Welsh Anaesthetic Trainees Journal Club

January 2018

Written by Dr C. Williams

Sexual harassment in medicine – #MeToo. Jagsi R. New England Journal of Medicine 2017 doi:10.1056/NEJMp1715962

This is a short but highly interesting article looking at the phenomenon of sexual harassment in medicine. Currently it seems that not a week passes without the media filled with news of celebrities engaged in sexual misconduct. This article is written by a medical academic who has led a study of workplace sexual harassment in medicine. She describes the numerous incidents reported to her of sexual harassment in medicine and how victims often do not report incidents and the ones that do experience marginalisation, retaliation, stigmatisation and worse. Despite the #MeToo movement, reporting such behaviour is still not straightforward.

But what is sexual harassment. Working in an operating theatre still seems to be a male dominated environment and often an environment where lewd ‘locker-room’ humour dominates. But at what point does this humour cross the line into sexual harassment? One only has to have a few conversations with other healthcare professionals to start to hear stories, often told in jest, of incidences that clearly cross this line. I too have multiple stories which when looking at them objectively are clearly examples of unacceptable behaviour. I was relating one such experience to a colleague as a humorous story (which it was – although not so much at the time). I was asked to formally report the event……..but I didn’t, for several reasons, not least the concern that it would effectively be career suicide. This is also touched upon in the article.

This article concentrates on females being subjected to sexual harassment. But females aren’t the only ones affected. I have witnessed a male colleague being harassed by a bay of 80-plus year old female patients. If the situation had been reversed then I suspect there may have been a different attitude to the event by the female nursing witnesses.

The article mentions an interesting concept devised by academic astronomers. They recognised that mandatory reporting dissuades people so developed a rescue system, or a list of ‘astronomy allies’. These are senior female astronomers who wear prominent buttons at national society meetings and make themselves available to remove colleagues from problematic situations ( The aim is to provide ‘judgement-free’ help if someone believes it is needed. As the author points out, it raises questions about our society and how sexual harassment is viewed that such a system is required in a professional setting. Maybe such a system is needed in medicine. Much work is clearly still needed on this but the fact we are now openly talking about is a start.

Risk of epilepsy in surgical patients undergoing general or regional anaesthesia. Chang HC, Liao CC, Chang CC et al. Anaesthesia 2017 doi:10.1111/anae.14099

This study looks at the rates of new-onset epilepsy occurring in patients after surgery where they have had either a general or a neuraxial anaesthetic. It is well known that patients who have epilepsy, especially poorly-controlled epilepsy, are at risk, as are patients undergoing brain surgery, open-heart surgery or liver transplantation. But new-onset epilepsy is not something generally that many anaesthetists would consider although both stress and anaesthetic medication have been associated with epilepsy. Previous studies looking at this issue have had many limitations. This nationwide retrospective cohort study of patients in Taiwan sought to evaluate the one-year risk of epilepsy after surgery in patients receiving general or neuraxial anaesthesia.

The Taiwan National Health Insurance Research Database was used to identify patients. Over 200,000 patients were included in each group (general or neuraxial anaesthesia). During the one-year follow-up period the incidence of postoperative epilepsy after general anaesthesia was 0.41 per 1000 and after neuraxial anaesthesia 0.32 per 1000 persons. Compared with patients who had neuraxial anaesthesia, the risk of postoperative epilepsy significantly increased in patients with general anaesthesia when co-existing medical conditions and postoperative complications were included.

This study raises questions about the epileptogenic effects of various anaesthetic agents. But it has limitations. Information about blood biochemistry, lifestyle factors, genetic susceptibility, drug use and the anaesthetic agents used is not available on the database and these could have significant impact on the risk of developing seizures post-operatively. Further clinical studies are needed to be able to draw and firm conclusions.

Doppler-guided goal-directed fluid therapy does not affect intestinal cell damage but increases global gastrointestinal perfusion in colorectal surgery: a randomised controlled trial. Resigner KW, Willigers HM, Jansen J et al. Colorectal disease 2017;19(12):1081-1091 doi:10.1111/codi.13923

Fluid management for colorectal surgery has been much debated recently – should we aim for a restrictive fluid regimen or more liberal fluid treatment? It has been suggested that both restrictive and liberal fluid regimens induce hypo perfusion, the former due to local tissue oedema and the latter due to hypovolaemia. It is also now thought that fluid management in the first hours following surgery may be as important as intra-operative fluid management in improving tissue perfusion and oxygenation. Goal directed fluid therapy (GDFT) has been proposed as a way to reduce complicaations, mortality and length of hospital stay after major colorectal surgery. This study hypothesised that oesophageal doppler guided GDFT as opposed to standard fluid therapy decreased intestinal injury and improved gastrointestinal perfusion during surgery and in the first few hours after surgery.

