Impact of spinal or epidural anaesthesia on perioperative outcomes in adult noncardiac surgery: a narrative review of recent evidence.

Spinal and epidural anaesthesia and analgesia are important anaesthetic techniques, familiar to all anaesthetists and applied to patients undergoing a range of surgical procedures. Although the immediate effects of a well-conducted neuraxial technique on nociceptive and sympathetic pathways are readily observable in clinical practice, the impact of such techniques on patient-centred perioperative outcomes remains an area of uncertainty and active research. The aim of this review is to present a narrative synthesis of contemporary clinical science on this topic from the most recent 5-year period and summarise the foundational scholarship upon which this research was based. We searched electronic databases for primary research, secondary research, opinion pieces, and guidelines reporting the relationship between neuraxial procedures and standardised perioperative outcomes over the period 2018-2023. Returned citation lists were examined seeking additional studies to contextualise our narrative synthesis of results. Articles were retrieved encompassing the following outcome domains: patient comfort, renal, sepsis and infection, postoperative cancer, cardiovascular, and pulmonary and mortality outcomes. Convincing evidence of the beneficial effect of epidural analgesia on patient comfort after major open thoracoabdominal surgery outcomes was identified. Recent evidence of benefit in the prevention of pulmonary complications and mortality was identified. Despite mechanistic plausibility and supportive observational evidence, there is less certain experimental evidence to support a role for neuraxial techniques impacting on other outcome domains. Evidence of positive impact of neuraxial techniques is best established for the domains of patient comfort, pulmonary complications, and mortality, particularly in the setting of major open thoracoabdominal surgery. Recent evidence does not strongly support a significant impact of neuraxial techniques on cancer, renal, infection, or cardiovascular outcomes after noncardiac surgery in most patient groups.

Celebrating the state of the art and innovations in regional anaesthesia in the British Journal of Anaesthesia.

To coincide with the annual scientific meeting of Regional Anaesthesia UK in London 2024, where there is a joint scientific session with the British Journal of Anaesthesia, a special regional anaesthesia edition of the journal has been produced. This editorial offers some highlights from the manuscripts contained within the special edition.

Workplace Productivity, Health and Wellbeing: Findings From a Cluster Randomised Controlled Trial of a Workplace Intervention to Reduce Sitting in Office Workers.

OBJECTIVE: The aim of the study was to evaluate the feasibility and potential effects of a workplace intervention to reduce and break up sitting. METHODS: Office workers were randomized in clusters to intervention ( n = 22) or control ( n = 22). The intervention included a height-adjustable workstation, education, computer prompt software, and line manager support. Outcomes included device-measured workplace sitting and ecological momentary assessed workplace productivity. Recruitment, retention, and data completion rates were assessed. RESULTS: Recruitment ( N = 44), retention (91%), and workplace sitting measurement rates demonstrated study feasibility. At 8 weeks, workplace sitting was 11% lower (95% CI: -20.71, -1.30) in the intervention group compared with control participants. Intervention participants were also more engaged, motivated, and productive while sitting ( P ≤ 0.016). CONCLUSIONS: It was feasible to implement and evaluate this office workplace intervention, with potential benefits on workplace sitting and ecological momentary assessed productivity.

Effects of colour-coded compartmentalised syringe trays on anaesthetic drug error detection under cognitive load.

BACKGROUND: Anaesthetic drug administration is complex, and typical clinical environments can entail significant cognitive load. Colour-coded anaesthetic drug trays have shown promising results for error identification and reducing cognitive load. METHODS: We used experimental psychology methods to test the potential benefits of colour-coded compartmentalised trays compared with conventional trays in a simulated visual search task. Effects of cognitive load were also explored through an accompanying working memory-based task. We hypothesised that colour-coded compartmentalised trays would improve drug-detection error, reduce search time, and reduce cognitive load. This comprised a cognitive load memory task presented alongside a visual search task to detect drug errors. RESULTS: All 53 participants completed 36 trials, which were counterbalanced across the two tray types and 18 different vignettes. There were 16 error-present and 20 error-absent trials, with 18 trials presented for each preloaded tray type. Syringe errors were detected more often in the colour-coded trays than in the conventional trays (91% vs 83%, respectively; P=0.006). In signal detection analysis, colour-coded trays resulted in more sensitivity to the error signal (2.28 vs 1.50, respectively; P<0.001). Confidence in response accuracy correlated more strongly with task performance for the colour-coded tray condition, indicating improved metacognitive sensitivity to task performance (r=0.696 vs r=0.447). CONCLUSIONS: Colour coding and compartmentalisation enhanced visual search efficacy of drug trays. This is further evidence that introducing standardised colour-coded trays into operating theatres and procedural suites would add an additional layer of safety for anaesthetic procedures.

