Andrew F Smith

Management of severe perioperative bleeding Guidelines from the European Society of Anaesthesiology

The aims of severe perioperative bleeding management are three-fold. First, preoperative identification by anamesis and laboratory testing of those patients for whom the perioperative bleeding risk may be increased. Second, implementation of strategies for correcting preoperative anaemia and stabilisation of the macro- and microcirculations in order to optimise the patients tolerance to bleeding. Third, targeted procoagulant interventions to reduce the amount of bleeding, morbidity, mortality and costs. The purpose of these guidelines is to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthetists throughout Europe to integrate this knowledge into daily patient care wherever possible. The Guidelines Committee of the European Society of Anaesthesiology (ESA) formed a task force with members of scientific subcommittees and individual expert members of the ESA. Electronic databases were searched without language restrictions from the year 2000 until 2012. These searches produced 20 664 abstracts. Relevant systematic reviews with meta-analyses, randomised controlled trials, cohort studies, case-control studies and cross-sectional surveys were selected. At the suggestion of the ESA Guideline Committee, the Scottish Intercollegiate Guidelines Network (SIGN) grading system was initially used to assess the level of evidence and to grade recommendations. During the process of guideline development, the official position of the ESA changed to favour the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. This report includes general recommendations as well as specific recommendations in various fields of surgical interventions. The final draft guideline was posted on the ESA website for four weeks and the link was sent to all ESA members. Comments were collated and the guidelines amended as appropriate. When the final draft was complete, the Guidelines Committee and ESA Board ratified the guidelines.

Systematic review and meta-analysis of enhanced recovery programmes in surgical patients

Enhanced recovery programmes (ERPs) have been developed over the past 10 years to improve patient outcomes and to accelerate recovery after surgery. The existing literature focuses on specific specialties, mainly colorectal surgery. The aim of this review was to investigate whether the effect of ERPs on patient outcomes varies across surgical specialties or with the design of individual programmes.

Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: A statement from the ESA-ESICM joint taskforce on perioperative outcome measures.

There is a need for large trials that test the clinical effectiveness of interventions in the field of perioperative medicine. Clinical outcome measures used in such trials must be robust, clearly defined and patient-relevant. Our objective was to develop standards for the use of clinical outcome measures to strengthen the methodological quality of perioperative medicine research. A literature search was conducted using PubMed and opinion leaders worldwide were invited to nominate papers that they believed the group should consider. The full texts of relevant articles were reviewed by the taskforce members and then discussed to reach a consensus on the required standards. The report was then circulated to opinion leaders for comment and review. This report describes definitions for 22 individual adverse events with a system of severity grading for each. In addition, four composite outcome measures were identified, which were designed to evaluate postoperative outcomes. The group also agreed on standards for four outcome measures for the evaluation of healthcare resource use and quality of life. Guidance for use of these outcome measures is provided, with particular emphasis on appropriate duration of follow-up. This report provides clearly defined and patient-relevant outcome measures for large clinical trials in perioperative medicine. These outcome measures may also be of use in clinical audit. This report is intended to complement and not replace other related work to improve assessment of clinical outcomes following specific surgical procedures.

Preoperative evaluation of the adult patient undergoing non-cardiac surgery: guidelines from the European Society of Anaesthesiology.

The purpose of these guidelines on the preoperative evaluation of the adult non-cardiac surgery patient is to present recommendations based on available relevant clinical evidence. The ultimate aims of preoperative evaluation are two-fold. First, we aim to identify those patients for whom the perioperative period may constitute an increased risk of morbidity and mortality, aside from the risks associated with the underlying disease. Second, this should help us to design perioperative strategies that aim to reduce additional perioperative risks. Very few well performed randomised studies on the topic are available and many recommendations rely heavily on expert opinion and are adapted specifically to the healthcare systems in individual countries. This report aims to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthetists all over Europe to integrate – wherever possible – this knowledge into daily patient care. The Guidelines Committee of the European Society of Anaesthesiology (ESA) formed a task force with members of subcommittees of scientific subcommittees and individual members of the ESA. Electronic databases were searched from the year 2000 until July 2010 without language restrictions. These searches produced 15 425 abstracts. Relevant systematic reviews with meta-analyses, randomised controlled trials, cohort studies, case–control studies and cross-sectional surveys were selected. The Scottish Intercollegiate Guidelines Network grading system was used to assess the level of evidence and to grade recommendations. The final draft guideline was posted on the ESA website for 4 weeks and the link was sent to all ESA members, individual or national (thus including most European national anaesthesia societies). Comments were collated and the guidelines amended as appropriate. When the final draft was complete, the Guidelines Committee and ESA Board ratified the guidelines.

Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008*.

Anaesthetic equipment plays a central role in anaesthetic practice but brings the potential for malfunction or misuse. We aimed to explore the national picture by reviewing patient safety incidents relating to anaesthetic equipment from the National Reporting and Learning System for England and Wales between 2006 and 2008. We searched the database using the system’s own classification and by scrutinising the free text of relevant incidents. There were 1029 relevant incidents. Of these, 410 (39.8%) concerned patient monitoring, most commonly screen failure during anaesthesia, failure of one modality or failure to transfer data automatically from anaesthetic room to operating theatre. Problems relating to ventilators made up 185 (17.9%) of the reports. Sudden failures during anaesthesia accounted for 142 (13.8%) of these, with a further 10 cases (0.9%) where malfunction caused a sustained or increasing positive pressure in the patient’s airway. Leaks made up 99 (9.6%) of incidents and 53 (5.2%) of incidents arose from the use of infusion pumps. Most (89%) of the incidents caused no patient harm; only 30 (2.9%) were judged to have led to moderate or severe harm. Although equipment was often faulty, user error or unfamiliarity also played a part. A large variety of causes led to a relatively small number of clinical scenarios, that anaesthetists should be ready, both individually and organisationally, to manage even when the cause is not apparent. We make recommendations for enhancing patient safety with respect to equipment.

Passing on tacit knowledge in anaesthesia: a qualitative study

Objective  To explore the acquisition of knowledge in anaesthetic practice using qualitative methods.

Communication between anesthesiologists, patients and the anesthesia team: a descriptive study of induction and emergence.

PurposeAlthough the importance of communication skills in anesthetic practice is increasingly recognized, formal communication skills training has hitherto dealt only with limited aspects of this professional activity. We aimed to document and analyze the informally-learned communication that takes place between anesthesia personnel and patients at induction of and emergence from general anesthesia.MethodsWe adopted an ethnographic approach based principally on observation of anesthesia personnel at work in the operating theatres with subsequent analysis of observation transcripts.ResultsWe noted three main styles of communication on induction, commonly combined in a single induction. In order of frequency, these were: (1) descriptive, where the anesthesiologists explained to the patient what he/she might expect to feel; (2) functional, which seemed designed to help anesthesiologists maintain physiological stability or assess the changing depth of anesthesia and (3) evocative, which referred to images or metaphors. Although the talk we have described is nominally directed at the patient, it also signifies to other members of the anesthetic team how induction is progressing. The team may also contribute to the communication behaviour depending on the context. Communication on emergence usually focused on establishing that the patient was awake.ConclusionCommunication at induction and emergence tends to fall into specific patterns with different emphases but similar functions. This communication work is shared across the anesthetic team. Further work could usefully explore the relationship between communication styles and team performance or indicators of patient safety or well-being.RésuméObjectifĽimportance de la communication est de plus en plus reconnue en anesthésie, mais la formation structurée sur le sujet n’a porté jusqu’ici que sur des aspects limités. Nous voulions documenter et analyser la communication apprise de façon informelle et qui a cours entre le personnel ďanesthésie et les patients au moment de ľinduction et du retour à la conscience lors ďune anesthésie générale.MéthodeNotre approche, ethnographique, était fondée sur ľobservation du personnel au travail dans les blocs opératoires et sur ľanalyse subséquente des observations transcrites.RésultatsLors de ľinduction, nous avons noté trois principaux styles ďinformations ordinairement combinés. En ordre de fréquences, la communication était : (1) descriptive, oò les anesthésiologistes expliquaient au patient ce qu’il pouvait s’attendre à ressentir ; (2) fonctionnelle, elle semblait organisée pour aider les anesthésiologistes à maintenir la stabilité physiologique ou à éva luer la différence de profondeur de ľanesthésie et (3) évocatrice, elle faisait appel à des images et à des métaphores. La conversation décrite était en principe dirigée vers le patient, mais elle indiquait aussi aux autres membres de ľéquipe comment ľinduction se déroulait. Dans certains contextes, ľéquipe pouvait aussi participer à la communication. Au réveil, la communication visait habituellement à démontrer que le patient était éveillé.ConclusionLa communication lors de ľinduction et du retour à la conscience tend vers des modèles spécifiques comportant des aspects dominants qui ont toutefois des fonctions similaires. Ce travail de communication est partagé par les membres de ľéquipe ďanesthésie. Il reste à explorer la relation entre les styles de communication et la performance de ľéquipe ou les indicateurs de la sécurité ou du bien-être du patient.Objectif Ľimportance de la communication est de plus en plus reconnue en anesthesie, mais la formation structuree sur le sujet n’a porte jusqu’ici que sur des aspects limites. Nous voulions documenter et analyser la communication apprise de facon informelle et qui a cours entre le personnel ďanesthesie et les patients au moment de ľinduction et du retour a la conscience lors ďune anesthesie generale.

