Checklists, checklists everywhere! Love them or hate them, since the introduction of the WHO surgical safety checklist there has been a tsunami of checklists affecting clinical areas of a hospital near you. Whilst there is good evidence that the WHO surgical safety checklist has been effective at improving patient safety, this same does not necessarily apply for the day surgery cannulation checklist-bundle branded QI by infection control. Much of the criticism raised cites poor construction and inclusion of irrelevant items, resulting in checklist fatigue and poor compliance. In this podcast we speak to Dr Ashley de bie Dekker, whose PhD work involves the construction of intelligent dynamic checklists, aimed at integrating patient data from multiple sources to produce context-sensitive and patient specific checklists.

BJA: British Journal of Anaesthesia

Checklist 2.0 with Dr Ashley de bie Dekker

Imagine you are sitting on the runway, waiting to take off to your holiday destination. As you begin to taxi the pilot announces that there is an engine warning light flashing, but that in his experience this almost always amounts to nothing and both him and co-pilot have made a pragmatic decision to proceed, given that the flight was already running late. In anaesthesia, one of the most fundamental decisions we take is whether or not to anaesthetise someone, something that can be relatively simple or profoundly complex given the circumstances. However, there are situations you would think that as a body of responsible professionals we would all agree on. Research from Oxford suggests that this may not be the case and that there is in fact a good deal of difference of opinion, particularly when it comes to matters of patient safety. In this podcast we talk with lead author Paul Greig about his interesting and thought-provoking work looking at risk tolerance in anaesthetists.

Decisions, decisions, decisions... BJA Podcast with Paul Greig

Children requiring urgent but simple surgery is a common place phenomenon that can sometimes wreak havoc on the best planned emergency list. Operating on children in an urgent capacity can be logistically difficult outside tertiary centres and is not help

Ketamine Kids

There has been an increasing realisation that the majority of complications from high risk surgeries are not due to technical failings in either the operating theatre or anaesthetic room, but from medical complications occurring out on the wards. 'Failure to rescue' has become part of critical care lexicon and with it, an awareness of the financial burden associated with treating morbidity associated with high risk surgeries. Over the last three years there has been an explosion of interest in perioperative medicine both as a solution to this problem and as a means to improving the quality of surgical care experienced by all patients. Accompanying the article on the multi-disciplinary team approach to the high risk surgical patient published in this month's BJA, Dr David Walker, director of the Masters programme in perioperative medicine at UCL, addresses some of our hopes, fears and maps out a possible future for this exciting new speciality.

Perioperative Medicine: today, tomorrow and the future of teamworking

Dr Chris Frerk, chair of the airway guideline group talk about the updated 2015 DAS guidelines. 11 years after the publication of the original, the new guidelines reflect technical advances in airway management over the last decade as well recognising the important role of human factors in crisis resource management. Dr Frerk explains the principles, rationale and evidence for this superbly constructed document that will become the fundamental basis of airway management for present and future generations of anaesthetists.

DAS unanticipated difficult intubation guidelines 2015 overview with Dr Chris Frerk

Probably one of the most talked about changes in the 2015 DAS guidelines will be Plan D. Whilst on a very basic level the recommendations have not altered, the emphasis on how to practically manage a 'can't intubate, can't oxygenate' scenario are quite a shift from many anaesthetist's current approach. Dr Ravi Bhagrath from The Royal London Hospital explains the rationale, research and most importantly, walks us through the new 'scalpel, bougie, tube' technique DAS now recommend.

DAS unanticipated difficult intubation guidelines 2015; Plan D with Dr Ravi Bhagrath

Accidental awareness under general anaesthesia (AAGA) is the stuff of nightmares for patients and anaesthetists alike. Data from NAP5 has demonstrated a relatively low incidence incidence of AAGA but recommendations from the project include the use of depth of anaesthesia monitors in at risk groups. This recommendation was preceded by esoteric guidance from NICE that BIS monitors were an 'option' for a broad and loosely defined group of patients. BIS is a proprietary technology and as such, we do not know exactly how it derives the value it displays. In 2003 a very small study (n=3) found that the BIS index could be made to drop to alarmingly low levels by administering suxamethonium alone without a hypnotic agent. This study has remained something of a curiosity and has never been replicated or further explored until now. In this special edition podcast, Peter Schuller talks to us about his impressive work and the truly astounding results it has produced. Whilst his study generates more questions than is answers with regard to BIS monitoring, a fascinating by-product is the insight into awareness which he has documented and shares with us in this podcast.

Through the looking glass: awareness, BIS and an anaesthetist's perspective

Traumatic brain injury carries a devastating burden of disease for both the individual patient and the population as a whole. Many patients are young and those who survive are commonly left with a significant disability. Sadly, treatment options for traumatic brain injury remain limited with little improvement in outcomes for the past two decades. Regenerative medicine using stem cell technologies has received a great deal of attention over the past 15 years and has been trialled as a therapy for a diverse range of conditions from cardiac disease to skin grafting, often with exciting results. In this podcast Dr Jae Lee, an anaesthetist and stem cell researcher explains some of the biology behind stem cells and their use in regenerative medicine as well as the encouraging pre-clinical work in TBI and the pathway for future studies.

Stem cell therapy - a new hope for traumatic brain injury?