The effects of adapted mind-body exercises on physical function, quality of life and wellbeing for older people: a systematic review and meta-analysis.

BACKGROUND: Participating in physical activity programmes is one way to optimise wellbeing and quality of life in older adults. Mind-body exercises could provide greater benefits than other forms of traditional physical activity and can be easily adapted for older people who are starting to develop functional decline. OBJECTIVES: To synthesise the literature looking at the effects of adapted mind-body interventions on older people. DESIGN: A systematic review and meta-analysis was conducted on articles from Web of Science, MEDLINE, SPORTDiscus, AMED and CINAHL that were searched up to 13 September 2023. Studies were extracted and assessed by two authors and included if they were adapted mind-body quasi experimental trials (QET) or randomised controlled trials (RCT) evaluating physical function, quality of life or wellbeing in community dwelling older adults aged 60 years and over. The Cochrane Risk of Bias 2 scale was used for quality appraisal. Analysis of the results included calculating standardised effect sizes (Hedge's g) and a narrative synthesis of results not included in meta-analysis. RESULTS: 18 studies (8 quasi-experimental trial designs, n = 310; 10 randomised control trials, n = 1829) were included in the systematic review, with 14 studies (9 RCT, n = 1776, 5 QET, n = 100) retained for meta-analysis. For the RCT studies, some improvement was noted in mobility (ES 0.36: 95% CI: 0.01, 0.71), flexibility (ES 0.36: 0.01, 0.70), well-being (ES 0.54: 0.18, 0.91) and quality of life (ES 0.50: 0.21, 0.79). No positive effect was observed for leg power (ES 0.09: -0.33, 0.51), leg endurance (ES 0.16: -0.72, 1.03), back scratch test (ES 0.24: -0.10, 0.59), or balance, (ES 0.05: -0.06, 0.15). Heterogeneity varied from 0%-87% across the different outcomes. For the QET studies, gait velocity was shown to improve (ES 0.54: 0.18, 0.91), while fear of falling showed no significant improvements (ES 0.82: -0.06, 1.69). A meta-regression for quality of life in which the total physical activity of the intervention, in hours, was used as a covariate, showed ES = 1.1 for every 100 h of physical activity. CONCLUSION: There is scope for adapted mind-body physical activity interventions to play a role in improving quality of life, wellbeing, and physical function in older adults. The provision of adapted interventions for older people might improve uptake of and engagement with physical activity interventions in older people with limited or reduced abilities.

Postoperative ulnar neuropathy: a systematic review of evidence with narrative synthesis.

BACKGROUND: Postoperative ulnar neuropathy (PUN) is an injury manifesting in the sensory or motor distribution of the ulnar nerve after anaesthesia or surgery. The condition frequently features in cases of alleged clinical negligence by anaesthetists. We performed a systematic review and applied narrative synthesis with the aim of summarising current understanding of the condition and deriving implications for practice and research. METHODS: Electronic databases were searched up to October 2022 for primary research, secondary research, or opinion pieces defining PUN and describing its incidence, predisposing factors, mechanism of injury, clinical presentation, diagnosis, management, and prevention. RESULTS: We included 83 articles in the thematic analysis. PUN occurs after approximately 1 in 14 733 anaesthetics. Men aged 50-75 yr with pre-existing ulnar neuropathy are at highest risk. Preventative measures, based on consensus and expert opinion, are summarised, and an algorithm of suspected PUN management is proposed, based upon the identified literature. CONCLUSIONS: Postoperative ulnar neuropathy is rare and the incidence is probably decreasing over time with general improvements in perioperative care. Recommendations to reduce the risk of postoperative ulnar neuropathy are based on low-quality evidence but include anatomically neutral arm positioning and padding intraoperatively. In selected high-risk patients, further documentation of repositioning, intermittent checks, and neurological examination in the recovery room can be helpful.

