Welsh Anaesthetic Trainees Journal Club



Cardiac arrest related to anaesthesia. How common is it? What are the risk factors?

Incidence and risk factors of anaesthetic-related perioperative cardiac arrest. European Journal of Anaesthesiology 2017;34:1–7 doi:10.1097/EJA.0000000000000685

 Presented by: Dr R Dean-Paccagnella


  • Many studies have analysed perioperative mortality in speciality sub-groups, but few have looked at unselected patient populations. Many studies have excluded patients undergoing cardiac surgery.
  • Previous papers have studied perioperative mortality but have not independently reviewed the incidence and risk factors of cardiac arrest.
  • This study aims to measure the incidence of perioperative cardiac arrest in an unselected anaesthetic population and retrospectively identify significant risk factors.

Design & Setting

  • Retrospective cohort study of non-ITU patients undergoing anaesthesia between January 2007 and December 2012 at a single tertiary hospital in Cologne, Germany.


  • 169,000 adult and paediatric patients underwent anaesthetic procedures within the time period.
  • Study population (n 318) was identified by the screening of critical incident report forms, performed by the authors.
  • Cases were categorised into 1. “anaesthesia related” (directly caused by an anaesthetic procedure), 2. “anaesthesia contributory” (caused by both surgical and anaesthetic events) or 3. “anaesthesia contributory” (possibly caused by factors under the control of the anaesthetist).


  • Undifferentiated anaesthetic procedures were analysed retrospectively.


  • Incidence of pulselessness requiring chest compressions within 24hours after anaesthetic procedure.


  • Incidence of perioperative cardiac arrest was 5.8/10,000 anaesthetic cases (95% CI 4.7-7.0).
  • Significantly increased risk of perioperative cardiac arrest was associated with ASA grade or 3 or more, revised cardiac risk index of 3 or more, NYHA or 3 or more, out of hours procedures, emergency surgery and pre-existing cardiomyopathy.
  • Multi-variate logistic regression identified 3 predictors of perioperative cardiac arrest. ASA grade of ≥3 (OR 2.59, p=0.007, 95% CI 1.29 to 5.19), emergency surgery (OR 4.00, p=0.001, 95% CI 2.15 to 7.54) and pre-existing cardiomyopathy (OR 17.48, p= <0.001, 95% CI 6.18 to 51.51).
  • Age over 75 years or less than 3 years, Gender, BMI ≥30 kg m3 , and patients with known difficult airways were not identified to be at significantly altered risk of perioperative cardiac arrest.


  • Patients with an ASA physical status grade of ≥3, undergoing emergency surgery or with pre-existing cardiomyopathy appear to be at an increased risk of perioperative cardiac arrest in this single centre European university hospital population.
  • Incidence of paediatric cardiac arrest directly caused by anaesthesia was high (5 of 12 cardiac arrests directly related to anaesthetic procedure).


  • Clinically relevant question addressing entire anaesthetic population.
  • Findings are in-line with previous papers addressing ASA grade and risk of anaesthesia related cardiac arrest.


  • Risk factors were identified retrospectively by reviewers. NYHA classification appears to have been categorised retrospectively by investigators.
  • Strength of relationship between anaesthetic procedure and cardiac arrest categorised by authors (although independently).
  • Single centre European study which may not provide generalisable results.
  • Main outcome measure is an infrequent event, and as such small variation in number of events will greatly influence the frequency reported.


  • ASA grading, urgency of surgery and pre-operative identification of cardiomyopathy may help identify high risk cases.
  • Further studies of peri-operative cardiac arrest would be improved by establishing a consensus for the definition of anaesthesia-related and anaesthesia-contributory cardiac arrests.
  • Incidence of anaesthesia-related cardiac arrest appears to remain relatively high in the paediatric population.

Potential for impact

  • If felt to be generalisable, ASA grade ≥3, emergency surgery and cardiomyopathy may indicate patients at significantly increased risk of perioperative cardiac arrest, although this remains an infrequent event.



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.


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.

SORT: A new tool to predict postoperative morbidity.

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.



