The procedure-specific postoperative pain management (PROSPECT) working group develops evidence-based pain management recommendations. PROSPECT methodology is unique and rigorous. However, several limitations were recognised that needed to be addressed, and several new factors were identified that improved PROSPECT methodology. The aim of this article is to present updated PROSPECT methodology for

The NHS is facing a massive backlog in elective surgical cases after the COVID-19 pandemic, with an estimated seven million people in the UK currently awaiting an elective procedure. Effective pre-operative assessment can identify patients at risk of postoperative complications, facilitate shared decision-making discussions and guide resource allocation to improve patient outcomes. In June 2021, the Centre

We thank Drs Buchanan and Scott [1] for commenting on our review [2] and the opportunity to reply. They point out that clinical examination has several uses in airway management, including diagnosis of endobronchial intubation, pneumothorax and bronchospasm, but mistakenly suggest we discourage using clinical signs during the intubation sequence. In fact, our systematic review is silent about these

We appreciate the insightful comments of Drs Cormier and Hyman [1] regarding our study [2]. Airway manoeuvres such as tongue traction and jaw thrust play an important role in successful fibrescopic tracheal intubation and the fact that not applying them may have prolonged the intubation time in our study has already been discussed in the limitations section. However, we would like to clarify that these

We welcome the publication of the guideline by Thomas et al. [1]. It offers clear and comprehensive instructions on the indications, conduct and interpretation of 4-point CT angiography for ancillary testing to aid the confirmation of death by neurological criteria. However, the guideline does not include any specific comment on isolated infratentorial brain pathology or injury. The Faculty of Intensive

Kamga et al. [1] evaluated the performance of the Airtraq® (Prodol Meditec S.A., Vizcaya, Spain) videolaryngoscope for awake flexible nasal bronchoscopy in patients with an anticipated difficult airway. To differentiate the effect of one factor on the primary outcome in a randomised controlled trial, all other factors must be standardised to avoid potential bias. However, other than the limitations

The Project for Universal Management of Airways (PUMA) guidelines for prevention of unrecognised oesophageal intubation [1] recommend universal use of videolaryngoscopy for tracheal intubation whenever feasible. Potential barriers to implementation of this recommendation relate to criticism that it may reduce the experience that anaesthetists gain in direct laryngoscopy techniques [2], as well as lack

We welcome the continuing discussion around the international consensus guideline for the prevention of unrecognised oesophageal intubation [1] as applied to cardiopulmonary resuscitation [2, 3]. Qureshi et al. share a vignette (unrelated to cardiopulmonary resuscitation) intended to highlight how adhering to the guideline might have caused harm. Yet the actions they advocate are entirely consistent

Dr Lyons [1] raises several questions about the consensus guidelines on prevention of unrecognised oesophageal intubation [2] and the Cochrane review of videolaryngoscopy vs. direct laryngoscopy [3]. He asks “Who is putting the tube in the oesophagus?” The answer is 3% of intubators who use direct laryngoscopy [4]. From review of numerous cases of fatal oesophageal intubation (https://www.universalairway

The growing body of evidence supporting the safety profile and success rates of videolaryngoscopy is likely to result in a wider range of these devices being made available for clinical use. The importance of human factors in anaesthesia with regard to improving patient safety has already been described by Kelly et al. [1]. Design is the most effective strategy to reduce errors and enhance patient

Whilst we wholly support the conclusion by Hansel et al. [1] that waveform capnography remains the reference standard and reaffirms the importance of the “no trace wrong place” campaign, we feel that the conclusions drawn regarding the utility of clinical tests in supporting tracheal intubation are not merited by the quality of data informing their systematic review. We suggest that the premise of

We appreciate the interest from Hajibandeh et al. [1] in the model that was developed to predict short-term mortality after an emergency laparotomy [2]. It was designed around a pragmatic set of commonly measured clinical variables to aid its transferability and ease of use. Collinearity can be a problem when selecting variables for a prediction model [3]. Among the continuous variables we considered

Choi et al. [1] compare tracheal intubation with a non-channelled Macintosh blade videolaryngoscope vs. a flexible intubation scope (fibrescope) in patients with neck immobilisation using a cervical collar. They conclude higher first attempt success, shorter time to intubation and less frequent use of airway manoeuvres with videolaryngoscopy. Two critical study design limitations, however, fundamentally

