Welsh Anaesthetic Trainees Journal Club


December 2017

Postpartum haemorrhage and fibrinogen replacement

Viscoelastometric-guided early fibrinogen concentrate replacement during postpartum haemorrhage: OBS2, a double-blind randomized controlled trial. Collins PW, Canning-John R, Bruynseels D et al. 

British Journal of Anaesthesia 2017;119(3):411-421 doi:10.1093/bja/aex181

Presented by: Dr Alasdair Rosie


Post Partum Haemorrhage (PPH) is the leading worldwide cause of maternal mortality and can be worsened by haemostats compromise. This study looked at whether giving early fibrinogen concentrate guided by coagulation point of care testing would reduce blood product usage and bleed size.

Design & Setting

Multi-centre, randomised, double-blinded, placebo controlled study. If patients had an ongoing major haemorrhage of 1000-1500ml a fibtem A5 was performed and if <15mm, the patient was randomised to receive fibrinogen concentrate or placebo.


Included were women >18years old, gestation >24 weeks and with ongoing haemorrhage as above.

Exclusion criteria included those with placenta accreta, those that had had a surgical intervention prior to randomisation, clinical suspicion of AFE and those that declined transfusion.

A total of 55 women were analysed based upon a power calculation of 80% requiring 54 patients to show a difference of 3.3 total allogenic units between groups.


As above, after randomisation, women either received a 50ml vial of normal saline in an opaque cover or 1g of fibrinogen in an opaque cover. FFP and blood products were then used as per local guidelines if bleeding was ongoing.


Primary outcome looked at the number of units of blood products used (red blood cells, FFP, cryoprecipitate, platelets) used between the treatment and control groups. pre-specified sub groups were analysed to look at outcomes in detail


In the treatment group a total of 58 units of products were used compared to 75 in the placebo group. This difference was primarily due to FFP with a similar use of RBC between groups. Blood loss between groups after the study medication was given was roughly similar and not statistically significant.

Outcomes between groups with Fibtem A5 >12mm were indistinguishable. Women with A5 <12m who received fibrinogen concentrate had fewer allergenic blood products, less bleeding and less time in level 2/3 care.

Post hoc analysis noted median blood loss of 300ml vs 800ml in fibrinogen and placebo groups respectively with starting fibrinogens less than 2.5g.


Infusion of fibrinogen concentrate in women triggered by a fibtem A5 <15mm did not improve outcomes. Fibrinogen replacement is not required is fibtem A5 is >12mm or fibrinogen >2-2.5g

Cannot exclude an effect of early fibrinogen use below these levels and further studies are required to look at whether a fibtem <12mm would be clinically and cost effective.


Well run multi-centre, randomised, placebo controlled study. Robust methodology based upon large observational studies.


Lower numbers than anticipated in terms of those randomised with fibrinogens less that 2g. This was thought to be due to the difficulties in consenting and conducting trial interventions during management of a moderate to severe PPH. This is likely to have excluded women most likely to have responded to the proposed intervention.


Has the ability to greatly reduce potentially unnecessary transfusion of blood products and therefore reduce morbidity related to allogenic product transfusion.

Re-enforces previous studies looking to move away from empirical transfusion of products in ratios found to be beneficial in patient populations not related to the obstetric patient (i.e trauma).

Potential for impact

Reduction of transfusion related morbidity.

Optimisation of management of PPH using point of care testing


How to improve patient flow……

The Health Foundation. Evidence Scan: Improving patient flow across organisations and pathways. Dr D de Silva. November 2013

 Presented by:Alex Kennedy


Patient flow is a domain of quality within healthcare. All patient care pathways can benefit from improved flow – in terms of improved safety, financial benefits and improved patient experiences.

Design & Setting

Think tank review of over 5000 papers where analysis and changing flow methodology had been implemented.


UK and international healthcare organisations. All patient pathways, although focus on unscheduled care.


  1. Change in analysis of flow
  2. Change interventions for improving flow


  1. Improved flow
  2. Patient safety
  3. Patient satisfaction


Improved analysis techniques included:

  • Assessing service use
  • Capacity and workflow planning
  • Simulation and other forms of modelling
  • Queuing theory
  • Failure mode and effects analysis
  • Systematic feedback from staff
  • Structured observation and ethnography.

Improved flow implementation techniques included:

  • Reducing variation
    • Continuous QI approaches (Lean/ six sigma)
    • Real-time management – to assess priorities
    • Match capacity to demand
      • Adding capacity, changing skill-mix
      • New roles – patient flow co-ordinators
      • Proactively planning discharge
      • Pull not push people through the system


Analysis and improvement techniques for addressing flow can be directly transferred from other healthcare organisations  and also other industries. For example techniques to improve patient flow in A&E can be adapted to work in an NCEPOD pathway for unscheduled surgery.


