BJA open最新文献

{"title":"Paediatric perioperative hypersensitivity: the performance of the current consensus formula and the effect of uneventful anaesthesia on serum tryptase","authors":"Nils Vlaeminck ,&nbsp;Marie-Line van der Poorten ,&nbsp;Cecilie Nygaard Madsen ,&nbsp;Birgitte Bech Melchiors ,&nbsp;Moïse Michel ,&nbsp;Constance Gonzalez ,&nbsp;Rik Schrijvers ,&nbsp;Jessy Elst ,&nbsp;Christel Mertens ,&nbsp;Vera Saldien ,&nbsp;Joana Vitte ,&nbsp;Lene H. Garvey ,&nbsp;Vito Sabato ,&nbsp;Didier G. Ebo","doi":"10.1016/j.bjao.2023.100254","DOIUrl":"https://doi.org/10.1016/j.bjao.2023.100254","url":null,"abstract":"<div><h3>Background</h3><p>Paired sampling of acute (aST) and basal (bST) serum tryptase has been recommended when investigating patients with a suspected perioperative hypersensitivity (POH) reaction. In the current consensus formula, an aST value exceeding (1.2×bST+2) confirms mast cell activation. The current consensus formula has been validated in adults but not in children.</p></div><div><h3>Methods</h3><p>We prospectively included 96 children who underwent uneventful anaesthesia and sampled serum tryptase at baseline and 60–90 min after induction. Tryptase changes were then compared with those in 94 children with suspected POH who were retrospectively included from four reference centres in Belgium, France, and Denmark.</p></div><div><h3>Results</h3><p>We observed a median decrease in serum tryptase during uneventful anaesthesia of 0.41 μg L⁻¹ (–15.9%; <em>P</em>&lt;0.001). The current consensus formula identified mast cell activation in 31.9% of paediatric POH patients. After generating receiver operating characteristic curves through 100 repeated five-fold cross-validation, aST&gt;bST+0.71 was identified as the optimal cut-off point to identify mast cell activation. This new paediatric formula has higher sensitivity than the current consensus formula (53.2% <em>vs</em> 31.9%, <em>P</em>&lt;0.001) with a specificity of 96.9%. Analysis in the subpopulation where a culprit was identified and in grade 3–4 reactions similarly yielded higher sensitivity for the new paediatric formula when compared with the current consensus formula (85.3% <em>vs</em> 61.8%; <em>P</em>=0.008 and 78.0% <em>vs</em> 48.8%; <em>P</em>&lt;0.001, respectively). Internally cross-validated sensitivity and specificity were 53.3% and 93.3%, respectively.</p></div><div><h3>Conclusions</h3><p>This is the first study suggesting the need for an adjusted formula in children to identify perioperative mast cell activation as tryptase is significantly lowered during uneventful anaesthesia. We propose a new formula (aST&gt;bST+0.71) which performs significantly better than the current consensus formula in our multicentric paediatric population.</p></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"9 ","pages":"Article 100254"},"PeriodicalIF":0.0,"publicationDate":"2024-01-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2772609623001338/pdfft?md5=e280cc14797bcb2a4431bdc9972c5ebe&pid=1-s2.0-S2772609623001338-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139480243","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Airway management of adult epiglottitis: a systematic review and meta-analysis","authors":"Anton W.G. Booth ,&nbsp;Karla Pungsornruk ,&nbsp;Stacey Llewellyn ,&nbsp;David Sturgess ,&nbsp;Kim Vidhani","doi":"10.1016/j.bjao.2023.100250","DOIUrl":"https://doi.org/10.1016/j.bjao.2023.100250","url":null,"abstract":"<div><h3>Background</h3><p>Adult epiglottitis is a life-threatening airway emergency where airway protection is the immediate priority. Despite its importance, the optimal approach to airway management remains unclear. We performed a systematic review of the airway management for adult epiglottitis, including meta-analysis of trends over time.</p></div><div><h3>Methods</h3><p>We systematically searched PubMed, Ovid MEDLINE®, and Embase® for adult epiglottitis studies that described the airway management between 1980 and 2020. The primary outcome was the prevalence of airway intervention. Secondary outcomes were prevalence of tracheal intubation, tracheostomy, and failed intubation. A random-effects model meta-analysis was performed with subgroups defined by decade of study publication. Cases that described the specific method of airway intervention and severity of epiglottitis were included in a separate technique summary.