ketamine prevents or exacerbates acute or post-traumatic stress disorders in military trauma patients. We conducted a retrospective study of a database from the French Military Health Service, including all soldiers surviving a war injury in Afghanistan (2010–2012). The diagnosis of post-traumatic stress disorder was made by a psychiatrist and patients were analysed according to the presence or absence of this condition. Analysis included the following covariables: age; sex; acute stress disorder; blast injury; associated fatality; brain injury; traumatic amputation; Glasgow coma scale; injury severity score; administered drugs; number of surgical procedures; physical, neurosensory or aesthetic sequelae; and the development chronic pain. Covariables related to post-traumatic and acute stress disorders with a p ≤ 0.10 were included in a multivariable logistic regression model. The data from 450 soldiers were identified; 399 survived, of which 274 were analysed. Among these, 98 (36%) suffered from post-traumatic stress disorder and 89 (32%) had received ketamine. Fifty-four patients (55%) in the post-traumatic stress disorder group received ketamine vs. 35 (20%) in the no PTSD group (p 
      PubDate: 2017-10-03T05:05:28.5946-05:00
      DOI: 10.1111/anae.14079
  • Continuous infusion vs. intermittent bolus injection of furosemide in
           acute decompensated heart failure: systematic review and meta-analysis of
           randomised controlled trials
    • Authors: K. T. Ng; J. L. L. Yap
      Abstract: Loop diuretics remain a fundamental pharmacological therapy to remove excess fluid and improve symptom control in acute decompensated heart failure. Several recent randomised controlled trials have examined the clinical benefit of continuous vs. bolus furosemide in acute decompensated heart failure, but have reported conflicting findings. The aim of this review was to compare the effects of continuous and bolus furosemide with regard to mortality, length of hospital stay and its efficacy profile in acute decompensated heart failure. All parallel-arm randomised controlled trials from MEDLINE, EMBASE, PubMed and the Cochrane Database of Systematic Reviews from inception until May 2017 were included. Cross-over randomised controlled trials, observational studies, case reports, case series and non-systematic reviews that involved children were excluded. Eight trials (n = 669) were eligible for inclusion. There was no difference between furosemide continuous infusion and bolus administration for all-cause mortality (four studies; n = 491; I2 = 0%; OR 1.65; 95%CI 0.93–2.91; p = 0.08) or duration of hospitalisation (six studies; n = 576; I2 = 71%; mean difference 0.27; 95%CI −1.35 to 1.89 days; p = 0.74). Continuous infusion of intravenous furosemide was associated with increased weight reduction (five studies; n = 516; I2 = 0%; mean difference 0.70; 95%CI 0.12–1.28 kg; p = 0.02); increased total urine output in 24 h (four studies; n = 390; I2 = 33%; mean difference 461.5; 95%CI 133.7–789.4 ml; p < 0.01); and reduced brain natriuretic peptide (two studies; n = 390; I2 = 0%; mean difference 399.5; 95%CI 152.7–646.3 ng.l−1; p < 0.01), compared with the bolus group. There was no difference in the incidence of raised creatinine and hypokalaemia between the two groups. In summary, there was no difference between continuous infusion and bolus of furosemide for all-cause mortality, length of hospital stay and electrolyte disturbance, but continuous infusion was superior to bolus administration with regard to diuretic effect and reduction in brain natriuretic peptide.
      PubDate: 2017-09-22T02:35:25.704274-05:
      DOI: 10.1111/anae.14038
  • Videolaryngoscopy vs. direct laryngoscopy use by experienced anaesthetists
           in patients with known difficult airways: a systematic review and
    • Authors: B. M. A. Pieters; E. H. A. Maas, J. T. A. Knape, A. A. J. van Zundert
      Abstract: Experienced anaesthetists can be confronted with difficult or failed tracheal intubations. We performed a systematic review and meta-analysis to ascertain if the literature indicated if videolaryngoscopy conferred an advantage when used by experienced anaesthetists managing patients with a known difficult airway. We searched PubMed, MEDLINE, Embase and the Cochrane central register of controlled trials up to 1 January 2017. Outcome parameters extracted from studies were: first-attempt success of tracheal intubation; time to successful intubation; number of intubation attempts; Cormack and Lehane grade; use of airway adjuncts (e.g. stylet, gum elastic bougie); and complications (e.g. mucosal and dental trauma). Nine studies, including 1329 patients, fulfilled the inclusion criteria. First-attempt success was greater for all videolaryngoscopes (OR 0.34 (95%CI 0.18–0.66); p = 0.001). Use of videolaryngoscopy was associated with a significantly better view of the glottis (Cormack and Lehane grades 1 and 2 vs. 3–4, OR 0.04 (95%CI 0.01–0.15); p < 0.00001). Mucosal trauma occurred less with the use of videolaryngoscopy (OR 0.16 (95%CI 0.04–0.75); p = 0.02). Videolaryngoscopy has added value for the experienced anaesthetist, improving first-time success, the view of the glottis and reducing mucosal trauma.
      PubDate: 2017-09-22T02:25:24.371757-05:
      DOI: 10.1111/anae.14057
  • Permissive hypotension for active haemorrhage in trauma
    • Authors: D. G. Nevin; K. Brohi
      PubDate: 2017-09-22T02:20:42.248298-05:
      DOI: 10.1111/anae.14034
  • Blood pressure in trauma resuscitation: ‘pop the clot’ vs. ‘drain
           the brain’'
    • Authors: M. D. Wiles
      PubDate: 2017-09-22T02:16:17.750471-05:
      DOI: 10.1111/anae.14042
  • Cerebral oximetry and postoperative delirium after cardiac surgery: a
           randomised, controlled trial
    • Authors: L. Lei; R. Katznelson, L. Fedorko, J. Carroll, H. Poonawala, M. Machina, R. Styra, V. Rao, G. Djaiani
      Abstract: Postoperative delirium is associated with increased morbidity and mortality. We hypothesised that restoration of regional cerebral oxygen desaturation would reduce the incidence of postoperative delirium in elderly patients after cardiac surgery. After institutional ethics review board approval and informed consent, a double-blinded, prospective, randomised, controlled trial was conducted in patients ≥ 60 years of age undergoing cardiac surgery with cardiopulmonary bypass. In the intervention group, an algorithm was commenced if regional cerebral oxygen saturation decreased below 75% of baseline value for 1 min or longer. In the control group, the cerebral oximetry monitor screen was electronically blinded. Assessment of delirium was performed with confusion assessment method for intensive care unit or confusion assessment method after discharge from intensive care unit at 12-h intervals for seven postoperative days. Postoperative delirium was present in 30 out of 123 (24.4%) and 31 out of 126 (24.6%) patients in the intervention and control groups, respectively, odds ratio 0.98 (95%CI 0.55–1.76), p = 0.97. Postoperative delirium was present in 20 (71%) out of 28 and in 41 (18%) out of 221 patients with baseline regional cerebral oxygen saturation ≤ 50, or> 50%, respectively, p = 0.0001. Higher baseline regional cerebral oxygen saturation and body mass index were protective against postoperative delirium. Restoration of regional cerebral oxygen desaturation did not result in lower postoperative delirium after cardiac surgery. Pre-operative regional cerebral oxygen saturation ≤ 50% was associated with increased postoperative delirium rates in elderly patients following cardiac surgery.