Regional analgesia for total hip arthroplasty and Schwartz's paradox.

Enhanced recovery after total hip arthroplasty aims to facilitate return to function and early hospital discharge, but the role of novel fascial plane block techniques in such pathways is uncertain. A randomised trial by Kukreja and colleagues describes superior quality of recovery after hip arthroplasty in patients receiving a pericapsular nerve group (PENG) block. We discuss the trial findings in the context of ongoing uncertainty regarding best analgesic practice for this surgical procedure.

Clinical hypnosis: implications in anaesthesia and perioperative care.

A randomised trial published in the British Journal of Anaesthesia describes hypnosis compared with general anaesthesia in 60 children undergoing superficial surgery. We describe a definition of clinical hypnosis; the goals and conduct of hypnotic communication; and its potential as both an adjunct and, in suitable cases, alternative to traditional pharmacological anaesthesia.

Integrated Care for Older People with Different Frailty Levels: A Qualitative Study of Local Implementation of a National Policy in Luton, England.

Introduction: The NHS England General Medical Services 2017-18 contract made it mandatory for general practices in England to identify and manage older people proactively. In response to the national policy, the Luton Framework for Frailty (LFF) programme was developed to target older residents of Luton and offer interventions according to their frailty level. The aim of this study was to gain a deeper understanding of the LFF and the factors that affect the implementation of a proactive integrated care service for older people with different frailty levels (OPDFL). Methods: We undertook document analyses and conducted semi-structured interviews with stakeholders to create a 'thick description' that provides insights into the LFF. Results: Healthy ageing interventions bring beneficial outcomes but to increase the uptake they should be co-produced with older people. A common electronic system within primary care and multidisciplinary team meetings (MDT) aid implementation. However, variation in implementation across Luton, different levels of buy-in for MDT, and different data systems in primary and secondary care make implementation challenging. Conclusion: The LFF is a promising initiative and lessons learned are likely to be transferable to other settings as proactive management of frailty takes on greater policy prominence in the UK and worldwide.

Standardised colour-coded compartmentalised syringe trays improve anaesthetic medication visual search and mitigate cognitive load.

BACKGROUND: Anaesthetic procedures are complex and subject to human error. Interventions to alleviate medication errors include organised syringe storage trays, but no standardised methods for drug storage have yet been widely implemented. METHODS: We used experimental psychology methods to explore the potential benefits of colour-coded compartmentalised trays compared with conventional trays in a visual search task. We hypothesised that colour-coded compartmentalised trays would reduce search time and improve error detection for both behavioural and eye-movement responses. We recruited 40 volunteers to identify syringe errors presented in pre-loaded trays for 16 trials in total: 12 error present and four error absent, with eight trials presented for each tray type. RESULTS: Errors were detected faster when presented in the colour-coded compartmentalised trays than in conventional trays (11.1 s vs 13.0 s, respectively; P=0.026). This finding was replicated for correct responses for error-absent trays (13.3 s vs 17.4 s, respectively; P=0.001) and in the verification time of error-absent trays (13.1 s vs 17.2 s, respectively; P=0.001). On error trials, eye-tracking measures revealed more fixations on the drug error for colour-coded compartmentalised trays (5.3 vs 4.3, respectively; P<0.001), whilst more fixations on the drug lists for conventional trays (8.3 vs 7.1, respectively; P=0.010). On error-absent trials, participants spent longer fixating on the conventional trials (7.2 s vs 5.6 s, respectively; P=0.002). CONCLUSIONS: Colour-coded compartmentalisation enhanced visual search efficacy of pre-loaded trays. Reduced fixations and fixation times for the loaded tray were shown for colour-coded compartmentalised trays, indicating a reduction in cognitive load. Overall, colour-coded compartmentalised trays were associated with significant performance improvements when compared with conventional trays.