</p></div><div><h3>Results</h3><p>Fifty-six studies with 10 630 patients were included in the meta-analysis. The overall rate of airway intervention was 15.6% (95% confidence interval [CI] 12.9–18.8%) but the rate decreased from 20% to 10% between 1980 and 2020. The overall rate of tracheal intubation was 10.2% (95% CI 7.1–13.6%) and that of failed intubation was 4.2% (95% CI 1.4–8.0%). The airway technique summary included 128 cases, of which 75 (58.6%) were performed awake and 53 (41.4%) involved general anaesthesia. We identified 32 cases of primary technique failure.</p></div><div><h3>Conclusion</h3><p>The rate of airway intervention for adult epiglottitis has decreased over four decades to a current level of 10%. Tracheal intubation is a high-risk scenario with a 1 in 25 failure rate. Specific technique selection is most likely influenced by contextual factors including the severity of epiglottitis.</p></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"9 ","pages":"Article 100250"},"PeriodicalIF":0.0,"publicationDate":"2024-01-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2772609623001296/pdfft?md5=197b83d667caf002a706f2798aab7e38&pid=1-s2.0-S2772609623001296-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139107471","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A randomised controlled trial comparing quality of recovery between desflurane and isoflurane inhalation anaesthesia in patients undergoing ophthalmological surgery at a tertiary hospital in South Africa (DIQoR trial)","authors":"Charlé Steyl,&nbsp;Hyla-Louise Kluyts","doi":"10.1016/j.bjao.2023.100246","DOIUrl":"https://doi.org/10.1016/j.bjao.2023.100246","url":null,"abstract":"<div><h3>Background</h3><p>The patient's experience of their postoperative recovery is an important perioperative outcome, with the 15-item quality of recovery scale (QoR-15) recommended as a standardised outcomes measure. Desflurane has a faster emergence from anaesthesia compared with other volatile anaesthetics, but it is uncertain whether this translates to better subjective quality of recovery. The hypothesis for this study is that patients receiving desflurane for maintenance of anaesthesia would have better postoperative quality of recovery than patients receiving isoflurane.</p></div><div><h3>Methods</h3><p>Male and female adult patients undergoing ophthalmological surgery under general anaesthesia were randomly allocated to receive desflurane or isoflurane for maintenance of anaesthesia. The primary outcome was to compare postoperative QoR-15 scores. Secondary outcomes included comparing preoperative QoR-15 scores, volatile agent consumption, and time spent in the recovery room.</p></div><div><h3>Results</h3><p>Data from 164 patients were analysed (80 desflurane, 84 isoflurane). Median (Q1, Q3) postoperative QoR-15 scores were not significantly different (desflurane: 145 [141, 148], isoflurane: 144 [139, 147], 95% confidence interval 0–3, <em>P</em>=0.176, minimal clinically important difference=8). Median (Q1, Q3) volatile agent consumption was 15.4 (12.5, 19.3) ml hr⁻¹ in the desflurane group, and 7.4 (5.9, 9.7) ml hr⁻¹ in the isoflurane group. Median (Q1, Q3) time spent in the recovery room was significantly shorter in the desflurane group (desflurane: 18 [13, 23]; isoflurane: 25 [19, 32], 95% confidence interval −10 to 5, <em>P</em>&lt;0.001).</p></div><div><h3>Conclusions</h3><p>This study found no difference in quality of recovery between patients who received desflurane or isoflurane for maintenance of general anaesthesia during ophthalmological surgery. A shorter time in the recovery room was not associated with improved QoR-15 scores.</p></div><div><h3>Clinical trial registration</h3><p>NCT04188314.