      PubDate: 2017-09-22T02:10:23.806427-05:
      DOI: 10.1111/anae.14056
  • Cerebral oximetry: another blow to non-invasive monitoring'
    • Authors: G. Kunst; Z. Milan
      PubDate: 2017-09-22T02:01:33.567047-05:
      DOI: 10.1111/anae.14064
  • Time spent in the clinical environment is the most important aspect of
           medical education – we need to protect it
    • Authors: A. J. England; B. J. Jenkins
      PubDate: 2017-09-18T06:05:23.383188-05:
      DOI: 10.1111/anae.14049
  • Time for training'
    • Authors: N. W. Penfold; C. Carey
      PubDate: 2017-09-18T06:00:46.380573-05:
      DOI: 10.1111/anae.14043
  • Nasotracheal intubation over a bougie vs. non-bougie intubation: a
           prospective randomised, controlled trial in older children and adults
           using videolaryngoscopy
    • Authors: R. O. Abrons; M. B. Zimmerman, Y. M. S. El-Hattab
      Abstract: Conventionally, nasotracheal intubation has consisted of blind nasal passage and external manipulation of the tube through the glottis (‘conventional technique’), a technique associated with a high incidence of nasal trauma. We evaluated a novel technique for routine asleep (i.e. post-induction) nasotracheal intubation using a bougie (‘bougie technique’), which uses a nasopharyngeal airway to guide a paediatric bougie nasotracheally for use as a Seldinger tracheal intubation guide. Two hundred and fifty-seven older children (> 8 years) and adults were randomly assigned to videolaryngoscopy-assisted nasotracheal intubation using either the conventional or the bougie technique. The hypothesis was that the bougie technique would result in less nasopharyngeal trauma. The bougie technique was associated with significantly less nasopharyngeal bleeding than the conventional technique at both 60–90 s (55% vs. 68%; p = 0.033) and 5 min (51% vs. 70%; p = 0.002). The severity of bleeding was also significantly less with the bougie technique, with an OR for active bleeding of 0.42 (95%CI 0.20–0.87; p = 0.020) at 60–90 s and 0.15 (95%CI 0.06–0.37; p < 0.0001) at 5 min. Magill forceps were needed significantly less often with the bougie technique (9% vs. 28%, p = 0.0001) and there was no difference in first attempt and overall success rates between the two techniques (p = 0.133 and p = 0.750, respectively). Not only is nasal intubation over a bougie as successful as the conventional technique, it also significantly decreases both the incidence and severity of nasopharyngeal trauma, as well as the need for the use of Magill forceps.
      PubDate: 2017-09-15T23:16:08.084906-05:
      DOI: 10.1111/anae.14029
  • Analgesic efficacy of local infiltration analgesia vs. femoral nerve block
           after anterior cruciate ligament reconstruction: a systematic review and
    • Authors: K. R. Kirkham; S. Grape, R. Martin, E. Albrecht
      Abstract: Many published reports consider blockade of the femoral nerve distribution the best available analgesic treatment after anterior cruciate ligament reconstruction. However, some argue that an alternative approach of infiltrating local anaesthetic into the surgical site has similar efficacy. The objectives of this meta-analysis were to compare the analgesic and functional outcomes of both treatments following anterior ligament reconstruction. The primary outcomes were pain scores at rest (analogue scale, 0–10) in the early (0–2 postoperative hours), intermediate (3–12 hours) and late postoperative periods (13–24 hours). Secondary outcomes included range of motion, quadriceps muscle strength and complication rates (neurological problems, cardiovascular events, falls and knee infections). Eleven trials, including 628 patients, were identified. Pain scores in the early, intermediate and late postoperative periods were significantly lower in patients who received a femoral nerve block, with mean differences (95%CI) of 1.6 (0.2–2.9), p = 0.02; 1.2 (0.4–1.5), p = 0.002; and 0.7 (0.1–1.4), p = 0.03 respectively. The quality of evidence for our primary outcomes was moderate to high. Regarding functional outcomes, only one trial reported a similar range of motion between groups at 48 postoperative hours. No trial sought to record complications. In conclusion, femoral nerve block provides superior postoperative analgesia after anterior cruciate ligament reconstruction to local infiltration analgesia. The impact of improved analgesia on function remains unclear due to the lack of reporting of functional outcomes in the existing literature.
      PubDate: 2017-09-15T00:00:38.239094-05:
      DOI: 10.1111/anae.14032
  • The effect of neuromuscular blockade on the efficiency of facemask
           ventilation in patients difficult to facemask ventilate: a prospective
    • Authors: S. Soltész; P. Alm, A. Mathes, M. Hellmich, J. Hinkelbein
      Abstract: Facemask ventilation of the lungs can be an important rescue intervention in a ‘cannot intubate’ scenario. We assessed the effect of neuromuscular blockade on expiratory tidal volumes in patients with expected difficulty in mask ventilation. The lungs of patients with at least three predictors of difficulty in mask ventilation were ventilated using a facemask held with two hands, with mechanical ventilation set in a pressure-controlled mode. Tidal volumes were recorded before and after the establishment of complete neuromuscular block. In 113 patients, median (IQR [range]) tidal volume increased from 350 (260–492 [80–850]) ml initially, by 48% to 517 (373–667 [100–1250]) ml 30 s after rocuronium administration, (p < 0.001). After the onset of the complete neuromuscular block, a median tidal volume of 600 (433–750 [250–1303]) ml was observed, corresponding to an increase of 71% from baseline values (p < 0.001), and 16% from values obtained 30 s after rocuronium administration, respectively; p = 0.003). No decrease in the tidal volume during the measurements was observed. We conclude that the administration of rocuronium at a dose of 0.6−1 was able to improve facemask ventilation in all cases with a potentially clinically relevant increase in tidal volume. The early use of a neuromuscular blocking agent can be considered as a therapeutic option in case of difficulty with mask ventilation.
      PubDate: 2017-09-14T23:51:09.82237-05:0
      DOI: 10.1111/anae.14035
  • Real-time continuous monitoring of injection pressure at the needle tip
           for peripheral nerve blocks: description of a new method
    • Authors: C. Quadri; A. Saporito, X. Capdevila
      Abstract: The measurement of injection pressure during the performance of peripheral nerve blocks can be pivotal to detect intraneural placement of the needle tip and thus avoid intrafascicular injection. However, injection pressure can only be measured along the injection line (tubing), which is influenced by several factors. The primary aim of this feasibility study was to describe and validate the principle of a novel nerve-block needle conceived for real-time continuous monitoring of injection pressures at the needle tip. Our secondary aim was to provide measurements and compare injection pressure values at the needle tip and in the injection line. Four porcine lower limb anatomic models were prepared and extraneural injections were performed with fractioned boluses of 2 ml saline at a controlled infusion rate of 10 ml.min−1 (0.16 ml.s−1). Injection pressure at the needle tip was monitored and compared with the pressure in the injection line. The system proved to be reliable. Thirty injections were successfully performed without technical failures. The mean (95%CI) difference between pressures at the needle tip and the injection line varied substantially from 14.33 (12.58–16.08) kPa at 0.5 ml injected volume to 41.56 (39.66–43.45) kPa at the end of the injection. This study demonstrates that the described system allows for real-time continuous monitoring of injection pressure at the needle tip. Moreover, this study shows that injection pressure values measured in the injection line cannot be assumed to be a reliable indicator of the injection pressure at the needle tip.
