The use of goal-directed fluid therapy (GDT) in the management of patients undergoing major surgery is controversial. A randomized controlled study of 179 anaerobically ‘fit or unfit’ patients undergoing colorectal surgery, (Challand et al., pages 53–62) compared standard and GDT fluid management and found no advantage for GDT. In contrast, a study in 50 neonates and infants found transoesophageal Doppler was useful in predicting fluid responsiveness (Raux et al., pages 100–7). A study of the effects of propofol of the mechanisms involved in dilation of cerebral arterioles (Hama-Tomioka et al., pages 21–9) found that propofol has significant effects which may have clinical relevance. Cardiopulmonary exercise testing (CPET) is used to stratify risk preoperatively and to determine intraoperative fluid management strategy. Comparison of CPET and a 6-min walk test in 110 patients found reasonable correlation between the two methods (Sinclair et al., pages 30–5).

Paediatric anaesthesia

Several import aspects of paediatric anaesthesia are investigated in articles in this month’s BJA. Paediatric cardiomyopathy is considered in a review article (Ing et al., pages 4–12). This describes the incidence and types and proposes anaesthetic management strategies. Standard coagulation testing and the use of ROTEM^® were compared in paediatric surgical patients by Haas et al. (pages 36–41) who found that overall they did not correlate well but that further work was needed. Remote measurement of leak around an uncuffed tracheal tube was examined in a study which progressed from lab-based simulation through to evaluation in 135 infants in ICU (Sims et al., pages 152–8). A useful objective measurement was obtained. Finally, a case report describes the development, diagnosis and treatment of opioid-induced hyperalgesia in an infant who underwent multiple surgical procedures (Hallet and Chalkiadis, pages 116–18).

Research priorities in anaesthesia

Anaesthesia can find it difficult to compete at a national/international level for research funding, particularly in the current setting of limited public resources. This may, in part, come from the perception that it is essentially ‘safe’ and hence lower priority than other, higher profile, disciplines. There are, however, still many important clinical and basic science aspects in which research in anaesthesia can play a vital part. In the UK, this subject has been addressed by the National Institute of Academic Anaesthesia (NIAA), which commissioned a research priority setting exercise. The process and its findings are described in an article by Howell et al. (pages 42–52). While this was UK-based, its methodology and outcome have a wider international applicability. These aspects are discussed in an accompanying Editorial (Mahajan and Reilly, pages 1–3).

Organ Donation Supplement

I would like to draw all readers’ attention to the supplement on Organ Donation that accompanies this issue of the BJA. This collection of articles, which has been produced in collaboration with the UK Organ Donation Taskforce, covers the current scientific, clinical, legal, ethical and practical aspects of organ donation. Given the importance of a multidisciplinary approach to this important subject, I suggest that readers may wish to recommend this collection to their medical, nursing and non-medical colleagues.

The program of the ARS meeting is available here.

Learning from simulators

The use of simulators is established in the teaching of basic and advanced skills in anaesthesia. However, it is not clear how long taught skills are retained, particularly if the procedure is one that, although important, is only used occasionally in an emergency setting. The retention of simulator-based teaching of cricothyroidectomy was assessed in a group of 38 anaesthetists (Boet et al., pages 533–9). They found that, after a single training session, the skills were retained at one year. The findings of this study are put into context in an accompanying Editorial by Reader (pages 483–7) who goes on to explore the role of episodic memory in simulator-based learning. The author emphasizes how we must also increase our understanding of how we expect simulation to influence the learning and practice of anaesthetists.

Anaesthesia for cardiac surgery

The use of etomidate for induction of anaesthesia produces good haemodynamic stability but is associated with adrenal suppression. The haemodynamic consequences of using etomidate in cardiac surgery patients were explored in an RCT comparing induction of anaesthesia with etomidate or propofol in 100 patients (Morel et al., pages 503–9). While there was evidence of adrenal suppression in the etomidate group in the first 24 h, there was no difference between the groups in the norepinephrine requirements in the first 24 or 48 h postoperatively. The use of a Doppler-derived index of LV filling pressure (Ele’) as a prognostic indicator was examined in 500 patients undergoing OPCAB (Jun et al., pages 519–24). An Ele’ >15 and high diastolic filling pressures were associated with increased postoperative morbidity. The value of ‘point of care’ platelet aggregometry in the management of children undergoing open heart surgery was evaluated in 50 children with cyanotic or non-cyanotic congenital heart disease (Hofer et al., pages 587–92). They found that platelet aggregation did not correlate with blood loss.