Patients having elective colorectal cancer surgery with a primary anastomosis were enrolled either to have doppler guided GDFT or standard fluid therapy. All patients had an oesophageal doppler probe inserted and this was kept in situ for a maximum of six hours postoperatively or until the patient could no longer tolerate the probe.

Intestinal damage was determined by measuring intestinal fatty acid binding protein (I-FABP) plasma levels with increasing levels said to correlate with gut-hypoperfusion. Gastric tonometry measuring the intramuscosal carbon dioxide pressure was used to detect gastrointestinal hypoperfusion with the gastric tonometry catheter also left in place for six hours postoperatively.

Interestingly the amount of fluid given did not differ between the intervention and the control groups. The results also showed no difference between the I-FABP levels although the gastric tonometry results indicated better global gastrointestinal fluid perfusion in the intervention group. The clinical outcomes were not statistically analysed but there seems to be relatively little difference between the two groups, although the patients in the intervention group stayed a median of 11 days in hospital as compared to the control groups median of 8 day stay!

Unfortunately this study fails to shed any more light on the best way to manage fluid therapy during major colorectal surgery. Although the authors state that the gastric tonometry results indicated better global gastrointestinal perfusion it is not actually known whether gastric tonometry correlates with colonic perfusion. It is unlikely that these findings will affect current clinical practice anytime soon.

Sugammadex and oral contraceptives: is it time for a revision of the anaesthesia informed consent? Cora DM, Robards CB. Anesthesia & Analgesia 2017 doi:10.1213/ANE.0000000000002677 

This is an interesting letter to the editors raising concerns abut potential issues for women on oral contraceptives who receive sugammadex in the perioperative period. Sugammadex administration can cause certain drugs, including oral contraceptives, to becomes less effective due to lowering of the free plasma concentration. The letter goes on to point out that the drug information that comes with sugammadex states that ‘in vitro binding studies indicate that Bridion may bind to progestogen………the administration of Bridion is considered equivalent to missing dose(s) of oral contraceptives containing oestrogen or progestogen’. The makers of sugammadex recommend that is the patient is taking oral contraceptives and receives a dose of sugammadex then they should be advised to use an additional non-hormonal contraceptive method for the next 7 days.

Sugammadex is not the only drug administered in the perioperative period that could affect oral contraceptives. Many of the routinely used antibiotics can have a similar effect. Currently, there is little emphasis on discussion and counselling patients about these potential drug interactions. The authors suggest that a revision of the anaesthetic consent should contain a general statement to make patients aware that certain medications given during the anaesthetic may interfere with the effectiveness of oral contraceptives. Maybe this is needed but a good starting place would be raising awareness of the issue amongst anaesthetists – in my questioning of a cross-section of anaesthetic colleagues about this issue, no one was aware that sugammadex may interfere with oral contraceptives.

Surgery and discontinuation of angiotensin converting enzyme inhibitors: current perspectives. Bardic N, Povsic-Cevra Z. Current Opinion in Anesthesiology 2017 doi:10.1097/ACO.0000000000000553 

Angiotensin-converting enzyme inhibitor (ACEIs) have been used since the 1970s to treat hypertension with angiotensin II receptors blockers (ARBs) introduced in the 1990s. These medications, collectively known as renin-angiotensin system or RAS antagonists) are thought to work be four different mechanisms:

  1. Cardiovascular protection via reduction of ischaemia
  2. Improvement in cardiac function and short-term survival after myocardial infarction
  3. Antihypertensive effects
  4. Delay in nephropathic progression in diabetic patients

Their use in the perioperative period continues to be a subject of debate. Although the general consensus amongst many anaesthetists is that these drugs should be omitted during the perioperative period in the context intraoperative vasoplegia, previous studies and review articles fail to make any clear recommendations. Multiple studies suggest that patients who take ACEIs or ARBs to treat hypertension are at increased risk of developing severe prolonged hypotension intraoperatively, commonly immediately after induction of anaesthesia.

A large multicentre study published in 2017 (as part of the VISION study) compared patients given ACEIs or ARBs on the day of surgery versus withholding them for 24 hours preoperatively. Their findings suggest that withholding RAS antagonists before major non-cardiac surgery was associated with less risk for complications or death. However, the data from this study had various limitations and it is important to note that withdrawal of ACEIs after surgery is associated with a significant risk of fatal and nonfatal complications postoperatively.

