BJA

In the May 2012 BJA …

LuluStader — Tue, 08 May 2012 13:21:02 +0000

Airway complications in the critically ill

The recent NAP4 publications drew attention to the incidence and outcomes relating to airway problems in the critically ill. A study in this month’s issue gathered data on all critical care tracheal intubations over a 4-month period in Scotland (Simpson et al., pages 792–9). A high success rate and few complications were recorded in nearly 800 patients. A different aspect is assessed in a survey from Australia and New Zealand, which collated the strategies for reducing airway complications that are in place in 176 ICUs (Husain et al., pages 800–6). Several problems in provision are highlighted. A study of19 postoperative patients found only a small ventilatory response to hypercapnia and hypoxia on discharge from HDU and this was unchanged 6 weeks later (Nieuwenhuijs et al., pages 864–71). A different aspect is addressed in an animal study of two lung assist devices (arterio-venous and veno-venous) in an acute lung injury model (Kopp et al., pages 745–53). Both appear to have potential.

Perioperative cardiovascular complications

Several aspects of cardiovascular complications that may arise in the perioperative period are addressed in this issue. Chondrogiannis et al. (pages 730–44) provide a comprehensive review of the management of hereditary arrhythmogenic syndromes. The role of aprotonin and blood transfusion in acute kidney injury (AKI) is explored in a retrospective analysis of 948 children having cardiac surgery (Bojan et al., pages 830–7). They found that blood transfusion but not aprotinin was associated with the development of AKI. A retrospective analysis of 173 patients undergoing intestinal transplantation found that over 80% had central venous thrombosis/stenosis requiring alternative venous access (Matsusaki et al., pages 776–83). This did not appear to affect outcome. In an animal study (Li et al., pages 857–63), the addition of epinephrine to lipid rescue after bupivacaine overdose improved the haemodynamic profile but not the hypoxaemia and acidosis.

Pharmacokinetics of analgesic drugs

Knowledge of the pharmacokinetic profile of drugs is essential in anaesthesia as is an awareness that this can be altered in some patient groups and clinical settings. A study of paracetamol kinetics in 33 children aged 1.8–15 yr (Mohammed et al., pages 823–9) found that body weight rather than age was the significant covariate. Nefopam has been used to improve tolerance of induced hypothermia but hypothermia could alter the pharmacokinetics of the drug. A study in volunteers describes a kinetic profile that can be used to maintain appropriate concentrations during hypothermia (Podranski et al., pages 784–91).

In the March 2012 BJA …

LuluStader — Tue, 28 Feb 2012 11:38:39 +0000

Postoperative nausea and vomiting

PONV is a major postoperative problem. The use of a new agent, palonosetron, is compared with ondansetron in a prospective randomized study (Moon et al., pages 417–22) and appears to be more effective. The potential role of this long acting drug in PONV and opioid induced vomiting is discussed in an accompanying Editorial (Apfel and Jukar-Rao, pages 371–3). The use of an impact scale to identify clinically important PONV is described by Myles and Wengritzky (pages 423–9). This scale may have a role in quality assessment and outcome measurement. The role of metoclopramide for PONV associated with Caesarean section is the subject of a systematic review (Mishriky and Habib, pages 374–83). Metoclopramide appears to be effective in this setting but further studies are required.

Fluid management

There is considerable interest in the use of dynamic indicators of cardiovascular function to predict fluid responsiveness in clinical settings. The use of several dynamic indices is evaluated in a group of cardiac surgery patients (Lansdorp et al., pages 395–401). The authors found that these were only reliable under specific conditions. This subject is expanded on in an accompanying Editorial (Michard and Biais, pages 369–71). The role of the classic Starling model in the setting of fluid resuscitation is challenged in a review developing the glycocalyx model (Woodcock and Woodcock, pages 384–94) that appears to better explain the responses. The use of transpulmonary ultrasound dilution to measure cardiac output in the presence of shunt is explored in an animal model (Vrancken et al., pages 409–16) and may have application in neonates.

Cancer outcomes

The effect of anaesthesia on long-term outcome in cancer patients is topical and the BJA has featured several articles on this subject in recent months. However, two other important aspects of this are addressed in articles in this month’s issue. Haematological malignancies are often regarded as having a poor prognosis if ICU admission is required. A review of nearly 200 patients admitted over a 5-year period to a specialist ICU (Bird et al., pages 452–9) showed a lower mortality. The need for mechanical ventilation and ≥2 organ failure was associated with higher mortality. The role of specialized preoperative assessment on perioperative care and outcome was investigated in over 300 patients having colorectal cancer surgery (Carlisle et al., pages 430–5). The findings suggest this approach may be beneficial.

