Seema Agarwal, Richard A. Armstrong, Emira Kursumovic, Andrew D. Kane, Tim M. Cook, Jasmeet Soar, Simon J. Finney, Gudrun Kunst, collaborators
Background
The 7th National Audit Project of the Royal College of Anaesthetists studied peri-operative cardiac arrest because of existing knowledge gaps in this important topic. This applies in particular to cardiology patients receiving anaesthetic care, because numbers, types and complexity of minimally invasive interventional procedures requiring planned and unplanned anaesthesia in the cardiac intervention suite is increasing.
Methods
We analysed collected data to determine the epidemiology, clinical features, management and outcomes of peri-operative cardiac arrest in adult patients receiving anaesthetic care for cardiology procedures.
Results
There were 54 reports of peri-operative cardiac arrest in adult patients receiving anaesthetic care for cardiology procedures, accounting for 54/881 (6.1%) of all reports to NAP7. The estimated incidence (95%CI) of cardiac arrests in this group was 1/450 or 0.22 (0.17–0.29)%. These patients were older than other adult patients in the NAP7 population, with a notably high proportion of patients of Asian ethnicity when compared with the remaining NAP7 cohort (9/54, 17% vs. 35/709, 5%). Rates of extracorporeal membrane oxygenation cardiopulmonary resuscitation were low (3/53, 6%). A common theme was that of logistical issues and teamworking, with reporters commenting on the difficulties of remote and/or unfamiliar locations and communication issues between specialties, on occasion resulting in poor teamworking and a lack of focus. The NAP7 panel review identified several other common themes which included: cardiogenic shock; late involvement of anaesthesia in the case; and transcatheter aortic valve implantation.
Conclusion
Cardiology procedures requiring anaesthesia care account for < 1% of anaesthesia activity but generate 6% of all peri-operative cardiac arrests. The incidence of cardiac arrest was disproportionately high in cardiological procedures requiring anaesthetic care. The nature of the cardiac arrest reports to NAP7 indicate that logistical and human factors in multidisciplinary teams in the cardiac intervention suite merit addressing to improve care.
{"title":"Cardiac arrest in adult cardiology patients receiving anaesthetic care: analysis from the 7th National Audit Project (NAP7) of the Royal College of Anaesthetists","authors":"Seema Agarwal, Richard A. Armstrong, Emira Kursumovic, Andrew D. Kane, Tim M. Cook, Jasmeet Soar, Simon J. Finney, Gudrun Kunst, collaborators","doi":"10.1111/anae.16413","DOIUrl":"10.1111/anae.16413","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>The 7th National Audit Project of the Royal College of Anaesthetists studied peri-operative cardiac arrest because of existing knowledge gaps in this important topic. This applies in particular to cardiology patients receiving anaesthetic care, because numbers, types and complexity of minimally invasive interventional procedures requiring planned and unplanned anaesthesia in the cardiac intervention suite is increasing.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We analysed collected data to determine the epidemiology, clinical features, management and outcomes of peri-operative cardiac arrest in adult patients receiving anaesthetic care for cardiology procedures.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>There were 54 reports of peri-operative cardiac arrest in adult patients receiving anaesthetic care for cardiology procedures, accounting for 54/881 (6.1%) of all reports to NAP7. The estimated incidence (95%CI) of cardiac arrests in this group was 1/450 or 0.22 (0.17–0.29)%. These patients were older than other adult patients in the NAP7 population, with a notably high proportion of patients of Asian ethnicity when compared with the remaining NAP7 cohort (9/54, 17% vs. 35/709, 5%). Rates of extracorporeal membrane oxygenation cardiopulmonary resuscitation were low (3/53, 6%). A common theme was that of logistical issues and teamworking, with reporters commenting on the difficulties of remote and/or unfamiliar locations and communication issues between specialties, on occasion resulting in poor teamworking and a lack of focus. The NAP7 panel review identified several other common themes which included: cardiogenic shock; late involvement of anaesthesia in the case; and transcatheter aortic valve implantation.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Cardiology procedures requiring anaesthesia care account for < 1% of anaesthesia activity but generate 6% of all peri-operative cardiac arrests. The incidence of cardiac arrest was disproportionately high in cardiological procedures requiring anaesthetic care. The nature of the cardiac arrest reports to NAP7 indicate that logistical and human factors in multidisciplinary teams in the cardiac intervention suite merit addressing to improve care.</p>\u0000 </section>\u0000 </div>","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"79 11","pages":"1212-1219"},"PeriodicalIF":7.5,"publicationDate":"2024-08-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142035024","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
There is some evidence for systematic biases and failures of research integrity in the anaesthesia literature. However, the features of problematic trials and effect of editorial selection on these issues have not been well quantified.
