Gonzalez-Estrada and colleagues report an estimated risk of severe or fatal perioperative anaphylaxis of one in 6,825 procedures during the period 2005–2014. This is slightly higher than that reported previously in France and England. Several predictors of near-fatal and fatal reactions are identified, such as increased age, cancer, and congestive cardiac failure.

Terms such as prospective, interventional, and controlled are redundant in the context of randomised trials, and are therefore distracting. Pragmatic should probably be reserved for trials that intentionally control little except the exposure. The term pilot should be reserved for trials that were designated a priori and registered as pilot trials, and have appropriate pilot outcomes. ‘Pragmatic’ and

Background Limited data exist regarding optimal intraoperative ventilation strategies for the paediatric population. This study aimed to determine the optimal combination of PEEP and tidal volume (VT) based on intratidal compliance profiles in healthy young children undergoing general anaesthesia. Methods During anaesthesia, infants (1 month–1 yr), toddlers (1–3 yr), and children (3–6 yr) were assigned

Background Oxygenation via a high-flow nasal cannula (HFNC) can be an alternative to tracheal intubation during short apnoeic procedures. This randomised, non-inferiority study assessed the efficacy of HFNC compared with tracheal intubation in laryngeal microsurgery. Methods Patients (≥20 yr old) undergoing laryngeal microsurgery under general anaesthesia and neuromuscular blockade were randomised

Background Sevoflurane anaesthesia induces phosphorylation of the microtubule-associated protein tau and cognitive impairment in neonatal, but not adult, mice. The underlying mechanisms remain largely to be determined. Sex hormones can be neuroprotective, but little is known about the influence of testosterone on age-dependent anaesthesia effects. Methods Six- and 60-day-old male mice received anaesthesia

Background Prehospital advanced airway management is a complex intervention composed of numerous steps, interactions, and variables that can be delivered to a high standard in the prehospital setting. Standard research methods have struggled to evaluate this complex intervention because of considerable heterogeneity in patients, providers, and techniques. In this study, we aimed to develop a set of

Background In the Handling Oxygenation Targets in the Intensive Care Unit (HOT-ICU) trial, a lower (8 kPa) vs a higher (12 kPa) PaO2 target did not affect mortality amongst critically ill adult patients. We used Bayesian statistics to evaluate any heterogeneity in the effect of oxygenation targets on mortality between different patient groups within the HOT-ICU trial. Methods We analysed 90-day all-cause

Background Prone position in non-intubated spontaneously breathing patients is becoming widely applied in practice alongside non-invasive respiratory support. This systematic review and meta-analysis evaluate the effect, timing and populations that might benefit from awake proning regarding oxygenation, mortality and intubation compared to supine position in hypoxemic acute respiratory failure. Methods

Background Pre-hospital anaesthesia is a core competency of helicopter emergency medical services (HEMS). Whether physician pre-hospital anaesthesia case volume affects outcomes is unknown in this setting. We aimed to investigate whether physician case volume was associated with differences in mortality or medical management. Methods We conducted a registry-based cohort study of patients undergoing

The use of motor vehicles to initiate mass casualty incidents is increasing in frequency and such events are called intentional vehicular assaults. Perpetrators are inspired by a range of terrorist ideologies or have extremist views, criminal intent, or mental health issues. Assaults using a motor vehicle as the principal weapon of attack are easy to launch and require little to no forward planning

Tracheal intubation is among the most frequently performed manoeuvres in the critical care setting, and can be life-saving in critical illness, though also associated with serious adverse events such as oesophageal intubation or tracheal tube obstruction, displacement, or disconnection from the ventilator. A key finding of the 4th National Audit Project (NAP4) was identification of waveform capnography

This editorial highlights the findings of the Balanced Anaesthesia Delirium study, a 515-patient substudy of the 6644 patient Balanced Anaesthesia trial, which found that targeting deep anaesthesia in patients undergoing major noncardiac surgery was not associated with significantly increased postoperative death or major morbidity. The substudy found that using bispectral index (BIS) guidance with

In this editorial, we examine how the STRoke After Surgery (STRAS) screening tool and similar risk scoring systems can be used to identify high-risk patients for postoperative stroke. Specific challenges to develop and implement preventative measures aimed at improving postoperative outcomes are discussed. Finally, we suggest potential future areas of research in this field.

Modern computerised medical devices emit large numbers of tone-based alerts and alarms. Notifications that comprise auditory icons or natural human speech substantially increase the psychological salience of alerts and alarms and may allow a larger set of notifications to be used, as they do not require memorisation of arbitrary sounds.

