British journal of anaesthesia
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Editorial Comment
Anaesthetic depth and delirium: a challenging balancing act.
This editorial highlights the findings of the Balanced Anaesthesia Delirium study, a 515-patient substudy of the 6644 patient Balanced Anaesthesia trial, which found that targeting deep anaesthesia in patients undergoing major noncardiac surgery was not associated with significantly increased postoperative death or major morbidity. The substudy found that using bispectral index (BIS) guidance with the intention of deliberately achieving deep volatile agent-based anaesthesia (target BIS reading 35 vs 50) significantly increased delirium incidence (28% vs 19%), although not subsyndromal delirium incidence (45% vs 49%). ⋯ We posit that subpopulation-based differences within this multicentre substudy could have affected delirium occurrence, since the findings appeared to rest on outcomes in patients from East Asia. We conclude that questions of whether and for whom deep anaesthesia is deliriogenic remain unanswered.
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Review
Morbidity, mortality, and systems safety in non-operating room anaesthesia: a narrative review.
Non-operating room anaesthesia (NORA) describes anaesthesia delivered outside a traditional operating room (OR) setting. Non-operating room anaesthesia cases have increased significantly in the last 20 yr and are projected to account for half of all anaesthetics delivered in the next decade. In contrast to most other medication administration contexts, NORA is performed in high-volume fast-paced environments not optimised for anaesthesia care. ⋯ Despite relatively few attempts to quantify safety concerns, it was possible to find a range of systems safety concerns repeated across multiple studies, including insufficient lighting, noise, cramped workspace, and restricted access to patients. Old and unfamiliar equipment, lack of team familiarity, and limited preoperative evaluation are also commonly noted challenges. Applying a systems view of safety, it is possible to suggest a range of methods to improve NORA safety and performance.
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Multicenter Study
Development and external validation of a prognostic model for ischaemic stroke after surgery.
There is an under-recognised patient cohort at elevated risk of postoperative ischaemic stroke. We aimed to develop and validate a prognostic model for the identification of such patients at high risk of ischaemic stroke within 1 yr after noncardiac surgery. ⋯ Stroke after surgery (STRAS) screening can reliably identify patients with a high risk for ischaemic stroke during the first year after surgery. A STRAS-guided risk stratification may inform the recruitment to future randomised trials testing the efficacy of treatments for the prevention of postoperative ischaemic stroke.
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Randomized Controlled Trial
Effect of Hypotension Prediction Index-guided intraoperative haemodynamic care on depth and duration of postoperative hypotension: a sub-study of the Hypotension Prediction trial.
Intraoperative and postoperative hypotension are associated with morbidity and mortality. The Hypotension Prediction (HYPE) trial showed that the Hypotension Prediction Index (HPI) reduced the depth and duration of intraoperative hypotension (IOH), without excess use of intravenous fluid, vasopressor, and/or inotropic therapies. We hypothesised that intraoperative HPI-guided haemodynamic care would reduce the severity of postoperative hypotension in the PACU. ⋯ Intraoperative HPI-guided haemodynamic care did not reduce the TWA of postoperative hypotension.
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Specialist training bodies continue to devise innovative methods of gathering information on trainee workplace performance to meet the requirements of competency-based medical education. We reviewed recent innovations in workplace-based assessment (WBA) tools to identify strengths, weaknesses, and trade-offs inherent in their design and use. ⋯ Our synthesis of the literature on innovative WBAs provides a framework for categorising tool characteristics across seven dimensions, systematically teasing apart the considerations in design and use of workplace assessments. It also draws attention to the trade-offs inherent in tool design and selection, and enables a more deliberate consideration of the tool characteristics most appropriate to the local context.