Methods
We analysed 209 randomised controlled trials submitted to Anaesthesia between 8 March 2019 and 31 March 2020. We evaluated the submitted manuscript, registry data and the results of investigations into the integrity of the trial undertaken at the time of submission. Trials were labelled ‘concerning’ if failures of research integrity were found, and ‘problematic’ if identified issues would have warranted retraction if they had been found after publication. We investigated how ‘problematic’ trials were detected, the distribution of p values and the risk of outcome reporting bias and p-hacking. We also investigated whether there were any factors that differed in problematic trials.
Results
We found that false data was the most common reason for a trial to be labelled as ‘concerning’, which occurred in 51/62 (82%) cases. We also found that while 195/209 (93%) trials were preregistered, we found adequate registration for only 166/209 (79%) primary outcomes, 100/209 (48%) secondary outcomes and 11/209 (5%) analysis plans. We also found evidence for a step decrease in the frequency of p values > 0.05 compared with p values < 0.05. ‘Problematic’ trials were all single-centre and appeared to have fewer authors (incident risk ratio (95%CI) 0.8 (0.7–0.9)), but could not otherwise be distinguished reliably from other trials.
Conclusions
Identification of ‘problematic’ trials is frequently dependent on individual patient data, which is often unavailable after publication. Additionally, there is evidence of a risk of outcome reporting bias and p-hacking in submitted trials. Implementation of alternative research and editorial practices could reduce the risk of bias and make identification of problematic trials easier.
{"title":"Risk of bias and problematic trials: characterising the research integrity of trials submitted to Anaesthesia","authors":"Paul Bramley, Joshua Hulman, Helen Wanstall","doi":"10.1111/anae.16411","DOIUrl":"10.1111/anae.16411","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>There is some evidence for systematic biases and failures of research integrity in the anaesthesia literature. However, the features of problematic trials and effect of editorial selection on these issues have not been well quantified.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We analysed 209 randomised controlled trials submitted to <i>Anaesthesia</i> between 8 March 2019 and 31 March 2020. We evaluated the submitted manuscript, registry data and the results of investigations into the integrity of the trial undertaken at the time of submission. Trials were labelled ‘concerning’ if failures of research integrity were found, and ‘problematic’ if identified issues would have warranted retraction if they had been found after publication. We investigated how ‘problematic’ trials were detected, the distribution of p values and the risk of outcome reporting bias and p-hacking. We also investigated whether there were any factors that differed in problematic trials.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>We found that false data was the most common reason for a trial to be labelled as ‘concerning’, which occurred in 51/62 (82%) cases. We also found that while 195/209 (93%) trials were preregistered, we found adequate registration for only 166/209 (79%) primary outcomes, 100/209 (48%) secondary outcomes and 11/209 (5%) analysis plans. We also found evidence for a step decrease in the frequency of p values > 0.05 compared with p values < 0.05. ‘Problematic’ trials were all single-centre and appeared to have fewer authors (incident risk ratio (95%CI) 0.8 (0.7–0.9)), but could not otherwise be distinguished reliably from other trials.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Identification of ‘problematic’ trials is frequently dependent on individual patient data, which is often unavailable after publication. Additionally, there is evidence of a risk of outcome reporting bias and p-hacking in submitted trials. Implementation of alternative research and editorial practices could reduce the risk of bias and make identification of problematic trials easier.</p>\u0000 </section>\u0000 </div>","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"79 12","pages":"1309-1316"},"PeriodicalIF":7.5,"publicationDate":"2024-08-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/anae.16411","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141981526","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Dáire N. Kelly, Edward R. Mariano, Kellie M. Jaremko
{"title":"The controversy of pre-operative opioid tapering and an opportunity to advance personalised, patient-centred pain medicine","authors":"Dáire N. Kelly, Edward R. Mariano, Kellie M. Jaremko","doi":"10.1111/anae.16412","DOIUrl":"10.1111/anae.16412","url":null,"abstract":"","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"79 11","pages":"1148-1152"},"PeriodicalIF":7.5,"publicationDate":"2024-08-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141981527","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
In a study of 904 tracheal intubations in 809 children, Sasu et al. showed that using a C-MAC® videolaryngoscope (Karl Storz, Tuttlingen, Germany) reduced the incidence of poor glottic views from 13% to 4% [1]. They also found the modified six-grade Cormack and Lehane system ineffective for predicting the ease of videolaryngoscopic tracheal intubation. The primary outcome of this study was defined as vocal cords only just or not visible. Restricted glottic views in the modified Cormack and Lehane classifications 2b, 2c and 3 during videolaryngoscopy in adult and paediatric patients are typically due to an enlarged epiglottis and impaired epiglottic movement. Such issues can be resolved by correct head positioning, increased lifting force, directly lifting the epiglottis or external laryngeal manipulation [2-4]. However, the results do not specify whether these techniques were applied to enhance the view of the glottis, leaving us unsure if the observed glottic view grades represent the best possible outcome using both modes of laryngoscopy, particularly direct laryngoscopy that requires aligning the three airway axes for proper visualisation.