</p></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"9 ","pages":"Article 100246"},"PeriodicalIF":0.0,"publicationDate":"2023-12-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2772609623001259/pdfft?md5=6f7fcd5d4c4cfdd7584eeb5ff0b53941&pid=1-s2.0-S2772609623001259-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139033370","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Ketamine for postoperative avoidance of depressive symptoms: the K-PASS feasibility randomised trial","authors":"Bradley A. Fritz ,&nbsp;Bethany R. Tellor Pennington ,&nbsp;Catherine Dalton ,&nbsp;Christine Horan ,&nbsp;Ben J.A. Palanca ,&nbsp;Julie A. Schweiger ,&nbsp;Logan Griffin ,&nbsp;Wilberforce Tumwesige ,&nbsp;Jon T. Willie ,&nbsp;Nuri B. Farber","doi":"10.1016/j.bjao.2023.100245","DOIUrl":"https://doi.org/10.1016/j.bjao.2023.100245","url":null,"abstract":"<div><h3>Background</h3><p>Surgical patients with previous depression frequently experience postoperative depressive symptoms. This study's objective was to determine the feasibility of a placebo-controlled trial testing the impact of a sustained ketamine infusion on postoperative depressive symptoms.</p></div><div><h3>Methods</h3><p>This single-centre, triple-blind, placebo-controlled randomised clinical trial included adult patients with depression scheduled for inpatient surgery. After surgery, patients were randomly allocated to receive ketamine (0.5 mg kg⁻¹ over 10 min followed by 0.3 mg kg⁻¹ h⁻¹ for 3 h) or an equal volume of normal saline. Depressive symptoms were measured using the Montgomery–Asberg Depression Rating Scale. On post-infusion day 1, participants guessed which intervention they received. Feasibility endpoints included the fraction of patients approached who were randomised, the fraction of randomised patients who completed the study infusion, and the fraction of scheduled depression assessments that were completed.</p></div><div><h3>Results</h3><p>In total, 32 patients were allocated a treatment, including 31/101 patients approached after a protocol change (31%, 1.5 patients per week). The study infusion was completed without interruption in 30/32 patients (94%). In each group, 7/16 participants correctly guessed which intervention they received. Depression assessments were completed at 170/192 scheduled time points (89%). Between baseline and post-infusion day 4 (pre-specified time point of interest), median depressive symptoms decreased in both groups, with difference-in-differences of −1.00 point (95% confidence interval −3.23 to 1.73) with ketamine compared with placebo. However, the between-group difference did not persist at other time points.</p></div><div><h3>Conclusions</h3><p>Patient recruitment, medication administration, and clinical outcome measurement appear to be highly feasible, with blinding maintained. A fully powered trial may be warranted.</p></div><div><h3>Clinical trial registration</h3><p>NCT05233566.</p></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"9 ","pages":"Article 100245"},"PeriodicalIF":0.0,"publicationDate":"2023-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2772609623001247/pdfft?md5=6eac958aafb846164a0a37ebc896cbff&pid=1-s2.0-S2772609623001247-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138739338","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Continuous wound infusion catheter as part of a multimodal analgesia regimen for post-Caesarean delivery pain: a quality improvement impact study","authors":"Cedar Fowler ,&nbsp;Emily Stockert ,&nbsp;Dan Hoang ,&nbsp;Nan Guo ,&nbsp;Edward Riley ,&nbsp;Pervez Sultan ,&nbsp;Brendan Carvalho","doi":"10.1016/j.bjao.2023.100242","DOIUrl":"https://doi.org/10.1016/j.bjao.2023.100242","url":null,"abstract":"<div><h3>Background</h3><p>The role of continuous wound infusion catheters as part of a multimodal analgesia strategy after Caesarean delivery is unclear. We introduced continuous wound infusion catheters to our multimodal analgesia regimen to evaluate the impact on analgesic outcomes after Caesarean delivery.