Rapid Sequence

The 7th UK National Audit Project (NAP7). The challenges of defining, studying and learning from peri‐operative cardiac arrest

Welcome to this Anaesthesia Journal Podcast which is all about the the 7th UK National Audit Project (NAP7), and more specifically, the challenges of defining, studying and learning from peri‐operative cardiac arrest.

With the discovery of general anaesthesia came the issue of cardiac arrest during anaesthesia. It is thought to occur rarely, ranging from 2-13 per 10,000 anaesthetics and there is much that remains incompletely understood. As such, peri-operative cardiac arrest has been chosen as the topic for the 7^th National Audit Project of the Royal College of Anaesthetists.

With us today we have the NAP7 clinical lead, Dr Jasmeet Soar, as well as NAP7 fellows Dr Andrew Kane and Dr Emira Kursumovic.

Awake tracheal intubation with the ProVu™ video stylet: a case series

Welcome to the first ever Anaesthesia Reports live broadcast – what will hopefully be the first of many - where we chat with the authors of their reports about the interesting scenarios they have encountered in their own clinical practice. This session was chaired by Dr Maryann Turner, who is an editor of Anaesthesia Reports and a paediatric anaesthetist based in Sydney.

Dealing with a predicted difficult airway is a common challenge in anaesthesia. There are several different devices on the market that are designed to facilitate tracheal intubation in these patients and traditionally, a bronchoscope or a video laryngoscope would be used. But today, we are going to discuss the use of the ProVu™ video stylet as an alternative device for use in these patients.

We were joined by Dr Imran Ahmad and Dr Siew-Ling Harrison, who are the authors the paper. Imran is a consultant anaesthetist at Guy’s and St Thomas’ and the director of the Guy’s Airway Management Course, as well as the honorary secretary of the Difficult Airway Society. Siew-ling is a senior trainee in the south east of London who is the outgoing airway fellow under Imran and the current thoracic fellow at Guys Hospital.

The Great Aerosol Debate 2!

There is much debate over the role of respiratory particles in guidelines for preventing transmission of COVID-19. Larger particles are traditionally called ‘droplets’ and are deemed to travel only 1-2 metres from an infected patient before falling to the ground. Aerosols are smaller particles and stay floating in the air for prolonged periods, spread further, may accumulate in poorly ventilated spaces, can be inhaled deep into the lungs and bypass looser fitting facemasks. Much current guidance is designed to protect from droplets and infection spread by aerosols is only considered a risk when caused by medical therapies. In this new study, the volunteers produced up to 100 times more aerosol particles with activities such as coughing than they did during treatment with oxygen therapies.

This challenges the current guidelines which state healthcare staff looking after patients with COVID-19 who are coughing and have breathing difficulty only need PPE that protects against the larger droplets. ‘Droplet protection’ includes surgical masks but does not prevent  aerosol particles passing around the edges of the masks and being inhaled. N95/FFP3 respirators which are tightfitting and filter better, block more aerosols but guidelines currently recommend these only for staff looking after patients receiving the advanced oxygen therapies.

This new study from Wilson et al. challenges the guidance that special aerosol precautions are only needed when using oxygen therapies for COVID-19 patients, and raises concerns about safety of staff and patients on hospital wards, if they are not protected from infectious aerosols. We were joined by authors Dr Nick Wilson and Professor Tim Cook, as well as expert Professor Tony Pickering and Editor Laura Duggan. The broadcast has already been viewed over 10k times!

The need for safe, stable and sustainable resumption of planned surgery in an era of COVID‐19

Today we published a new editorial which outlines the principles laid out in the recently released document from the Royal College of Anaesthetists, the Association of Anaesthetists and the Faculty of Intensive Care Medicine on resumption of planned surgical services.

The resumption of planned healthcare in 2021 is both a necessity and an opportunity, but it will require co‐ordination at all levels and acknowledgement and planning that accommodates the physical and psychological needs of those who have worked throughout the pandemic in order to deliver the safe, stable and sustainable service that will be required in the years to come.

Authors Professor Tim Cook and Dr Tei Sheraton are joined by Dr Kariem El-Boghdadly to go through the many issues raised in the paper.