Difficult videolaryngoscopic tracheal intubation was documented as a difficult airway alert based on the videolaryngoscopic intubation and difficult airway classification (VIDIAC) score in adult patients with anticipated difficult airways. Kohse et al. classified difficulty into four levels using VIDIAC scores [2], but it is unclear whether a score of 1, which indicates a 50% probability of a difficult airway, was counted as difficult in this study. Although the VIDIAC score was a secondary outcome, its results were not reported, nor was its effectiveness in differentiating easy from difficult videolaryngoscopic tracheal intubations in paediatric patients analysed, despite most having normal airways. Clarifying these aspects could strengthen the conclusions.
The overall first attempt tracheal intubation success rate is significantly lower at 67% compared with a rate of 86.8% in a previous study, which focused on children undergoing elective airway management using videolaryngoscopes with standard blades [5]. Similarly, the success rate for first attempt tracheal intubation in children aged ≤ 1 y (48%) is much lower than the rate in a recent trial studying urgent tracheal intubations in newborns using C-MAC videolaryngoscopy (74%) [6]. Based on our own experience and existing studies [7], a stylet aids in directing the tracheal tube tip to the glottis and enhances tracheal intubation performance with the C-MAC videolaryngoscopy, even when there is a clear view of a child's vocal cords. Hence, we would like to know if a stylet was used in all cases.
{"title":"First-choice videolaryngoscopy for paediatric tracheal intubation","authors":"Fu-Shan Xue, Dan-Feng Wang, Xiao-Chun Zheng","doi":"10.1111/anae.16419","DOIUrl":"10.1111/anae.16419","url":null,"abstract":"<p>In a study of 904 tracheal intubations in 809 children, Sasu et al. showed that using a C-MAC® videolaryngoscope (Karl Storz, Tuttlingen, Germany) reduced the incidence of poor glottic views from 13% to 4% [<span>1</span>]. They also found the modified six-grade Cormack and Lehane system ineffective for predicting the ease of videolaryngoscopic tracheal intubation. The primary outcome of this study was defined as vocal cords only just or not visible. Restricted glottic views in the modified Cormack and Lehane classifications 2b, 2c and 3 during videolaryngoscopy in adult and paediatric patients are typically due to an enlarged epiglottis and impaired epiglottic movement. Such issues can be resolved by correct head positioning, increased lifting force, directly lifting the epiglottis or external laryngeal manipulation [<span>2-4</span>]. However, the results do not specify whether these techniques were applied to enhance the view of the glottis, leaving us unsure if the observed glottic view grades represent the best possible outcome using both modes of laryngoscopy, particularly direct laryngoscopy that requires aligning the three airway axes for proper visualisation.</p><p>Difficult videolaryngoscopic tracheal intubation was documented as a difficult airway alert based on the videolaryngoscopic intubation and difficult airway classification (VIDIAC) score in adult patients with anticipated difficult airways. Kohse et al. classified difficulty into four levels using VIDIAC scores [<span>2</span>], but it is unclear whether a score of 1, which indicates a 50% probability of a difficult airway, was counted as difficult in this study. Although the VIDIAC score was a secondary outcome, its results were not reported, nor was its effectiveness in differentiating easy from difficult videolaryngoscopic tracheal intubations in paediatric patients analysed, despite most having normal airways. Clarifying these aspects could strengthen the conclusions.</p><p>The overall first attempt tracheal intubation success rate is significantly lower at 67% compared with a rate of 86.8% in a previous study, which focused on children undergoing elective airway management using videolaryngoscopes with standard blades [<span>5</span>]. Similarly, the success rate for first attempt tracheal intubation in children aged ≤ 1 y (48%) is much lower than the rate in a recent trial studying urgent tracheal intubations in newborns using C-MAC videolaryngoscopy (74%) [<span>6</span>]. Based on our own experience and existing studies [<span>7</span>], a stylet aids in directing the tracheal tube tip to the glottis and enhances tracheal intubation performance with the C-MAC videolaryngoscopy, even when there is a clear view of a child's vocal cords. Hence, we would like to know if a stylet was used in all cases.