      PubDate: 2017-09-14T23:46:29.283773-05:
      DOI: 10.1111/anae.14041
  • Effects of epidural volume extension by saline injection on the efficacy
           and safety of intrathecal local anaesthetics: systematic review with
           meta-analysis, meta-regression and trial sequential analysis
    • Authors: M. Heesen; S. Weibel, M. Klimek, R. Rossaint, L. R. Arends, P. Kranke
      Abstract: Epidural volume extension, a modification of combined spinal–epidural anaesthesia, involves the epidural injection of saline in order to increase the spread of drugs given intrathecally. Results from individual studies have so far been contradictory and we aimed to gather the available evidence for this technique. We performed a systematic literature search for randomised, controlled trials comparing epidural volume extension after spinal injection with a control group without epidural injection in patients undergoing surgery. Conventional meta-analyses, trial sequential analyses and meta-regression were performed, with the Grading of Recommendations on Assessment, Development and Evaluation (GRADE) approach used to express reliability of outcome estimates. We included 15 studies with 1177 participants. Meta-analyses for the primary outcomes, such as maximum sensory height (6 studies, 274 participants, mean difference (MD) (95%CI) −0.59 (−1.24 to 0.07) dermatomes, low-quality evidence) and hypotension (10 studies, 683 participants, risk ratio (95%CI) 0.84 (0.66–1.07), low-quality evidence), did not differ significantly between the two treatment arms, but trial sequential analysis suggested insufficient evidence to be certain of these findings. Meta-regression suggested a volume-dependent effect, with higher volumes causing a higher spread of intrathecal drugs and a higher incidence of hypotension. A sub-group analysis indicated a pronounced effect on motor block recovery time when a lower anaesthetic dose plus epidural volume extension was compared with a higher anaesthetic dose without epidural volume extension, the MD (95%CI) being −66.75 (−76.0 to −57.5) min, with trial sequential analysis suggesting the evidence was sufficient to draw this conclusion. In trials using the same anaesthetic mixture in the epidural volume extension and the control groups, motor block recovery time did not differ between groups, with a MD (95%CI) of −1.06 (−5.48 to 3.36) min, although trial sequential analysis suggested insufficient evidence. In summary, there is not enough evidence to draw definite conclusions on the effect of epidural volume extension. The quality of the current evidence is low for both efficacy (maximum sensory height) and safety (hypotension). However, there may be a significantly shorter motor block recovery time when different anaesthetic mixtures are used in epidural volume extension and control groups; this warrants further investigation.
      PubDate: 2017-09-11T02:00:22.625368-05:
      DOI: 10.1111/anae.14033
  • The association of postoperative pulmonary complications in 109,360
           patients with pressure-controlled or volume-controlled ventilation
    • Authors: A. Bagchi; M. I. Rudolph, P. Y. Ng, F. P. Timm, D. R. Long, S. Shaefi, K. Ladha, M. F. Vidal Melo, M. Eikermann
      Abstract: We thought that the rate of postoperative pulmonary complications might be higher after pressure-controlled ventilation than after volume-controlled ventilation. We analysed peri-operative data recorded for 109,360 adults, whose lungs were mechanically ventilated during surgery at three hospitals in Massachusetts, USA. We used multivariable regression and propensity score matching. Postoperative pulmonary complications were more common after pressure-controlled ventilation, odds ratio (95%CI) 1.29 (1.21–1.37), p < 0.001. Tidal volumes and driving pressures were more varied with pressure-controlled ventilation compared with volume-controlled ventilation: mean (SD) variance from the median 1.61 (1.36)−1 vs. 1.23 (1.11)−1, p < 0.001; and 3.91 (3.47) cmH2O vs. 3.40 (2.69) cmH2O, p < 0.001. The odds ratio (95%CI) of pulmonary complications after pressure-controlled ventilation compared with volume-controlled ventilation at positive end-expiratory pressures < 5 cmH2O was 1.40 (1.26–1.55) and 1.20 (1.11–1.31) when ≥ 5 cmH2O, both p < 0.001, a relative risk ratio of 1.17 (1.03–1.33), p = 0.023. The odds ratio (95%CI) of pulmonary complications after pressure-controlled ventilation compared with volume-controlled ventilation at driving pressures of < 19 cmH2O was 1.37 (1.27–1.48), p < 0.001, and 1.16 (1.04–1.30) when ≥ 19 cmH2O, p = 0.011, a relative risk ratio of 1.18 (1.07–1.30), p = 0.016. Our data support volume-controlled ventilation during surgery, particularly for patients more likely to suffer postoperative pulmonary complications.
      PubDate: 2017-09-11T01:55:59.210427-05:
      DOI: 10.1111/anae.14039
  • Current options in aerosolised drug therapy for children receiving
           respiratory support
    • Authors: S. Trend; B. S. Ungern-Sternberg, S. G. Devadason, A. Schultz, M. L. Everard
      Abstract: Inhalation of aerosolised medications are the mainstay of treatment for a number of chronic lung diseases and have several advantages over systemically-administered medications. These include more rapid onset of action for drugs such as β-adrenergic agonists when compared with oral medication, high luminal doses for inhaled antibiotics when used to treat endobronchial infection, and an improved therapeutic index compared with systemic delivery for these and other classes of drugs such as corticosteroids. The use of aerosolised drugs to treat patients whose tracheas are intubated is less well established, in part because systemic delivery via the intravenous route can be a simpler alternative for many drugs. Consequently, research in this area is largely limited to a number of in vitro studies and very few clinical trials. Unfortunately, a lack of focus in this area has resulted in a number of practices which at best are ineffective, and at worst dangerous for the patient. Although there have been some attempts to re-invigorate research in order to improve delivery systems, current devices are, to a great extent, based on long-standing technology developed more than 50 years ago. In this review, we explore current knowledge and provide guidance as to when and how the inhaled route may be of value when treating patients whose tracheas are intubated, and we set out the challenges facing those attempting to advance the topic. We conclude by reviewing current areas of interest that may lead to more effective and widespread use of aerosols in the treatment of intubated patients.
      PubDate: 2017-09-05T05:21:26.667066-05:
      DOI: 10.1111/anae.14011
  • Evidence of hysteresis in propofol pharmacodynamics
    • Authors: P. O. Sepúlveda; E. Carrasco, L. F. Tapia, M. Ramos, F. Cruz, P. Conget, Q. F. B. Olivares, I. Cortínez
      Abstract: It is commonly assumed that loss of responsiveness and recovery of responsiveness occur at similar concentrations of propofol. However, the ‘conscious’ and ‘anaesthetised’ conditions produced by general anaesthetics may behave as two bistable states. We hypothesised that loss of responsiveness and recovery of responsiveness occur at different propofol concentrations. Propofol was administered to 19 healthy volunteers by effect-site target-controlled infusion using increasing and decreasing stable concentration steps of 7 min. Propofol serum concentrations were measured from venous blood samples at the end of each 7-min step. A long step of 14 min was performed at loss of responsiveness. At this step, propofol concentrations were measured at 7 and 14 min. Propofol concentrations measured at loss of responsiveness and recovery of responsiveness were 2.6 (1.2–4.7) μ−1 and 1.6 (0.6–3.3) μ−1, respectively (p < 0.001). Propofol plasma concentration and the corresponding bispectral index values measured at minute 7 and minute 14 of the long step performed at loss of responsiveness were 2.6 (1.2–4.7) vs. 2.6 (1.3–4.3) at recovery of responsiveness, (p = 0.96) and 61.2 (49.0–77.0) vs. 58.4 (45.0–74.0), (p = 0.058), respectively. Loss of responsiveness and recovery of responsiveness appear to occur at different propofol concentrations. However, it is possible that, if equilibration was not achieved between plasma and effect-sites at the end of each 7-min step, the higher concentrations found at loss of responsiveness compared with those observed during recovery of responsiveness could be explained by a possible bias in estimations of the effect-site concentrations of propofol by the Schnider model, rather than neural inertia.