Background Specialist training bodies continue to devise innovative methods of gathering information on trainee workplace performance to meet the requirements of competency-based medical education. We reviewed recent innovations in workplace-based assessment (WBA) tools to identify strengths, weaknesses, and trade-offs inherent in their design and use. Methods In this scoping review, using the Preferred

Background Postoperative delirium is a serious complication of surgery associated with prolonged hospitalisation, long-term cognitive decline, and mortality. This study aimed to determine whether targeting bispectral index (BIS) readings of 50 (light anaesthesia) was associated with a lower incidence of POD than targeting BIS readings of 35 (deep anaesthesia). Methods This multicentre randomised clinical

Background Children's exposure to anaesthesia has been associated with risk of developing attention-deficit/hyperactivity disorder (ADHD). The goal of this study was to determine if selected patient characteristics moderate the association between exposure to anaesthesia and ADHD. Methods In a cohort of children born in between 2006 and 2012, exposure to anaesthesia before the age of 5 yr was categorised

Non-operating room anaesthesia (NORA) describes anaesthesia delivered outside a traditional operating room (OR) setting. Non-operating room anaesthesia cases have increased significantly in the last 20 yr and are projected to account for half of all anaesthetics delivered in the next decade. In contrast to most other medication administration contexts, NORA is performed in high-volume fast-paced environments

Aim We systematically reviewed published outcome measures across randomised controlled trials (RCTs) of donor management interventions. Methods The systematic review was conducted in accordance with recommendations by the Cochrane Handbook and Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We searched MEDLINE, Embase, CENTRAL, Web of Science, and trial databases from

Background Acoustic alarms in medical devices are vital for patient safety. State-of-the-art patient monitoring alarms are indistinguishable and contribute to alarm fatigue. There are two promising new sound modalities for vital sign alarms. Auditory icons convey alarms as brief metaphorical sounds, and voice alerts transmit information using a clear-spoken language. We compared how reliably healthcare

Background The African Surgical OutcomeS-2 (ASOS-2) trial tested an enhanced postoperative surveillance intervention to reduce postoperative mortality in Africa. We undertook a concurrent evaluation to understand the process of intervention delivery. Methods Mixed-methods process evaluation, including field notes, interviews, and post-trial questionnaire responses. Qualitative analysis used the framework

Background Opioid-overdose deaths are associated with poisoning with prescription and illicit opioids in the USA. In contrast, opioid-related deaths (ORDs) in the UK often involve drugs and substances of misuse, and may not be associated with a high dose of prescribed opioids. This study aimed to investigate the association between prescribed opioid dose and ORDs in UK primary care. Methods This case-crossover

Background Poor medical outcomes often result from series of minor events. The present study assessed events related to airway management to determine whether targeted changes to departmental strategies for airway management can reduce the incidence. Methods This prospective before-and-after study was performed with ethics committee approval and written informed consent from patients. Major and minor

Background Lung rest has been recommended during extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS). Whether positive end-expiratory pressure (PEEP) confers lung protection during ECMO for severe ARDS is unclear. We compared the effects of three different PEEP levels whilst applying near-apnoeic ventilation in a model of severe ARDS treated with ECMO. Methods

Communication is critical to safe patient care. In this issue of the British Journal of Anaesthesia, Jaulin and colleagues show that use of a Post-Anaesthesia Team Handover (PATH) checklist is associated with fewer hypoxaemia events in the PACU, reduced handover interruptions, and other important metrics related to improved communication. The PATH checklist provides a link within a broader chain of

Background Childhood obesity has become a serious global healthcare challenge. No UK data currently define its anaesthetic and perioperative implications. We aimed to determine obesity prevalence amongst UK children undergoing general anaesthesia and the incidence of predefined adverse perioperative events, and to compare perioperative obesity rates with National Child Measurement Programme (NCMP)

The results of the PErioperAtive CHildhood ObesitY (PEACHY) study showed an alarmingly high incidence of obesity amongst children presenting for surgical procedures under general anaesthesia in the UK. The study was performed by the Paediatric Anaesthesia Trainee Research Network (PATRN), a network of trainee anaesthetists seeking to quantify important clinical problems. Networks and consortia that

Clinical research involving human subjects and quality improvement (QI) projects share a common goal of seeking to improve human health, whether by directly changing the standard of care (research) or by improving the process(es) by which that care is delivered (QI). Whether a QI project requires informed consent (written or oral) is a function of the risk–benefit analysis of the study; such a determination

Accurate preoperative risk prediction for perioperative complications such as acute kidney injury (AKI) may serve to better inform patients and families of risk before surgery, assist with resource requirement planning, and aid with cohort enrichment for enrolment into clinical trials. Where a specific risk factor is modifiable, it may offer a potential therapeutic target for risk reduction. The report

Safe delivery of patient care in the operating theatre is complex and co-dependent of many individual, organisational, and environmental factors, including patient, task and technology, individual, and human factors. The Six Sigma approach aims to implement a data-driven strategy to reduce variability and consequently improve safety. Analytical data platforms such as a Black Box ought to be embraced

Background Innovation and human adaptation in the face of unfolding catastrophe is the cornerstone of an effective systemwide response. Capturing, analysing, and disseminating this is fundamental in developing resilience for future events. The aim of this study was to understand the characteristics of adaptations to practice early in a paediatric major trauma centre during a mass casualty incident

Background Acute kidney injury (AKI) is common after cardiac surgery and is difficult to predict. N-terminal pro-B-type natriuretic peptide (NT-proBNP) is highly predictive for perioperative cardiovascular complications and may also predict renal injury. We therefore tested the hypothesis that preoperative NT-proBNP concentration is associated with renal injury after major cardiac surgery. Methods

Background Cardiac assessment in noncardiac surgery clinical practice guidelines should be supported by the highest-quality evidence such as that offered by systematic reviews. Currently, the methodological and reporting quality of these studies remains unknown. Methods We used PubMed to search for all clinical practice guidelines related to perioperative cardiovascular patients undergoing noncardiac

Intrathecal morphine in combination with fentanyl is an effective and safe alternative to diamorphine for Caesarean delivery analgesia. Evidence suggests minimal differences in clinical efficacy and side-effects between intrathecal morphine and diamorphine. Recommended intrathecal morphine doses for Caesarean delivery analgesia are 100–150 ug.