July 2017

Written by: Dr C. Williams

A national survey of the effects of fatigue on trainees in anaesthesia in the UK.  McClelland L, Holland J, Lomas J-P, Redfern N, Plunkett E. Anaesthesia 2017 doi:10.1111/anae.13965

This article publishes the results of a survey carried out by two Welsh trainees looking at the impact of fatigue reported by anaesthetic trainees. With news headlines of junior doctors dying following crashes while driving after night shifts and recent BBC Inside Out South coverage of a junior doctor’s driving ability after a night shift* this is an important topic to look at. Since the introduction of the European Working Time Directive in 2009 the working patterns of junior doctors have changed with far more shift work and often rotas that change from days to nights and back again very quickly. Also with training arranged in the way it is now, many trainees may move hospital every 6 months to 1 year, sometimes over large geographical areas.  Maybe this issue has always been the case, maybe we are more aware due to increased knowledge, understanding and recognition of the effects of fatigue but what is clear is that it is not something that can be ignored. The results of this survey highlight some worrying figures. High numbers of trainees say that fatigue has affected their physical health, psychological wellbeing, personal relationships and ability to train including exams, audits/QI projects. A high proportion reported being involved in an accident or near miss when travelling home after a night shift. This has implications both to the safety of the trainee and to the public.

This survey has highlighted this important issue. It has been a contributing factor in the establishment of a ‘fatigue group’ in association with the AAGBI, GAT and the RCoA. There have been efforts made by some trusts to highlight the risks of fatigue and provide strategies and advice to help junior doctors. Of course, fatigue is not something that only affects doctors or even just healthcare professionals but anyone who works shifts particularly night shifts. Although this survey only concentrates on one set of junior doctors, it would seem sensible that strategies that work for trainee anaesthetists to cope with fatigue may be generalizable to other groups of people affects by this issue. Hopefully highlighting the problem of fatigue and supporting doctors, managers and trusts on how to tackle this issue will make things safer for doctors, and ultimately our patients and the public.


Prehabilitation in perioperative care. Moorthy K, Wynter-Blyth V. British Journal of Surgery 2017;104(7):802-803. doi:10.1002/bjs.10516

This is article looking at prehabilitation and the role it plays in patients with upper gastrointestinal cancer. It is a well known fact now that there are greater demands placed on surgical systems with the patient population undergoing major abdominal surgery becoming older and increasingly frail with multiple co-morbidities. This is coupled with organizational issues such as a drive for earlier postoperative discharge and with surgeons facing increased scrutiny of their work and complication rates in response to governmental and public demands for greater transparency. High-risk patients are undoubtedly at greater risk of adverse postoperative events and a longer recovery time. The article talks about enhanced recovery programmes which are well established in many surgical specialties and have led to post operative outcome improvements. However, they mainly focus on the intraoperative and postoperative phases of the patient journey. The concept of prehabilitation is based on the principle that amongst other things, structured exercise in the preoperative period will provide the patient with a ‘physiological buffer’ to withstand the stress of surgery. Although preoperative exercise is associated with improved preoperative functional capacity there is currently limited evidence to show that it improves postoperative outcomes. There are several clinical trials in progress that aim to address this evidence gap. Importantly, prehabilitation must be about more than just exercise. Addressing all the other factors that contribute to outcome such as body weight, nutrition, alcohol, smoking and the critical but often forgotten psychological aspect. The preoperative period is an ideal opportunity to make the most of a ‘teachable moment’ and emphasise the importance of making positive lifestyle changes. This is an exciting area that is being explored. The publication of new clinical trials should provide some answers. Future research is needed possibly looking at cost-effectiveness and how prehabilitation can be linked to enhanced recovery pathways. Ultimately the aim is a better outcome for the patient.

Claims for compensation after injuries relating to airway management: a nationwide study covering 15 years. Fornebo I, Simonsen KA, Bukholm IRK, Kongsgaard UE. Acta Anaesthesiologic Scandinavica 2017 doi:10.1111/aas.12914

One of the anaesthetist’s ‘raison d’être’ is to manage the airway by whichever method they chose for the given situation – facemask, oral or nasal airway, a supraglottic device or an endotracheal tube. However, no method is risk free and all may cause complications ranging dental damage, soft tissue trauma through to catastrophic complications due to failure to secure the airway. A subset of patients have specific characteristics that may mean we can predict a likely difficult airway. Equally there are patients who have none of these characteristics yet are found to have a difficult airway at induction of anaesthesia.