Tobacco smoking is associated with a substantially increased risk of postoperative complications. The peri-operative period offers a unique opportunity to support patients to stop tobacco smoking, avoid complications and improve long-term health. This systematic review provides an up-to-date summary of the evidence for tobacco cessation interventions in surgical patients. We conducted a systematic

Oxytocin is widely used to prevent atonic postpartum haemorrhage after caesarean delivery. Initial treatment failure rates are high and inadequate dosing may contribute. Excessive doses, however, are associated with serious adverse effects. The pharmacokinetic data from this context are sparse and there is a lack of data in the immediate postpartum minutes after an initiating bolus. The pharmacodynamic

Point-of-care gastric sonography offers an objective approach to assessing individual pulmonary aspiration risk before induction of general anaesthesia. We aimed to evaluate the potential impact of routine pre-operative gastric ultrasound on peri-operative management in a cohort of adult patients undergoing elective or emergency surgery at a single centre. According to pre-operative gastric ultrasound

Assessment of cardiorespiratory fitness is routinely carried out in the pre-operative period. Cardiopulmonary exercise testing (CPET) is the gold standard for assessing functional capacity [1], but in centres where CPET is not routinely performed, alternative methods are recommended such as the Duke Activity Status Index (DASI). This self-reported questionnaire equates physical activity scores with

The National Emergency Laparotomy Audit (NELA) is to be commended for its significant contribution to raising the standard of care for patients undergoing emergency laparotomy. We are pleased to see that the risk score has been updated to a more simplified ‘Parsimonious NELA Risk Calculator’ [1] requiring fewer clinical and biochemical parameters. Risk stratification for emergency laparotomy is now

Postoperative systemic inflammation is strongly associated with surgical outcomes, but its relationship with patient-centred outcomes is largely unknown. Detection of excessive inflammation and patient and surgical factors associated with adverse patient-centred outcomes should inform preventative treatment options to be evaluated in clinical trials and current clinical care. This retrospective cohort

We have read with interest the increasing number of publications that seek, in line with the NHS long-term plan, to reduce the ‘carbon footprint’ of the NHS. Different ways have been proposed to reduce the emissions resulting from anaesthesia, including transitioning to total intravenous anaesthesia (TIVA), volatile capture and catalytic destruction (cracking) of nitrous oxide. Vaghela et al. [1] report

International recommendations encourage liberal administration of oxygen to patients having surgery under general anaesthesia, ostensibly to reduce surgical site infection. However, the optimal oxygen regimen to minimise postoperative complications and enhance recovery from surgery remains uncertain. The hospital operating theatre randomised oxygen (HOT-ROX) trial is a multicentre, patient- and assessor-blinded

Brearley et al. have published a qualitative study ‘nested’ within a randomised controlled trial. They have examined patients' expectations and their experience of two different analgesic regimens [1]. The authors used a grounded theory technique; this is a general methodology for developing theory that is ‘grounded’ in data systematically gathered and analysed. Many readers may not be familiar with

Peri-operative medication safety is complex. Avoidance of medication errors is both system- and practitioner-based, and many departments within the hospital contribute to safe and effective systems. For the individual anaesthetist, drawing up, labelling and then the correct administration of medications are key components in a patient's peri-operative journey. These guidelines aim to provide pragmatic

Cefazolin is one of the leading causes of peri-operative hypersensitivity reactions in many parts of the world. Few publications report the incidence of peri-operative hypersensitivity reactions to cefazolin. A retrospective multicentre cohort study at five Australian hospitals (January 2010–December 2015) [1] identified 124 cases of in-hospital antimicrobial anaphylaxis. The most common cause was

We would like to draw attention to a concerning issue regarding the use of glucagon-like peptide 1 (GLP-1) agonists, commonly prescribed for diabetes management and weight loss, and their potential impact on gastric emptying and the associated aspiration risk. The GLP-1 agonist is an incretin, a naturally occurring peptide primarily synthesised in intestinal endocrine cells located in the terminal

Postoperative nausea or vomiting occurs in up to 40% in patients with multiple risk factors, despite prophylaxis. Olanzapine is an antipsychotic drug that is used to prevent nausea and vomiting in palliative care and to treat chemotherapy-induced nausea and vomiting. This study aimed to examine whether pre-operative olanzapine, as a prophylactic anti-emetic added to intra-operative dexamethasone, ondansetron

