Preventing oesophageal intubation

If the PUMA guideline was the most important paper from this year, the results from NAP7 promise to deliver the same in 2023. But before all is revealed, this new paper takes us through the methods in detail. That the authorship delivered the project during the COVID-19 pandemic is a remarkable achievement and underscores the drive and determination behind the whole team. Not only that, the NAP7 infrastructure was activated to monitor the impact of COVID-19 on anaesthetic and surgical activity between October 2020 and January 2021 (ACCC-track). One of the many difficulties faced was to derive a unified definition of ‘peri-operative cardiac arrest’, which has been a source of controversy for many years. Although these events are rare and there is a great deal to learn from the analysis of individual cases, the project will also report some interesting trends at a national level with implications for all doctors, patients and policy makers.

Was it worth treating patient with COVID-19 in critical care areas? This new prospective single centre study from Schallner et al. found that direct medical costs for the treatment of COVID-19 patients were higher than for other critically ill patients, which was not exclusively due to longer length of stay (Fig. 1). Despite these high costs, they conclude the associated care to be cost-effective and beneficial regarding QALYS gained in relation to other medical measures. In the associated editorial, Pandit highlights several limitations of the analysis which suggest that we should not allow these data to inform public policy.

Postoperative morbidity following colorectal surgery can only be improved if it is measured and modelled. This new study from Bedford et al. describes the development and internal validation of the PQIP colorectal risk model. It demonstrates good calibration to risk-adjust postoperative day 7 morbidity defined by the POMS in the setting of elective major colorectal surgery with discrimination performance superior to published morbidity risk models. In the associated editorial, Coulson et al. set the work in its context and describe a pyramid model of investigation into unexpected variation is proposed (Fig 2.).

This new study aims to break the cycle of unnecessary lengthy periods of pre-operative fasting by using iterative ‘plan-do-study-act’ methods. They managed overall to reduce the median liquid fasting time from 12 h to 2 h, which is in keeping with international guidance. The key factor here is use of the term ‘unrestricted’, because putting limits on pre-operative clear fluid quantity and time presents logistical issues for staff, patients and hospitals. Is pre-oxygenation with high flow nasal oxygen easier for the anaesthetist and more comfortable for patients as compared with a facemask? This new RCT from Merry et al. finds this to be the case albeit with no clinically relevant differences in effectiveness (Fig. 3).

Elsewhere we have: a review of obstetric anaesthesia emergencies; a review of peri-operative frailty; and a comparison of standard and flexible tip bougies for tracheal intubation using a non-channelled hyperangulated videolaryngoscope. Finally, Shelton and Goodwin provide a guide on how to plan, report and get your qualitative study accepted. Teaching in this important area is scarce in undergraduate and postgraduate medical curricula, but this paper aims to bring us all up to speed on aspects such as reflexivity, generalisability and credibility.