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Decisions, decisions, decisions... BJA Podcast with Paul Greig

Imagine you are sitting on the runway, waiting to take off to your holiday destination. As you begin to taxi the pilot announces that there is an engine warning light flashing, but that in his experience this almost always amounts to nothing and both him and co-pilot have made a pragmatic decision to proceed, given that the flight was already running late. In anaesthesia, one of the most fundamental decisions we take is whether or not to anaesthetise someone, something that can be...


When Size Really Does Matter

The continual and often flagrant misuse of statistics within various sectors of society is something with which we are all familiar. But when it comes to science and peer reviewed work, we almost take it for granted that the calculations are correct and the conclusions drawn valid. Medical statistics can be complex and whilst somewhere in our distant past we probably once had an understanding of the maths involved, for many of us our expertise now lie elsewhere and we are left relying on...


Perioperative Medicine: today, tomorrow and the future of teamworking

There has been an increasing realisation that the majority of complications from high risk surgeries are not due to technical failings in either the operating theatre or anaesthetic room, but from medical complications occurring out on the wards. 'Failure to rescue' has become part of critical care lexicon and with it, an awareness of the financial burden associated with treating morbidity associated with high risk surgeries. Over the last three years there has been an explosion of...


DAS unanticipated difficult intubation guidelines 2015; Plan D with Dr Ravi Bhagrath

Probably one of the most talked about changes in the 2015 DAS guidelines will be Plan D. Whilst on a very basic level the recommendations have not altered, the emphasis on how to practically manage a 'can't intubate, can't oxygenate' scenario are quite a shift from many anaesthetist's current approach. Dr Ravi Bhagrath from The Royal London Hospital explains the rationale, research and most importantly, walks us through the new 'scalpel, bougie, tube' technique DAS now recommend.


Through the looking glass: awareness, BIS and an anaesthetist's perspective

Accidental awareness under general anaesthesia (AAGA) is the stuff of nightmares for patients and anaesthetists alike. Data from NAP5 has demonstrated a relatively low incidence incidence of AAGA but recommendations from the project include the use of depth of anaesthesia monitors in at risk groups. This recommendation was preceded by esoteric guidance from NICE that BIS monitors were an 'option' for a broad and loosely defined group of patients. BIS is a proprietary technology and as...


Stem cell therapy - a new hope for traumatic brain injury?

Traumatic brain injury carries a devastating burden of disease for both the individual patient and the population as a whole. Many patients are young and those who survive are commonly left with a significant disability. Sadly, treatment options for traumatic brain injury remain limited with little improvement in outcomes for the past two decades. Regenerative medicine using stem cell technologies has received a great deal of attention over the past 15 years and has been trialled as a...


‘Fit to fly’: overcoming barriers to preoperative haemoglobin optimization in surgical patients

Patient blood management (PBM) is a multifaceted approach to reducing allogenic blood transfusion (ABT) in the surgical population. In this podcast Professor Manuel Munoz, a haematologist from Malaga in Spain, talks to us about the way in which a PBM program functions to reduce ABT and in so doing, can have a dramatic impact on patient morbidity and mortality. One of the cornerstones of PBM is the detection and treatment of preoperative anaemia which is in itself an independent and...


They tried to make me go to prehab...

Whilst medical cancer therapies are increasing in their utility and efficacy, the physiological effects of intensive combined treatment regimes on patients' reserves are becoming a greater concern. It is now routine practice to combine medical and surgical therapeutic options in the form of neoadjuvant chemoradiotherapy for conditions such as colorectal cancer. Since the 1990s we have been aware of the inverse relationship between cardiorespiratory fitness as measured by CPET and...


Pregabalin use in the perioperative period: indications, dosage and the current evidence

As with many anticonvulsants, pregabalin is enjoying an ever increasing spectrum of use. Originally licensed for the treatment of epilepsy, diabetic neuropathic pain and post-herpetic neuralgia; pregabalin has become a staple of the chronic pain armamentarium. To date, well over 100 studies have explored pregabalin's use in the perioperative period on a diverse range of symptoms including acute pain and preoperative anxiety. This issue of the BJA carries a meta-analysis looking at the...


Repercussions: post-operative morbidity and the mortality hangover

Millions of operations take place in the UK each year; the majority occurring without undue patient morbidity. However, dependant on the nature of the procedure, post-operative morbidity is not uncommon and we will all recall patients who have suffered an unexpected complication after surgery. Large epidemiological studies have suggested that post-operative morbidity is not confined to the discrete episode of post-operative care, and in fact may have a significant impact on a patient's...