I would also like to draw the readers’ attention to the set of 29 abstracts (pages 537–55P) from the first joint meeting of the Anaesthetic Research Society with the Chinese Society of Anaesthesiology that was held in Shandong, China in September 2011.

In the January 2012 BJA …

LuluStader — Wed, 28 Dec 2011 13:51:48 +0000

Fluid responsiveness

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 2011 BJA/PGA supplement: a selection of nine educational reviews

LuluStader — Fri, 09 Dec 2011 16:08:37 +0000

Click here for the table of content and to access the papers online

In the December 2011 BJA …

LuluStader — Fri, 25 Nov 2011 13:01:34 +0000

Genetics and patient outcome

The role of genetic variation in disease processes is established but there is increasing interest in the effect of genetic factors on patient responses and outcome. Frey and colleagues (pages 869–78) have explored the genetic interactions between the β-adrenergic receptor and one of its signalling proteins on mortality following cardiac surgery. The found that specific haplotypes appear to carry a higher mortality. The findings of this study are put into context in an excellent Editorial (Schwinn, pages 839–41). The Editorial also provides an overview of translational research, that is, translating initial laboratory-based genetic studies across to clinical studies. There is a further example of this in this month’s issue (Ecimovic et al., pages 916–23), where the known effect of morphine on cancer cell migration was explored and NET1 gene expression was shown to mediate the effect of morphine.

Anticoagulants in the perioperative period

An increasing number of patients are on maintenance antiplatelet therapy and their perioperative management is controversial. A number of studies in this month’s BJA address key aspects of the perioperative management of these patients. Benzon and colleagues (pages 966–71) studied a small group of patients taking clopidogrel and assessed the recovery of platelet function 3, 5 and 7 days after stopping clopidogrel. All had <30% platelet inhibition after 5 days. The findings of this interesting study are discussed in an accompanying Editorial (Tanaka and Dietrich, pages 841–3) that welcomes the data and puts it into context. The effect of stopping or continuing aspirin in the perioperative period on bleeding and thrombotic events was explored in an RCT (STRATAGEM) of nearly 300 patients (Mantz et al., pages 899–910). No difference was found between the groups in the incidence of events. In contrast, a retrospective review of patients with hip fractures found that 23 of 111 patients in whom clopidogrel was stopped had an acute coronary event between days 4 and 8 (Collyer et al., pages 911–15). The role of anticoagulants is touched on in two other papers where the risks and benefits of thoracic epidurals are reviewed (Freise and Van Aken, pages 859–68) and the one year outcome of the NAP3 project is assessed (Cook et al., pages 978–82).

Early detection of ‘at-risk’ patients

Three studies in this month’s BJA focus on different aspects of the early identification and detection of factors which increase perioperative risk. Cata and colleagues (pages 844–58) have reviewed the utility of a number of biomarkers for the prediction of neurological damage in the perioperative period. They conclude that, as yet, none can be recommended for use in cardiac or non-cardiac surgery. A multicentre study of over 3300 moderate to high risk patients found an incidence of major cardiac or cerebrovascular events of 4.3% and used this to identify seven independent risk factors which can be used to identify at risk patients (Sabaté et al., pages 879–90). A study of the utility of Doppler renal resistive index for the early detection of acute kidney damage in post-bypass cardiac surgery patients suggests that this could be a useful predictor (Bossard et al., pages 891–8).

‘Health Services Research’ session at ARS meeting on 28 Nov

LuluStader — Sat, 05 Nov 2011 14:02:06 +0000

The ARS Winter meeting on 28 November is featuring a ‘Health ”Health Services Research” session. Registration is now open and can be performed on-line here at £90.

The program of the ARS meeting is available here.

In the October 2011 BJA …

LuluStader — Sat, 01 Oct 2011 12:52:25 +0000

Pain management

Several aspects of pain management are addressed in articles in this month’s issue of the BJA. Capsaicin has been used topically for neuropathic and musculoskeletal pain. Anand and Bley (pages 490–502) review both the efficacy of capsaicin and recent work of its mechanism of action in pain. A systematic review of the use of ketamine as an adjunct for paediatric caudal analgesia found benefits in prolonging analgesia with no increase in adverse effects (Schnabel et al., pages 601–11). The potential of using electroacupuncture for postoperative analgesia is explored in an animal study (Groppetti et al., pages 612–18), which found evidence of efficacy. Numeric rating scales are used widely for assessing postoperative pain, but the threshold between mild and moderate pain is poorly defined. In a comparison of four assessment methods by Gerbershagen et al. (pages 619–26) the likely threshold appears to be a score of ≥4. In an Editorial, McCartney and McLeod (pages 487–9) address the use of local infiltration as sole analgesia after knee arthroplasty. They conclude that while the technique has some merits it cannot yet replace the use of femoral nerve block.