Although not common, disastrous outcomes with failed or difficult tracheal intubation are well known to anaesthetists. An integral part of our training is the learning strategies to manage both the anticipated and unanticipated difficult airway.

This study looked at compensation claims relating to airway management over a 15-year period in Norway. 0.8% of claims relating to anaesthesia involved airway management. 38% of claims related to dental injuries. Severe injuries were defined as failed intubation, misplaced endotracheal tube, aspiration or a ‘miscellaneous’ group. They accounted for 10% of all the claims but made up 37% of claims relating to emergency procedures. Interestingly all claims made from patients needing airway management in a pre-hospital setting and 87% of the claims from ICU were rejected. This may reflect the situation in which airway management is considered a life-saving procedure.

Although the results of this study are specific to Norway it serves to highlight that airway management can result in complications and we should continue to be vigilant particularly in emergency cases.

Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicenter, double-blind, randomized clinical trial. Avidan MS, Maybrier HR, Abdallah AB, Jacobsohn E et al. The Lancet. 2017;390(10091):267-275 doi:10.1016/S0140-6736(17)31467-8

In patients over the age of 60 delirium is one of the most common complications and is associated with increased morbidity and mortality. It has many causes and the pathophysiology is not completely understood which makes it difficult to predict and treat. In surgical patients risk factors are likely to be pain, treatment with opioids and the inflammatory response to injury. In theory a drug that provides analgesia and prevents delirium would be an important advance in perioperative medicine. A postoperative infusion of dexmedetomidine has shown promise although further studies are recommended. However, this drug is expensive and requires a continuous intravenous infusion therefore is unlikely to be a practical solution.

It has been reported that intraoperative subanaesthetic ketamine administration reduces postoperative pain, reduces postoperative opioid requirement and reduces the postoperative markers of inflammation. Based on this the study authors hypothesise that intraoperative ketamine may reduce the incidence of postoperative delirium. But ketamine is also well known to be a psychoactive drug with hallucinogenic properties so could theoretically contribute to postoperative delirium.

This multicentre study randomly allocated patients to one of three groups – placebo (to receive normal saline), low dose ketamine (0.5mg/kg) or high dose ketamine (1mg/kg) to be given after induction of general anaesthesia but before surgical incision. They found that there was no difference in the incidence of delirium in any of the groups and there were more postoperative hallucinations and nightmares with increasing doses of ketamine.

In conclusion, ketamine does not reduce postoperative delirium and may actually increase harm by increasing the incidence of hallucinations and nightmares. Ketamine use has increased particularly with the introduction of enhanced recovery programmes – maybe the time has come for some further studies regarding its use in elderly patients.

Falls from the O.R. or procedure table. Prielipp RC, Weinkauf JL, Esser TM, Thomas BJ, Warner MA. Anesthesia & Analgesia 2017. doi:10.1213/ANE.0000000000002125 

Patients falling from the operating table is a scenario that thankfully most anaesthetists will not encounter. I know of one event that happened in a neighbouring theatre when I had just started my anaesthetic training. The patient was unharmed and that was the last I heard about it. The American Society of Anesthesiologists highlights that anaesthesia is the practice of medicine with one of its primary foci being ‘management and preservation of patient safety’. A patient falling from the operating table is a clear breakdown of this responsibility and can have medical, professional, legal and financial consequences.

This study looked at claims recorded in the Anaesthesia Closed Claims Project database looking for claims associated with falling from the year 2000 to now. There were 21 claims identified – 15 in patient having general anaesthsia and 4 in those receiving regional anaesthesia. Approximately half of the claims resulted in payouts to the patients ranging from $18,000 to $925,000. Patient falls from the operating table must be considered preventable adverse events. Injuries from falls such as these can be catastrophic including brain damage, paralysis and even death.

