Authors: Mike Charlesworth and Andrew Klein
We are all familiar with the successes of the National Emergency Laparotomy Audit, but what about those patients where emergency surgery is not appropriate? For five common acute surgical conditions, this new database study from Hutchings et al. compares those who did and did not receive emergency general surgery. They included nearly a million patients who were inpatients between 2010 and 2019. The primary outcome (DAH90) was similar for emergency surgery and non-emergency surgery strategies. However, the most striking result was the influence of frailty, age and number of comorbidities. There is a wealth of information which can be used to assist with discussions between clinicians and patients in the context of emergency general surgery. In the associated editorial, Forrester and Wren put the decision to operate in the context of its epidemiological triad (Fig. 1). They argue for caution when interpreting the results of Hutchings et al. because determining the ‘effectiveness’ of surgery is complex. It seems that more research is required and despite the advantages of instrument variable analysis provides, a prospective randomised study may provider more clarity.
Persistent pain following knee arthroplasty is common, and persistent opioid use in these patients is of concern. This new secondary analysis from Kluger et al. identified pre-operative opioid use, increased body mass index and multiple comorbid pain sites as important risk factors. In the associated editorial, Levy et al. argue for the need to improve opioid prescribing in patients undergoing orthopaedic surgery. They look to the pre-operative period and highlight the fact that opioids are not a benign class of drug. Adverse effects include: increased surgical site infection risk; increased rate of early revision surgery; prolonged hospital stay; and greater likelihood of non-home discharge.
There has been increasing evidence that lower doses of oxytocin and carbetocin following caesarean section are just as effective as higher doses but with a better side effect profile. This new double-blind, randomised, controlled, non-inferiority trial from McDonagh et al. compared the effect of low- and high-dose carbetocin and low- and high-dose oxytocin on uterine tone intensity at elective caesarean delivery. They found that low-dose carbetocin (20 μg) was non-inferior to high-dose carbetocin (100 μg) for the primary and secondary outcomes of uterine tone intensity at 2, 5 and 10 min after drug administration. Similarly, low-dose oxytocin (0.5 IU) was non-inferior to high-dose oxytocin (5 IU) for these outcomes (Fig. 2). A systematic review and network meta-analysis from Halliday et al. compared ultra-low, low and high concentration local anaesthetic for labour epidural analgesia. They found that ultra-low concentration local anaesthetic is associated with reduced total local anaesthetic dose, shorter first stage of labour and reduced incidence of Apgar < 7 at 1 min compared with low concentration, without compromising maternal analgesia, side-effect profile, satisfaction or neonatal outcomes. A narrative review from McCombe and Bogod brings together learning from 21 years of litigation for anaesthetic negligence resulting in peripartum hypoxic ischaemic encephalopathy. They explore four themes: delay; communication; hypotension following neuraxial anaesthesia; and documentation. Their paper is essential reading for all anaesthetists who work with pregnant women. Earlier this year, Plaat et al. published guidance on prevention and management of intra-operative pain during caesarean section under neuraxial anaesthesia. This new editorial from McGlennan and Christmas explores the background to the paper as well as the clinical context. They remind us that we should always remain open to the possibility of a suboptimal block, and that true failure on behalf of the anaesthetist is failure to recognise and act.
Elsewhere we have an evaluation of the outcome metric ‘days alive and at home’ in older patients after hip fracture surgery and an editorial praising developments in adult critical care transfer in England, which it is argued is a positive legacy of the COVID-19 pandemic. Finally, Miles and Story provide us with the first a new series of articles of ‘Reviewer Recommendations’. They takes us through the steps of how to design and publish quality science studies, which examine how readily and effectively research findings and guideline recommendations are translated into clinical practice and the outcomes of iterative quality improvement. These articles will become essential reading for anyone who wishes to increase their chances of publication acceptance not just in Anaesthesia, but wherever authors might choose to send their work.