The Importance of Mitral Valve Prolapse Doming Volume in the Assessment of Left Ventricular Stroke Volume with Cardiac MRI.

There remains a debate whether the ventricular volume within prolapsing mitral valve (MV) leaflets should be included in the left ventricular (LV) end-systolic volume, and therefore factored in LV stroke volume (SV), in cardiac magnetic resonance (CMR) assessments. This study aims to compare LV volumes during end-systolic phases, with and without the inclusion of the volume of blood on the left atrial aspect of the atrioventricular groove but still within the MV prolapsing leaflets, against the reference LV SV by four-dimensional flow (4DF). A total of 15 patients with MV prolapse (MVP) were retrospectively enrolled in this study. We compared LV SV with (LV SVMVP) and without (LV SVstandard) MVP left ventricular doming volume, using 4D flow (LV SV4DF) as the reference value. Significant differences were observed when comparing LV SVstandard and LV SVMVP (p < 0.001), and between LV SVstandard and LV SV4DF (p = 0.02). The Intraclass Correlation Coefficient (ICC) test demonstrated good repeatability between LV SVMVP and LV SV4DF (ICC = 0.86, p < 0.001) but only moderate repeatability between LV SVstandard and LV SV4DF (ICC = 0.75, p < 0.01). Calculating LV SV by including the MVP left ventricular doming volume has a higher consistency with LV SV derived from the 4DF assessment. In conclusion, LV SV short-axis cine assessment incorporating MVP dooming volume can significantly improve the precision of LV SV assessment compared to the reference 4DF method. Hence, in cases with bi-leaflet MVP, we recommend factoring in MVP dooming into the left ventricular end-systolic volume to improve the accuracy and precision of quantifying mitral regurgitation.

Closing the gap: artificial intelligence applied to ultrasound-guided regional anaesthesia.

The role of artificial intelligence in ultrasound-guided regional anaesthesia is explored in a recent study by Bowness and colleagues, published in the British Journal of Anaesthesia. The investigators showed that non-expert ability to identify key sono-anatomical structures was improved with the assistance of proprietary artificial intelligence software. Whether such software could increase learning efficiency, and thereby patient access, to regional anaesthesia, will require further study.

The Frail-LESS (LEss Sitting and Sarcopenia in Frail older adults) intervention to improve sarcopenia and maintain independent living via reductions in prolonged sitting: a randomised controlled feasibility trial protocol.

BACKGROUND: Sarcopenia is a progressive and generalised loss of muscle mass and function with advancing age and is a major contributor to frailty. These conditions lead to functional disability, loss of independence, and lower quality of life. Sedentary behaviour is adversely associated with sarcopenia and frailty. Reducing and breaking up sitting should thus be explored as an intervention target for their management. The primary aim of this study, therefore, is to examine the feasibility, safety, and acceptability of conducting a randomised controlled trial (RCT) that evaluates a remotely delivered intervention to improve sarcopenia and independent living via reducing and breaking up sitting in frail older adults. METHODS: This mixed-methods randomised controlled feasibility trial will recruit 60 community-dwelling older adults aged ≥ 65 years with very mild or mild frailty. After baseline measures, participants will be randomised to receive the Frail-LESS (LEss Sitting and Sarcopenia in Frail older adults) intervention or serve as controls (usual care) for 6 months. Frail-LESS is a remotely delivered intervention comprising of tailored feedback on sitting, information on the health risks of excess sitting, supported goal setting and action planning, a wearable device that tracks inactive time and provides alerts to move, health coaching, and peer support. Feasibility will be assessed in terms of recruitment, retention and data completion rates. A process evaluation will assess intervention acceptability, safety, and fidelity of the trial. The following measures will be taken at baseline, 3 months, and 6 months: sitting, standing, and stepping using a thigh-worn activPAL4 device, sarcopenia (via hand grip strength, muscle mass, and physical function), mood, wellbeing, and quality of life. DISCUSSION: This study will determine the feasibility, safety, and acceptability of evaluating a remote intervention to reduce and break up sitting to support improvements in sarcopenia and independent living in frail older adults. A future definitive RCT to determine intervention effectiveness will be informed by the study findings. TRIAL REGISTRATION: ISRCTN, ISRCTN17158017; Registered 6 August 2021, https://www.isrctn.com/ISRCTN17158017.

