Ambient operating room temperature: mother, baby or surgeon?
Editor —We thank Siedentopf1 for raising an important point regarding ambient operating theatre temperature and its potential influence upon maternal and neonatal hypothermia during and after Caesarean delivery. The World Health Organization (WHO) recommends a delivery room temperature of 25 –28 °C to reduce the incidence of neonatal hypothermia.2 These guidelines do not, however, specifically recommend ideal operating theatre ambient temperatures nor the optimal temperature required to prevent maternal hypothermia. A recently published study by Duryea and colleagues3 specifically explored the impact of operating th...
Source: British Journal of Anaesthesia - September 28, 2017 Category: Anesthesiology Source Type: research
Does surrounding temperature influence the rate of hypothermia during Caesarean section?
Editor —I read the meta-analysis by Sultan and colleagues1 and the comment thereon by Nair2 with great interest. Although the duration of a Caesarean section is short, the exposed abdomen loses warmth by radiation and convection, leading to a reportedly high rate of hypothermia after surgery. In addition to the size of the exposed area, temperature loss is proportional to the difference in temperature (Fourier ’s law). I am astonished that neither the review by Sultan and colleagues1, nor other reviews like the one by Munday and colleagues,3 mention the temperature of the operation theatre as an influential factor to t...
Source: British Journal of Anaesthesia - September 28, 2017 Category: Anesthesiology Source Type: research
Cardiopulmonary exercise testing in preoperative risk assessment and patient management
Editor —The article by Swart and colleagues1 aroused our interest. In 1999 our group published a paper in which we used cardiopulmonary exercise testing (CPX) to stratify surgical risk in 548 consecutive patients>60 years of age (or younger with known cardiopulmonary disease).2 We found that, to quote, ‘In elderly patients undergoing major intra-abdominal surgery, the AT (anaerobic threshold), as determined by CPX testing, is an excellent predictor of mortality from cardiopulmonary causes in the postoperative period. Preoperative screening using CPX testing allowed the identification of high-ris k patients and th...
Source: British Journal of Anaesthesia - September 28, 2017 Category: Anesthesiology Source Type: research
Should we use hypotonic or isotonic maintenance intravenous fluids in sick patients? Why a study in healthy volunteers will not provide the answer Response to: Effect of isotonic versus hypotonic maintenance fluid therapy on urine output, fluid balance, and electrolyte homeostasis: a crossover study in fasting adult volunteers
Editor —Sick patients who are unable to ingest oral fluids usually receive i.v. maintenance fluid therapy (IVMFT). The main goal of IVMFT is to temporarily meet water, electrolyte and glucose needs pending a more sustainable (par)enteral solution for feeding and hydration. Despite routine application, IV MFT is often based on dogmatic principles rather than high quality empirical research.1 Furthermore, macro- and micronutrient deficiencies, fluid overload, hyperchloraemic acidosis and hyponatraemia have all been reported as potentially detrimental complications. Fortunately, well-designed high quality studies performed ...
Source: British Journal of Anaesthesia - September 28, 2017 Category: Anesthesiology Source Type: research
The dilemma of interventional pain trials: thinking beyond the box
“I want a parachute that is based on good research”1Interventional pain medicine is rapidly growing, yet it is lacking in robust evidence. The problem is not limited to a particular geography, rather it is ubiquitous across the globe, with uniform dearth of good-quality data. The increasing numbers of intervention procedures speak for themselves; as per 2014 –15 UK Hospital Episodes Statistics (HES) data, there were 82 188 therapeutic epidurals, 13 796 facet joint denervations, and 83 308 ‘other procedures’ around the spine.2 The narrative is similar in the USA, with a ∼11% annual increase in select Medic...
Source: British Journal of Anaesthesia - September 28, 2017 Category: Anesthesiology Source Type: research
Monitoring nociception —getting ‘ there yet’ might be easier with a road map
General anaesthesia can be described simplistically as a combination of hypnosis, anti-nociception and muscle relaxation. To allow a goal-directed approach to each component, validated and user-friendly monitoring solutions are essential. However, although the measurement of neuromuscular paralysis, as well as depth of anaesthesia, has been established for decades,12 the reliable assessment of (anti-)nociception appears to remain an elusive goal. The lack of such a tool is of specific interest as it relates to the current debate about the ideal (if any) doses of intraoperative opioids, because of the growing understanding ...