      PubDate: 2017-09-05T04:55:36.720683-05:
      DOI: 10.1111/anae.14009
  • Major trauma and the need for massive transfusion
    • Authors: A. F. Smith; S. W. Choi
      PubDate: 2017-09-01T00:25:48.661533-05:
      DOI: 10.1111/anae.14031
  • Major trauma in older people: implications for anaesthesia and intensive
           care medicine
    • Authors: R. Griffiths; D. Surendra Kumar
      PubDate: 2017-08-22T06:34:09.624894-05:
      DOI: 10.1111/anae.14027
  • The view from the top. Is it worth recording for posterity'
    • Authors: B. J. Jenkins
      PubDate: 2017-08-22T01:35:26.150333-05:
      DOI: 10.1111/anae.14028
  • The effect of acetazolamide on intra-ocular pressure after Trendelenburg
           positioning – a randomised double-blind crossover trial in volunteers
    • Authors: P. Vitish-Sharma; A. J. King, A. Abbas, C. Maxwell-Armstrong, B. Guo, A. G. Acheson
      Abstract: Recent evidence suggests Trendelenburg positioning can produce a significant rise in intra-ocular pressure. Peri-operative vision loss in patients undergoing laparoscopic colorectal surgery has been reported with the rise in intra-ocular pressure suggested as a possible factor. Acetazolamide decreases intra-ocular pressure by reducing the formation of aqueous humour, so we aimed to investigate if it could attenuate the intra-ocular pressure rise that can occur in the Trendelenburg position. Nine healthy volunteers were recruited and randomly assigned to a double-blind crossover comparison of placebo or acetazolamide with a minimal 4 days’ washout period before the second study day. One and a half hours after taking the medication, volunteers lay head-down at 17° for 4 h. Intraocular pressure measurements were repeated in both eyes every 30 min over a 4-h period. There were two males and seven female volunteers, with a mean (SD) age of 54.3 (18.5) years. The mean (SD) increase in intra-ocular pressure following 4 h in the Trendelenburg position was 3.17 (4.63) mmHg after the placebo, and 0.02 (4.01) mmHg (p = 0.02) after acetazolamide. We have shown than acetazolamide can attenuate the rise that occurs in intra-ocular pressure when in the Trendelenburg position.
      PubDate: 2017-08-22T01:12:05.54551-05:0
      DOI: 10.1111/anae.14017
  • Size matters
    • Authors: S. W. Choi; D. M. H. Lam
      PubDate: 2017-08-14T06:08:02.100653-05:
      DOI: 10.1111/anae.14030
  • Ultrasound assessment of gastric contents in children undergoing elective
           ear, nose and throat surgery: a prospective cohort study
    • Authors: F.-P. Desgranges; A.-C. Gagey Riegel, C. Aubergy, M. Queiroz Siqueira, D. Chassard, L. Bouvet
      Abstract: Ultrasound examination of the gastric antrum allows reliable assessment of gastric contents and volume. Postoperative assessment of gastric contents before recovery from anaesthesia could help the physician to choose the most appropriate extubation technique after surgery in children. In this prospective observational study, we assessed whether significant changes occurred in gastric contents during the intra-operative period in children undergoing elective ear, nose and throat (ENT) surgery. Children aged between six months and 16 years were recruited consecutively. Ultrasound examination of the antrum was performed before induction of anaesthesia and at the end of surgery before tracheal extubation, and included quantitative and qualitative assessment of gastric contents. The mean (SD) gastric volume was 0.28 (0.30)−1 before surgery and 0.27 (0.30)−1 after surgery, p = 0.82. No solid contents were identified in the antrum, and the gastric volume was < 1.5−1 in all patients during both ultrasound examinations. Our results suggest that, after elective ENT surgery, children are not at risk of a full stomach before tracheal extubation, and that pulmonary aspiration of blood that may occur after elective ENT surgery is probably not related to regurgitation of ingested blood from the stomach.
      PubDate: 2017-08-14T04:45:18.365068-05:
      DOI: 10.1111/anae.14010
  • A comparison of gastric emptying of soluble solid meals and clear fluids
           matched for volume and energy content: a pilot crossover study
    • Authors: T. Okabe; H. Terashima, A. Sakamoto
      Abstract: We previously demonstrated that the gastric emptying time of different liquids with the same volume mainly depended on their energy content, regardless of differences in composition. In this crossover study, we investigated whether the same applies when soluble solid foods are ingested with water. Ten healthy volunteers ingested one of five test diets consisting of two test meals (Calorie Mate® 100 and 200 kcal) and three test solutions (water and glucose solutions of 100 and 200 kcal), each given in a volume of 400 ml, and then underwent ultrasonography to measure the gastric antral cross-sectional area every 10 min for 120 min. The gastric emptying time was defined as the time for the antral cross-sectional area to revert to its initial value. When test diets with the same energy content were ingested, the gastric emptying curves were nearly identical, regardless of whether the original form was solid or liquid. The median (IQR[range]) gastric emptying times of Calorie Mate® of 100 kcal with water vs. isocaloric glucose solution were 65 (60–78 [50–80]) vs. 65 (60–70 [50–80]) min (p = 0.58), and for Calorie Mate® of 200 kcal with water vs. isocaloric glucose solution they were 100 (93–108 [90–120]) vs. 105 (90–110 [90–120]) min (p = 0.54). The median (IQR [range]) for water was 40 (30–40 [30–50]) min. Energy content may be a critical determinant of the gastric emptying time when ingesting soluble solid diets with water.
      PubDate: 2017-08-14T04:40:24.00939-05:0
      DOI: 10.1111/anae.14026
  • Safety and efficacy of rescue flexible bronchoscopic intubation using the
           Bentson floppy-tip guidewire via a supraglottic airway in critically ill
    • Authors: D. Cross; A. Nyman, P. James, A. Durward
      Abstract: Difficulty in tracheal intubation in paediatric intensive care patients is associated with increased morbidity and mortality. Delays to intubation and interruption to oxygenation and ventilation are poorly tolerated. We developed a safe and atraumatic tracheal intubation technique. A floppy-tipped guidewire and airway exchange catheter were placed to a pre-determined length under bronchoscopic guidance while oxygenation and ventilation was maintained via a supraglottic airway device (SAD). We performed a retrospective review of this technique on patients who were either known to have or who had an unexpected difficultly in intubation. We describe the safety and experience of this in a broad range of critically ill children. Thirteen patients, median (IQR [range]) (9.0 (5.0–10.0 [4.0–12.0]) kg and 15.4 (12.1–23.2 [3.3–49.7]) months) underwent emergency tracheal intubation using this technique, after unsuccessful attempts at intubation using standard laryngoscopy blades. All intubations were successful at the first attempt using this technique and no airway trauma or significant clinical deteriorations were recorded.