</p></div><div><h3>Methods</h3><p>After institutional review board (IRB) approval, a 4-month practice change was instituted as a quality improvement initiative. In addition to multimodal analgesia, continuous wound infusion catheters for up to 3 days were offered on alternate weeks for all women undergoing Caesarean deliveries. The primary outcome was postoperative in-hospital opioid consumption. Secondary outcomes were static and dynamic pain scores at 24 and 72 h, time until first analgesic request, opioid-related side-effects, length of stay, satisfaction (0–100%), and continuous wound infusion catheter-related complications.</p></div><div><h3>Results</h3><p>All women scheduled for Caesarean delivery (<em>n</em>=139) in the 4-month period were included in the analysis, with 70 women receiving continuous wound infusion catheters, and 69 in the control group. Opioid consumption (continuous wound infusion catheter group 11.3 [7.5–61.9] mg morphine equivalents <em>vs</em> control group 30.0 [11.3–48.8] mg morphine equivalents), pain scores (except 24 h resting pain scores which were higher in the control group 2 [1–3] <em>vs</em> 1.5 [0–3] in the continous wound infusion catheters group; <em>P</em>=0.05), side-effects, length of stay, and complications were similar between groups. Satisfaction scores at 24 h were higher with continuous wound infusion catheters (100% [91–100%] <em>vs</em> 90% [86–100%]; <em>P</em>=0.003) with no differences at 72 h. One patient demonstrated symptoms of systemic local anaesthetic toxicity which resolved without significant harm.</p></div><div><h3>Conclusions</h3><p>The addition of continuous wound infusion catheters to a multimodal analgesia regimen for post-Caesarean delivery pain management demonstrated minimal clinically significant analgesic benefits. Future studies are needed to explore the use of continuous wound infusion catheters in populations that may benefit most from this intervention.</p></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"9 ","pages":"Article 100242"},"PeriodicalIF":0.0,"publicationDate":"2023-12-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2772609623001211/pdfft?md5=41a73c7c696ee5a9aa704f384aa8e1a8&pid=1-s2.0-S2772609623001211-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138738648","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Primary perioperative haemodynamic effects of ß-receptor blockade in patients with catecholamine-secreting tumours","authors":"Harald Groeben ,&nbsp;Bente J. Nottebaum ,&nbsp;Aarne Feldheiser ,&nbsp;Steffen Buch ,&nbsp;Piero F. Alesina ,&nbsp;Martin K. Walz","doi":"10.1016/j.bjao.2023.100240","DOIUrl":"https://doi.org/10.1016/j.bjao.2023.100240","url":null,"abstract":"<div><h3>Introduction</h3><p>Guidelines for the treatment of catecholamine-producing tumours strictly recommend starting ß-receptor blocking medication only after α-receptor blockade has been established. This recommendation is supported only by non-surgical case reports. However, in clinical practice ß-receptor blockade is often started before the diagnosis of a phaeochromocytoma is made. As we routinely treat patients with catecholamine-producing tumours without α-receptor blockade, our aim was to evaluate haemodynamic changes in such patients with and without ß-receptor blockade.</p></div><div><h3>Methods</h3><p>Perioperative blood pressure was assessed prospectively for all patients. The primary outcome was the highest pre-, intra-, and postoperative systolic blood pressure in patients with or without a ß-receptor blockade. Secondary outcomes were the incidence of intraoperative systolic blood pressure peaks &gt;250 mm Hg and hypotensive episodes. Subsequently, a propensity score matching (PSM) analysis was performed.</p></div><div><h3>Results</h3><p>Out of 584 phaeochromocytoma and paraganglioma resections, 383 operations were performed without α-receptor blockade (including 84 with ß-receptor blockade). Before operation and intraoperatively, patients with ß-receptor blockade presented with higher systolic blood pressure (155 [25] and 207 [62] mm Hg) than patients without ß-receptor blockade (147 [24] and 183 [52] mm Hg; <em>P</em>=0.006 and <em>P</em>=0.001, respectively). Intraoperatively, patients with ß-receptor blockade demonstrated a higher incidence of hypotensive episodes (25% without <em>vs</em> 41% with ß-blockade; <em>P</em>&lt;0.001). After propensity score matching no difference between the groups could be confirmed.