Source: British Journal of Anaesthesia - September 28, 2017 Category: Anesthesiology Source Type: research
NeuPSIG: investing in solutions to the growing global challenge of neuropathic pain
This issue of theBritish Journal of Anaesthesia (BJA) includes two excellent review papers discussing epidemiology, mechanisms and management of pain after cancer.12 These were presented in a workshop at the 6th International Congress on Neuropathic Pain, in June 2017, sponsored by theBJA. Cancer pain is a distressing, chronic painful condition, which is generally under-recognized yet whose importance in society is increasing as cancer survivorship improves and people live longer with lasting side-effects of treatment.3 (Source: British Journal of Anaesthesia)
Source: British Journal of Anaesthesia - September 28, 2017 Category: Anesthesiology Source Type: research
Guidelines for perioperative pain management: need for re-evaluation
Optimal perioperative pain management facilitates postoperative ambulation and rehabilitation, and is considered a prerequisite to enhancing recovery after surgery.12 Despite well-documented benefits, postoperative pain continues to be inadequately treated.3–5 Although the reasons for the lack of appropriate pain management are not precisely known, conflicting and confusing evidence as well as lack of clear guidance could be contributing factors. (Source: British Journal of Anaesthesia)
Source: British Journal of Anaesthesia - September 28, 2017 Category: Anesthesiology Source Type: research
Special section on pain: progress in pain assessment and management
This issue of theBritish Journal of Anaesthesia has a special section on pain, featuring a number of editorials, reviews and original articles across a range of areas in pain medicine. The lastBJA special issue on pain medicine was in July 2013, entitled “Managing pain: recent advances and new challenges”, as summarized in the lead editorial of that issue.1 A similar title could be used for this month's special section. Pain medicine continues to evolve, with advances in acute, chronic and cancer pain understanding and management. However, the challenges remain, and arguably, increase, as our population ages: Pain is o...
Source: British Journal of Anaesthesia - September 28, 2017 Category: Anesthesiology Source Type: research
Speaking up: does anaesthetist gender influence teamwork and collaboration?
Speaking up can be defined as explicitly communicating observations or concerns, requesting clarification or explanation, or explicitly challenging a colleague ’s decision or action.1 Speaking up provides an opportunity to intervene before patient harm occurs, or to mitigate actual harm, and is a key element in effective teamwork and collaboration.2 The importance of speaking up is most evident in its absence, where colleagues remain silent or make ineffectual attempts at speaking up, and erroneous actions proceed to cause patient harm. There are many prominent examples where failing to speak up in an effective manner ha...
Source: British Journal of Anaesthesia - September 28, 2017 Category: Anesthesiology Source Type: research
Fading whispers down the lane: signal propagation in anaesthetized cortical networks
An active area of enquiry in the neuroscientific investigation of general anaesthesia is the question of whether anaesthetic-induced unconsciousness is mediated by bottom-up or top-down mechanisms in the brain. Candidates for the bottom-up approach include suppression of arousal centres in the brainstem and diencephalon,12 activation of sleep-promoting neurones or nuclei in similar locations,13 blockade of sensory informationen route from the thalamus to the cortex,4 and a disabled thalamic conductor for the neuronal orchestra of the cortex.5 Candidates for the top-down approach include direct effects on long-latency activ...
Source: British Journal of Anaesthesia - September 28, 2017 Category: Anesthesiology Source Type: research
Hierarchy in disruption of large-scale networks across altered arousal states
Understanding how anaesthetics act within neural circuits to induce altered arousal states that range from sedation to general anaesthesia is an important question in neuroscience. Studies in laboratory animals demonstrate that anaesthetics including propofol, ether derivatives, and dexmedetomidine induce activity patterns in brainstem arousal nuclei that are similar to natural sleep.1 –3 However, anaesthetic drug action in brainstem arousal nuclei may provide only a partial answer to explain the behavioural and neurophysiological distinctions between anaesthesia-induced states and sleep, because anaesthetics also signif...
Source: British Journal of Anaesthesia - September 28, 2017 Category: Anesthesiology Source Type: research
Age and inflammation after cardiac surgery
The cardiac surgical population is aging and these patients have increased expectations with respect to quantity and quality of postoperative survival. Some of the physiological changes related to aging that impact surgical outcomes are better understood than others, and recently we are also beginning to gain a better understanding of the impact of aging on immunity and the immune response to surgery.12 (Source: British Journal of Anaesthesia)
Source: British Journal of Anaesthesia - September 28, 2017 Category: Anesthesiology Source Type: research
Readmission after surgery: are neuromuscular blocking drugs a cause?
Neuromuscular blocking drugs (NMBDs) play an integral role in balanced anaesthesia. They improve intubating conditions, reduce iatrogenic damage to the upper airway and decrease postoperative hoarseness.1 They also improve surgical operating conditions.2 But use of NMBDs always carries the risk of residual neuromuscular block postoperatively. About 30% of all patients who receive NMBDs intraoperatively show signs of residual neuromuscular block when arriving in the post-anaesthesia care unit.3 –5 It has been suggested that residual neuromuscular block can cause postoperative pulmonary complications.6 –8 (Source: Britis...
Source: British Journal of Anaesthesia - September 28, 2017 Category: Anesthesiology Source Type: research
Diastolic dysfunction and sepsis: the devil is in the detail
Diastolic dysfunction is the consequence of impaired left ventricular relaxation, decreased recoil and decreased ventricular compliance.1 Before the era of tissue Doppler imaging (TDI), pulmonary vein Doppler imaging in conjunction with transmitral Doppler, was a major tool in identifying diastolic dysfunction, also in septic shock patients.2 Pulmonary vein Doppler assessment with a systolic (S)< diastolic (D) flow velocity supports the finding of elevated left ventricular filling pressures in a euvolaemic patient. (Source: British Journal of Anaesthesia)
Source: British Journal of Anaesthesia - September 28, 2017 Category: Anesthesiology Source Type: research
