January - February 2023

Open Access Emergency Medicine

Submitted January 2023 by Dr Renee Burton

Read by 260 Journal Watch subscribers

This is an excellent article from BJA education that explores a general approach to a child presenting with a possible high-risk ingestion. In a concise fashion, expected examination findings, red flags as well as the principles of management are explored. The article concludes with a review of the anaesthetic challenges of treating paediatric patients after the ingestion of caustic agents, batteries and magnets. For those looking to refresh and review their understanding of the mechanism of injury and anaesthetic management of ingestion of these agents, the article is recommended.

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European Journal of Anaesthesiology

Submitted January 2023 by Dr Shona Chung

Read by 281 Journal Watch subscribers

This editorial focuses on the difficulties of implementing Fatigue Risk Management Systems (FRMS) in healthcare – and more specifically in anaesthesia and intensive care. Written by members of the European Board of Anaesthesiology Standing Committee on Work Force, Working Conditions, Welfare, the article reiterates some of the knowledge we have gained about fatigue over the last 20 years suggests how this should influence the care of our patients but also ourselves as practitioners.

The article highlights that medicine is one of the last safety critical industries to not have an enforceable FRMS and looks at why this is. The reasons presented by the authors include: changing knowledge of how sleep is important; the difference in attitudes to work from baby boomers to generation X, Y and Z workers; and outdated attitudes such as “this is shift work, you don’t need a break”. The authors acknowledge that formal FRMS are not necessarily easily transferable to medicine especially in a workforce that is often understaffed.

The authors suggest simpler solutions – providing dark areas for staff to have power naps, teaching medical professionals about how to assess their own fatigue risk, ensuring senior clinicians/managers are aware of fatigue related risk and writing rosters appropriately to mitigate against these risks.

Finally, the article highlights the steps taken by several organisations to prevent fatigue related risk such as the FATIGUE project started in 2019 with the aim of “raising awareness about the consequences of fatigue on both patient safety and anaesthesiologist wellbeing” and the creation of the Fatigue and Facilities Charter by the British Medical Association. The authors suggest that we as high acuity clinicians should be more aware of the risks of
fatigue to all involved, and that if 20% of people in our profession alter our behaviour to establish a new norm in which fatigue is acknowledged as a significant risk factor this will lead to a safer, more contented workforce.

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Anaesthesia

Submitted January 2023 by Dr Shona Chung

Read by 286 Journal Watch subscribers

This extensive editorial starts with the history of research into neurodevelopmental effects of general anaesthesia in children: from the initial study in rats in 2003 to the FDA black box warning in 2016, to a summary of larger trials – GAS, PANDA and MASK which have recently been combined in a meta-analysis. This meta-analysis confirmed that exposure to anaesthesia did not alter FSIQ (full scale intelligence quotient) scores but was related to parental reports of behavioural problems.

Subsequently, the authors comment on a recent study by Moser et all which looks at very preterm infants receiving anaesthesia and how this affects their FSIQ at 3 years of age. They highlight that this retrospective study contributes significantly to the literature as it focuses only on extreme prematurity but also note that there is a significant amount of missing FSIQ data. The study authors have acknowledged and dealt with this “missingness” by using a sophisticated statistical tool – multiple imputed chained equations (MICE). The use of MICE has also inverted the statistical significance of FDA labelled drugs, leading the editorial authors to question how it has affected the other results of the trial.

Finally, Bailey and Whyte ask, “where to now?”, and reinforce the fact that paediatric anaesthesiolgists “must explore all avenues to apply primum non nocere”. They explain the different between the SmartTots and Safetots initiatives: the former being a partnership to fund research into the potential direct neurotoxic effect of anaesthesia medications; the latter focusing more on the quality of anaesthesia management with a lot of their recommendations arising from the NECTARINE study.

The main future directions suggested by the editorial include minimising FDA labelled drug exposure where feasible, more routine use of NIRS, more regular use of novel drugs such as dexmedetomidine and a shift in research from the direct neurotoxic effects of anaesthesia drugs to research focused on observed patterns of neonatal white matter injury in a variety of circumstances.

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Pediatric Anesthesia

Submitted January 2023 by Dr Shona Chung

Read by 277 Journal Watch subscribers

This perspective article outlines the development of a paediatric fellowship curriculum from the initial thought in 2012 to the publication of the final document on the SPANZA website in 2020. The process involved 4 years of work by the SPANZA education committee. This commenced with Delphi rounds and progressed to the development of a curriculum structured around EPA’s (Entrustable Professional Activities). After the curriculum based around EPA’s was completed it was then sent to the Heads of Departments of tertiary paediatric hospitals and mixed adult and paediatric hospitals to seek feedback. The final stage of the development was the Phase 2 evaluation stage in which the document was available on the SPANZA website for a year in draft form to allow members to provide feedback.
Finally, the paediatric fellowship curriculum was published on the SPANZA website and can be found here: https://d311i5pe49swog.cloudfront.net/web-ass
ets/spanza/assets/uploads/2022/04/22125405/SP
ANZACurriculum-March-2021-FINAL.pdf

The salient features of the curriculum described in this perspective article is that it is based on Entrustable Professional Activities (EPAs) - which are “an actual unit of work or expected task for the competent professional and is made up of multiple sub competencies” - and that it is a flexible curriculum in which the trainer and trainee can choose the important EPAs for their fellowship time and their planned future workplace. This enables the curriculum to cater for those planning to work in tertiary paediatric hospitals as well as those who intend to work in more rural and remote areas. There are no formal assessments, however the authors suggest using the graduated supervision levels described by Ten Cate; these range from Level 1 (no permission to act) to Level 5 (permission to provide supervision to junior trainees). The perspective article indicates that SPANZA is an incorporated society and does not have the power to enforce the implementation or the assessment of the curriculum.