Two articles in this month’s journal deal with different aspects of the anaesthetic management of Caesarean sections. The efficacy of using lower doses of bupivacaine for Caesarean sections is reviewed and analysed by Arzola and Wieczorek (pages 308–18). They conclude that lower doses are associated with fewer adverse effects but more interventions for additional peroperative analgesia. The use of intraoperative cell salvage in obstetric surgery has been hindered by concerns over fetal cell and amniotic fluid contamination. In a series of 70 patients (Ralph et al., pages 404–8) found a very low incidence of antibody formation and a median fetal cell contamination volume of <1 ml. Of interest to obstetric anaesthetists, there is also a laboratory based evaluation of 4-D ultrasound for epidural catheter insertion (Belavy et al., pages 438–45). The authors found both advantages and disadvantages for 4-D compared with 2-D ultrasound.

Critical care

Several aspects of the care of critically ill patients are addressed in this month’s issue. A prospective study of over 330 trauma patients (Tauber et al., pages378–87) concluded that ROTEM^® assays were useful in the diagnosis and treatment of trauma induced coagulopathy. A laboratory study of acute lung injury (Spieth et al., pages 388–97) compared an open lung approach with the ARDSnet one and found the former resulted in better oxygenation and perfusion. Fungal infections in ICU patients are a serious problem. An Editorial (Philips, pages 299–302) provides a timely review of current recommendations and practice. The use of NSAIDs following neurosurgical operations is controversial. An RCT of 100 patients given either paracoxib or placebo following craniotomy (Williams et al., pages 398–403) found no increase in adverse effects with paracoxib but also no additional analgesic benefit. The role of NSAIDs in intracranial surgery is discussed in an accompanying Editorial (Kelly et al., pages302–5).

Assessing academic performance

The academic performance of journals is assessed annually by the Impact Factor (IF) and the BJA team is pleased to note increase in the journal’s IF to 4.224. Assessment of the performance of an individual academic is often based on the number of publications and the IF of the journals they are published in. There have been several other methods proposed for the evaluation of an individual’s academic ‘worth’. Of these the h-index has gained the most currency. Two studies in this month’s journal assess the use of the h-index in UK academic department members (Moppett and Hardman, pages 351–6) and in Board members of international anaesthesia journals (Pagel and Hudetz, pages 357–61). Both studies are generally supportive of the index. The subject of academic assessment, including the h-index, is addressed in an accompanying Editorial (Webster, pages 306–7).

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Link here to the Editorial of this issue of BJA

Several aspects of thoracic anaesthesia are addressed in studies in this month’sBJA. The potential preventative action of magnesium in preventing post-thoracotomy cardiac arrhythmias was investigated in a prospective RCT of 200 patients (Saran et al., pages 785–91). They found that magnesium did not reduce the incidence other than in patients following pneumonectomy. The relationship of hypoxaemia during one lung anaesthesia to both ventilation and perfusion is explored in an Editorial from Ng and Swanevelder (pages 761–3). They identify elements of clinical care that may help to minimize this problem. A RCT comparing the use of a bronchial blocker or double-lumen tube for single lung ventilation (Ruetzler et al., pages 896–902) found similar surgical conditions, although the blocker took longer to place. While not specifically thoracic anaesthesia, the risk of tracheomalacia producing airway problems is a feared complication following thyroidectomy. Analysis of over 300 cases, 62 of whom had CT evidence of tracheal compression (Findlay et al., pages 903–6), found no cases with tracheomalacia and no postoperative airway problems.

Recovery from anaesthesia

A number of previous studies have shown that women have a faster recovery from anaesthesia than men. A multicentre prospective study of 500 matched patients (Buchanan et al., pages 832–9), confirmed a quicker immediate recovery (awakening) but found poorer overall recovery with higher pain scores, more PONV and longer recovery room stay. Impaired cognitive dysfunction following cardiac surgery is a recognized complication. In a randomized comparison of sevoflurane- or propofol-based anaesthesia, Schoen et al. (pages 840–50) measured the effect of any episodes of cerebral desaturation. They found that episodes of desaturation were associated with poorer cognitive performance postoperatively and that those receiving sevoflurane had a better short term performance in cognitive function testing.

Responses to a critical incident

Two studies in this month’s issue look at aspects of anaesthetists’ management of critical situation during anaesthesia. Burtscher et al. (pages 801–6) used a simulator setting to study the coordination of the response by a two person anaesthesia team to a critical incident. Better coordination resulted in better performance. The use of eye-tracking as a measure of visual attention in a simulator-based critical incident (Schulz et al., pages 807–13) found that more experienced anaesthetists directed more attention to manual tasks and less to monitors during critical incidents than less experienced trainees.