This paper talks very much about the anaesthetists duty and role in preventing falls. The reality is that it should preventing falls should be shared responsibility for every member of the team. Many of the falls occurred when patients were partially sedated or awakening from general anaesthesia and potentially confused or agitated. From experience this is the time at which other staff may be distracted and concentrating on other tasks. The entire operating theatre team need to be proactive in maintaining patient safety at all times.


Perioperative COX-2 inhibitors may increase the risk of post-operative acute kidney injury. Abrahamsson A, Oras J, Snygg J, Block L. Acta Anaesthesiologica Scandinavica 2017;61(7):714-721 doi:10.1111/aas.12912

This was a study looking at patients who had undergone pancreaticoduodenectomy. In 2012, enhanced recovery after surgery (ERAS) guidelines were published for these patients recommending a restrictive fluid regimen to avoid the fluid overload that has been shown to be hazardous for these patients. Acute kidney injury (AKI) is not uncommon after major abdominal surgery and is known to be a major cause of postoperative morbidity and mortality. Perioperative hypotension and hypovolaemia are known to contribute to AKI.

Anaesthetists in Gothenburg, Sweden made the observation that patients undergoing open pancreatic surgery with an ERAS restrictive fluid protocol were more likely to develop postoperative AKI and spend longer on ICU. Consequently, they reviewed the notes of patients who underwent pancreatic surgery prior to the introduction of the ERAS fluid protocol and compared this to patients who underwent surgery after the introduction of the ERAS fluid protocol. They found that the incidence of AKI was significantly higher in the patients who underwent surgery using the ERAS restrictive fluid protocol (13% vs 2% in the pre-ERAS patient group). They also found that COX-2 inhibitors were given more frequently to patients in the ERAS group.

They concluded that the combination of a goal-directed restrictive fluid therapy with the administration of COX-2 inhibitors significantly increases the risk of AKI.

Postoperative respiratory complications in patients at risk for obstructive sleep apnea: a single-institution cohort study. Ramachandran SK, Pandit J, Devine S, Thompson A, Shanks A. Anesthesia & Analgesia 2017;125(1):272-279 doi:10.1213/ANE.0000000000002132 

Obstructive sleep apnoea (OSA) is not an uncommon condition and is thought to affect up to 25% of middle-aged men and up to 10% of middle-aged women. It has a significant impact on quality of life, life expectancy, cardiovascular disease and respiratory disease. Recent evidence also suggest that it is associated with a 3 to 6 times increase in post-operative respiratory complications. The majority of patients with OSA remain undiagnosed and preoperative screening remains the most efficient method to identify those at risk.

This retrospective observational study looked back over the notes of 108,479 patients and assigned OSA risk retrospectively using the Perioperative Sleep Apnea Predictive (PSAP) score*. They found that a high PSAP score was associated with a higher incidence of postoperative respiratory complications and an increased need for postoperative intubation. Other factors that were associated with postoperative respiratory complications include the anaesthetic agent used, neuromuscular blocking agents and opioid use.

Patients with suspected OSA should be identified, assessed and commenced on appropriate treatment preoperatively where possible. They may also require a modification of the anaesthetic technique used to try to minimize the risk of postoperative respiratory complications (PRCs) and a recognition that they are at higher risk of developing PRCs.

*Ramachandran SK, Kheterpal S, Consens F et al. Derivation and validation of a simple perioperative sleep apnea prediction score. Anesth Analg. 2010;110:1007-1015

Body height and the spread of spinal anaesthesia for caesarean section: a prospective controlled trial. Acta Anaesthesiologica Scandinavica 2017;61(7):824-831 doi:10.1111/aas.12928

Spinal anaesthesia is the preferred anaesthetic technique for caesarean sections. However, as this article rightly points out there is a considerable variability in the dose regimens used. As a trainee one only has to ask several different consultants to realise that each one has a preferred dose for the ‘best’ spinal anaesthetic! The aim is a dose of intrathecal bupivacaine that maintains anaesthesia but minimizes the risk of maternal hypotension. Several patient variables are usually factored into predicting the spread of spinal anaesthesia including age, height, weight and body mass index. The time required to achieve an adequate sensory block for surgery tends to increase linearly with height and decrease with increasing weight.

