By: Amy Walker,
on 11/12/2015
We are used to lines that guide – from those that keep our words straight on the page to those that direct planes down runways or trains along tracks. Moving from lines that guide our direction to guidelines that direct our behaviour, particularly in clinical medicine, is a very exciting time.
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By: Amy Walker,
on 5/27/2015
We all want our doctors to be familiar with the latest developments in medicine, and to be able to offer us as patients the very best and informed healthcare. It is important that doctors in the fields of anaesthesia, critical care, and pain are up to date and familiar with the latest developments in these rapidly developing areas of medicine, with new techniques and drugs emerging which improve outcomes for patients. As professionals, we cannot stand still and we must always strive to improve outcomes for our patients.
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By: Alice,
on 10/16/2014
World Anaesthesia Day commemorates the first successful demonstration of ether anaesthesia at the Massachusetts General Hospital on 16 October 1846. This was one of the most significant events in medical history, enabling patients to undergo surgical treatments without the associated pain of an operation. To celebrate this important day, we are highlighting a selection of British Journal of Anaesthesia podcasts so you can learn more about anaesthesia practices today.
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 potentially practice changing national anaesthetic audit. Professor Pandit highlights areas of AAGA risk in anaesthetic practice, discusses some of the factors (both technical and human) that lead to accidental awareness, and describes the review panels findings and recommendations to minimise the chances of AAGA.
October 2014 || Volume 113 – Issue 4 || 36 Minutes
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 to advanced airway management, which patients benefit from pre-hospital anaesthesia and the evolution of RSI algorithms. Professor Lockey goes on to discuss induction agents, describes how to achieve a 100% success rate for surgical airways and why too much choice can be a bad thing, as he gives us an insight into the exciting world of pre-hospital emergency care.
August 2014 || Volume 113 – Issue 2 || 35 Minutes
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, but in emergency departments and on intensive care units this monitoring me be unavailable or misleading. For this podcast Dr Paul Marik, Professor and Division Chief of Pulmonary Critical Care at Eastern Virginia Medical Center delivers a masterclass on the physiology of fluid optimisation, tells us which monitors to believe and importantly under which circumstances, and reviews some of the current literature and thinking on fluid responsiveness.
April 2014 || Volume 112 – Issue 4 || 43 Minutes
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 studies and the important concept of a cognitive trajectory. In addition, Dr Sanders discusses the risk factors and role of inflammation in causing brain injury, and reveals the possibility that certain patients may in fact undergo post-operative cognitive improvement (POCI).
March 2014 || Volume 112 – Issue 3 || 20 Minutes
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 circumstances. Dr Kate Jenkins, a hospital clinical psychologist describes both the psychology and physiology of needle phobia, what we as anaesthetists need to be aware of, and how we can better serve out patients for whom ‘just a small scratch’ may be their biggest fear.
July 2014 || Volume 113 – Issue 1 || 32 Minutes
For more information, visit the dedicated BJA World Anaesthesia Day webpage for a selection of free articles.
Headline image credit: Anaesthesia dreams, by Tc Morgan. CC-BY-SA-2.0 via Flickr.
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By: DanP,
on 7/27/2014
Major trauma impacts on the lives of young and old alike. Most of us know or are aware of somebody who has suffered serious injury. In the United Kingdom over five-thousand people die from trauma each year. It is the most common cause of death in people under forty. Many of the fifteen-thousand people who survive major trauma suffer life-changing injuries and some will never fully recover and require life-long care. Globally it is estimated that injuries are responsible for sixteen-thousand deaths per day together with a large burden of people left with permanent disability. These sombre statistics are driving a revolution in trauma care.
A key aspect of the changes in trauma management in the United Kingdom and around the world is the organisation of networks to provide trauma care. People who have been seriously hurt, for example in a road traffic accident, may have suffered a head injury, injuries to the heart and lungs, abdominal trauma, broken limbs, and serious loss of skin and muscle. The care of these injuries may require specialist surgery including neurosurgery, cardiothoracic surgery, general (abdominal and pelvic) surgery, orthopaedic surgery, and plastic surgery. These must be supported by high quality anaesthetic, intensive care, radiological services and laboratory services. Few hospitals are able to provide all of the services in one location. It therefore makes sense for the most seriously injured patients to be transported not to the nearest hospital but to the hospital best equipped to provide the care that they need. Many trauma services around the world now operate on this principle and from 2010 these arrangements have been established in England. Hospitals are designated to one of three tiers: major trauma centres, trauma units, and local emergency hospitals. The most seriously injured patients are triaged to bypass trauma units and local emergency hospitals and are transported directly to major trauma centres. While this is a new system and some major trauma centres in England have only “gone live” in the past two years, it has already had an impact on trauma outcomes, with monitoring by the Trauma Audit and Research Network (TARN) indicating a 19% improvement in survival after major trauma in England.
Not only have there been advances in the organisation of trauma services, but there have also been advances in the immediate clinical management of trauma. In many cases it is appropriate to undertake “early definitive surgery/early total care” – that is, definitive repair of long bone fractures within twenty-four hours of injury. However, patients who have suffered major trauma often have severe physiological and biochemical derangements by the time they arrive at hospital. The concepts of damage control surgery and damage control resuscitation have emerged for the management of these patients. In this approach resuscitation and surgery are directed towards stopping haemorrhage, performing essential life-saving surgery, and stabilising and correcting the patient’s physiological state. This may require periods of surgery followed by intervals for the administration of blood and clotting factors and time for physiological recovery before further surgery is undertaken. The decision as to whether to undertake early definitive care or to institute a damage control strategy can be complex and is made by senior clinicians working together to formulate an overview of the state of the patient.
Modern radiology and clinical imaging has helped to revolutionise modern trauma management. There is increasing evidence to suggest that early CT scanning may improve outcome in the most unstable patients by identifying life-threatening injuries and directing treatment. When a source of bleeding is identified it may be treated surgically, but in many cases interventional radiology with the placement of glue or metal coils into blood vessels to stop the bleeding offers an alternative and less invasive solution.
The evolution of the trauma team is at the core of modern trauma management. Advances in resuscitation, surgery, and imaging have undoubtedly moved trauma care forward. However, the care of the unstable, seriously injured patient is a major challenge. Transporting someone who is suffering serious bleeding to and from the CT scanner requires excellent teamwork; parallel working so that several tasks are carried out at the same time requires coordination and leadership; making the decision between damage control and definitive surgery requires effective joint decision-making. The emergence of modern trauma care has been matched by the development of the modern trauma team and of specialists dedicated to the care of seriously injured patients. It is to this, above all, that the increasing numbers of survivors from serious trauma owe their lives.
Dr Simon Howell is on the Board of the British Journal of Anaesthesia (BJA) and is the Editor of this year’s Postgraduate Educational Issue: Advances in Trauma Care. This issue contains a series of reviews that give an overview of the revolution in trauma care. The reviews expand on a number of presentations that were given at a two-day meeting on trauma care organised by the Royal College of Anaesthetists in the Spring of 2014. They visit aspects of the trauma patient’s journey from the moment of injury to care in the field, on to triage, and arrival in a trauma centre finally to resuscitation and surgical care.
Founded in 1923, one year after the first anaesthetic journal was published by the International Anaesthesia Research Society, the British Journal of Anaesthesia remains the oldest and largest independent journal of anaesthesia. It became the Journal of The College of Anaesthetists in 1990. The College was granted a Royal Charter in 1992. Since April 2013, the BJA has also been the official Journal of the College of Anaesthetists of Ireland and members of both colleges now have online and print access. Although there are links between BJA and both colleges, the Journal retains editorial independence.
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