      PubDate: 2017-08-03T06:55:49.55592-05:0
      DOI: 10.1111/anae.14008
  • The mid-point transverse process to pleura (MTP) block: a new end-point
           for thoracic paravertebral block
    • Authors: I. Costache; L. Neumann, C. J. Ramnanan, S. L. Goodwin, A. Pawa, F. W. Abdallah, C. J. L. McCartney
      Abstract: Current descriptions of thoracic paravertebral block techniques require the needle tip to be anterior to the superior costotransverse ligament. We hypothesised that an injection point midway between the posterior border of the transverse process and the pleura would result in spread to the paravertebral space. We completed bilateral injections of 5 ml methylene blue 0.2% midway between the posterior border of the transverse process and the pleura at T2, T4, T6, T8 and T10 in three unembalmed cadavers. The presence of methylene blue dye at the nerve root in the paravertebral space, the corresponding intercostal nerve and sympathetic chain at the level of injection, and at additional levels, was examined. We identified the superior costotransverse ligament, pleural displacement and spread to the erector spinae plane. We describe two case reports using this technique in patients. Our cadaver results and clinical cases demonstrate that, with the exception of cadaver 1, an injection point midway between the posterior border of the transverse process and pleura consistently achieved spread of dye at least to the paravertebral space at the level of injection, and frequently to adjacent levels. This may be a plausible explanation for the landmark technique's inability to reliably achieve a multilevel block. We describe a new ultrasound-guided technique for a single level paravertebral block.
      PubDate: 2017-08-01T06:49:29.006108-05:
      DOI: 10.1111/anae.14004
  • The effect of pre-operative methylprednisolone on early endothelial damage
           after total knee arthroplasty: a randomised, double-blind,
           placebo-controlled trial
    • Authors: V. Lindberg-Larsen; S. R. Ostrowski, M. Lindberg-Larsen, M. L. Rovsing, P. I. Johansson, H. Kehlet
      Abstract: We wished to evaluate whether inhibition of the systemic inflammatory response by a single pre-operative dose of methylprednisolone reduced markers of early endothelial damage after fast-track total knee arthroplasty. We randomly allocated 70 patients undergoing elective unilateral total knee arthroplasty (1:1) to receive either pre-operative intravenous methylprednisolone 125 mg (methylprednisolone group) or isotonic saline (control group). All procedures were performed under spinal anaesthesia without a tourniquet, using a standardised multimodal analgesic regime. The outcomes included changes in Syndecan-1 concentrations, a marker of glycocalyx degradation, markers of endothelial cell damage and activation (plasma soluble thrombomodulin and sE-Selectin), and permeability by vascular endothelial growth factor, as well as C-reactive protein concentrations. Blood samples were collected at baseline and 2 h, 6 h and 24 h after surgery, with complete sampling from 63 patients for analyses. Methylprednisolone significantly reduced markers of endothelial damage at 24 h following surgery compared with saline (methylprednisolone group vs. control group, adjusted means (SEM)) expressed by circulating Syndecan-1: 11.6 (1.0)−1 vs. 13.4 (1.1)−1 p = 0.046; soluble thrombomodulin: 5.1 (0.1)−1 vs. 5.7 (0.2)−1, p = 0.009; sE-Selectin: 64.8 (1.8)−1 vs. 75.7 (1.9)−1, p = 0.001, and vascular endothelial growth factor: 35.3 (2.7)−1 vs. 58.5 (2.8)−1, p < 0.001. The effect of the intervention increased with time for soluble thrombomodulin, sE-Selectin and vascular endothelial growth factor, and was more pronounced in patients with high baseline values. Finally, methylprednisolone reduced the C-reactive protein response 24 h postoperatively; 31.1 (1.1) mg.l−1 vs. 68.4 (1.1) mg.l−1, p < 0.001. Pre-operative administration of methylprednisolone 125 mg reduced circulating markers of endothelial activation and damage, as well as the systemic inflammatory response (C-reactive protein) early after fast-track total knee arthroplasty. These findings may have a positive effect on surgical outcome, but require studies in major surgery.
      PubDate: 2017-07-26T00:40:21.059062-05:
      DOI: 10.1111/anae.13983
  • The illusion of informed consent
    • Authors: N. Chrimes; S. D. Marshall
      PubDate: 2017-07-26T00:10:22.846258-05:
      DOI: 10.1111/anae.14002
  • A randomised controlled trial of oral chloral hydrate vs. intranasal
           dexmedetomidine before computerised tomography in children
    • Authors: V. M. Yuen; B. L. Li, D. K. Cheuk, M. K. M. Leung, T. W. C. Hui, I. C. Wong, W. W. Lam, S. W. Choi, M. G. Irwin
      Abstract: Chloral hydrate is commonly used to sedate children for painless procedures. Children may recover more quickly after sedation with dexmedetomidine, which has a shorter half-life. We randomly allocated 196 children to chloral hydrate syrup 50−1 and intranasal saline spray, or placebo syrup and intranasal dexmedetomidine spray 3 μ−1, 30 min before computerised tomography studies. More children resisted or cried after drinking chloral hydrate syrup than placebo syrup, 72 of 107 (67%) vs. 42 of 87 (48%), p = 0.009, but there was no difference after intranasal saline vs. dexmedetomidine, 49 of 107 (46%) vs. 40 of 87 (46%), p = 0.98. Sedation was satisfactory in 81 of 107 (76%) children after chloral hydrate and 64 of 87 (74%) children after dexmedetomidine, p = 0.74. Of the 173 children followed up for at least 4 h after discharge, 38 of 97 (39%) had recovered normal function after chloral hydrate and 32 of 76 (42%) after dexmedetomidine, p = 0.76. Six children vomited after chloral hydrate syrup and placebo spray vs. none after placebo syrup and dexmedetomidine spray, p = 0.03.
      PubDate: 2017-07-25T06:10:55.296636-05:
      DOI: 10.1111/anae.13981
  • An evaluation of the validity of the pre-operative oxygen uptake
           efficiency slope as an indicator of cardiorespiratory fitness in elderly
           patients scheduled for major colorectal surgery
    • Authors: B. C. Bongers; A. E. Berkel, J. M. Klaase, N. L. Meeteren
      Abstract: This study aimed to investigate the validity of the oxygen uptake efficiency slope as an objective and submaximal indicator of cardiorespiratory fitness in elderly patients scheduled for major colorectal surgery. Patients ≥ 60 years of age, with a metabolic equivalent score using the Veterans Activity Questionnaire ≤ 7 and scheduled for major colorectal surgery participated in a pre-operative cardiopulmonary exercise test. The oxygen uptake efficiency slope was calculated up to different exercise intensities, using 100%, 90% and 80% of the exercise data. Data from 71 patients (47 men, mean (SD) age 75.2 (6.7) years) were analysed. The efficiency slope obtained from all the data was statistically significantly different from the values when 90% (p = 0.027) and 80% (p = 0.023) of the data were used. The 90% and 80% values did not differ significantly from each other (p = 0.152). Correlations between the oxygen uptake efficiency slope and the peak oxygen uptake ranged from 0.816 to 0.825 (all p < 0.001), and correlations between oxygen uptake efficiency slope and the ventilatory anaerobic threshold ranged from 0.793 to 0.805 (all p < 0.001). Receiver operating characteristic curves showed that the oxygen uptake efficiency slope is a sensitive and specific predictor of a peak oxygen uptake ≤ 18.2−1.min−1, with an area under the curve (95%CI) of 0.876 (0.780–0.972, p < 0.001) and a ventilatory anaerobic threshold ≤ 11.1−1.min−1, with an area under the curve (95%CI) of 0.828 (0.726–0.929, p < 0.001). These correlations suggest that the oxygen uptake efficiency slope provides a valid (sub)maximal measure of cardiorespiratory fitness in these patients, and the predictive ability described indicates that it might help discriminate patients at higher risk of postoperative morbidity. However, future research should investigate the prognostic value of the oxygen uptake efficiency slope for postoperative outcomes.