This study hypothesized that shorter patients need a lower spinal anaesthesia dose than taller patients. 270 pregnant women were assigned to either the tall (T) group or shorter (S) group. Both groups were then randomly assigned to one of nine subgroups of intrathecal ropivacaine dose (between 7-15mg). They found that height did not significantly affect the height of the block achieved with the different doses. However, larger ropivacaine doses were associated with increased hypotension which was more pronounced in shorter patients.

This was a small study and maybe separating patients on height alone is too simplistic to answer the question. Ultimately, the answer as to the best dose of local anaesthetic for spinal anaesthesia remains to be discovered.

Can lung recruitment predict need for fluid?

Changes in stroke volume induced by lung recruitment maneuvr predict fluid responsiveness in mechanically ventilated patients in the operating room

Anesthesiology 2017;126:260-7

Presented by: Dr C Williams


  • Haemodynamic optimisation in the perioperative period can reduce morbidity and mortality
  • Stroke volume (SV) and SV variation/pulse pressure (PP) and PP variation can be used as objective measures of fluid responsiveness.
  • Reliability of SVV and PVV limited in patient receiving low tidal volume ventilation (Vt <8ml/kg predicted body weight)
  • Lung protective ventilation is standard of care for ARDS patients. Also demonstrated to be beneficial in patients undergoing surgery.
  • Lung recruitment manoeuvres (LRMs) are a key component of lung-protective ventilation strategies but as they increase intrathoracic pressure, lead to a decrease in venous return with a subsequent decrease in SV.
  • Authors hypothesised that degree of decrease in SV during LRM could represent a functional test to predict fluid responsiveness.

Design & setting

  • Single centre study
  • No data on the centre – type of hospital etc.
  • Nonconsecutive case series – low quality evidence


  • Over 1 year twenty-eight mechanically ventilated patients studied
  • Patients ventilated with low tidal volumes (6-8ml/kg) & PEEP 5
  • All patients needed radial arterial cannula and cardiac output monitoring – unclear if this was standard for surgery or extra for study

Inclusion criteria:

  1. >18 years old
  2. Having neurosurgery

Exclusion criteria extensive:

  1. <18 years old
  2. Intracranial hypertension
  3. Co-morbidities that may affect dynamic waveform indices: arrhythmia, lung disease, EF <50%, possible RV dysfunction, sleep apnoea, COPD, pulmonary hypertension
  4. Extremes of body habitus (BMI <15 or >40)


  • Lung recruitment manoeuvre (LRM) by applying continuous positive airway pressure of 30 cmH2O for 30 seconds
  • Volume expansion with 250 ml 0.9% saline over more than 10 minutes
  • Heart rate/MAP/SA/PPV measured before and after both LRM and volume expansion


Unclear exactly what the primary outcomes were. Aims of the study were:

  1. Assess ability of LRM induced decrease in SV to predict fluid responsiveness in mechanically ventilated patients in theatre
  2. Compare the ability of the LRM induced decrease in SV and PPV to predict fluid responsiveness
  3. Assess the relationship between LRM induced SV decrease and SV changes induced by volume expansion


  • Sixteen (out of 28) patients were classified as responders (i.e. SV index increased by >10% after 250ml of fluid)
  • LRM induced a significant decrease (p = 0.001) in MAP and SV in ALL patients
  • Volume expansion caused a significant increase in SV (p = 0.001) in ALL patients
  • The bigger the drop in SV with LRM, the bigger the change in SV after fluid expansion.
  • Drop in SV with LRM was more sensitive and more specific at predicting fluid responsiveness than the change in PPV with LRM
  • Fluid responsive patients had a bigger PPV


  1. A 30% decrease in SV during an LRM could predict the effect of infusing 250ml of fluid
  2. The SV change seen during LRM was a better indicator than PPV to predict fluid responsiveness
  3. The SV change during LRM and the SV change during volume expansion were strongly correlated (i.e. the bigger the SV drop with LRM the bigger the SV increase with fluid)


Authors recognise limitations of the study


Study Design

  • Nonconsecutive case series – definition of nonconsecutive case series is a clinical study that includes some but not all eligible patients identified during the research period. Why were not all eligible patients included? No comment made on this.
  • Low sample size – 28 patients over 1 year period
  • Unclear what primary outcomes were