Global approach to addressing flow. Particular focus on unscheduled care pathways.


Not specific to particular patient pathways (applied to all healthcare).


This paper provides a platform to implement some of the interventions described. A focus group discussion identified improvements in our local hospital’s NHFD/hip fracture pathway as a result of adapting the techniques used in this paper.

Potential for impact

Significant benefits to perioperative care pathways and all pathways in hospitals for improved efficiency, safety and cost saving.


Does diabetes cause postoperative cognitive dysfunction?

Diabetes is associated with risk of postoperative cognitive dysfunction: A meta-analysis.

Diabetes Metabolism Research and Reviews 2017;33:e2284 doi:10.1002/dmrr.2884

Presented by: Dr C Beynon


Post operative cognitive dysfunction (POCD) is common, especially in the elderly and affects 10-38% during the first 2-3 months following surgery. This paper looks to quantify the risk of POCD associated with known diabetes, chronic hyperglycaemia and those with a history of hypoglycaemia.

Design & Setting

  • This is a meta-analysis study.
  • Pubmed and Cochrane databases were searched for longitudinal studies.
  • The criteria for study inclusion were:
  1. Adult patients (>18years) undergoing surgery, where the association between POCD and diabetes, glycaemic levels and hypoglycaemic episodes was included as relative risk or odds ratios.
  2. Cognitive function pre and post surgery had to be measured using standardised, performance based, neuropsychological assessments.
  3. Glycaemic level was defined by blood glucose or HbA1c levels.
  4. Diabetic status or a history of hypoglycaemia was ascertained from hospital records and self reporting.
  5. The papers had to be in the English language

Results of systematic search

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  • 14 studies out of the 246 identified in the initial search were used for data extraction this included 2642 patients.
  • Fields extracted included proportion of men, mean age, surgical procedure and type of anaesthesia, definition of POCD, exposure to diabetes, hyperglycaemia and history of hypoglycaemia, associations of exposure with POCD and covariates.
  • Data analysis included use of computer programmes to estimate summary relative risk ratios, fixed and random effect modelling, I2 index calculated to look for statistical heterogeneity and sub group analysis.
  • Sensitivity analysis was used to assess the influence of individual studies on the pooled sub group analysis.


  • A total of 2642 patients over 14 studies were analysed. Patients with diabetes has a 1.26 fold increased risk of POCD compared to non diabetics.
  • One study demonstrated a higher HbA1c level associated with increased risk of POCD (RR per percent higher HbA1c 2.0)


  • Diabetic patients have a higher risk of POCD than non diabetics. In middle aged to older adults that risk is increased by 26% compared to diabetic free individuals.
  • Those with poorer glycaemic control are at further risk (relative risk per percent higher 2.0)


  • The paper set out clear inclusion and exclusion criteria for their meta-analysis paper and asked a specific question.
  • The patients underwent formal assessment for POCD.
  • Their methods of review included STROBE quality scores.
  • The explanation of statistical tests and modelling applied to the studies included in the paper appear to be comprehensive.


  • Of the studies included 8/14 contained patients undergoing cardiac surgery with cardio-pulmonary bypass. 3/14 contained carotid endarterectomy cases under GA. Only 1/14 contained patients undergoing major general or orthopaedic surgery.
  • The majority of studies included had small numbers of patients (4/14 <100, 6/14 100-200, 4/14>200 (the largest contained 585).
  • The papers were assessed by one person, ideally and to avoid bias this should be performed by 2 people.


  • Perioperative glycaemic control is important and should be optimised prior to surgery if possible to reduce to additional risk of POCD associated with hyperglycamia.
  • Diabetic patients are at higher risk of dementia and POCD and consideration should be given to anaesthetic technique to minimise risk due to anaesthetic if possible.
  • The predominance of cardiac and carotid surgery within the studies included may have overestimated the risk of POCD, although other studies have found that at 3 months post surgery the type of surgery or anaesthetic has no influence on the incidence of POCD.

Potential for impact

This paper aims to quantify the increased risk of hyperglycaemia on POCD and I believe it has done that. It provides yet more detail on the importance of good glycaemic control pre and perioperatively.


December 2017

Written by: Dr C. Williams

Systematic review of psychological, emotional and behavioural impacts of surgical incidents on operating theatre staff. Sera N, Sahota A, Husband AK et al. British Journal of Surgery Open 2017 doi:10.1002/bjs5.21

Evidence suggests that medical errors affect up to 16% of patients admitted to hospital with 50% of those errors occurring during surgery or other invasive procedures. The operating theatre is an environment uniquely characterised by acute stress, heavy workload and quick decision-making. With more and more healthcare institutions worldwide considering strategies for promoting a safety culture and staff well-being, the purpose of this review was to provide potentially transferable insights into how best to support staff following a surgical incident.