The probability of death after emergency laparotomy varies greatly between patients. Accurate pre-operative risk prediction is fundamental to planning care and improving outcomes. We aimed to develop a model limited to a few pre-operative factors that performed well irrespective of surgical indication: obstruction; sepsis; ischaemia; bleeding; and other. We derived a model with data from the National

Accidental dural puncture during an attempt to establish labour epidural analgesia can result in postdural puncture headache and long-term debilitating conditions. Epidural blood patch, the gold standard treatment for this headache, is invasive and not always successful. Inserting an intrathecal catheter after accidental dural puncture may prevent postdural puncture headache. We evaluated the effect

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) recommends that quantitative mortality risk estimates be communicated to patients before surgery and used to plan care [1]. The multiply validated surgical outcome risk tool (SORT) [2] displayed the best performance and usability in a recent systematic review [3]. It was developed and validated using non-cardiac, non-neurosurgical

Anaesthesia has been shown to contribute disproportionately to maternal mortality in low-resource settings. This figure exceeds 500 per 100,000 live births in Tanzania, where anaesthesia is mainly provided by non-physician anaesthetists, many of whom are working as independent practitioners in rural areas without any support or opportunity for continuous medical education. The three-day Safer Anaesthesia

Desflurane was withdrawn from NHS Scotland in March 2023 [1], and NHS England will follow from March 2024 [2]. As noted previously [3], decommissioning may lead to retained desflurane in vaporisers that is unsuitable for administration clinically. These vaporisers must be discharged before disposal. Emptying vaporisers by ‘flushing’ through an anaesthetic machine could incur a substantial carbon-equivalent

Adequate postoperative analgesia is a key element of enhanced recovery programmes. Thoracic epidural analgesia is associated with superior postoperative analgesia but can lead to complications. Rectus sheath catheter analgesia may provide an alternative. In a nested qualitative study (within a two-year randomised controlled trial) focussing on the acceptability, expectations and experiences of receiving

Prescription of modified-release opioids for acute postoperative pain is widespread despite evidence to show their use may be associated with an increased risk of adverse effects. This systematic review and meta-analysis aimed to examine the available evidence on the safety and efficacy of modified-release, compared with immediate-release, oral opioids for postoperative pain in adults. We searched

We read with interest the editorial by Qureshi et al. [1] regarding the international consensus guidelines for preventing unrecognised oesophageal intubation [2]. They suggest that, in cardiac arrest patients receiving cardiopulmonary resuscitation (CPR), the recommendation for default tube removal if the criteria for ‘sustained exhaled carbon dioxide’ are not met should be revised in future iterations

We thank Dr Murali and Professor Inada-Kim for their editorial [1] that accompanied our article [2] and would like to respond to some of the issues they have raised. They asked why we chose to compare the New Zealand Early Warning Score (NZEWS) with the original UK National Early Warning Score (NEWS) and not its successor, NEWS2. There are several reasons for this. NZEWS was designed before the release

We appreciate the comments from Hickey et al. [1] regarding our article [2]. They raise important concerns regarding the analgesic protocol used in our study and the potential effects of ephedrine on analgesia nociception index values. Unfortunately, due to limited hospital resources, we were unable to provide multimodal analgesia, such as surgical wound infiltration, regional analgesic techniques

The purpose of this study was to understand the views and experiences of patients enrolled and staff involved in the prehabilitation of elective patients undergoing cardiac surgery trial. This sub-study was informed by normalisation process theory, a framework for evaluating complex interventions, and used consecutive sampling to recruit patients assigned to both the intervention and control groups

The feasibility, safety and efficacy of prehabilitation in adult patients awaiting elective cardiac surgery are unknown. A total of 180 participants undergoing elective cardiac surgery were allocated randomly to receive either standard pre-operative care or prehabilitation, consisting of pre-operative exercise and inspiratory muscle training. The primary outcome was change in six-minute walk test distance

We thank our colleagues, Coppens et al. [1] for their interest in the updated PROSPECT recommendations for postoperative analgesia for elective caesarean delivery [2]. They raise concerns regarding our recommendation to use the erector spinae plane (ESP) block as an alternative to long-acting neuraxial opioids, other abdominal wall blocks or wound infiltration. Their main criticism is related to the