This perspective article was the subject of an editorial entitled “To bend but not to break: rethinking fellowship training in pediatric anesthesiology” in which the authors applauded the work by Kaur and Taylor but also questioned some of its aspects. This editorial compared the “standardized, highly regulated model” of training in place in the United States to the nimbler curriculum established by SPANZA. It questioned the lack of structured feedback mechanisms in the SPANZA curriculum and whether there is too much flexibility in the EPA structure; suggesting that this may lead to paediatric anaesthesiologists with significantly varying skillsets. Other concerns that were raised in this editorial included – relative novices setting their own curriculum and therefore potentially missing important skills all paediatric anaesthesiologists should have; and having a curriculum based on assumed knowledge of their future workplace – when this is not necessarily always known and subject to change.

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Anaesthesia

Submitted January 2023 by Dr Derek Rosen

Read by 264 Journal Watch subscribers

Overview
- Systematic review of the effect of high-flow nasal oxygen (NHFO2) vs conventional oxygen (nasal prongs, face mask, mouth guard) for procedural sedation in adults and children.
- Methods: Literature review of randomised controlled trials that reported the effects of high-flow nasal oxygen during procedural sedation. The primary outcome measure was hypoxaemia and the secondary outcomes were minimum oxygen saturation; hypercarbia; requirement for airway manoeuvres; and procedure interruptions.
- 19 RCTs published between 2015 and 2021 were included with a total of 4121 patients, of which 2059 received HFNO and 2062 received conventional oxygenation, deemed to be the control group. Included trials included 8 gastrointestinal, 5 bronchoscopy, 3 cardiology, 2 dental and 1 endovascular. 3 trials (cardiology, bronchoscopy and dental) included children. 16/19 used propofol based sedation techniques.
- Findings: NHFO2 use reduced hypoxaemia (RR 0.37), minor airway manoeuvres (0.26), procedural interruptions, and increased minimum oxygen saturations (mean difference 4.1%) when compared to conventional oxygen techniques. There was no impact on hypercarbia. Grading of recommendations, assessment, development and evaluation (GRADE) was used to categorise the certainty of evidence which was deemed moderate for all but procedural interruptions which was deemed low.

Commentary
Oxygen desaturation is the most prevalent adverse event during procedural sedation, followed by airway obstruction and apnoea. Risk factors for hypoxaemia include higher ASA, reduced cardiopulmonary reserve, obesity, sleep apnoea and prolonged procedural sedation.
This is a pertinent review as the high uptake of NHFO2 into procedural sedation is associated with increased consumables and costs and warrants ongoing evaluation. It supports the use of NHFO2 in high-risk patient groups.

The relevance to paediatrics is limited since paediatric studies in this review and they were not discussed separately from the pooled data. The definitions of hypoxaemia and sedation protocols varied between studies but the direction and size of the difference did not change.

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Current Opinion in Anaesthesiology

Submitted January 2023 by Dr Derek Rosen

Read by 275 Journal Watch subscribers

This review article discusses the evidence for the different techniques used to prolong sensory neural blockade. Of the commonly used adjuvants dexamethasone (perineural 4mg, followed by intravenous 0.1-0.2mg/kg) was the most effective adjuvant (4-8h prolongation), closely followed by dexmedetomidine (50-60mcg perineural or 1mcg/kg IV, (3-4.5h prolongation) and then clonidine (75-150 mcg perineurally, 3h prolongation). Catheter techniques while effective are more expensive, have more complications and can interfere with ERAS protocols, whilst liposomal bupivacaine has not met expectations.

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Anaesthesia

Submitted January 2023 by Dr Derek Rosen

Read by 273 Journal Watch subscribers

This useful review article discusses the benefits of regional anaesthesia in children (anaesthesia sparing, opioid sparing, and a reduction in emergence delirium severity) despite its lower use compared with adult anaesthesia and highlights seven high value nerve blocks which should become core competencies. The proposed ‘plan A blocks’ are:

• Axillary
• Femoral
• Popliteal sciatic
• Rectus sheath
• Lateral quadratus lumborum
• Caudal
• Dorsal penile nerve

These blocks have a good safety profile and can be employed in common paediatric surgeries. The authors advocate for ultrasound use, catheter use and highlight that performing blocks in anaesthetised children carries no increased risk of nerve injury.

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Anesthesia Analgesia

Submitted January 2023 by Dr Justin Skowno

Read by 257 Journal Watch subscribers

This RCT in 134 low risk children having general anaesthesia with an LMA were randomized between propofol and sevoflurane anaesthesia, with fentanyl analgesia, awake LMA removal and other clinical processes standardized between groups. They measure the rates of post operative respiratory adverse events, and showed clearly that sevoflurane led to a higher rate across multiple metrics (cough, laryngospasm, desaturation) than propofol. Most of their propofol anaesthetics were “pure” TIVA, with only 3 needing sevoflurane inductions. Secondary outcomes measured included emergence agitation and PONV, and for both of these sevoflurane had higher rates than propofol. This study specifically follows up work done at Perth Children’s Hospital on PRAE and propofol-sevoflurane differences. It is methodologically rigorous and easy to read, with a good discussion section.

Commentary
My main conflict of interest to declare is that I do virtually all my anaesthetics as TIVA, and so a paper like this is one I really like. It is very useful to guide your practice if you are not set in your ways yet. It looks at a very common anaesthetic recipe, applicable to a large number of procedures, and shows clearly that propofol has lower rates of respiratory complications, as well as PONV and emergence agitation (secondary outcomes). These are all things we specifically want to reduce in our patients, and the authors provide a useful head on head comparison to guide one’s choice. Over to you.

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