</p>","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"79 12","pages":"1383-1384"},"PeriodicalIF":7.5,"publicationDate":"2024-08-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/anae.16419","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141974201","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Time for mandatory safety preparedness: a responsibility for individuals, hospitals and national bodies.","authors":"Andrew D Kane, Jasmeet Soar, Tim M Cook","doi":"10.1111/anae.16418","DOIUrl":"https://doi.org/10.1111/anae.16418","url":null,"abstract":"","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2024-08-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141915911","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<p>Nathanson et al. make a case for “<i>career-long mandatory training</i>” for rare but potentially fatal anaesthetic events and that this should be implemented and funded as a matter of urgency [<span>1</span>]. Despite having less than half the reported combined clinical years of anaesthesia experience of the sagacious authors, we echo their sentiment, with a particular focus on mandatory training for airway emergencies. The 7th National Audit Project (NAP7) demonstrated that airway complications occur commonly and ‘airway failure’ was reported to account for 30% of airway complications in cases surveyed [<span>2</span>]. Notably, such complications resulted in a significant number of cardiac arrests, deaths and adverse outcomes [<span>2</span>].</p><p>A recent Health Services Safety Investigations Body report described the tragic case of a 12-year-old boy with an anticipated difficult airway who died due to failed airway management, including multiple attempts at videolaryngoscopy and an emergency front-of-neck airway [<span>3</span>]. The report made several recommendations, including that the Royal College of Anaesthetists (RCoA) and other key stakeholders, provide guidance on requirements to update airway skills regularly, but did not propose how this could be mandated.</p><p>Therefore, we wish to consider two key areas: how mandatory training could be mandated; and what training is required, recognising potential benefits and challenges (Table 1). As Nathanson et al. highlight, the pathway or organisation with the authority to mandate training is opaque. In the UK, the General Medical Council may be best placed to do so [<span>1</span>], but the time required and the practicalities of delivery could be limiting factors. The RCoA could consider recommending training within its <i>Guidelines for the Provision of Anaesthetic Services</i>, but these would simply be guidelines rather than mandatory. A multi-organisation scoping exercise led by the RCoA is currently ongoing and may be a proactive step forward. However, until formalised mandatory training by a responsible authority is implemented widely, a bottom-up approach may be necessary. This could include evidence of airway training for annual sign-off or revalidation, as well as leadership for implementing this from the Airway Leads Network. Clinical Leads and Directors should embrace and enforce regular training in their departments and ensure dedicated time and resources to support delivery. Importantly, this will require clinicians themselves to take ownership of their training and actively seek opportunities for continuing development.</p><p>We believe that mandatory training should extend to technical skills training in frequently used airway equipment, such as videolaryngoscopes – particularly those used in the clinician's usual place of work – as well as procedures, such as awake tracheal intubation, to maintain proficiency. Worryingly, NAP7 found that a lack of familiarity with or
{"title":"The how and the what of mandatory training","authors":"Nisha Abraham-Thomas, Imran Ahmad, Kariem El-Boghdadly","doi":"10.1111/anae.16414","DOIUrl":"10.1111/anae.16414","url":null,"abstract":"<p>Nathanson et al. make a case for “<i>career-long mandatory training</i>” for rare but potentially fatal anaesthetic events and that this should be implemented and funded as a matter of urgency [<span>1</span>]. Despite having less than half the reported combined clinical years of anaesthesia experience of the sagacious authors, we echo their sentiment, with a particular focus on mandatory training for airway emergencies. The 7th National Audit Project (NAP7) demonstrated that airway complications occur commonly and ‘airway failure’ was reported to account for 30% of airway complications in cases surveyed [<span>2</span>]. Notably, such complications resulted in a significant number of cardiac arrests, deaths and adverse outcomes [<span>2</span>].</p><p>A recent Health Services Safety Investigations Body report described the tragic case of a 12-year-old boy with an anticipated difficult airway who died due to failed airway management, including multiple attempts at videolaryngoscopy and an emergency front-of-neck airway [<span>3</span>]. The report made several recommendations, including that the Royal College of Anaesthetists (RCoA) and other key stakeholders, provide guidance on requirements to update airway skills regularly, but did not propose how this could be mandated.