Patient Group

  • Neurosurgery patients?? Unsure if these are the most appropriate group of patients to carry this study out on! Why would you deliberately chose to carry out a manoeuvre that could alter intracranial pressure and drop blood pressure in this group of patients?
  • Patient characteristics not split into responders vs non-responders – same types of patients in each group?
  • 18 of the 28 patients were ASA III. Large numbers of comorbidities excluded therefore what made them ASA III?
  • Co-morbidities excluded therefore cannot extrapolate results for patient with any kind of arrhythmia, preoperative lung disease or COPD, EF <50%, possible RV dysfunction, sleep apnoea, pulmonary hypertension, extremes of body habitus (BMI <15 or >40) or patients requiring vasopressors/inotropes

Data collection

  • LRM performed in the supine position during steady-state period and before skin incision – results cannot be extrapolated to positions other than supine or after knife-to-skin
  • LRM performed shortly after induction of anaesthesia – haemodynamic effects may have been impacted by degree of vasoplegia due to anaesthetic drugs
  • LRM consisted of applying continuous positive airway pressure of 30 cmH2O for 30 seconds – study authors say results cannot be extrapolated for other LRMs. Is this an adequate LRM? ARDS studies talk about LRM of 2 minutes – would 30 seconds be an adequate time in a clinical situation and how often would it need to be done?
  • Change in SV was estimated using pulse contour analysis technology – accuracy in measuring exact SV disputable. Better for measuring trends over time than SV at a given point


More objective evidence is needed from a much larger and better designed study to be able to answer this clinical question. Flawed and poorly designed study with many limitations (admitted by the authors). A decrease in SV during LRM may indicate the need for volume expansion but realistically to be clinically effective how often would LRM need to be carried out? Therefore few clinical implications of this study.

Potential for impact

Whist no conclusive evidence is presented in this paper it does highlight that LRMs cause a decrease in SV which can be greater if the patient is hypovolaemic.

This is a good reminder to us all that care should be taken when performing LRMs in patients with cardiac dysfunction or those that are inadequately fluid resuscitated.

January 2017

Written by Dr C. Williams

A systematic review of the analgesic efficacy of cannabinoid medications in the management of acute pain. Acta Anaesthesiologica Scandinavica 2017 doi:10.1111/aas.12851

It is becoming increasingly common to find reports or see patients who are convinced that cannabis or cannabinoid medication help with their acute pain. Recently I have spoken to several elderly patients who like to ‘smoke a joint’ every night because it helps with various aches and pains. This systematic review aimed to assess the analgesic efficacy and adverse effects of cannabinoids when used for acute pain. It looked at 7 studies. 5 studies found cannabinoids worked as well as a placebo, 1 study found them to be superior and 1 found them to be inferior.

Sadly for these patients convinced that cannabis is the answer to their pain, this systematic review concluded that cannabinoids were no better than a placebo either by themselves or combined with opioids and 5 of the studies found that adverse effects were more common than with placebo.

Calling the patient’s own name facilitates recovery from general anaesthesia: a randomised double-blind trial. Anaesthesia 2017;72:197-203

‘The cocktail party effect’ describes the effect where one can tune into one voice even in a noisy room, and also how one can immediately detect words of importance such as hearing one’s name in another conversation.

The authors of this study found that after discontinuing the anaesthetic, calling the patient by their name meant that they opened their eyes quicker and the time to i-gel removal was faster. A BIS of 60 was reached in a shorter time and patients spent less time in the post anaesthetic care unit. There are limitations to the study but either way using the patient’s name is an easy method to aid recovery.

But surely out of respect for the patient should we not be doing this anyway?

Editorial: Real-time physiologic monitoring and physician feedback: Are we ready? Canadian Journal of Anaesthesiology 2017;64:239-241

Individual and group data feedback was given to anaesthetists regarding their management of intraoperative temperature monitoring, firstly the percentage of time the patient was hypothermic and secondly the time taken from the start of the case to the first temperature measurement. Giving feedback didn’t change the amount of time the patient was hypothermic however it did reduce the delay in starting to monitor temperature.