We thank Dr Geoghegan [1] for his interest in the updated PROSPECT recommendations for postoperative analgesia for elective caesarean delivery [2]. He has critically reviewed the evidence concerning the analgesic effects of dexamethasone. In the initial PROSPECT guideline, four trials were used to support the recommendation. The trials by Shalu et al. [3] and Ituk et al. [4] have methodological limitations

We thank Dr Mackay [1] for his interest in our study [2]. He is indeed correct that the National Early Warning Score (NEWS) was much better at predicting 24-h mortality in the Kovacs et al. [3] study on emergency surgical admissions (c-statistic 0.89), than 30-day mortality following emergency bowel surgery in our paper (c-statistic 0.71). The reason for this difference is that we have used NEWS to

Kriege et al. [1] have made a significant contribution to the ongoing debate regarding switching from direct laryngoscopy (DL) to videolaryngoscopy (VL) as a standard procedure [2-5]. They studied a large number of elective patients with predicted normal airways and demonstrated the clear advantages of VL. However, I would welcome explanation of some important observations, particularly the relationship

The UK General Medical Council recently published a report confirming that progression in training and careers varies by ethnicity [1]. The gap in attainment levels between groups of doctors negatively affects those from black, Asian and minority ethnic backgrounds [2]. Differential attainment is thought to result from ethnic minorities experiencing barriers at multiple stages in postgraduate training

Exposure to opioid analgesics due to surgery increases the risk of new persistent opioid use. A mechanistic hypothesis for opioids' abuse liability rests on the belief that, in addition to pain relief, acute opioid treatment improves well-being (e.g. via euphoria) and relieves anxiety. However, opioids do not consistently improve mood in laboratory studies of healthy non-opioid users. This observational

The amount of aerosol generation associated with the use of positive pressure ventilation via a supraglottic airway device has not been quantified. We conducted a two-group, two-centre, prospective cohort study in which we recruited 21 low-risk adult patients scheduled for elective surgery under general anaesthesia with second-generation supraglottic airway devices. An optical particle sizer and an

It is essential that academic publishing complies with the highest standards in terms of ethics, research conduct and manuscript preparation. This protects the rights and welfare of research participants, ensures the integrity of study results and aids the communication and dissemination of novel findings into clinical practice. This position statement outlines the current policies and practices of

Modified-release opioids are often prescribed for the management of moderate to severe acute pain following total hip and knee arthroplasty, despite recommendations against their use due to increasing concerns regarding harm. The primary objective of this multicentre study was to examine the impact of modified-release opioid use on the incidence of opioid-related adverse events compared with immediate-release

The aim of neuraxial analgesia is to achieve excellent pain relief with the fewest adverse effects. The most recently introduced technique for epidural analgesia maintenance is the programmed intermittent epidural bolus. In a recent study, we compared this with patient-controlled epidural analgesia without a background infusion and found that a programmed intermittent epidural bolus was associated

We read with interest the study by McDonagh et al. [1] who reported a randomised controlled, non-inferiority trial comparing low-dose oxytocin (0.5 IU) and carbetocin (20 μg) with the more traditional high dose (5 IU and 100 μg respectively) regimens for elective caesarean delivery. Uterine tone after 2 min was the primary outcome and measured on a 0–10 verbal numerical rating scale (VNRS) where 0

We read with interest the article by Yoon et al. [1]. The authors found no difference in their primary outcome (postoperative pain scores), or their secondary outcomes, compared with remifentanil titrated to the patients' systolic blood pressure. We have several questions for the authors regarding the analgesic strategy utilised in both of their study groups. According to the study protocol, the patient's

We wish to inform readers of the potential peri-procedural risk of ketoacidosis in association with sodium-glucose cotransporter 2 inhibitors (SGLT2i) use in patients without diabetes. These are increasingly prescribed for patients with heart failure and chronic kidney disease, irrespective of their diabetic status. Until now, the risk of ketoacidosis with SGLT2i use has been reportedly limited to

The PROSPECT group recently added an update [1] to their original recommendations for the management of post-caesarean section pain [2]. Amongst the updates was a strengthened recommendation for the benefits of dexamethasone. The original guidelines recommended the use of dexamethasone on the basis of four trials [3-6] and this recommendation was graded as Grade A. The recent guidelines strengthened