</p><p>Therefore, we wish to consider two key areas: how mandatory training could be mandated; and what training is required, recognising potential benefits and challenges (Table 1). As Nathanson et al. highlight, the pathway or organisation with the authority to mandate training is opaque. In the UK, the General Medical Council may be best placed to do so [<span>1</span>], but the time required and the practicalities of delivery could be limiting factors. The RCoA could consider recommending training within its <i>Guidelines for the Provision of Anaesthetic Services</i>, but these would simply be guidelines rather than mandatory. A multi-organisation scoping exercise led by the RCoA is currently ongoing and may be a proactive step forward. However, until formalised mandatory training by a responsible authority is implemented widely, a bottom-up approach may be necessary. This could include evidence of airway training for annual sign-off or revalidation, as well as leadership for implementing this from the Airway Leads Network. Clinical Leads and Directors should embrace and enforce regular training in their departments and ensure dedicated time and resources to support delivery. Importantly, this will require clinicians themselves to take ownership of their training and actively seek opportunities for continuing development.</p><p>We believe that mandatory training should extend to technical skills training in frequently used airway equipment, such as videolaryngoscopes – particularly those used in the clinician's usual place of work – as well as procedures, such as awake tracheal intubation, to maintain proficiency. Worryingly, NAP7 found that a lack of familiarity with or","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"79 12","pages":"1382-1383"},"PeriodicalIF":7.5,"publicationDate":"2024-08-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/anae.16414","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141915910","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<p>We read with interest the article by Choi et al., which examines the association between acute kidney injury in patients who have had their angiotensin-converting enzyme inhibitors or angiotensin receptor-blocking drugs withheld or continued, respectively, pre-operatively [<span>1</span>]. We commend them on a well-designed study that paid great attention to relevant propensity matching.</p><p>We want to comment on the difference between statistical significance and clinical relevance [<span>2</span>]. While we agree that an increase of 26.4 μmol.l<sup>-1</sup> in < 48 h is the definition of acute kidney injury as set out by the Acute Kidney Injury Network, both groups show increased serum creatinine values in the postoperative period [<span>1, 3</span>]. The actual difference in increased serum creatinine values is relatively small between the two groups, which would lead us to question the clinical significance. In contrast, the statistical significance of those who breach the threshold of 26.4 μmol.l<sup>-1</sup> is clear and undeniable. As discussed in the article, a recent meta-analysis by Hollmann et al. failed to show an association between peri-operative administration of angiotensin-converting enzyme inhibitors or angiotensin receptor-blocking drugs and mortality or major adverse cardiac events in patients undergoing non-cardiac surgery [<span>3</span>].</p><p>While we agree that the article by Choi et al. supports the routine withholding of angiotensin-converting enzyme inhibitors and angiotensin receptor-blocking drugs pre-operatively, we think the more interesting question is whether we can identify specific subsets of patients who are more significantly impacted by the continuation of these drugs in the peri-operative period. This is addressed in the supplementary material where we see that the odds ratio of developing an acute kidney injury appears to be much greater in those patients who present for surgery with an elevated baseline creatinine, low baseline haemoglobin, low BMI and those requiring pre-operative red blood cell transfusion. We are interested if the authors, knowing the data in detail, have any opinion on whether they see a need to cancel surgery in the higher-risk cohort of patients who erroneously continue these drugs peri-operatively.</p><p>The authors report that continuation of these drugs was associated with a mean reduction in intra-operative mean arterial pressure of 1.3 mmHg. While this has reached statistical significance, again, we question its clinical relevance. The patients who had these medications withheld also had a relatively large increase in baseline creatinine levels in the postoperative period. The difference in mean arterial pressure, fluid boluses and vasopressor administration between the groups was statistically significant but, again, we question the clinical significance.</p><p>The authors highlight that the type of maintenance of anaesthesia (volatile, total intravenous or even neura
{"title":"Withholding or continuing angiotensin-converting enzyme inhibitors or angiotensin 2 receptor blockers on acute kidney injury after non-cardiac surgery","authors":"Marike Rademan, Conall Hayes, Aoife Lavelle","doi":"10.1111/anae.16409","DOIUrl":"10.1111/anae.16409","url":null,"abstract":"<p>We read with interest the article by Choi et al., which examines the association between acute kidney injury in patients who have had their angiotensin-converting enzyme inhibitors or angiotensin receptor-blocking drugs withheld or continued, respectively, pre-operatively [<span>1</span>]. We commend them on a well-designed study that paid great attention to relevant propensity matching.