Overall, this article gives a good summary of the recent evidence surrounding RAS antagonists during the perioperative period but still does not provide an answer to the question of whether these drugs should be withheld before surgery or not. It does makes some sensible suggestions as to how to manage these patients:

  • The decision to discontinue RAS antagonists should take into account the original indications for their use, the patient’s clinical status, variability in the patient’s blood pressure and the type of surgery
  • Special attention is needed in surgery with presumed larger blood loss or haemodynamic instability
  • If ACEIs or ARBs are discontinued, they should be restarted as soon as the patient’s condition allows.

Postoperative nausea and vomiting after unrestricted clear fluids before day surgery: a retrospective analysis. McCracken GC, Montgomery J. European Journal of Anaesthesiology 2017 doi:10.1097/EJA.0000000000000760 

Nil by mouth timing remains a contentious issue and a topic that continues to be discussed to great extent in the literature. Current European guidelines encourage the intake of oral fluids until up to two hours before induction of general anaesthesia. The reality is that many patients continue to be starved from the early hours of the morning before surgery and that it is difficult to give patients a true two hour cut-off time for clear fluids.

This study was carried out at Torbay Hospital Day Surgery Unit with a change in the day surgery policy permitting unrestricted clear oral fluids up until the time of transfer to theatre. The aim was to assess the incidence of postoperative nausea and vomiting (PONV) before and after the change to unrestricted pre-operative clear oral fluids.

A total of 11500 patients who received either sedation, general anaesthesia, regional anaesthesia or a combination were included. The results showed a reduction in PONV from 5.2% in patients who could not drink within 2 hours or surgery to 3.8% in patients who had unrestricted clear oral fluids. This suggests that the liberal consumption of clear fluids before the induction of day case anaesthesia reduces PONV.

During the time of the study there were no recorded adverse events of pulmonary aspiration of gastric content requiring patient admission. Since the conclusion of the study a further 10487 patients have undergone surgery on the ‘new’ day surgery pathway which continues to include liberal preoperative clear fluid consumption. During this time there was one episode of aspiration by a patient breathing via a supraglottic airway – the review of the case would suggest that possibly a supraglottic airway was not the most suitable choice for this patient!

This study does seem to present a strong argument that allowing clear oral fluids up until the time of transfer to theatre in day surgery patients is safe, reduces PONV, is not associated with increased episodes of aspiration and gives an improvement in patient satisfaction.

Journal Club: 19th December 2017

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


Journal Club: 14th December 2017

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.


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.

Journal Club 28th November 2017

Fluid therapy in the perioperative setting—a clinical review

Journal of Intensive Care. 2016;4:27. 

Presented by Dr. M. Creed


  • Perioperative hypovolemia and fluid overload have effects on both complications following surgery and on patient survival.
  • Therefore, the administration of intravenous fluids before, during, and after surgery at the right time and in the right amounts is of great importance.
  • This review analyzes the literature concerning perioperative fluid therapy in abdominal surgery and provides evidence-based recommendations for clinical practice.

Design & Setting

  • Clinical Review Article


  • Preoperative oral or intravenous administration of carbohydrate containing fluids has been shown to improve postoperative well-being and muscular strength and to reduce insulin resistance. Hence, the intake of fluid (preferably containing carbohydrates) should be encouraged up to 2 h prior to surgery in order to avoid dehydration.
  • Excessive intravenous fluid administration adds to tissue inflammation and edema formation, thereby compromising tissue healing.
  • During major abdominal surgery a “zero-balance” intraoperative fluid strategy aims at avoiding fluid overload (and comparable to the so-called restrictive approach) as well as goal-directed fluid therapy (GDT). Both proved to significantly reduce postoperative complications when compared to “standard fluid therapy”.
  • Trials comparing “restrictive” or zero-balance and GDT have shown equal results, as long as fluid overload is avoided in the GDT group as well (categorized as “zero-balance GDT”).
  • It is possible that high-risk surgical patients, such as those undergoing acute surgery, may benefit from the continuous monitoring of circulatory status that the GDT provides. Data on this group of patients is not available at present, but trials are ongoing.


  • In elective surgery, the zero-balance approach has shown to reduce postoperative complications and is easily applied for most patients.
  • It is less expensive and simpler than the zero-balance GDT approach and therefore recommended in this review.
  • In outpatient surgery, 1–2 litres of balanced crystalloids reduces postoperative nausea and vomiting and improves well-being.


  • Good review of literature, assessing/referencing 71 papers.
  • Data well presented for comparison between trials (Tables 1, 2) and also including data from selected meta-analysis (Fig 1).


  • An overview of a very broad subject, therefore wide ranging.
  • Review not conducted as a Systematic review and no description of search methodology in arriving at source articles.
  • No meta-analysis of reviewed data other than that taken from other articles.