</p></div><div><h3>Conclusion</h3><p>Overall, patients with isolated ß-receptor blockade developed higher blood pressure before operation and intraoperatively. After propensity score matching a difference could no longer be detected. Overall, ß-receptor blockade seems to be more a sign for severe disease than a risk factor for haemodynamic instability.</p></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"8 ","pages":"Article 100240"},"PeriodicalIF":0.0,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2772609623001193/pdfft?md5=535e16dd7aff33ea71270172098d6c39&pid=1-s2.0-S2772609623001193-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138501543","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Predictors and outcomes of perioperative cardiac arrest in children undergoing noncardiac surgery","authors":"Carine Foz,&nbsp;Steven J. Staffa,&nbsp;Morgan L. Brown,&nbsp;James A. DiNardo,&nbsp;Viviane G. Nasr","doi":"10.1016/j.bjao.2023.100244","DOIUrl":"https://doi.org/10.1016/j.bjao.2023.100244","url":null,"abstract":"<div><h3>Background</h3><p>Perioperative cardiac arrest continues to occur. This study aims to identify risk factors for perioperative cardiac arrest in children presenting for noncardiac surgery and characterise its outcomes.</p></div><div><h3>Methods</h3><p>Using the National Surgical Quality Improvement Program (NSQIP) Pediatric Database 2019 and 2020, 261 276 patients were included. Patients ≥18 yr and cardiac surgical procedures were excluded. Exploratory multivariable analysis was performed to identify independent predictors of perioperative cardiac arrest and associated outcomes.</p></div><div><h3>Results</h3><p>The overall rate of cardiac arrest was 0.1%, with an intraoperative rate of 0.05% and 48-h postoperative rate of 0.06%. Significant risk factors for perioperative cardiac arrest included age &lt;12 months (adjusted odds ratios [aOR] 3.07, <em>P</em>&lt;0.001), American Society of Anesthesiology Physical Status classification (ASA-PS 3 aOR=2.57, <em>P</em>&lt;0.001; ASA-PS 4 aOR=5.27, <em>P</em>&lt;0.001; ASA-PS 5 aOR=13.1, <em>P</em>&lt;0.001), admission through the emergency room (aOR 1.7, <em>P</em>=0.003), inpatient (aOR 2.19, <em>P</em>=0.008), major and severe cardiac disease (aOR 1.58, <em>P</em>=0.008), impaired cognitive status (aOR 1.54, <em>P</em>=0.009), and longer anaesthesia duration (aOR 1.1 per 30 min, <em>P</em>&lt;0.001). Perioperative cardiac arrest was significantly associated with longer hospital length of stay, reoperation, differences in discharge destination, and 30-day mortality. In addition, patients experiencing postoperative cardiac arrest had a significantly higher rate of in-hospital and 30-day mortality than those experiencing intraoperative cardiac arrest.</p></div><div><h3>Conclusions</h3><p>The incidence of cardiac arrest in this study is higher than previously reported. This may be related to selection bias and the rigorous data collection required by NSQIP. Lower 30-day mortality after intraoperative cardiac arrest could be related to prompt recognition and rapid initiation of intraoperative resuscitation. Identification of perioperative risk factors for cardiac arrest is crucial to improve the safety and quality of patient care.</p></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"8 ","pages":"Article 100244"},"PeriodicalIF":0.0,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2772609623001235/pdfft?md5=ac658e48a31931f9fa3027147d6cd991&pid=1-s2.0-S2772609623001235-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138473873","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Regional anaesthesia training in the UK – a national survey","authors":"Boyne Bellew ,&nbsp;David Burkett St-Laurent ,&nbsp;Martin Shaw ,&nbsp;Toby Ashken ,&nbsp;Jonathan Womack ,&nbsp;Jonathan Debenham ,&nbsp;Michael Getty ,&nbsp;Shveta Kajal ,&nbsp;Neil Verma ,&nbsp;Katie Samuel ,&nbsp;Alan J.R. Macfarlane ,&nbsp;Rachel J. Kearns ,&nbsp;Regional Anaesthesia UK Research Network","doi":"10.1016/j.bjao.2023.100241","DOIUrl":"https://doi.org/10.1016/j.bjao.2023.100241","url":null,"abstract":"<div><h3>Background</h3><p>Adequate training of anaesthetists in regional anaesthesia is important to ensure optimal patient access to regional anaesthesia.