</p><p>We want to comment on the difference between statistical significance and clinical relevance [<span>2</span>]. While we agree that an increase of 26.4 μmol.l<sup>-1</sup> in < 48 h is the definition of acute kidney injury as set out by the Acute Kidney Injury Network, both groups show increased serum creatinine values in the postoperative period [<span>1, 3</span>]. The actual difference in increased serum creatinine values is relatively small between the two groups, which would lead us to question the clinical significance. In contrast, the statistical significance of those who breach the threshold of 26.4 μmol.l<sup>-1</sup> is clear and undeniable. As discussed in the article, a recent meta-analysis by Hollmann et al. failed to show an association between peri-operative administration of angiotensin-converting enzyme inhibitors or angiotensin receptor-blocking drugs and mortality or major adverse cardiac events in patients undergoing non-cardiac surgery [<span>3</span>].</p><p>While we agree that the article by Choi et al. supports the routine withholding of angiotensin-converting enzyme inhibitors and angiotensin receptor-blocking drugs pre-operatively, we think the more interesting question is whether we can identify specific subsets of patients who are more significantly impacted by the continuation of these drugs in the peri-operative period. This is addressed in the supplementary material where we see that the odds ratio of developing an acute kidney injury appears to be much greater in those patients who present for surgery with an elevated baseline creatinine, low baseline haemoglobin, low BMI and those requiring pre-operative red blood cell transfusion. We are interested if the authors, knowing the data in detail, have any opinion on whether they see a need to cancel surgery in the higher-risk cohort of patients who erroneously continue these drugs peri-operatively.</p><p>The authors report that continuation of these drugs was associated with a mean reduction in intra-operative mean arterial pressure of 1.3 mmHg. While this has reached statistical significance, again, we question its clinical relevance. The patients who had these medications withheld also had a relatively large increase in baseline creatinine levels in the postoperative period. The difference in mean arterial pressure, fluid boluses and vasopressor administration between the groups was statistically significant but, again, we question the clinical significance.</p><p>The authors highlight that the type of maintenance of anaesthesia (volatile, total intravenous or even neura","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"79 12","pages":"1379-1380"},"PeriodicalIF":7.5,"publicationDate":"2024-08-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/anae.16409","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141915912","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<p>In Europe, out-of-hospital cardiac arrests have an annual incidence rate of 7–17/10,000 per capita and in-hospital cardiac arrests have an annual incidence rate of 15–28/10,000 hospital admissions [<span>1</span>]. The incidence of in-hospital cardiac arrests in Sweden is 16/10,000 hospital admissions [<span>2</span>]. We conducted a study assessing if the incidence of peri-operative cardiac arrest had decreased in Sweden from 2013 to 2022. We also assessed the association between 30-day mortality, patient characteristics and urgency of surgery. All patients aged ≥ 18 y experiencing peri-operative cardiac arrest in the Swedish Perioperative Register (SPOR) between January 2013 and June 2022 were included. Total number of surgical procedures with complete data for patients aged ≥ 18 y registered in SPOR from 2013 to 2022 was used as the denominator (n = 3,049,782).</p><p>The primary outcome was the incidence of peri-operative cardiac arrest in 2022 compared with 2013. Secondary outcomes were 30-day all-cause mortality and association of peri-operative cardiac arrest with patient characteristics and urgency. Descriptive and regression analysis was performed. In total, 749 patients (51.6% male, mean (SD) age 69 (17.4) y) experienced peri-operative cardiac arrest during the study period. Patient characteristics and urgency are presented in Table 1. Year was missing for 13 cases of peri-operative cases leaving 736 for analysis. This equates to an overall annual incidence of peri-operative cardiac arrest of 2.4/10,000 procedures (95%CI 2.2–2.6). There was no significant difference over the period studied: 2.9/10,000 procedures in 2013 vs. 1.8/10,000 procedures in 2022. The highest incidence of peri-operative cardiac arrest and highest 30-day mortality rate was seen in patients who underwent emergency surgeries (54%). Hip fracture surgery was the most common planned surgical intervention, (n = 120, 16%) during the study period, followed by abdominal surgery (n = 118, 16%). 30-day mortality following cardiac arrest was 48% and mortality rate was 1.2/10,000 procedures (95%CI 0.7–1.5). Odds ratio (OR) for 30-day mortality increased with age (65–80 y, OR 2.32 (95%CI 1.43–3.77), > 80 y, OR 6.11 (95%CI 3.57–10.45)); ASA physical status 3–5 (OR 2.81 (95%CI 1.74–4.54)); and surgical urgency (emergent OR 2.89 (95%CI 1.85–4.51), immediate 9.20 (95%CI 4.80–17.65)) but showed no significant change over time when adjusted for co-factors.</p><p>The overall incidence of peri-operative cardiac arrest in Sweden among adult patients (2.4 per 10,000 procedures) is lower compared with previous studies which ranged between 3–7 per 10,000 [<span>3, 4</span>]. A recent UK study found incidence rates of 3.0–3.5 per 10,000 interventions [<span>4</span>]. In that cohort, however, patients from infancy up to age 18 y (n = 12%) were included in the study. The Royal College of Anaesthetists, in its updated National Audit project (NAP7), defined peri-operative cardiac arrest a