Potential for impact

  • Provides focus to reflect on perioperative fluid management.
  • May provide opportunity to alter individual practice to reflect current evidence base.

Journal Club: 21st November 2017

Predicting postoperative morbidity in adult elective surgical patients using the Surgical Outcome Risk Tool (SORT). Wong DJN, Oliver CM, Moonesinghe SR.

British Journal of Anaesthesia 2017;119(1):95-105 doi: 10.1093/bja/aex117

Presented by: Dr Alex Cormack


  • Perioperative risk assessment is a key part of the consent process
  • Risk stratification tools also allow comparison between outcomes of different institutions
  • Morbidity following surgery can have a significant impact on quality of life and needs to be a consideration when considering surgical options
  • Morbidity is more common than mortality following surgery and potentially provides a more sensitive measure of comparison between different healthcare providers
  • P-POSSUM and POSSUM are currently the most frequently used tools for perioperative risk prediction


  • Physiological and Operative Severity Score for the enumeration of Mortality and morbidity
  • Developed in the 1990s
  • For use in elective and emergency general surgical procedures
  • Does not apply to trauma patients
  • Calculated at the time the decision to operate is made
  • Variants include CR-POSSUM, Vascular-POSSUM and O-POSSUM
  • Requires 12 physiological and 6 operative parameters to calculate


  • Portsmouth modification of the Physiological and Operative Severity Score for the enumeration of Mortality and morbidity.
  • A variation of the POSSUM tool


  • Surgical Outcome Risk Tool
  • Developed after the 2011 NECEPOD report
  • Uses six parameters collected preoperatively
  • Designed to predict probability of 30 day mortality following surgery
  • The authors state that it ‘compared favourably with other previously validated risk stratification tools’ and ‘has been externally validated recently in a cohort of patients undergoing hip fracture surgery’.
  • Predictor variables: ASA grade (III, IV or V), surgical urgency (expedited, urgent or immediate), high risk specialities (GI, thoracic or vascular surgery), surgical severity (major or complex), malignancy, age (65-79 or >80)

 Design and Setting

  • Single centre prospective study at University College London Hospital to:

“develop and validate a new model to predict the likelihood of postoperative                       morbidity using predictor variables found in SORT, and then compare its      performance against POSSUM.”

  • 3 year period (June 2009 – May 2012)
  • Data collection carried out by trained research staff independent of the clinical teams responsible for the patient


Inclusion criteria:

  • Patients undergoing elective major inpatient operations
  • 1934 patients included

Exclusion criteria:

  • Patients with duplicated or missing data
  • Patients who did not have POMS (Post Operative Morbidity Survey) scores recorded on Day 7


  • Data collected:
    • 1934 patients identified, 1583 patients included
    • 58% female
    • 45% orthopaedic and 39% abdominal procedures
    • 6 deaths within 30 days of surgery
  • Data excluded:
    • 351 patients excluded
    • Missing predictor variables: DOB, ASA status, surgical speciality, malignancy status
    • Missing POMS outcomes: duplicated or missing entries
    • Clear summary of reasons for exclusion, no patients unaccounted for
  • POMS administered prospectively to patients at several time points postoperatively (day 3,5,7 or 8, 14 or 15 and 21)
  • Morbidity outcome measure selected was POMS-defined morbidity recorded after postoperative day 7 or 8
  • Data randomly split into two groups
    • 1/3 validation group (n=527)
    • 2/3 derivation group to define new model (n=1056)


  • Predictor variables from the original SORT variables were adjusted to generate SORT-morbidity models
  • Outcome variable was set as the presence of POMS defined morbidity on postoperative day 7 or 8
  • SORT-morbidity models then tested in the validation group using statistical analysis
  • Final model then tested against POSSUM


  • No statistically significant difference between new SORT-morbidity model and POSSUM at discrimination of morbidity at 7 days post surgery
  • Linear shrinkage factors estimated to improve prediction of morbidity at later time points


  • New SORT-morbidity model is comparable to POSSUM at prediction of morbidity 1 week post operatively
  • Linear shrinkage factors can be applied to improve morbidity prediction further in the postoperative course


  • Morbidity is an important consideration within the surgical consent process
  • Data collection carried out by research staff independent of clinical teams
  • Clear documentation of reasons for exclusion
  • Good number of data sets
  • New SORT-morbidity model found to compare favourably to POSSUM
  • POMS is a validated measure of morbidity to use in data collection