</p></div><div><h3>Methods</h3><p>We undertook a national survey of UK trainee anaesthetists and Royal College of Anaesthetists (RCoA) tutors to assess experiences of training in regional anaesthesia. We performed descriptive statistics for baseline characteristics, and logistic regression of training indices and tutor confidence that their hospital could provide regional anaesthesia training at all three stages of the RCoA 2021 curriculum.</p></div><div><h3>Results</h3><p>A total of 492 trainees (19.2%) and 114 tutors (45.2%) completed the survey. Trainees were less likely to have received training in chest/abdominal wall compared with upper/lower limb blocks {erector spinae <em>vs</em> femoral block (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.16–0.39), <em>P</em>&lt;0.001}, or achieved &gt;20 chest/abdominal wall blocks by Stage 3 of training (chest <em>vs</em> lower limb block [OR 0.09, 95% CI 0.05–0.15, <em>P</em>&lt;0.001]. There was a strong association between training received, number of blocks performed (&gt;20 <em>vs</em> 0–5 blocks), and self-reported ability to perform blocks independently, OR 20.9 (95% CI 9.38–53.2). 24/182 (13%) and 10/182 (5.5%) of trainees had performed ≥50 non-obstetric lumbar and thoracic epidurals, respectively, by Stage 3 training. There was a positive association between having a lead clinician for regional anaesthesia, particularly those with paid sessions, and reported confidence to provide regional anaesthesia training at all stages of the curriculum (Stage 3 OR 7.27 [95% CI 2.64–22.0]).</p></div><div><h3>Conclusion</h3><p>Our results confirm the importance of clinical experience and access to training in regional anaesthesia, and support the introduction of departmental regional anaesthesia leads to improve equity and quality in training opportunities.</p></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"8 ","pages":"Article 100241"},"PeriodicalIF":0.0,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S277260962300120X/pdfft?md5=2f1ffc7b6907927142ffb1cd1d287712&pid=1-s2.0-S277260962300120X-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138484125","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of acute kidney injury on major adverse cardiovascular events in intensive care survivors","authors":"Mark Andonovic ,&nbsp;Jennifer Curle ,&nbsp;Jamie P. Traynor ,&nbsp;Martin Shaw ,&nbsp;Malcolm A.B. Sim ,&nbsp;Patrick B. Mark ,&nbsp;Kathryn A. Puxty","doi":"10.1016/j.bjao.2023.100243","DOIUrl":"https://doi.org/10.1016/j.bjao.2023.100243","url":null,"abstract":"<div><h3>Background</h3><p>Acute kidney injury commonly occurs in patients admitted to ICU. After acute kidney injury, kidney function may not completely recover leading to increased risk of future cardiovascular events. We sought to ascertain the rates of cardiovascular events in ICU survivors and if these rates were affected by the presence of acute kidney injury whilst in ICU.</p></div><div><h3>Methods</h3><p>This retrospective observational cohort study utilised routinely collected data to identify patients who had survived an admission to one of two ICUs between July 2015 and June 2018. Baseline serum creatinine and subsequent values were used to identify acute kidney injury. Major adverse cardiovascular events described were myocardial injury, coronary artery intervention, or radiological evidence of stroke.</p></div><div><h3>Results</h3><p>Of the 3994 ICU survivors, major adverse cardiovascular events were identified in 385 patients (9.6%; 95% confidence interval [CI] 8.8–10.6%). Presence of acute kidney injury whilst in ICU was significantly associated with future major adverse cardiovascular events (hazard ratio=1.38; 95% CI 1.12–1.70; <em>P</em>-value=0.003) and future biochemical myocardial injury (hazard ratio=1.48; 95% CI 1.16–1.89; <em>P</em>-value=0.001). Acute kidney injury did not have a statistically significant association with future coronary artery interventions or future cerebrovascular events.