Association between anesthesia modality and clinical outcomes following endovascular stroke treatment in the extended time window.

BACKGROUND: There is a paucity of data on anesthesia-related outcomes for endovascular treatment (EVT) in the extended window (>6 hours from ischemic stroke onset). We compared functional and safety outcomes between local anesthesia (LA) without sedation, conscious sedation (CS) and general anesthesia (GA). METHODS: Patients who underwent EVT in the early (<6 hours) and extended time windows using LA, CS, or GA between October 2015 and March 2020 were included from a UK national stroke registry. Multivariable analyses were performed, adjusted for age, sex, baseline stroke severity, pre-stroke disability, EVT technique, center, procedural time and IV thrombolysis. RESULTS: A total of 4337 patients were included, 3193 in the early window (1135 LA, 446 CS, 1612 GA) and 1144 in the extended window (357 LA, 134 CS, 653 GA). Compared with GA, patients treated under LA alone had increased odds of an improved modified Rankin Scale (mRS) score at discharge (early: adjusted common (ac) OR=1.50, 95% CI 1.29 to 1.74, p=0.001; extended: acOR=1.29, 95% CI 1.01 to 1.66, p=0.043). Similar mRS scores at discharge were found in the LA and CS cohorts in the early and extended windows (p=0.21). Compared with CS, use of GA was associated with a worse mRS score at discharge in the early window (acOR=0.73, 95% CI 0.45 to 0.96, p=0.017) but not in the extended window (p=0.55). There were no significant differences in the rates of symptomatic intracranial hemorrhage or in-hospital mortality across the anesthesia modalities in the extended window. CONCLUSION: LA without sedation during EVT was associated with improved functional outcomes compared with GA, but not CS, within and beyond 6 hours from stroke onset. Prospective studies assessing anesthesia-related outcomes in the extended time window are warranted.

The Association between Social Vulnerability and Frailty in Community Dwelling Older People: A Systematic Review.

The aim of this systematic literature review was to determine whether social vulnerability is associated with frailty in older people. Databases were searched for literature from January 2001 to March 2022. Hand searches of reference lists of the selected articles were also used to identify other relevant studies. Studies that met the inclusion criteria were selected. Two independent reviewers assessed the methodological quality using an established tool. Eleven eligible studies from Canada, Europe, USA, Tanzania, Mexico, and China were selected. The level of social vulnerability measured by the Social Vulnerability Index (SVI) from a meta-analysis was 0.300 (95% CI: 0.242, 0.358), with the highest SVI in Tanzania (0.49), while the lowest level of SVI was reported in China (0.15). The highest frailty level of 0.32 was observed in both Tanzania and Europe, with the lowest frailty reported in a USA study from Hawaii (0.15). In all studies, social vulnerability was a significant predictor of mortality for both sexes at subsequent data collection points. The association between SVI and frailty was high in Tanzania (r = 0.81), with other studies reporting stronger correlations for females compared to males, but at small to moderate levels. In one study, an increase of 1SD in SVI was linked to a 20% increase in frailty score at a subsequent evaluation. Additional study is warranted to determine a potential causality between social vulnerability and frailty.

Erector Spinae Plane Blocks for the Early Analgesia of Rib Fractures in Trauma (ESPEAR): protocol for a multicentre pilot randomised controlled trial with feasibility and embedded qualitative assessment.