      PubDate: 2017-07-25T05:43:06.797098-05:
      DOI: 10.1111/anae.14003
  • A randomised, controlled trial of rectus sheath bupivacaine and
           intrathecal bupivacaine, without or with intrathecal morphine, vs.
           intrathecal bupivacaine and morphine after caesarean section
    • Authors: M. W. Lui; T. K. T. Li, F. Lui, C. Y. T. Ong
      Abstract: We recruited 144 women of whom 131 underwent scheduled caesarean section and were allocated to intrathecal bupivacaine without (46) or with (47) morphine and postoperative rectus sheath bupivacaine; or intrathecal bupivacaine with morphine and postoperative rectus sheath saline (38). We measured postoperative pain with a 10-point numeric rating scale. The mean (SD) areas under the curve for pain on movement during 48 postoperative hours were 273.5 (63.6), 223.8 (80.7) and 223.8 (80.7), respectively, p = 0.008. There was no difference between women who had intrathecal morphine with or without rectus sheath bupivacaine, p = 1. The equivalent values for pain at rest were 160.8 (64.7), 85.8 (79.4) and 82.8 (74.3), respectively, p < 0.001. There was no difference between women who had intrathecal morphine with or without rectus sheath bupivacaine, p = 0.98.
      PubDate: 2017-07-25T05:15:58.813131-05:
      DOI: 10.1111/anae.13998
  • Closing in on the best supraglottic airway for paediatric anaesthesia'
    • Authors: A. K. Nørskov; C. V. Rosenstock, J. Leahy, C. Walsh
      PubDate: 2017-07-24T06:20:21.679785-05:
      DOI: 10.1111/anae.13985
  • A network meta-analysis of the clinical properties of various types of
           supraglottic airway device in children
    • Authors: T. Mihara; A. Asakura, G. Owada, A. Yokoi, K. Ka, T. Goto
      Abstract: We conducted both conventional pairwise and Bayesian network meta-analyses to compare the clinical properties of supraglottic airway devices in children. We searched six databases for randomised clinical trials. Our primary end-points were oropharyngeal leak pressure, risk of insertion failure at first attempt, and blood staining risk. The risk of device failure, defined as the abandonment of the supraglottic airway device and replacement with a tracheal tube or another device, was also analysed. Sixty-five randomised clinical trials with 5823 participants were identified, involving 16 types of supraglottic airway device. Network meta-analysis showed that the i-gel™, Cobra perilaryngeal airway™ and Proseal laryngeal mask airway (LMA®-Proseal) showed statistically significant differences in oropharyngeal leak pressure compared with the LMA®-Classic, with mean differences (95% credible interval, CrI) of 3.6 (1.9–5.8), 4.6 (1.7–7.6) and 3.4 (2.0–4.8) cmH2O, respectively. The i-gel was the only device that significantly reduced the risk of blood staining of the device compared with the LMA-Classic, with an odds ratio (95%CrI) of 0.46 (0.22–0.90). The risk (95%CI) of device failure with the LMA-Classic, LMA®-Unique and LMA-Proseal was 0.36% (0.14–0.92%), 0.49% (0.13–1.8%) and 0.50% (0.23–1.1%), respectively, whereas the risk (95%CI) of the i-gel and PRO-Breathe was higher, at 3.4% (2.5–4.7%) and 6.0% (2.8–12.5%), respectively. The risk, expressed as odds ratio (95%CrI), of insertion failure at first attempt, was higher in patients weighing < 10 kg at 5.1 (1.6–20.1). We conclude that the LMA-Proseal may be the best supraglottic airway device for children as it has a high oropharyngeal leak pressure and a low risk of insertion. Although the i-gel has a high oropharyngeal leak pressure and low risk of blood staining of the device, the risk of device failure should be evaluated before its routine use can be recommended.
      PubDate: 2017-07-24T06:12:29.46961-05:0
      DOI: 10.1111/anae.13970
  • The association between peri-operative acute risk change (ARC) and
           long-term survival after cardiac surgery
    • Authors: T. G. Coulson; M. Bailey, C. M. Reid, L. Tran, D. V. Mullany, J. A. Smith, D. Pilcher
      Abstract: Acute risk change has been described as the difference in calculated mortality risk between the pre-operative and postoperative periods of cardiac surgery. We aimed to assess whether this was associated with long-term survival after cardiac surgery. We retrospectively analysed 22,570 cardiac surgical patients, with minimum and maximum follow-up of 1.0 and 6.7 years. Acute risk change was calculated as the arithmetic difference between pre- and postoperative mortality risk. ‘Rising risk’ represented an increase in risk from pre- to postoperative phase. The primary outcome was one-year mortality. Secondary outcomes included mortality at 3 and 5 years and time to death. Univariable and multivariable analyses were undertaken to examine the relationship between acute risk change and outcomes. Rising risk was associated with higher mortality (5.6% vs. 3.5%, p < 0.001). After adjusting for baseline risk, rising risk was independently associated with increased 1-year mortality (OR 2.6, 95%CI 2.2–3.0, p < 0.001). The association of rising risk with long-term survival was greatest in patients with highest baseline risk. Cox regression confirmed rising risk was associated with shorter time to death (HR 1.86, 1.68–2.05, p < 0.001). Acute risk change may represent peri-operative clinical events in combination with unmeasured patient risk and noise. Measuring risk change could potentially identify patterns of events that may be amenable to investigation and intervention. Further work with case review, and risk scoring with shared variables, may identify mechanisms, including the interaction between miscalibration of risk and true differences in peri-operative care.
      PubDate: 2017-07-13T00:10:25.677951-05:
      DOI: 10.1111/anae.13967
  • Arterial to end-tidal carbon dioxide difference in children undergoing
           mechanical ventilation of the lungs during general anaesthesia
    • Authors: C. Onodi; P. K. Bühler, J. Thomas, A. Schmitz, M. Weiss
      Abstract: Capnography (ETCO2) is routinely used as a non-invasive estimate of arterial carbon dioxide (PaCO2) levels in order to modify ventilatory settings, whereby it is assumed that there is a positive gap between PaCO2 and ETCO2 of approximately 0.5 kPa. However, negative values (ETCO2 > PaCO2) can be observed. We retrospectively analysed arterial to end-tidal carbon dioxide differences in 799 children undergoing general anaesthesia with mechanical ventilation of the lungs in order to elucidate predictors for a negative gap. A total of 2452 blood gas analysis readings with complete vital sign monitoring, anaesthesia gas analysis and spirometry data were analysed. Mean arterial to end-tidal carbon dioxide difference was −0.18 kPa (limits of 95% agreement −1.10 to 0.74) and 71.2% of samples demonstrated negative values. The intercept model revealed PaCO2 to be the strongest predictor for a negative PaCO2-ETCO2 difference. A decrease in PaCO2 by 1 kPa resulted in a decrease in the PaCO2-ETCO2 difference by 0.23 kPa. This study demonstrates that ETCO2 monitoring in children whose lungs are mechanically ventilated may paradoxically lead to overestimation of ETCO2 (ETCO2 > PaCO2) with a subsequent risk of unrecognised hypocarbia.