{"title":"Peri-operative cardiac arrests in Sweden 2013–2022: data analysis of incidence and trends","authors":"Malin Sunborger, Jan G. Jakobsson","doi":"10.1111/anae.16396","DOIUrl":"10.1111/anae.16396","url":null,"abstract":"<p>In Europe, out-of-hospital cardiac arrests have an annual incidence rate of 7–17/10,000 per capita and in-hospital cardiac arrests have an annual incidence rate of 15–28/10,000 hospital admissions [<span>1</span>]. The incidence of in-hospital cardiac arrests in Sweden is 16/10,000 hospital admissions [<span>2</span>]. We conducted a study assessing if the incidence of peri-operative cardiac arrest had decreased in Sweden from 2013 to 2022. We also assessed the association between 30-day mortality, patient characteristics and urgency of surgery. All patients aged ≥ 18 y experiencing peri-operative cardiac arrest in the Swedish Perioperative Register (SPOR) between January 2013 and June 2022 were included. Total number of surgical procedures with complete data for patients aged ≥ 18 y registered in SPOR from 2013 to 2022 was used as the denominator (n = 3,049,782).</p><p>The primary outcome was the incidence of peri-operative cardiac arrest in 2022 compared with 2013. Secondary outcomes were 30-day all-cause mortality and association of peri-operative cardiac arrest with patient characteristics and urgency. Descriptive and regression analysis was performed. In total, 749 patients (51.6% male, mean (SD) age 69 (17.4) y) experienced peri-operative cardiac arrest during the study period. Patient characteristics and urgency are presented in Table 1. Year was missing for 13 cases of peri-operative cases leaving 736 for analysis. This equates to an overall annual incidence of peri-operative cardiac arrest of 2.4/10,000 procedures (95%CI 2.2–2.6). There was no significant difference over the period studied: 2.9/10,000 procedures in 2013 vs. 1.8/10,000 procedures in 2022. The highest incidence of peri-operative cardiac arrest and highest 30-day mortality rate was seen in patients who underwent emergency surgeries (54%). Hip fracture surgery was the most common planned surgical intervention, (n = 120, 16%) during the study period, followed by abdominal surgery (n = 118, 16%). 30-day mortality following cardiac arrest was 48% and mortality rate was 1.2/10,000 procedures (95%CI 0.7–1.5). Odds ratio (OR) for 30-day mortality increased with age (65–80 y, OR 2.32 (95%CI 1.43–3.77), > 80 y, OR 6.11 (95%CI 3.57–10.45)); ASA physical status 3–5 (OR 2.81 (95%CI 1.74–4.54)); and surgical urgency (emergent OR 2.89 (95%CI 1.85–4.51), immediate 9.20 (95%CI 4.80–17.65)) but showed no significant change over time when adjusted for co-factors.</p><p>The overall incidence of peri-operative cardiac arrest in Sweden among adult patients (2.4 per 10,000 procedures) is lower compared with previous studies which ranged between 3–7 per 10,000 [<span>3, 4</span>]. A recent UK study found incidence rates of 3.0–3.5 per 10,000 interventions [<span>4</span>]. In that cohort, however, patients from infancy up to age 18 y (n = 12%) were included in the study. The Royal College of Anaesthetists, in its updated National Audit project (NAP7), defined peri-operative cardiac arrest a","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"79 10","pages":"1128-1129"},"PeriodicalIF":7.5,"publicationDate":"2024-08-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/anae.16396","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141905557","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
We would like to thank and applaud the authors and contributors to the 7th National Audit Project (NAP7) for such a thorough investigation and Anaesthesia for its dissemination and sharing of content [1]. However, we must ask if the primary purpose of the project has been lost among the volume of papers (we think this is the 12th)? Having spoken to a number of colleagues, none of them admit to having read all of them. Rather, comments include how long the report [2] is (567 pages compared with the 219 pages of NAP4 [3]); how many papers have been published (12 compared with 2 for NAP4); and the confusion as to what they should read.
We appreciate there are a lot of data and discussion points, but we fear the key messages relating to the primary purpose of the project may have been missed or lost in the volume of published materials. We believe the authors would have been better focusing more on the primary outcome rather than the overwhelming number of secondary outcomes and publication noise.
That said, the additional materials produced are excellent, namely the infographic [4] and overview slides [5]. We very much hope to continue seeing these being produced in future NAPs.