The complex cellular interactions that underlie pathologies related to reduced oxygen delivery after surgery are poorly defined and difficult to measure. Heywood and colleagues explored the patterns of protein expression in skin biopsies taken from a subgroup of patients enrolled in a randomised trial designed to evaluate perioperative goal-directed therapy. One of their key findings was that a failure

Background More than 50% of patients have a major complication after emergency gastrointestinal surgery. Intravenous (i.v.) fluid therapy is a life-saving part of treatment, but evidence to guide what i.v. fluid strategy results in the best outcome is lacking. We hypothesised that goal-directed fluid therapy during surgery (GDT group) reduces the risk of major complications or death in patients undergoing

Background Different instruments have been used to assess ability to perform everyday functional activities, such as activities of daily living (ADL) and instrumental activities of daily living (IADL). No measures of functional activity have been validated in cardiac surgery. We assessed the reliability and validity of the Standardized Assessment of Global activities in the Elderly (SAGE) scale. Methods

Background Nitric oxide (NO) is an important signalling molecule in the cardiovascular system with protective properties in ischaemia–reperfusion injury. Inorganic nitrate, an oxidation product of endogenous NO production and a constituent in our diet, can be recycled back to bioactive NO. We investigated if preoperative administration of inorganic nitrate could reduce troponin T release and other

Background Hydroxyethyl starch (HES) 130 is a frequently used fluid to replace intravascular losses during surgery or trauma. In the past years, several trials performed in critically ill patients have raised questions regarding the safety of this product. Our aim in this meta-analysis was to evaluate the safety and efficacy of 6% HES during surgery and in trauma. Methods This systematic review and

Background Excess mitochondrial reactive oxygen species (mROS) in sepsis is associated with organ failure, in part by generating inflammation through the NOD-, LRR- and pyrin domain-containing protein 3 (NLRP3) inflammasome. We determined the impact of a mitochondrial-targeted antioxidant (MitoTEMPO) on mitochondrial dysfunction in renal proximal tubular epithelial cells, peritoneal immune cell function

Background The cellular and molecular mechanisms by which general anaesthesia occurs is poorly understood. Hippocampal interneurone subpopulations, which are critical regulators of cognitive function, have diverse neurophysiological and synaptic properties, but their responses to anaesthetics are unclear. Methods We used live-cell imaging of fluorescent biosensors expressed in mouse hippocampal neurones

Background Procedural pain and anxiety in children can be poorly controlled, leading to significant short- and long-term sequelae, such as longer procedure times or future healthcare avoidance. Caregiver anxiety can exacerbate these effects. We aimed to evaluate the effect of interactive video game interventions on children's procedural pain and anxiety, including the effect of different types of video

Background Previous studies on the association between renal tissue desaturation and acute kidney injury (AKI) in infant cardiac surgery are limited by small sample sizes and inconsistent results. This prospective study aimed to determine the association between renal desaturation and AKI in infants undergoing surgical repair of an isolated ventricular septal defect (VSD). Methods Infants undergoing

Background Laparoscopic cholecystectomy is a common surgical procedure that frequently results in substantial postoperative pain. Erector spinae plane block (ESPB) has been shown to have beneficial postoperative analgesic effects when used as a part of multimodal analgesia. The aim of this study was to determine whether ESPB improves postoperative recovery quality in patients undergoing laparoscopic

Background Awake tracheal intubation is commonly performed with flexible bronchoscopes, but the emerging role of alternative airway devices, such as videolaryngoscopes, direct laryngoscopes, and optical stylets, has been recognised. Methods CENTRAL, CINAHL, EMBASE, MEDLINE, and Web of Science were searched for RCTs that compared flexible bronchoscopes, direct laryngoscopes, optical stylets and channelled

Mechanical ventilation induces a number of systemic responses for which the brain plays an essential role. During the last decade, substantial evidence has emerged showing that the brain modifies pulmonary responses to physical and biological stimuli by various mechanisms, including the modulation of neuroinflammatory reflexes and the onset of abnormal breathing patterns. Afferent signals and circulating

Background Cognitive dysfunction after surgery is a major issue in older adults. Here, we determined the effect of APOE4 on perioperative neurocognitive function in older patients. Methods We enrolled 140 English-speaking patients ≥60 yr old scheduled for noncardiac surgery under general anaesthesia in an observational cohort study, of whom 52 underwent neuroimaging. We measured cognition; Aβ, tau