  • Morbidity defined as POMS defined morbidity after day 7
    • Patients discharged prior to this time period excluded despite possible morbidity
  • Only looked at elective patients
  • Single centre study
  • Unequal representation of surgical specialities
  • Comparatively low mortality rate (0.31%) documented – the authors comment that rates of 0.37-0.67% have been documented elsewhere in the literature
  • POMS domains include some relatively minor measures of morbidity that may influence the results (for example urinary catheter following elective urology cases)
  • Required ‘linear shrinkage factors’ to enable morbidity to be predicted later than 7 days postoperatively

Implications and Potential for Impact

  • Possible development of a new tool to use alongside existing risk assessment tools
  • SORT-morbidity was only used in elective cases and therefore could not be used in a CEPOD setting without further studies
  • Potential for further studies to develop the SORT-morbidity tool for more widespread use
  • P-POSSUM currently universally understood amongst the theatre MDT whereas SORT is less widely understood
  • SORT and SORT-morbidity require fewer variables to calculate, however this is less relevant as SORT-morbidity has only been developed using elective cases

The use of SORT-morbidity as an alternative to P-POSSUM does not yet seem a realistic prospect. P-POSSUM is understood amongst surgical and anaesthetic professionals and allows management decisions to be made appropriately. It is used for both emergency and elective patients, and arguably its most important use is in planning the management of emergency patients. This is an area that the SORT-morbidity tool has not been developed for. Further studies and multi-centre validation would be required before it could reliably be used in clinical practice.



Journal Club: 14th November 2017

Serratus plane block: a novel ultrasound-guided thoracic wall nerve block

Anaesthesia 2013;68:1107-1113 doi:10.1111/anae.12344

Presented by: Dr. A. Gańska


  • The serratus plane block is an alternative block to paravertebral block and thoracic epidural (which are more challenging and have higher potential side-effect profile
  • It can provide a long lasting analgesia for breast, axilla surgery and prevention of acute pain progressing to chronic pain
  • It has fewer side-effects, is safe and easy to perform

Design and Settings

  • Descriptive study on 4 volunteers and 3D reconstruction of local anaesthetic spread using fat-suppression MRI imaging


  • 4 female volunteers


  • USS guided injections, two per volunteer of solution of 0.4ml/kg 0.125% levobupivacaine mixed with 0.1mmol/kg gadolinium.
    • First superficial to serratus anterior
    • Second underneath the muscle at level of 5th rib in midaxillary line.
  • Thoracodorsal artery was used as an extra reference point


  • Test of sensory loss after 30min with hypodermic needle
  • MRI scan after 1h to show distribution of gadolinium
  • Two observers compared images with MRI atlases


  • T2 – T9 dermatomal paresthesia
  • Weak crossed-arm adduction movement


  • injection I: 752min duration of paresthesia for sensory nerves and 43min for motor nerves
  • Injection II: 386min duration of paresthesia for sensory nerves and 150min for motor nerves
  • MRI showed good spread with both injections

Study limitations

  • Descriptive study on volunteers
  • Small number of participants
  • Needs randomised controlled trial
  • MRI distribution of gadolinium may mimic fat tissue, image analysis software had to be used
  • Possibility of false impression of extent of LA spread – there was greater extension of the clinical effect then MRI suggested

Potential for impact

  • The serratus plane lock appears to give predictable and long lasting regional anaesthesia
  • Alternative to surgical LA infiltration, paravertebral blocks, thoracic epidural and intercostal nerves blocks
  • Compared with above this technique could be better for day case surgery
  • Superficial block was more effective

Journal Club: 7th November 2017

A Perioperative Smoking Cessation Intervention with Varenicline, Counseling, and Fax Referral to a Telephone Quitline Versus a Brief Intervention: A Randomized Controlled Trial

Anesthesia & Analgesia 2017;125(2):571-579 doi:10.1213/ANE.0000000000001894

Presented by Dr T. Sheppard


  • Smoking is addictive
  • High health burden with smoking-related diseases (but also high tax revenue)
  • Increased incidence of surgical complications associated with smoking
    • Wound
    • Pulmonary
    • Infection
  • Treatment with chemical & behavioural interventions is effective in reducing smoking in surgical patients – but has not been tested in a pre-op assessment clinic setting
  • Varenicline (Champix®) is effective in increasing abstinence in both surgical & non-surgical patients

Design & Setting

  • RCT
  • Open label
  • Prospective
  • Pre-op assessment clinic with 6 anaesthetists and 1 pharmacist delivering BOTH interventions


  • Elective ambulatory and inpatient surgery
  • Preoperative surgical clinics: general surgery, orthopaedics, urology, plastic surgery, vascular surgery, otolaryngology, ophthalmology, and neurosurgery
  • Smokers of at least 10/day with no abstinence for 3 months in past year
  • Equal proportions based on “Stage of Change” i.e. readiness to quit smoking