{"title":"NAP7 – have we lost the point?","authors":"William Ward, Helen Aoife Iliff","doi":"10.1111/anae.16404","DOIUrl":"10.1111/anae.16404","url":null,"abstract":"<p>We would like to thank and applaud the authors and contributors to the 7th National Audit Project (NAP7) for such a thorough investigation and <i>Anaesthesia</i> for its dissemination and sharing of content [<span>1</span>]. However, we must ask if the primary purpose of the project has been lost among the volume of papers (we think this is the 12th)? Having spoken to a number of colleagues, none of them admit to having read all of them. Rather, comments include how long the report [<span>2</span>] is (567 pages compared with the 219 pages of NAP4 [<span>3</span>]); how many papers have been published (12 compared with 2 for NAP4); and the confusion as to what they should read.</p><p>We appreciate there are a lot of data and discussion points, but we fear the key messages relating to the primary purpose of the project may have been missed or lost in the volume of published materials. We believe the authors would have been better focusing more on the primary outcome rather than the overwhelming number of secondary outcomes and publication noise.</p><p>That said, the additional materials produced are excellent, namely the infographic [<span>4</span>] and overview slides [<span>5</span>]. We very much hope to continue seeing these being produced in future NAPs.</p>","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"79 11","pages":"1260-1261"},"PeriodicalIF":7.5,"publicationDate":"2024-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/anae.16404","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141900730","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Arjen J. G. Meewisse, Annerixt Gribnau, Steven E. Thiessen, Dirk Jan Stenvers, Jeroen Hermanides, Mark L. van Zuylen
Background
The timing of elective surgery could affect clinical outcome because of diurnal rhythms of patient physiology as well as surgical team performance. Waiting times for elective surgery are increasing in many countries, leading to increasing interest in undertaking elective surgery in the evening or at night. We aimed to systematically review the literature on the effect of the timing of elective (but not urgent or emergency) surgery on mortality, morbidity and other clinical outcomes.
Methods
We searched databases for relevant studies combining the terms ‘circadian rhythm’ and ‘anaesthesia/surgery’. Additional relevant articles were found by hand-searching the references. All studies were screened for bias. Included studies examined daytime vs. evening/night-time surgery, morning vs. afternoon surgery, multiple timeslots or used time as a continuous variable.
Results
Nineteen retrospective cohort studies, one prospective cohort study and one randomised controlled trial were included (n = 798,914). Evening/night-time elective surgery was associated with a higher risk of mortality when compared with daytime procedures in three studies (n = 611,230), with odds ratios (95%CI) for mortality ranging from 1.35 (1.16–1.56) to 3.98 (1.54–10.30), while no differences were found in three other studies (n = 142,355). No differences were found for morning vs. afternoon surgery (four studies, n = 3277). However, most studies had a low quality of evidence due to their retrospective nature and because not all studies corrected for patient characteristics. Moreover, the studies were heterogeneous in terms of the reported time slots and clinical outcomes.
Conclusions
We found that evening/night-time elective surgery is associated with a higher risk of mortality compared with daytime surgery. However, the quality of evidence was graded as low, and thus, future prospective research should publish individual patient data and standardise outcome measures to allow firm conclusions and facilitate interventions.
{"title":"Effect of time of day on outcomes in elective surgery: a systematic review","authors":"Arjen J. G. Meewisse, Annerixt Gribnau, Steven E. Thiessen, Dirk Jan Stenvers, Jeroen Hermanides, Mark L. van Zuylen","doi":"10.1111/anae.16395","DOIUrl":"10.1111/anae.16395","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>The timing of elective surgery could affect clinical outcome because of diurnal rhythms of patient physiology as well as surgical team performance. Waiting times for elective surgery are increasing in many countries, leading to increasing interest in undertaking elective surgery in the evening or at night. We aimed to systematically review the literature on the effect of the timing of elective (but not urgent or emergency) surgery on mortality, morbidity and other clinical outcomes.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We searched databases for relevant studies combining the terms ‘circadian rhythm’ and ‘anaesthesia/surgery’. Additional relevant articles were found by hand-searching the references. All studies were screened for bias. Included studies examined daytime vs. evening/night-time surgery, morning vs. afternoon surgery, multiple timeslots or used time as a continuous variable.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Nineteen retrospective cohort studies, one prospective cohort study and one randomised controlled trial were included (n = 798,914). Evening/night-time elective surgery was associated with a higher risk of mortality when compared with daytime procedures in three studies (n = 611,230), with odds ratios (95%CI) for mortality ranging from 1.35 (1.16–1.56) to 3.98 (1.54–10.30), while no differences were found in three other studies (n = 142,355). No differences were found for morning vs. afternoon surgery (four studies, n = 3277). However, most studies had a low quality of evidence due to their retrospective nature and because not all studies corrected for patient characteristics. Moreover, the studies were heterogeneous in terms of the reported time slots and clinical outcomes.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>We found that evening/night-time elective surgery is associated with a higher risk of mortality compared with daytime surgery. However, the quality of evidence was graded as low, and thus, future prospective research should publish individual patient data and standardise outcome measures to allow firm conclusions and facilitate interventions.</p>\u0000 </section>\u0000 </div>","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"79 12","pages":"1325-1334"},"PeriodicalIF":7.5,"publicationDate":"2024-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/anae.16395","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141896496","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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