Malignant hyperthermia guideline from the Association of Anaesthetists

Malignant hyperthermia (MH) is a rare anaesthetic emergency. It has been estimated to occur in between 1:10,000 and 1:150,000 general anaesthetics, though there is much uncertainity about the precision of these estimates.

The Association of Anaesthetists has not previously published full MH guidelines. In the absence of any recent guidelines published in a peer reviewed journal, rather than simply updating the 2011 crisis management laminates, a Working Party was established to produce these formal comprehensive guidelines. Importantly, the scope of these guidelines is extended to include practical guidance for anaesthetists dealing with a case of suspected malignant hyperthermia once the acute reaction has been reversed.

With us today we have the lead author of the paper, Professor Phil Hopkins from the Malignant Hyperthermia Unit at St. James’ University Hospital and the University of Leeds. We are also delighted to be joined by Connor Philips, an award-winning television presenter, BBC radio presenter, writer and live event host whose broadcasting work includes sport, entertainment, current affairs, film, music, travel, comedy and property. Connor and several family members have been affected by MH, and his insights and experiences of this rare condition will be of interest to all.

Timing of surgery following SARS-CoV-2 infection

Today we will explore our exciting new publication that examines the timing of surgery after SARS-CoV-2 infection. 

With us today we have Joana Simoes, Dmitri Nepogodiev and Aneel Bhangu who are co-authors of the paper. They were interviewed by Ben Morton, who is an Editor of Anaesthesia. The authors are representatives from the NIHR Global Health Research Unit on Global Surgery, a collaborative team who authored this piece.

This multi-cente, multi-country prospective cohort study examined the risk of death after surgery following an episode of SARS-CoV-2 infection. We, at the journal, felt that the findings are highly clinically relevant and are extremely pleased that the team has agreed to this live broadcast to discuss their findings.

The importance of women’s health in peri‐operative care

“When we get it right for girls and women, everyone benefits." 

On #InternationalWomensDay2021 we were delighted to publish a special issue of 17 free to access articles all about the importance of women's health in peri-operative care. 

For this podcast, Seema Agarwal and Helen Laycock were joined by Ed Mullins and Alana Flexman to discuss some of the most important themes from the issue. 

The prevention of opioid‐related harm in adult surgical patients

With us today we have Dr Jane Quinlan from Oxford and Dr Nicholas Levy from Bury St. Edmunds, who are co-authors of a new international multidisciplinary consensus statement on the prevention of opioid‐related harm in adult surgical patients. Their aim was to provide balanced guidance on the safe peri‐operative use of opioids in adults.

The guidance should assist healthcare professionals and hospitals across the world to implement effective opioid stewardship practices that achieve a balance between the administration of sufficient opioid analgesia to facilitate recovery and restoration of function, while concurrently minimising the risk of opioid‐related harms.

This one is not just aimed at anaesthetists or doctors, but all healthcare professionals, patients and the public alike!

Mortality in patients admitted to intensive care with COVID‐19

Armstrong et al. conducted an initial systematic review and meta‐analysis of 24 observational studies published by 31 May 2020, which included 10,150 patients, finding that mortality was 41.6%, with evidence that this was decreasing as the pandemic progressed.

This new updated meta-analysis seems to show that any fall in mortality rate between June and September appears to have flattened or plateaued.

For this podcast, Mike Charlesworth speaks with authors Richard Armstrong and Tim Cook, as well as Danny Bryden, Rupert Pearse, Mandeep-Kaur Phull and Zudin Puthucheary. 

Direct reporting of awareness in maternity patients (DREAMY)

The direct reporting of awareness in maternity patients (DREAMY) study was a multicentre, prospective cohort study that aimed to establish the incidence, risk‐factors and sequelae of AAGA in obstetrics. A secondary study was embedded within it with the aim of describing general anaesthesia practice in obstetric patients in the UK.

We were joined live by authors Dr Peter Odor and Professor Nuala Lucas, as well as OAA President Dr Chris Elton. We discussed everything to do with these papers but also obstetric general anaesthesia more generally.