  • Patients with contraindications to varenicline (Champix®), pregnancy or breastfeeding, use of nicotine replacement therapy in last 3 months, use of tobacco products other than cigarettes


Randomised to either;

A 10- to 15-minute structured preoperative counselling session


Pharmacotherapy with a free 3-month supply of varenicline


An educational pamphlet


A fax referral to a quitline for proactive telephone counselling and follow-up


Control group that received brief advice regarding smoking cessation and quitline                information for self-referral



  • 7-day point prevalence (PP) abstinence at 12 months after surgery


  • Abstinence at 1, 3, and 6 months
  • Measurement of urinary cotinine (metabolite of nicotine) levels and expired-air carbon monoxide levels used to prove smoking cessation


  • 18-month period
  • 296 patients randomised (8570 pts screened, 1024 smokers, 788 excluded)
  • Significant increase in smoking abstinence in intervention group vs control (42.4% vs 26.2% (RR, 1.62; 95% CI, 1.16–2.25; P = .003))
  • Significant increase in PP of secondary outcome measures;
    • 1 month: 45.7% vs 25.5% (RR, 1.79; 95% CI, 1.29–2.49; P < .001)
    • 3 months: 46.4% vs 26.9% (RR, 1.72; 95% CI, 1.25–2.37; P ≤ .001)
    • 6 months: 45.0% vs 26.2% (RR, 1.72; 95% CI, 1.24–2.38; P < .001)


  • Smoking abstinence significantly increased in intervention group and was also sustained for a longer period
  • Increased nausea reported in the intervention group, but other complications were no different
  • Significantly greater effect on in-patients than day-surgery


  • Significant reduction in short-term and long-term smoking habits
  • Representative cohort of surgical patients


  • Observer bias – advice given by anaesthetists & pharmacist as opposed to independent researcher
  • Details of surgery were not explored
    • Malignancy
    • Prolonged in-patient stay
    • ITU stay
  • Open label – significant reductions in smoking in both groups
  • Multiple interventions in the intervention group
  • Which part had the biggest impact?
  • Free prescription of Champix® – would otherwise have to be paid for


  • The smoking cessation methods on display in this trial were very effective
  • Unclear what the potential for long-term outcomes would be compared with a “control” population re: wound healing, pulmonary complications

Potential for impact

  • Some form of smoking cessation advice for surgical patients would likely lead to some reduction in smoking habits
  • With the move to day-of-surgery-admissions it is difficult to find an appropriate time for discussion about smoking cessation
  • Pre-op clinics themselves are extremely busy and with all the other important pieces of information, would smoking cessation be lost in a cloud of do’s and don’ts before surgery?

November 2017

Written by Dr C. Williams

Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study. British Medical Journal 2017;359:j4366 doi:10.1136/bmj.j4366

This is a very interesting article published during a time when the argument about males vs females rages on. One only has to do a quick google search to see some of these arguments relating to the medical profession – from female medics have better outcomes to how the high number of female doctors are destroying the NHS.

This population based, retrospective, matched cohort study looked at patients who had surgery between 2007 and 2015. It looked at death rates, readmissions and complications based solely on the sex of the surgeon. The results suggest that patients treated by female surgeons were less likely to die within 30 days but there was no significant difference in readmission or complication rates. This difference in mortality was small and whether it makes any difference to long term survival is unclear. Interestingly no differences were found for patients who were operated on in emergency situations.

This study was done in Canada where, unlike the NHS, patients can freely choose their operating surgeon. The differences seen for elective surgery would suggest confounding factors play a role. The lack of difference in patients having emergency surgery would back this up. So, although an interesting study it would not suggest that one should pick a surgeon based on their sex alone.

Effect of various duration of smoking cessation on postoperative outcomes: A retrospective cohort analysis. Turn A, Koyuncu O, Egan C et al. European Journal of Anaesthesiology 2017 doi: 10.1097/EJA.0000000000000701 

There is now a solid evidence base that smoking is an independent risk factor for perioperative complications. Smokers are 1.4 times more likely to die after surgery than patients who have never smoked. Active smokers also have higher risks of respiratory, cardiovascular and neurological adverse events and are more likely to have problems with infections.

Preoperative smoking cessation would be expected to reduce postoperative smoking and it would be reasonable to expect that longer period of abstinence would correlate with stronger benefits. But the optimal period of preoperative smoking cessation remains controversial. Several randomised trials conclude that 3 to 8 weeks of preoperative cessation reduce wound complications but briefer periods do not seem to reduce respiratory complications. However, a meta-analysis published in 2011 suggested that each additional week of smoking cessation has a significant impact in the reduction in post-operative complications.

