Anaesthesia最新文献

While the study of Urmale Kusse et al. [1] makes a valuable contribution to the topic, I believe that several aspects warrant further discussion.

First, the sample size was based on a randomised controlled trial investigating postoperative analgesia in patients undergoing laparoscopic cholecystectomy [2]. The trial compared rectus sheath block with rectus sheath block and erector spinae plane block, which differs from the comparison in the current study. Thus, using this reference to calculate the sample size may not be appropriate. Additionally, the blinding in this study presents challenges, as the puncture sites for erector spinae plane block and rectus sheath block are located on the back and abdomen, respectively, compromising blinding for both patients and postoperative caregivers. The inclusion of placebo or sham blocks would have improved blinding.

Second, regarding the evaluation of postoperative analgesic outcomes, the study measured total opioid consumption and converted the 24-h opioid use into standardised morphine milligram equivalents (MME). The results showed mean (SD) opioid consumption of 3.5 (8.7) MME in the erector spinae plane block group vs. 8.2 (2.8) MME in the rectus sheath block group (p = 0.003). However, the minimum clinically important difference for 24-h postoperative opioid consumption is 10 MME [3], indicating that the observed difference between the two groups did not meet this threshold. I believe this may be attributed to the analgesic protocol employed, which involved administering medication based on pain assessment rather than patient-control. This approach may have resulted in delayed opioid administration, potentially compromising pain control, as a significant proportion of patients experienced moderate to severe pain (NRS 4–7) postoperatively. This could be related to the constraints typical of low- and middle-income settings.

Finally, I have concerns regarding the timeline of the nerve block procedures. Both blocks were performed while patients were anaesthetised. While rectus sheath block can be administered with the patient in a supine position, erector spinae plane block requires the patient to be in the lateral decubitus position. This necessitates repositioning the anaesthetised patient from supine to lateral and then back to supine, which is complex and time-consuming. However, the reported mean (SD) anaesthesia duration of 164 (16) min for the erector spinae plane block group and 159 (14) min for the rectus sheath block group; and the surgery duration of 150 (14) min for the erector spinae plane block group and 143 (18) min for the rectus sheath block group, do not indicate a longer non-surgical anaesthesia time for the erector spinae plane block group.

We congratulate Nathanson et al. for their timely editorial [1], and share their regret that lives continue to be lost to preventable errors. Twenty years ago, the death in similar circumstances of Elaine Bromiley led to the creation of the charity we now represent.

The reasons why skilled and conscientious practitioners make such errors are well-established. We know that human beings under stress are prone to ‘mind lock’ – rigid fixation on a diagnosis or course of action – and confirmation bias, where contradictory data (such as an abnormal capnography trace) are ignored, while corroborative information (such as breath sounds) is favoured. Sense of time dissipates and memory recall becomes difficult. These are fundamentally human responses and no amount of training will prevent them.

However, there is a common thread in all these tragedies, which is too often overlooked. In nearly all cases, senior colleagues arrived to assist within minutes, but these rescuers failed to cut through the ‘mind lock’ and followed the primary caregiver down the wrong, fatal, path. The role of rescuer is critically important but almost completely undefined. It is something few if any of us are formally trained in, yet it is in dire need of a formal, structured and, above all, standardised approach. In short, if we're going to train our way out of this problem, we need to train the rescuers.

Some of the attributes that make a good rescuer can be found in guidelines from the Association of Anaesthetists for implementing human factors in anaesthesia [2]. Much of it is counterintuitive (for example, the advice to stand back and analyse rather than pile in and do something) or counter-cultural (using checklists rather than relying on memory). Yet these seeds are sown on barren ground. How often does the Quick Reference Handbook sit on a shelf uselessly while a crisis is unfolding?

Specific rescuer training would reinforce these skills, while also achieving the aim of rehearsing rare scenarios, all of which is easily done in a simulator. Above all, such training should be standardised nationally, so that everyone involved in an incident, rescuer and rescuee, knows exactly how it will play out. This is a big challenge, but one that falls to our profession alone.

Finally, while we recognise the value of teams training together, the costs are enormous and insisting on this counsel of perfection too often leads to teams not training at all. Pilots are required to take a simulator assessment every 6 months, in which they rehearse their responses to rare emergencies in exactly the way envisaged by Nathanson et al., and they do so individually. Aircrews do not train as teams, yet no-one has died from an accident on a British commercial aircraft for 35 years.

Would that we could say the same for anaesthesia.

Introduction: Point-of-care gastric ultrasound is an emerging tool in peri-operative practice. However, data on the technical challenges of gastric ultrasound, which are essential for optimised training, remain scarce. We analysed gastric ultrasound examinations performed after basic training to identify factors associated with difficulty.

Methods: This was an analysis of data from a prospective observational study evaluating the potential impact of routine pre-operative gastric ultrasound on peri-operative management in adult patients undergoing elective or emergency surgery at a single centre. Before initiation, physicians received extensive structured training with at least 30 supervised gastric sonograms before independent practice. We then used regression models to identify factors associated with deviation from a predefined sonography algorithm, performance time and scan difficulty.

Results: Seventy-three trained physicians performed 2003 ultrasound scans. Median (IQR [range]) performance time was 5 (4-6 [1-20]) min, which was achieved after 20-27 scans following structured training. Patient characteristics associated with more difficult and longer duration scans were: increase in BMI per 5 kg.m^-2 (odds ratio (95%CI) 1.57 (1.35-1.83), p < 0.001 for difficulty and percentage change coefficient (95%CI) 1.03 (1.02-1.05), p < 0.001 for duration); and male sex (odds ratio (95%CI) 3.31 (2.28-4.88), p < 0.001 for difficulty and percentage change coefficient (95%CI) 1.08 (1.04-1.12), p < 0.001, for duration). Trauma surgery (odds ratio (95%CI) 3.26 (1.88-5.68), p < 0.001), ASA physical status of 3 or 4 (odds ratio (95%CI) 1.86 (1.21-2.88), p = 0.0049) and emergency surgery (odds ratio (95%CI) 1.86 (1.20-2.89), p = 0.006) were associated with deviation from the predefined sonography algorithm.

Discussion: Approximately 50 scans are required to achieve a baseline performance of 5 min per gastric ultrasound. Future training programmes should focus on patients with obesity, male sex, higher ASA physical status and trauma.