Surgical incidents may or may not result in patient harm but yet may still affect the health professionals involved. Studies looking at the effects on surgeons have found that they report depression and emotional distress symptoms likened to those of post-traumatic stress disorder. Evidence shows that operating theatre nurses and allied health professionals can also suffer loss of self-confidence and job dissatisfaction. The UK Care Quality Commission recommend that organisational support be offered to staff at this time and stressed the importance of actively supporting the health and well-being of staff.

The studies reviewed reported a range of emotional impact on staff and a variety of different coping mechanisms used. It also showed that surgical incidents occurring during elective surgery appeared to have more of an impact on operating staff that those occurring during emergency surgery. What is clear is that the majority of operating theatre staff felt that there is inadequate support from their managers within their organisation after a surgical incident. Surgeons in particular reported a blame culture and therefore a reluctance to disclose or discuss incidents for fear of consequences. Morbidity and mortality meetings are designed to encourage informal and constructive discussions about surgical incidents but there are reports of surgeons becoming ‘defensive and aggressively pursuing angles that put them in the best possible light’ during these meetings.

There are a variety of ways in which healthcare professionals can be supported. But what is evident is that health professionals can suffer severe emotional distress following surgical incidents. This must not be ignored and ideally tools should be developed to help the team deconstruct surgical incidents that occur in a blame-free culture to encourage open discussion and promote shared learning within organisations. Organisations themselves need to actively cultivate a culture of ‘psychological safety’ and in this way they can potentially reduce the impact of incidents on individuals and promote learning. Clearly we still a lot to learn.

Enhancing the quality and safety of the perioperative patient. Stander S, Smith A. Current Opinion in Anaesthesiology 2017;30(6):730-735 doi:10.1097/ACO.0000000000000517 

Although the anaesthetists work is still concentrated mainly in the operating theatre, the spectrum of our job is evolving with work ranging from pre-clinical emergency medicine, preoperative optimisation clinics, treating patients throughout the whole journey from operating room to postoperative care in recovery rooms, intensive and intermediate care facilities, normal wards and acute and chronic pain services. This broad spectrum means that the role of her perioperative physician is firmly linked to the anaesthetist. This review focuses on some aspects of perioperative management where the patient’s quality and safety can be enhanced.

There are many hazards that threaten perioperative outcomes for patients and this review focuses on three areas. The first is pre-operative assessment. We know that optimisation and risk stratification using risk-scores are important early steps in safety management. Secondly, checklists and cognitive aids are becoming more widely used in perioperative care, but vary considerably in quality and usability. Proper design, implementation and recurrent training is crucial to their success.

Finally, addressing the burden of complications in the postoperative period is a future challenge. This can possibly be addressed by proper patients’ preparation and complication management avoiding the so called ‘failure-to’rescue’ concept where complications are not recognised or treated in a timely manner.

Can lung ultrasound be the first-line tool for evaluation of intraoperative hypoxemia? Díaz-Gómez JL, Renew JR, Ratzlaff RA et al. Anaesthesia & Analgesia 2017 doi:10.1213/ANE.0000000000002578 

The use of ultrasound in perioperative settings is becoming more and more popular. ‘Traditional’ evaluation of intraoperative hypoxaemia involves assessing technical factors such as gas mixture, mechanical ventilator function and settings, anaesthetic machine and circuit issues and patient factors with the use of techniques such as auscultation, chest radiography and flexible bronchoscopy. The authors argue that the inherent qualities of lung ultrasound (the wide availability, lack of radiation, portability and immediate interpretation) make it attractive for use in the intraoperative period.

Lung ultrasound has emerged as a timely non-invasive bedside tool and evidence shows that it demonstrates a higher diagnostic accuracy compared to chest radiography and auscultation for many conditions. Currently the evidence for intraoperative use of lung ultrasound to diagnose hypoxaemia is scarce. The arguments for incorporating lung ultrasound into clinical practice are reasonable but it does rely on it being widely available, being able to access the patient to obtain appropriate images in the middle of surgery and that the user has the appropriate skills to interpret images. It remains to be seen how widespread lung ultrasound will become as a first line use for intraoperative diagnosis of causes of hypoxaemia.

Acute physiologic stress and subsequent anxiety among family members of ICU patients. Beesley SJ, Hopkins RO, Holt-Lunstad J et al. Critical Care Medicine 2017 doi:10.1097/CCM.0000000000002835

It is well established that patients who survive critical illness experience high rates of anxiety, depression and post traumatic stress disorder that persist for months to years after hospital discharge. As doctors our focus is often on the patient, however the impact of having a relative on the critical care unit must not be forgotten. Studies have shown that family members of intensive care patients commonly suffer from psychologic disorders including persistent anxiety, depression and PTSD and may experience a decrease in quality of life that persists for 2 or more years associated with significant financial and emotional burden.