Prospective evaluation of the effects of smoking cessation on postoperative outcomes is not easy – a substantial number of patients do not want to stop smoking and even among those that attempt to stop the success rate is thought to be about 50% which makes it difficult to recruit patients in the context of a defined protocol. This paper was a retrospective cohort analysis of adult patients undergoing non-cardiac surgery with the main outcome easier being the relationship between smoking cessation and in-hospital morbidity/mortality.

The summary of the results is that smoking cessation is associated with reduced in-hospital morbidity and mortality – importantly this was shown to be independent of the cessation interval. From a clinical perspective, patients should be encouraged to stop smoking regardless of the time period before surgery.

Incidence of venous thromboembolic events in enhanced recovery after surgery for colon cancer: a retrospective, population-based cohort study. Moms MI, Vendler TA, Haidari JE et al for the Copenhagen cOmplete Mesocolic Excision Study group (COMES). Colorectal disease 2017 doi:10.1111/codi.13910

Abdominal surgery in patients with cancer is associated with an increased risk of venous thromboembolism (VTE). Both the Danish and NICE guidelines recommend prolonged thromboprophylaxis with low-molecular weight heparin for 28 days after executive surgery for colon cancer. The evidence behind these guidelines relies on randomised controlled trials that included both benign and malignant colorectal disorders or colorectal abdominal cancers pooled with other gastrointestinal tract, urinary tract and gynaecological malignancies including palliative surgery. None of these trials included enhanced recovery after surgery (ERAS) programmes.  This study aimed to investigate the risk of symptomatic VTE in patients undergoing elective resection of colon cancer following an ERAS without prolonged VTE prophylaxis.

This was a retrospective analysis of patient who underwent surgery between 2008 and 2013. The median length of stay was 4 days. Of the 1893 patients included, 4 (0.2%) had a non-fatal symptomatic VTE. All 4 of these patients had other postoperative complications prior to the VTE. The rate of VTE found in this study is much lower that the overall 14% risk quoted after major abdominal or pelvic surgery.

It would appear that the risk of symptomatic VTEs is negligible in patients having colon cancer resection following an ERAS programme with an uncomplicated post-operative recovery. It may be that the early mobilisation in an ERAS programme may contribute to the lower risk. The findings of this study suggest that there is a possibility that prolonged VTE prophylaxis may not be cost-effective in these patients.

However, before any changes are made or guidelines rewritten – this is a retrospective study. It does raise questions but further randomised trials are needed to investigate this further.

Randomised feasibility trial of high-intensity training before elective abdominal aortic aneurysm repair. New GA, Batterham K, Colling J et al. British Journal of Surgery 2017 doi:10.1002/bjs.10669

Abdominal aortic aneurysms (AAAs) are usually asymptomatic until they rupture which then carries an overall mortality rate in excess of 80%. Elective surgery, either open or endovascular, is the most effective treatment for preventing AAA-related rupture and death. Open aneurysm repair in particular is associated with neuroendocrine, metabolic and inflammatory changes that lead to an increase in global tissue oxygen uptake of up to 50%. Patients who have a low cardiorespiratory fitness levels are less able to meet these extra demands which can lead to tissue hypoxia and life-threatening complications. A study published in 2010 found that up to half of the patients presenting for intra-abdominal surgery did not have the fitness levels to be deemed at low risk of perioperative complications as quantified by cardiopulmonary exercise testing.

It seems intuitive that improving cardiorespiratory fitness would lead to reduced complications rates after surgery. The clinical effectiveness and cost effectiveness of preoperative exercise testing has not yet been established. It is unclear whether meaningful improvements in cardiorespiratory fitness can be achieved for patients with a large AAA in the limited window available before surgery (usually 4-6 weeks). This study aimed to look at the feasibility and acceptability of high-intensity training (HIT) for preoperative optimisation of patients with a large AAA. Patients were either randomised to usual care or preoperative HIT consisting of three exercise sessions a week for four weeks.

The preoperative HIT seemed to be feasible and acceptable to patients although twenty of the twenty-seven exercise participants had to have their exercise aims adjusted due to triggering safety criteria (such as a systolic blood pressure over 180mmHg). This may have contributed to the fact that measured cardiorespiratory fitness did not change substantially at group level. However, the results seem to point to a beneficial effect of the exercise programme on health status and physical function for up to 12 weeks after hospital discharge.