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.

In the September 2011 BJA …

LuluStader — Fri, 12 Aug 2011 18:26:30 +0000

Caesarean sections

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).

In the August issuse of BJA …

LuluStader — Mon, 18 Jul 2011 12:30:31 +0000

Saving Mothers’ Lives

The eighth triennial report of the UK Enquiries into Maternal Deaths, covering 2006–08, was published in March of this year. Previously, the BJA has published the anaesthesia and critical care chapters of the Report in their entirety to help to disseminate the anaesthesia related findings to a wider audience. Unfortunately, due to a change in publication policy, we are not able to do this for the Report on this occasion due to copyright restrictions. However, the authors of the anaesthesia and critical care chapters have produced a review of the Report findings which is published in this issue (McClure et al., pages 127–32). While the maternal mortality rate has declined overall, there were still some anaesthesia related deaths and the authors highlight substandard care as an element in several of these. The review is expertly put into an international context in the accompanying Editorial by Professor Wong (pages 119–22).

Risk prediction
Prediction of risks, particularly mortality and major perioperative events, is a major concern in anaesthesia and critical care and the subject of considerable research effort. Four articles in this month’s BJA address different aspects of risk prediction. The utility of clinical predictors of cardiovascular events is reviewed by Biccard and Rodseth (pages 133–43). They conclude that all current approaches have limitations and propose that age is included as a variable and encourage repeated, rather than single, assessments perioperatively. The use of brain natriuretic peptide (BNP) as a predictor of mortality is explored in a prospective study of 345 patients (Payne et al., pages 144–9), who conclude that it is a predictor of longer-term survival. The ASA classification is a long-established broad-based assessment of perioperative risk. Zuidema and colleagues (pages 180–5) have assessed the use of a computer-based questionnaire in estimating ASA classification and found it comparable with those made by clinicians. In a prospective study of 100 elderly patients admitted to a medical HDU (Hood et al., pages 186–92), age was not found to be an independent predictor of outcome. The authors argue that age alone should not be a limit on admission to HDU.

New airway devices

There are a number of interesting new developments in anaesthesia airway devices and laryngoscopes. It is appropriate that these devices undergo thorough evaluation in different clinical settings as they are introduced into practice. Two linked studies (Theiler et al., pages 243–50 and Kleine-Brueggeneyet al., pages 251–7) evaluate the use if the sILMA™ and i-Gel™ laryngeal masks for fibreoptic and ‘blind’ tracheal intubation in a total of 240 patients with a predicted difficult airway. The authors found the devices comparable for fibreoptic intubation but the sILMA™ was much more successful for blind intubation. The use of two different LMAs (Supreme™ and Proseal™) in patients in the prone position was evaluated in a study (López et al., pages 265–71) that found similar efficacy. The use of C-MAC® and Airtaq® larygnoscopes was compared with a Macintosh in a prospective study of 90 patients with cervical immobilization. All were successful but the authors conclude that Airtraq®performed best.

Mobile BJA!

LuluStader — Tue, 28 Jun 2011 09:07:30 +0000

With immediate effect, you no longer need to stay at your computer screen to read our journal content: BJA and CEACCP now have a mobile optimized version of our respective websites.

This means you’ll be able to access the content you need from virtually anywhere via your smartphone.

What these sites can do for you

The mobile websites offers the following features for our readers:

Easy access to all current and archive content
A quick search page
An ‘Email me this article’ feature

Please find below the codes to access the mobile optimized copies of BJA & CEACCP. You simply scan these images with your phone to take you directly to the mobile version of the site. These are for iPhone and android hardware. You can just type in the URL instead if you prefer, of course.

Additional info here about mobile websites, and some FAQ’s.

The access codes are as follows:

BJA

CEACCP

How to access the mobile sites

You can browse table of contents and abstracts for free using any WiFi or 3G network.

If you’re logging in to the Oxford Journals website on your mobile device through an institution’s WiFi service, you’ll be able to access your institution’s subscriptions.

If you have a personal subscription, simply log-in to your Oxford Journals My Account as usual at http://www.oxfordjournals.org/register

When you access the Oxford Journals website from either an ios or Android os, you will automatically be re-directed to the mobile friendly versions of the site. Alternatively, you can access them directly via the links above.

The small print

The websites will be fully accessible from any mobile device with optimum display on iOS (iPhone; iPod Touch), Blackberry and Android smartphones. Support for Symbian OS and Windows Mobile is in development.