The concept of physician feedback as a QI tool is becoming increasingly popular. The authors reason that the reduction shown in the time taken to start temperature monitoring is evidence that providing feedback may contribute to improved perioperative outcomes.

Or is it possible that giving feedback results in the Hawthorne effect – the knowledge of being measured changes behaviour? Does it matter if the goal is to modify current practice? Individualised and group feedback means we need to accept our imperfections to drive improvement. Hospitals will continue to use QI strategies to improve patient care and reduce costs.

As clinicians we need to accept feedback and undergo a cultural shift from ‘shame and blame’ to high-quality continuous improvement focusing on providing the best care for the patient.

Impact of a perioperative quality improvement programme on postoperative pulmonary complications. Anaesthesia 2017;72:317-327

Postoperative pulmonary complications are

  1. common (incidence of between 2-40%)
  2. associated with adverse outcomes (death/increased length of stay/survival)

Enhanced recovery programmes don’t really address this. A team in Manchester developed an ERAS+ programme aimed at reducing pulmonary complications. It incorporated ICOUGH and surgery school (with videos via youtube). In patients undergoing major surgery admitted to critical care postoperatively, pulmonary complications reduced from 19.3% to 10.5% post implementation of ERAS+. One year after ERAS+ was introduced pulmonary complication rate was 8.7%. Patient surveys showed satisfaction with the surgery school. From the data presented it appeared a relatively low-cost programme to set up. Is the new type of peri-operative pathway involving the patients and their families working with multi-professional healthcare teams where we should be heading? On first glance it seems low-cost, effective and well received by patients………

Surgery School focused on:
Oral health
Psychological support
General health
Family support


I incentive spirometry
C cough/deep breathing
O oral care
U understanding patient education
G get out of bed
H head of bed elevation


Implantation of an Artificial Larynx after Total Laryngectomy. New England Journal of Medicine 2017;376:97-98 doi:10.1056/NEJMc1611966

Total laryngectomy is a lifesaving operation in patients with advanced laryngeal and hypo laryngeal cancer. But it comes with a substantial reduction in the quality of life.  This is a case report of a patient from France who had an artificial larynx implanted in 2015. The artificial larynx consists of a permanent tracheal prothesis with a removable open-ventilation cap that allows continuous passage of air while protecting the patient’s airway from aspiration. This cap allows the patient to breathe and drink fluids. It also opens transiently with coughing to allow secretion expulsion. Over a 16 month follow-up period the patient was able to breathe and expectorate through the upper airways and maintain oxygen saturations on air. He was able to swallow saliva although occasionally aspirated food.

A very short case report and clearly more work may be needed before this becomes a common place procedure but could this be the future for patients needing total laryngectomy?

Anaesthesia and Developing Brains – Implications of the FDA warning. New England Journal of Medicine 2017 doi:10.1056/NEJMp1700196

For a long time there has been a lot of debate about the neurotoxic effects of anaesthetic agents on the neurodevelopment of young children and foetuses. In 2014 an FDA Science Board meeting found that all anaesthetic agents have ‘immediate neuroanatomical consequences and are associated with long-lasting, if not permanent functional effects’.

Clinically this is a little more difficult to interpret. Healthy children rarely undergo repeated or long procedures under general anaesthetic. Brains of premature or children with congenital heart disease may have already been injured by inflammation or chronic hypoxia before having general anaesthetic. More recent studies have shown that a brief single exposure to general anaesthesia is not associated with poorer neurodevelopment outcomes. More results are expected later this year with the conclusion of the Mayo Anesthesia Safety in Kids (MASK) study.

Yet in December 2016 the FDA issued a ‘Drug Safety Communication’ warning that repeated or prolonged (>3 hours) anaesthesia in children under 3 years old and in women in their third trimester may affect the development of children’s brains. Rarely can procedures be safely delayed if indicated during these periods of life. Is the FDA warning wise?

This will already be a time of high stress for parents and families, and there is a risk that the FDA warning may cause delay in procedures that are needed. Parents, patients and doctors must be careful when considering the risk of delaying procedures due to this warning, especially given it states that ‘additional high quality research is needed’. We must be prepared for this question to be asked given that this was covered in the mainstream media and tabloids at the time………

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