Studies have begun to look at risk factors among family members for developing psychological problems and ones elucidated so far include female sex, age of family member or patient, history of anxiety and levels of social support. Persistent psychologic distress also seemed to be more common if family members were involved in medical decision making or perceived that communication with clinicians was inadequate. This study hypothesised that measuring salivary cortisol early in an ICU admission was associated with subsequent anxiety levels among ICU family members.

Family members provided five salivary cortisol samples over 24 hours at the time of the patients admission to critical care. They were then followed up at 3 months primarily looking at anxiety but also depression and post traumatic stress disorder. The results appear to show that higher cortisol levels are associated with anxiety in family members 3 months after ICU admission with roughly one-third of family members affected. There are confounding factors that are not accounted for and this study includes a small sample size so further studies would be needed to confirm this finding. However, being able to identify ICU family members who may be at higher risk of adverse psychologic outcomes may enable early targeted therapies to mitigate post-ICU anxiety.

Improve postoperative sleep: what can we do? Xian S; Dong-Xin W. Current Opinion in Anaesthesiology 2017 doi: 10.1097/ACO.0000000000000538 

Sleep disturbances are common in patients after surgery and they can affect postoperative recovery. Recent evidence points towards multiple perioperative factors that are related to the development of postoperative sleep disturbances – some of these factors can potentially be managed to reduce the severity of sleep disturbances and possibly improve postoperative recovery.

Patients having major surgery often develop significant sleep disturbances in the immediate postoperative period. Severe sleep deprivation and sleep fragmentation is often seen during the night after surgery. For the majority of people their sleep structure gradually returns to normal within a week.

Factors associated with an increased risk of sleep disturbance include:

  • Increasing age
  • Preoperative comorbidity – including obstructive sleep apnoea and coronary artery disease
  • Type of anaesthesia – patients having hysterectomies under spinal anaesthesia had less disturbed sleep than those having general anaesthesia.
  • Pain – pain affects sleep but so does the use of opioid analgesia
  • Severity of surgical trauma – the bigger the surgery the more severe the sleep disturbance
  • Postoperative factors – including noise and light levels on the wards, disturbances from healthcare staff and disturbances by other patients

There are several recognised harmful effects of sleep disturbances on postoperative outcomes including the development of delirium, increased pain levels, increased risk of cardiovascular events in high risk patients, longer hospital stays, poorer functional recovers, poorer emotional state and a lower quality of life.

There are many strategies to reduces sleep disturbance both pharmacological and non pharmacological, both of which may help to improve postoperative recovery. Sleep-promotion strategies are helpful for the recovery of postoperative patients. Although research is still needed what is clear is that sleep is an essential factor to consider when looking to improve patient perioperative outcomes.

Restoration of resident sleep and wellness with block scheduling. Bordet J, Agustin AG, Ahmed MA et al. Medical Education 2017;51(12):1241-1249 doi:10.1111/medu.13392

Sleep deprivations and the effects of fatigue on anaesthetic trainees has been highlighted recently in journals and mainstream media (Journal watch July 2017). Following on from this has been a campaign to raise fatigue awareness by both the AAGBI and the RCoA. The hazards of sleep deprivation have been consistently demonstrated including reduced memory capacity, impaired reaction time and reduced vigilance with increased incidences of medical errors. Trainees in anaesthesia have also been shown to be at higher risks of burnout, depression and be involved n motor vehicle accidents. Although much of the work has been in looking at anaesthetic trainees, all healthcare professionals and indeed non-healthcare professionals are at risk from sleep deprivation.

This paper is an observational study of intensive care residents looking at how changing work schedules may have a positive impact in residents sleep and wellness. The ICU in this study looked at whether using a block scheduling meant that trainees had better sleep and wellness compared to traditional scheduling. The paper describes in detail what ‘block scheduling’ entails but briefly over a 4 week period residents work 3 weeks in ICU and have one week of ‘ambulatory’ work. Although it is difficult to work out exactly what ‘ambulatory work entails it is made up of a week of 8am-5pm days as opposed to the 12-13 hour shifts (day or night) while working on ICU.

All residents wore wrist actigraphy which measured total sleep time, sleep latency, sleep efficiency, light exposure, steps and activity levels. Residents also filled out weekly questionnaires including the Epworth Sleepiness Scale and the Perceived Stress Scale. Residents slept significantly longer during their week away from ICU (ambulatory week). Their Sleepiness Scale and Stress Scale scores worsened the longer they spent working ICU shifts but improved significantly during their ‘ambulatory week’. Residents who stayed on ICU for the whole 4 week block continued to show a trend with a decline in perceived wellness.

Although further studies are needed this type of ‘block’ scheduling may have some benefits in repaying sleep debt, correcting circadian misalignment and improving wellness.

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