This feasibility study points to the fact that preoperative exercise and improving cardiorespiratory fitness could be beneficial. Large, multicentre trials that explore clinical and cost effectiveness are needed before recommendations can be safely made about preoperative exercise programmes.

Echocardiography and passive leg raising in the postoperative period: A prospective observational study. El Hadouti Y, Valencia L, Becerra A et al. European Journal of Anaesthesiology 2017;34(11):748-754 doi:10.1097/EJA.0000000000000679 

Perioperative fluid management is a controversial and challenging issue. Both over hydration and conservative fluid therapy can lead to postoperative complications. The difficulty is that many patients have signs that could suggest hypovolaemia (such as oliguria, tachycardia and hypotension) but not all these patients will respond to fluid administration.

Passive leg raising has been demonstrated to simulate preload increase and distinguish fluid responders from non-responders. Studies validating passive leg raising have been carried out most frequently on non-surgical patients. In this study patients in whom low cardiac output was suspected in the immediate postoperative period were included. A baseline echocardiogram was done then repeated 90 seconds after the patients legs had been elevated by 45 degrees. The measurements were repeated after legs had been lowered and finally repeated again after 500mls of fluid administered as a bolus. An increase in cardiac output of greater than 11% after passive leg raising predicted a volume response following fluid with 68% sensitivity and 100% specificity.

This study had a very low sample size and a note is made of difficulty in carrying out the echocardiogram as left lateral decubitus position is best for the echocardiogram but passive leg raising in this position is not really possible. Despite the positive results the potential benefits or clinical uses of using echocardiography and passive leg raising to determine fluid responsiveness remain to be seen.

Acute kidney injury in trauma patients. Harris A, Libert N, Duranteau J. Current Opinion in Critical Care. 2017 doi:10.1097/MCC.0000000000000463 

Multiple organ failure is a later complication of severe trauma that substantially increases morbidity and mortality. Acute kidney injury (AKI) after trauma is associated with an independent association with prolonged hospital stay and mortality. Severe trauma is a time when several renal aggressions occur at the same time making it challenging to establish a strategy to prevent AKI. Factors such as haemorrhage, rhabdomyolysis, traumatic inflammation and renal hits due to emergency surgery or infections may cause acute renal disorders.

The incidence of severe AKI ranges from 9 to 23% and a total of 2 to 8% of trauma patient will require renal replacement therapy. The main risk factors for the development of AKI in trauma patients include haemorrhage, rhabdomyolysis, trauma inflammation, excessive fluid resuscitation and abdominal compartment syndrome.

Trauma care aims at stopping haemorrhage as soon as possible. The earlier this is achieved the better for tissue perfusion. Post traumatic vasoplegic shock can occur and in this situation attention should be paid to arterial pressure to try to optimise renal perfusion. Fluid resuscitation with balanced solute solutions seem to be the most beneficial for trauma patients with regards to AKI although there are no randomised controlled trials looking at this. What this paper makes clear is that AKI is a very real risk for trauma patients and once the initial trauma resuscitation has been carried out special attention should be paid to maintaining renal perfusion. Given the diverse nature of why patients develop AKI after trauma it is difficult to have one protocol to try to reduce the risk.

Sex differences in mortality after abdominal aortic aneurysm repair in the UK. Sidloff D, Saratzis M, Sweeting J et al.  British Journal of Surgery 2017;104(12):1656-1664 doi:10.1002/bjs.10600

Abdominal aortic aneurysm (AAA) screening has been shown to be effective in men both at reducing AAA-related mortality and in cost-effectiveness. Consequently there is now an established AAA screening programme for men over the age of 65 in England and Wales. The benefit of screening for women has not been established. However, one in seven elective AAA repairs are on women and women account for approximately one-third of all deaths from ruptured AAA. Furthermore women have a fourfold higher rupture rate than men at equivalent aortic diameters which suggests there is a strong case for intimating AAA screening in women. Perioperative risk is critical in determining the effectiveness of a screening programme and risk estimates are lacking for women having AAA repairs.

Data from the UK National Vascular Registry was analysed for a 4 year period from 2010 to 2014 with the primary outcome being in-hospital mortality. 13% of the patients included were women. Mortality rates were higher in women for both elective AAA repair (open or endovascular) and emergency repair. The excess mortality rate was found to be largely independent of age, aneurysm diameter and smoking status. It is not clear why this difference in mortality exists although the Canadian Society for Vascular Surgery Aneurysm Study Group identified that women are more likely to be older, have a positive family history of AAA and have significant aortoiliac occlusive disease.

A well designed trial of matched women and men undergoing elective AAA repair would be needed to explain the differences seen. The higher mortality rate in women may have an impact on the benefit offered by any AAA screening programme.

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