      PubDate: 2017-07-11T06:21:29.359469-05:
      DOI: 10.1111/anae.13969
  • Sugammadex: when should we be giving it'
    • Authors: C. R. Bailey
      PubDate: 2017-07-11T06:21:20.029114-05:
      DOI: 10.1111/anae.13960
  • Withdrawal of treatment after devastating brain injury: post-cardiac
           arrest pathways lead in best practice
    • Authors: A. R. Manara; D. K. Menon
      PubDate: 2017-07-11T06:20:24.991451-05:
      DOI: 10.1111/anae.13966
  • In search of consensus on ethics in airway research
    • Authors: T. M. Cook; L. V. Duggan, M. S. Kristensen
      PubDate: 2017-06-12T00:50:19.609681-05:
      DOI: 10.1111/anae.13961
  • An analysis of the delivery of anaesthetic training sessions in the United
    • Authors: A. Green; K. C. Tatham, S. M. Yentis, J. Wilson, M. Cox
      Abstract: We analysed data from the electronic rota system CLWRota, covering 2,689,962 anaesthetic sessions between 01/01/2014 and 31/12/2015, in 91 UK Trusts, in order to investigate trainees’ supervision. There were 8209 trainee attachments analysed, during which 618,695 sessions were undertaken by trainees. The number of supervised sessions per week that trainees worked varied considerably (median (IQR [range]) 2.6 (1.6–3.6 [0–10]) for all grades combined), with senior trainees more likely than junior trainees to be supervised for fewer than the three sessions per week mandated by the Royal College of Anaesthetists. The number of supervised sessions was unrelated to Trusts’ size, suggesting that trainees in smaller hospitals receive the same level of supervision as in larger teaching hospitals. Analysis of a dataset of this size should be a good reflection of the delivery of anaesthesia training in the UK.
      PubDate: 2017-06-06T02:00:22.293488-05:
      DOI: 10.1111/anae.13950
  • Change of transfusion and treatment paradigm in major trauma patients
    • Authors: P. Stein; A. Kaserer, K. Sprengel, G. A. Wanner, B. Seifert, O. M. Theusinger, D. R. Spahn
      Abstract: Trauma promotes trauma-induced coagulopathy, which requires urgent treatment with fixed-ratio transfusions of red blood cells, fresh frozen plasma and platelet concentrates, or goal-directed administration of coagulation factors based on viscoelastic testing. This retrospective observational study compared two time periods before (2005–2007) and after (2012–2014) the implementation of changes in trauma management protocols which included: use of goal-directed coagulation management; admission of patients to designated trauma centres; whole-body computed tomography scanning on admission; damage control surgery; permissive hypotension; restrictive fluid resuscitation; and administration of tranexamic acid. The incidence of massive transfusion (≥ 10 units of red blood cells from emergency department arrival until intensive care unit admission) was compared with the predicted incidence according to the trauma associated severe haemorrhage score. All adult (≥ 16 years) trauma patients primarily admitted to the University Hospital Zürich with an injury severity score ≥ 16 were included. In 2005–2007, the observed and trauma associated severe haemorrhage score that predicted the incidence of massive transfusion were identical, whereas in 2012–2014 the observed incidence was less than half that predicted (3.7% vs. 7.5%). Compared to 2005–2007, the proportion of patients transfused with red blood cells and fresh frozen plasma was significantly lower in 2012–2014 in both the emergency department (43% vs. 17%; 31% vs. 6%, respectively), and after 24 h (53% vs. 27%; 37% vs. 16%, respectively). The use of tranexamic acid and coagulation factor XIII also increased significantly in the 2012–2014 time period. Implementation of a revised trauma management strategy, which included goal-directed coagulation management, was associated with a reduced incidence of massive transfusion and a reduction in the transfusion of red blood cells and fresh frozen plasma.
      PubDate: 2017-05-23T02:05:35.256724-05:
      DOI: 10.1111/anae.13920
  • Comparison of reversal with neostigmine of low-dose rocuronium vs.
           reversal with sugammadex of high-dose rocuronium for a short procedure
    • Authors: E. S. Choi; A. Y. Oh, B. W. Koo, J. W. Hwang, J. W. Han, K. S. Seo, S. H. Ahn, W. J. Jeong
      Abstract: Some short procedures require deep neuromuscular blockade, which needs to be reversed at the end of the procedure. Forty-four patients undergoing elective laryngeal micro-surgery were randomly allocated into two groups: rocuronium 0.45−1 with neostigmine (50 μ−1 with glycopyrrolate 10 μ−1) reversal (moderate block group) vs. rocuronium 0.90−1 with sugammadex (4−1) reversal (deep block group). The primary outcome was the intubating conditions during laryngoscopy secondary outcomes included recovery of neuromuscular block; conditions for tracheal intubation; satisfaction score as determined by the surgeon; onset of neuromuscular block; and postoperative sore throat. The onset of neuromuscular block was more rapid, and intubation conditions and ease of intra-operative laryngoscopy were more favourable, and the satisfaction score was lower in the moderate block group compared with the deep block group. No difference was found in the incidence of postoperative sore throat. In laryngeal micro-surgery, the use of rocuronium 0.9−1 with sugammadex for reversal was associated with better surgical conditions and a shorter recovery time than rocuronium 0.45−1 with neostigmine.
      PubDate: 2017-05-11T05:05:23.96063-05:0
      DOI: 10.1111/anae.13894
  • Issue Information – Editorial Board
    • Pages: 1165 - 1165
      PubDate: 2017-09-11T00:42:19.97156-05:0
      DOI: 10.1111/anae.13680
  • Performance of the Minto model for the target-controlled infusion of
           remifentanil during cardiopulmonary bypass
    • Authors: Y. J. Cho; W. Y. Jo, H. Oh, C.-H. Koo, J. Oh, J.-Y. Cho, K.-S. Yu, Y. Jeon, T. K. Kim
      Pages: 1196 - 1205
      Abstract: We studied the predictive performance of the Minto pharmacokinetic model during cardiopulmonary bypass in patients undergoing cardiac surgery. Patients received remifentanil target-controlled infusion using the Minto model during total intravenous anaesthesia with propofol. From 56 patients, 275 arterial blood samples were drawn before, during and after bypass to determine the plasma concentration of remifentanil, and the predicted concentrations were recorded at each time. For pooled data, the median prediction error and median absolute prediction error were 21.3% and 21.8%, respectively, and 22.1% and 22.3% during bypass. Both were 148.4% during hypothermic circulatory arrest and measured concentrations were more than three times greater than predicted (26.9 (17.0) vs. 7.1 (1.6)−1). The Minto model showed considerable bias but overall acceptable precision during bypass. The target concentration of remifentanil should be reduced when using the Minto model during hypothermic circulatory arrest.
