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Three interesting recent studies looking at specific choices around anaesthetic technique. In the Canadian Journal of Anesthesia, da Silveira reviews the benefits of opioid-free laparoscopic surgery; in the Journal of Cardiothoracic and Vascular Anesthesia, Ford goes deep on the pros and cons of different anaesthetic techniques for AF ablation procedures; and finally in the JCA, Liu reports on a single-centre RCT investigating the beneficial effects of LMAs on atelectasis.

Opioid-Free Laparoscopic Surgery: Less Nausea, Similar Pain Control

An interesting meta-analysis from da Silveira et al. explores whether we can effectively manage minimally invasive abdominal surgery without using opioids - an important question given how common opioid-related side effects are.

This was a comprehensive systematic review and meta-analysis of 26 randomised controlled trials, including 2,025 patients. The researchers specifically compared opioid-free versus opioid-containing anesthesia in minimally invasive abdominal surgeries. They were particularly interested in looking at side effects like PONV and bradycardia, as well as pain control and recovery times.

The results were quite interesting. The authors found that opioid-free anaesthesia:

• Reduced PONV by 45% (from 24% to 13% / RR CI 0.40 to 0.74).
• Led to slightly lower immediate postoperative pain scores (though not clinically significant).
• Required less postoperative opioid use in the first 2 hours.
• Showed no difference in recovery room length of stay.
• Showed no increase in bradycardia, a previously noted concern when using intraoperative dexmedetomidine.

Read more...

The British Cycling Revolution: A Lesson in Marginal Gains

When Dave Brailsford was appointed Performance Director of British Cycling in 2003, he inherited a program defined by failure. The national team hadn't won Olympic gold since 1908, and no British cyclist had ever claimed victory in the Tour de France's 110-year-long history. The 39-year-old cyclist-turned-performance consultant would transform British cycling and our approach to improvement through an unexpectedly simple philosophy: the aggregation of marginal gains.

Growing up in one of the few English families in North Wales, Brailsford developed a perpetual drive to prove himself. "Somehow I always felt I did not quite fit in," he reflected. "So I always thought I must try harder than the others to be accepted, to be successful." This outsider mentality would fuel his pursuit of excellence.

Read on for how marginal gains relate to anaesthesia...

Kindness is the foundation of positive human relationships. Kindness is also the foundation of quality anaesthesia, framing not just the goals of care but the paths we tread to reach them: kindness to our patients, kindness to one's team, and kindness to oneself. Kindness is the oxygen that sustains our practice.

"[Kindness is] helpfulness towards someone in need, not in return for anything, nor for the advantage of the helper himself, but for that of the person helped." – Aristotle, Book II of Rhetoric

Like many anaesthetists, I often fixate on outcomes. Yet, the journey usually matters as much for patients as the destination. While modern medicine makes successful outcomes the lowest bar, the hospital experience shapes the patient's entire perception of care, sometimes turning a medical success into a perceived failure. When we centre our practice on kindness, we elevate both process and outcome, giving them equal weight.

Read on for anaesthesia and kindness...

We are now two and a half years into the COVID pandemic, and just beginning to see yet another case surge with the arrival of the BA.5 Omicron sub-variant. The good news just keeps coming! 😉

Along with new variants, 30 months has also given us a lot of research and data. Metajournal alone has indexed almost 39,000 COVID-related publications relevant to anaesthesia, pain, critical care and emergency medicine.

Of course that's a crazy volume of research to manage, with a pretty low signal-to-noise ratio. Sifting through that for quality and relevant studies is exactly what metajournal was designed for.

Here's a quick round-up of interesting COVID-related research...

RAT tests & infectiousness

As good quality, locally validated RAT tests become increasingly available, we are also collecting more data showing they are a good indicator of individual infectiousness at the moment in time the test is performed.

The article collection 'Does a COVID RAT-negative result mean non-infectious?' explores several of these studies, suggesting that a negative RAT is likely a reliable indicator of being non-infectious.

The bottom line...

A correctly-performed adequately-validated RAT, is likely a sensitive indictor of individual infectiousness at that specific moment in time. The reliability of a negative RAT will be improved if using the same manufacturer and technique as a previously positive test, and more so if there are several subsequent negative RATs.

Return to exercise after COVID?

A recent J Sci Med Sport editorial (Hughes 2022) from Australian elite sport, exercise medicine and sports cardiology experts, provides reassuring encouragement when returning to exercise after COVID recovery.

Read on for more on exercise after COVID...

A very interesting study in JAMA Surgery from Wallis et al. received a lot of press coverage. The research team showed that female patients treated by male surgeons not only more commonly experienced post-operative complications, but also suffered a higher mortality, than when treated by female surgeons.

What did they do?

This big-data study covered 12 years of the 20-most-common surgical procedures performed in Ontario, Canada. Wallis and team investigated how patient-surgeon sex discordance correlated to a composite for adverse postoperative outcomes. (A deeper investigation of the earlier Wallis 2017 study).

And they found?

While ~15% of all patients experienced an adverse post-operative outcome, female patients treated by a male surgeon experienced significantly higher odds of a composite of adverse events (OR 1.15 [1.10-1.20]), 30-day complications (OR 1.16 [1.11-1.22]), readmissions (OR 1.11 [1.04-1.19]), and death (OR 1.32 [1.14-1.54]) compared to when treated by female surgeons.

Yet male patients treated by female surgeons experienced either lower odds (death 0.87 [0.78-0.97]) or statistically-similar odds of complications (composite end-point, readmission or post-op complications).

The hot-take

Women once again receive the metaphorical short-end of the medical-stick. Whether societal or elsewhere in the health industry value-chain, long established gender inequity reveals itself in worse surgical outcomes for female patients.

Hang on a sec…

But this cannot just be written off as a consequence of existing social gender inequity, but rather a disquieting causal loop between this as a cause and the result then perpetuating further inequity.

If some part of a surgeon’s ’professional success’ is wrapped-up in the ability to achieve positive outcomes for patients while minimising the adverse, then male surgeons are failing their female patients when compared to either female surgeons, or to the care they provide their male patients.

And yet the same discordance cost is not true for female surgeons.

Read on for the take-home & more medical-gender influences...