INTRODUCTION: Patients with rib fractures commonly experience significant acute pain and are at risk of hypoxia, retained secretions, respiratory failure and death. Effective analgesia improves these outcomes. There is widespread variation in analgesic treatments given to patients including oral, intravenous and epidural routes of administration. Erector spinae plane (ESP) blockade, a novel regional analgesic technique, may be effective, but high-quality evidence is lacking. METHODS AND ANALYSIS: To determine if a definitive trial of ESP blockade in rib fractures is possible, we are conducting a multicentre, randomised controlled pilot study with feasibility and qualitative assessment. Fifty adult patients with rib fractures will be randomised in a 1:1 ratio to ESP blockade with multimodal analgesia or placebo ESP blockade with multimodal analgesia. Participants and outcome assessors will be blinded. The primary feasibility outcomes are recruitment rate, retention rate and trial acceptability assessed by interview. ETHICS AND DISSEMINATION: The study was approved by the Oxford B Research Ethics Committee on 22 February 2022 (REC reference: 22/SC/0005). All participants will provide written consent. Trial results will be reported via peer review and to grant funders. TRIAL REGISTRATION NUMBER: ISRCTN49307616.

Kat-ARC accelerated 4D flow CMR: clinical validation for transvalvular flow and peak velocity assessment.

BACKGROUND: To validate the k-adaptive-t autocalibrating reconstruction for Cartesian sampling (kat-ARC), an exclusive sparse reconstruction technique for four-dimensional (4D) flow cardiac magnetic resonance (CMR) using conservation of mass principle applied to transvalvular flow. METHODS: This observational retrospective study (2020/21-075) was approved by the local ethics committee at the University of East Anglia. Consent was waived. Thirty-five patients who had a clinical CMR scan were included. CMR protocol included cine and 4D flow using Kat-ARC acceleration factor 6. No respiratory navigation was applied. For validation, the agreement between mitral net flow (MNF) and the aortic net flow (ANF) was investigated. Additionally, we checked the agreement between peak aortic valve velocity derived by 4D flow and that derived by continuous-wave Doppler echocardiography in 20 patients. RESULTS: The median age of our patient population was 63 years (interquartile range [IQR] 54-73), and 18/35 (51%) were male. Seventeen (49%) patients had mitral regurgitation, and seven (20%) patients had aortic regurgitation. Mean acquisition time was 8 ± 4 min. MNF and ANF were comparable: 60 mL (51-78) versus 63 mL (57-77), p = 0.310). There was an association between MNF and ANF (rho = 0.58, p < 0.001). Peak aortic valve velocity by Doppler and 4D flow were comparable (1.40 m/s, [1.30-1.75] versus 1.46 m/s [1.25-2.11], p = 0.602) and also correlated with each other (rho = 0.77, p < 0.001). CONCLUSIONS: Kat-ARC accelerated 4D flow CMR quantified transvalvular flow in accordance with the conservation of mass principle and is primed for clinical translation.

Pressor therapy in acute ischaemic stroke: an updated systematic review.

Background: Low blood pressure (BP) in acute ischaemic stroke (AIS) is associated with poor functional outcome, death, or severe disability. Increasing BP might benefit patients with post-stroke hypotension including those with potentially salvageable ischaemic penumbra. This updated systematic review considers the present evidence regarding the use of vasopressors in AIS. Methods: We searched the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE and trial databases using a structured search strategy. We examined reference lists of relevant publications for additional studies examining BP elevation in AIS. Results: We included 27 studies involving 1886 patients. Nine studies assessed increasing BP during acute reperfusion therapy (intravenous thrombolysis, mechanical thrombectomy, intra-arterial thrombolysis or combined). Eighteen studies tested BP elevation alone. Phenylephrine was the most commonly used agent to increase BP (n = 16 studies), followed by norepinephrine (n = 6), epinephrine (n = 3) and dopamine (n = 2). Because of small patient numbers and study heterogeneity, a meta-analysis was not possible. Overall, BP elevation was feasible in patients with fluctuating or worsening neurological symptoms, large vessel occlusion with labile BP, sustained post-stroke hypotension and ineligible for intravenous thrombolysis or after acute reperfusion therapy. The effects on functional outcomes were largely unknown and close monitoring is advised if such intervention is undertaken. Conclusion: Although theoretical arguments support increasing BP to improve cerebral blood flow and sustain the ischaemic penumbra in selected AIS patients, the data are limited and results largely inconclusive. Large, randomised controlled trials are needed to identify the optimal BP target, agent, duration of treatment and effects on clinical outcomes.