      PubDate: 2017-09-11T00:42:16.919508-05:
      DOI: 10.1111/anae.14019
  • A survey of acute pain services in the UK
    • Authors: M. Rockett; R. Vanstone, J. Chand, D. Waeland
      Pages: 1237 - 1242
      Abstract: The organisational state of inpatient pain management in UK hospitals is difficult to determine. We sent an electronic questionnaire to 209 acute pain service leads throughout the UK. Questions were about staffing and service provision. We received 141 responses (67%); 47% of all UK hospitals. Each service was responsible for a median (IQR [range]) of 566 (400–839 [120–2800]) beds. Each acute pain specialist nurse was responsible for 299 (238–534 [70–1923]) beds. The mean (SD) number of consultant hours per week was 5.54 (4.62), delivered by a median of 1.0 (1.0–2.5 [0.2–7.0]) consultant. Overnight cover was provided by 20 (15%) acute pain services, and weekend cover by 39 (29%). Acute pain services commonly (in 50 (35%) hospitals) had roles in addition to acute pain management. Most teams (105, (77%)) reviewed medical patients and patients with chronic pain (in 131, (96%) teams). Half of the services (56, (49%)), reported that they were part of an integrated acute and chronic pain service, however, 83 (59%) did not have any members who work in chronic pain clinics. The majority (79, (70%)) were able to access a nominated chronic pain consultant for advice. Provision of acute pain services throughout the UK is highly variable. The majority do not meet core UK standards.
      PubDate: 2017-09-11T00:42:17.387377-05:
      DOI: 10.1111/anae.14007
  • International publication trends originating from anaesthetic departments
           from 2001 to 2015
    • Authors: J. Ausserer; C. Miller, G. Putzer, D. Pehböck, P. Hamm, V. Wenzel, P. Paal
      Pages: 1243 - 1250
      Abstract: The aim of this study was to analyse publication trends from the anaesthetic literature of the G-20 countries. We performed a literature search in Medline to identify articles related to anaesthetic departments published between 2001 and 2015, by specific G-20 countries according to the affiliation field of the authors, and to three time periods 2001–2005, 2006–2010 and 2011–2015. The number of articles, number of original articles (vs. reviews, editorials or correspondence), articles per million inhabitants, and citations per article were analysed. In total, 96,920 articles were published between 2001 and 2015 in 74 anaesthetic and in 4117 non-anaesthetic journals, with an increase of +104% absolute (i.e. from 23,028 in 2001–05 to 46,887 articles ìn 2010–15) and +85% as articles per million inhabitants. Similarly, the number of original articles increased by 21%, but the anaesthetic specialty's share of original articles (as a proportion of total articles in biomedicine) decreased from 31% in 2001–2005 to 19% in 2011–2015 (−38%). The USA published most articles (2011–15 16,016; 31% of total), second came the EU as a whole and third Japan (from 2001 to 2005) or Germany (2006–2010) until 2011–2015 when China took over the third rank. In 2011–2015, Canada published most articles per million inhabitants (68.7 articles/million inhabitants). China and India exhibited the most publication growth 11- and 9-fold, respectively, and are now among the top five countries for the number of published articles.
      PubDate: 2017-09-11T00:42:17.820891-05:
      DOI: 10.1111/anae.14016
  • A systematic review of information format and timing before scheduled
           adult surgery for peri-operative anxiety
    • Authors: J. Hounsome; A. Lee, J. Greenhalgh, S. R. Lewis, O. J. Schofield-Robinson, C. H. Coldwell, A. F. Smith
      Pages: 1265 - 1272
      Abstract: We included 34 trials with 3742 participants, identified through 6 database and supplementary searches (to May 2017): 29 were randomised; 4 were quasi-randomised and 1 was cluster-randomised. Disparate measurements and outcomes precluded meta-analyses. Blinding was attempted in only 6 out of 34 (18%) trials. A multimedia format, alone or in combination with text or verbal formats, was studied in 20/34 (59%) trials: pre-operative anxiety was unaffected in 10 out of 14 trials and reduced by the multimedia format in three; postoperative anxiety was unaffected in four out of five trials in which formats were compared. Multimedia formats increased knowledge more than text, which in turn increased knowledge more than verbal formats. Other outcomes were unaffected by information format. The timing of information did not affect pre-operative anxiety, postoperative pain or length of stay. In conclusion, the effects of pre-operative information on peri-operative anxiety and other outcomes were affected little by format or timing.
      PubDate: 2017-09-11T00:42:16.265755-05:
      DOI: 10.1111/anae.14018
  • S-shaped tracheal tubes for videolaryngoscopy
    • Authors: N. Desai; T. Jerrom, L. Chigaru
      Pages: 1277 - 1277
      PubDate: 2017-09-11T00:42:20.619708-05:
      DOI: 10.1111/anae.14052
  • Consensus on ethics in airway research – a reply
    • Authors: M. G. Irwin; P. A. Ward
      Pages: 1278 - 1279
      PubDate: 2017-09-11T00:42:18.883926-05:
      DOI: 10.1111/anae.14021
  • Ultrasound examination of gastric contents: are qualitative and
           quantitative assessments complementary'
    • Authors: L. Bouvet; F.-P. Desgranges, D. Chassard
      Pages: 1279 - 1280
      PubDate: 2017-09-11T00:42:16.765501-05:
      DOI: 10.1111/anae.14020
  • Ultrasound examination of gastric contents: are qualitative and
           quantitative assessments complementary' A reply
    • Authors: V. Yuen; C. Chen, L. Liu, C. Y. Wang, S-W Choi
      Pages: 1281 - 1282
      PubDate: 2017-09-11T00:42:20.679801-05:
      DOI: 10.1111/anae.14055
  • Medtronic electromyographic tracheal tube
    • Authors: M. B. Vera-Sanchez; B. Quintana-Villamandos
      Pages: 1282 - 1283
      PubDate: 2017-09-11T00:42:18.980397-05:
      DOI: 10.1111/anae.13986
  • 3-D printing in anaesthesia: challenges and controversies
    • Authors: A. Hartopp; I. Ahmed, G. Miller
      Pages: 1283 - 1284
      PubDate: 2017-09-11T00:42:18.100496-05:
      DOI: 10.1111/anae.14053
  • Epidural pressure waveforms
    • Authors: C. L. Gwinnutt
      Pages: 1284 - 1285
      PubDate: 2017-09-11T00:42:16.856517-05:
      DOI: 10.1111/anae.14044
  • Iron homeostasis: complex effects beyond anaemia
    • Authors: H. Hammerbeck
      Pages: 1285 - 1286
      PubDate: 2017-09-11T00:42:20.048854-05:
      DOI: 10.1111/anae.14045
  • Calculating oxygen consumption during low flow anaesthesia. A reply
    • Authors: O. Sykes; M. Rahlf-Luong
      Pages: 1286 - 1287
      PubDate: 2017-09-11T00:42:16.678663-05:
      DOI: 10.1111/anae.14047
  • Surgical Outcome Risk Tool (SORT) validation in hepatectomy
    • Authors: G. T. C. Wong; W. C. Ang, T. C. L. Wong, S. W. Choi
      Pages: 1287 - 1289
      PubDate: 2017-09-11T00:42:17.266079-05:
      DOI: 10.1111/anae.14051
  • ‘On lock’ – a further single-operator ultrasound-guided
           regional anaesthesia grip
    • Authors: P. Gupta; A. Berrill
      Pages: 1289 - 1289
      PubDate: 2017-09-11T00:42:19.281031-05:
      DOI: 10.1111/anae.14050
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