Fifth National Audit Project on Accidental Awareness during General Anaesthesia

Accidental awareness during general anaesthesia (AAGA) is a rare but feared complication of anaesthesia. Studying such rare occurrences is technically challenging but following in the tradition of previous national audit projects, the results of the fifth national audit project have now been published receiving attention from both the academic and national press. In this BJA podcast Professor Jaideep Pandit (NAP5 Lead) summarises the results and main findings from another impressive and...


Expiratory flow control: a novel mode of ventilation for the injured lung

Achieving adequate gas exchange whilst minimising ventilator induced lung inury is a major challenge in intensive care. The world of ICU ventilation is rich with novel proprietary modes but so far, none have proven an outcome benefit in ARDS. Whilst the differences between various modes are often subtle, most focus on modifying the inspiratory phase of the respiratory cycle, whilst maintaining a constant level of end-expiratory pressure. A group from the Division of Experimental...


Pre-hospital Anaesthesia

Emergency airway management in trauma patients is a complex and somewhat contentious issue, with opinions varying on both the timing and delivery of interventions. London's Air Ambulance is a service specialising in the care of the severely injured trauma patient at the scene of an accident, and has produced one of the largest data sets focusing on pre-hospital rapid sequence induction. Professor David Lockey, a consultant with London's Air Ambulance, talks to the BJA about LAA's approach...


Needle Phobia - A Psychological Perspective

For anaesthetists, intravenous cannulation is the gateway procedure to an increasingly complex and risky array of manoeuvres, and as such becomes more a reflex arc than a planned motor act. For some patients however, that initial feeling of needle penetrating epidermis, dermis and then vessel wall is a dreaded event, and the cause of more anxiety than the surgery itself. Needle phobia can be a deeply debilitating disease causing patients not to seek help even under the most dire...


Kidney donation after circulatory death: review and regional variation

Successful kidney transplants have been shown to improve quality of life for the recipients and dramatically reduce the cost of caring for patients with end stage renal failure. However, there is still a significant shortfall in the number of donor organs available, particularly in the UK. This is in part being addressed by an increase in donation after circulatory death (DCD), where organs are recovered from patients whose death is determined according to cardiorespiratory criteria after...


Fluid responsiveness: an evolution in our understanding

Fluid therapy is a central tenet of both anaesthetic and intensive care practice, and has been a solid performer in the medical armamentarium for over 150 years. However, mounting evidence from both surgical and medical populations is starting to demonstrate that we may be doing more harm than good by infusing solutions of varying tonicity and pH into the arms of our patients. As anaesthetists we arguably monitor our patient's response to fluid-based interventions more closely than most,...


Post-operative Cognitive Decline

Post-operative cognitive decline (POCD) has been detected in some studies in up to 50% patients undergoing major surgery. With an ageing population and an increasing number of elective surgeries, POCD may represent a major public health problem. However POCD research is complex and difficult to perform, and the current literature may not tell the full story. Dr Rob Sanders from the Wellcome Department of Imaging Neuroscience at UCL talks to us about the methodological limitations of previous...


Incident Reporting Systems

Widely regarded as champions of patient safety, it was anaesthetists who first pioneered incident reporting systems within hospital medicine. Signed in 2010, the Helsinki declaration for patient safety in anaesthesiology requires members to contribute to national reporting systems, and this podcast accompanies a paper surveying reporting systems within member countries. Professor Andy Smith from the Lancaster Patient Safety Research Unit talks to us about why incident reporting is such a...


A new player in an old debate

Opinions remain divided on the best form of post-operative analgesia following lower abdominal surgery, with an even split between those favouring epidural anaesthesia versus patient-controlled intravenous infusion. Many variations and combinations have attempted to refine and unify these two techniques without clear-cut success. In Sweden, one group has spent several years pioneering intra-abdominal local anaesthetic infusion delivered via intraperitoneal catheters. Talking about their...


How effective is simulation training in anaesthesia?

As a speciality, anaesthesia has long been a champion of simulation training. But whilst ever increasing numbers of simulation based courses are available, what evidence exists for the proposed advantages of this learning modality? For this podcast Dr Ryan Brydges, an educational academic from the University of Toronto, talks to us about his meta-anaylsis on the topic published in this issue of the BJA. Dr Brydges takes us through the current state of the literature, highlighting the areas...