</p></div><div><h3>Conclusions</h3><p>One in 10 ICU survivors experiences a major adverse cardiovascular event after discharge. Acute kidney injury whilst in ICU was associated with an increased risk of major adverse cardiovascular events and specifically myocardial injury. Further research is warranted on whether ICU survivors with acute kidney injury merit enhanced strategies for cardiovascular protection.</p></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"8 ","pages":"Article 100243"},"PeriodicalIF":0.0,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2772609623001223/pdfft?md5=865b992741c587d3a5633e3fa1993ebe&pid=1-s2.0-S2772609623001223-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138480726","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Heart rate recovery after orthostatic challenge and cardiopulmonary exercise testing in older individuals: prospective multicentre observational cohort study","authors":"Aaron James ,&nbsp;David Bruce ,&nbsp;Nicholas Tetlow ,&nbsp;Amour B.U. Patel ,&nbsp;Ethel Black ,&nbsp;Nicole Whitehead ,&nbsp;Anna Ratcliff ,&nbsp;Alice Jamie Humphreys ,&nbsp;Neil MacDonald ,&nbsp;Gayle McDonnell ,&nbsp;Ravishankar Raobaikady ,&nbsp;Jeeveththaa Thirugnanasambanthar ,&nbsp;Jeuela I. Ravindran ,&nbsp;Nicole Whitehead ,&nbsp;Gary Minto ,&nbsp;Tom E.F. Abbott ,&nbsp;Shaman Jhanji ,&nbsp;Don Milliken ,&nbsp;Gareth L. Ackland","doi":"10.1016/j.bjao.2023.100238","DOIUrl":"https://doi.org/10.1016/j.bjao.2023.100238","url":null,"abstract":"<div><h3>Background</h3><p>Impaired vagal function in older individuals, quantified by the ‘gold standard’ delayed heart rate recovery after maximal exercise (HRR^exercise), is an independent predictor of cardiorespiratory capacity and mortality (particularly when HRR ≤12 beats min⁻¹). Heart rate also often declines after orthostatic challenge (HRR^orthostatic), but the mechanism remains unclear. We tested whether HRR^orthostatic reflects similar vagal autonomic characteristics as HRR^exercise.</p></div><div><h3>Methods</h3><p>Prospective multicentre cohort study of subjects scheduled for cardiopulmonary exercise testing (CPET) as part of routine care. Before undergoing CPET, heart rate was measured with participants seated for 3 min, before standing for 3 min (HRR^orthostatic). HRR^exercise 1 min after the end of CPET was recorded. The primary outcome was the correlation between mean heart rate change every 10 s for 1 min after peak heart rate was attained on standing and after exercise for each participant. Secondary outcomes were HRR^orthostatic and peak VO₂ compared between individuals with HRR^exercise &lt;12 beats min⁻¹.</p></div><div><h3>Results</h3><p>A total of 87 participants (mean age: 64 yr [95%CI: 61–66]; 48 (55%) females) completed both tests. Mean heart rate change every 10 s for 1 min after peak heart rate after standing and exercise was significantly correlated (<em>R</em>²=0.81; <em>P</em>&lt;0.0001). HRR^orthostatic was unchanged in individuals with HRR^exercise ≤12 beats min⁻¹ (<em>n</em>=27), but was lower when HRR^exercise &gt;12 beats min⁻¹ (<em>n</em>=60; mean difference: 3 beats min⁻¹ [95% confidence interval 1–5 beats min⁻¹]; <em>P</em>&lt;0.0001). Slower HRR^orthostatic was associated with lower peak VO₂ (mean difference: 3.7 ml kg^-1 min⁻¹ [95% confidence interval 0.7–6.8 ml kg^-1 min⁻¹]; <em>P</em>=0.039).</p></div><div><h3>Conclusion</h3><p>Prognostically significant heart rate recovery after exhaustive exercise is characterised by quantitative differences in heart rate recovery after orthostatic challenge. These data suggest that orthostatic challenge is a valid, simple test indicating vagal impairment.</p></div><div><h3>Clinical trial registration</h3><p>researchregistry6550.</p></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"8 ","pages":"Article 100238"},"PeriodicalIF":0.0,"publicationDate":"2023-11-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S277260962300117X/pdfft?md5=2e96d909cd26610c248577f0426f6edc&pid=1-s2.0-S277260962300117X-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"92044487","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}