Beyond competence: defining and promoting excellence in anaesthesia

Recent trends in medical training have tended to focus on competence, in the sense of adequate performance, rather than excellence. This article reviews published literature and relevant concepts relating to excellence and professionalism from within anaesthesia, from medicine more generally and from outside the profession. A number of conceptual frameworks are presented that could be adapted for the promotion of excellence, and some of the necessary prerequisites for this promotion discussed.

Communication skills for anesthesiologists

PurposeTo provide a simple, practical guide to communication skills which might be useful to practising anesthesiologists.SourceSelected citations from the literature on patient-physician communication, and the personal observations of the authors based on their reading and experiences.Principal findingsBasic communication skills are introduced, and then their application to clinical anesthesiology described. The possible benefits resulting from the enhancement of clinical communication are outlined. Strategies for tackling four commonly-encountered situations — handling others’ feelings, imparting information, explaining complex concepts simply and breaking bad news — are presented. By taking a skills-oriented approach, we hope that readers will be encouraged to view this area of their work as one that can be improved upon with continued observation and practice.ConclusionCommunication skills can enhance medical practice and improve patient outcomes. We suggest that all anesthesiologists should give thought to their effectiveness in this area.RésuméObjectifPrésenter un guide simple et pratique des qualités relationnelles utiles aux anesthésiologistes en exercice.SourceCitations choisies dans des articles sur la communication patient-médecin et observations personnelles des auteurs basées sur leurs lectures et leurs expériences.Constatations principalesNous décrivons les qualités relationnelles fondamentales et leur application à l’anesthésiologie clinique. Nous indiquons les avantages possibles de l’amélioration de la communication clinique. Nous présentons des stratégies pour aborder quatre situations habituelles — tenir compte des sentiments d’autrui, transmettre des informations, expliquer simplement des concepts complexes et annoncer une mauvaise nouvelle. En choisissant une méthode axée sur des techniques, nous souhaitons que les lecteurs seront encouragés à considérer cet aspect de leur travail comme pouvant être amélioré par l’observation et la pratique.ConclusionUne bonne communication peut rehausser la pratique médicale et améliorer l’évolution du patient. Tous les anesthésiologistes devraient songer à leur compétence dans ce domaine.

'From darkness into light': time to make awake intubation with videolaryngoscopy the primary technique for an anticipated difficult airway?

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