Patient blood management (PBM) is a multifaceted approach to reducing allogenic blood transfusion (ABT) in the surgical population. In this podcast Professor Manuel Munoz, a haematologist from Malaga in Spain, talks to us about the way in which a PBM program functions to reduce ABT and in so doing, can have a dramatic impact on patient morbidity and mortality. One of the cornerstones of PBM is the detection and treatment of preoperative anaemia which is in itself an independent and potentially modifiable risk factor in both elective and emergency surgery. Professor Munoz dispels some of the widely held misconceptions regarding anaemia, talks through the implications of starting surgery with sub-optimal haemoglobin levels and describes some of the effective and surprisingly expeditious treatments available in the preoperative period.

'Fit to fly': overcoming barriers to preoperative haemoglobin optimization in surgical patients

Assessment, calculation and composition of replacement fluid is a fundamental tenet of anaesthetic practice. Mounting evidence from the colorectal and enhanced recovery literature shows that attention to detail throughout the perioperative period results in both reduced patient morbidity and length of stay. In addition to our highly tuned clinical acumen, exist a myriad of monitors we can use to augment our decision making and maintain our patients' milieu interieur. As such, one would expect to observe a high degree of consistency in the volumes of fluid given by experienced anaesthetic practitioners to similar groups of patients or at the very least, a degree of internal consistency when looking at an individual anaesthetist's practice. A large retrospective data analysis from the US looking at over 6000 patients has yielded results that are as alarming as they are surprising. Whilst it would appear the God doesn't play dice, we observe the distinct possibility the anaesthetists may! Professor Monty Mythen from UCLH talks to us about his reaction to the paper, the repercussions of poor perioperative fluid management and strategies for getting it right.

Fluid Thinking with Professor Monty Mythen

Whilst medical cancer therapies are increasing in their utility and efficacy, the physiological effects of intensive combined treatment regimes on patients' reserves are becoming a greater concern. It is now routine practice to combine medical and surgical therapeutic options in the form of neoadjuvant chemoradiotherapy for conditions such as colorectal cancer. Since the 1990s we have been aware of the inverse relationship between cardiorespiratory fitness as measured by CPET and post-operative morbidity. This raises legitimate concerns over whether improvements in resection margins may come at the expense of increased surgical morbidity and mortality. Mr Malcolm West, an NIHR clinical academic fellow at the unit of cancer services in Southampton, talks to us about his ground breaking work in the field of prehabilitation medicine; the concept of improving a patient's cardiorespiratory fitness pre-operatively after a deliberate and in this case, measured toxic insult. Not only does his group's structured exercise program have a statistically and clinically significant effect on functional reserve, but this impressive pilot study hints at an unexpected and potentially yet more remarkable story.

They tried to make me go to prehab...

As with many anticonvulsants, pregabalin is enjoying an ever increasing spectrum of use. Originally licensed for the treatment of epilepsy, diabetic neuropathic pain and post-herpetic neuralgia; pregabalin has become a staple of the chronic pain armamentarium. To date, well over 100 studies have explored pregabalin's use in the perioperative period on a diverse range of symptoms including acute pain and preoperative anxiety. This issue of the BJA carries a meta-analysis looking at the utility and prescribing rationale for pregabalin in the peri-operative period. In this podcast Dr Ashraf Habib from Duke University Medical Centre takes us through the potentially practice changing evidence for pregabalin use in the perioperative period.

Pregabalin use in the perioperative period: indications, dosage and the current evidence

Millions of operations take place in the UK each year; the majority occurring without undue patient morbidity. However, dependant on the nature of the procedure, post-operative morbidity is not uncommon and we will all recall patients who have suffered an unexpected complication after surgery. Large epidemiological studies have suggested that post-operative morbidity is not confined to the discrete episode of post-operative care, and in fact may have a significant impact on a patient's long-term mortality. Dr Ramani Moonesinghe from the UCL/UCLH Surgical Outcomes Research Centre talks to us about her work in this area, pre and post-operative scoring systems and the post-operative morbidity domains significantly associated with decreased survival after surgery, as well as what we can do as peri-operative physicians to influence longer-term patient outcomes.

Repercussions: post-operative morbidity and the mortality hangover

Accidental awareness during general anaesthesia (AAGA) is a rare but feared complication of anaesthesia. Studying such rare occurrences is technically challenging but following in the tradition of previous national audit projects, the results of the fifth national audit project have now been published receiving attention from both the academic and national press. In this BJA podcast Professor Jaideep Pandit (NAP5 Lead) summarises the results and main findings from another impressive and potentially practice changing national anaesthetic audit. Professor Pandit highlights areas of AAGA risk in anaesthetic practice, discusses some of the factors (both technical and human) that lead to accidental awareness, and describes the review panels findings and recommendations to minimise the chances of AAGA.

Fifth National Audit Project on Accidental Awareness during General Anaesthesia

Achieving adequate gas exchange whilst minimising ventilator induced lung inury is a major challenge in intensive care. The world of ICU ventilation is rich with novel proprietary modes but so far, none have proven an outcome benefit in ARDS. Whilst the differences between various modes are often subtle, most focus on modifying the inspiratory phase of the respiratory cycle, whilst maintaining a constant level of end-expiratory pressure. A group from the Division of Experimental Anaesthesiology at University Medical Centre in Freiburg have recently customised a standard ventilator to control the expiratory phase in a volume controlled mode. Dr Stefan Schumann, the biomedical engineer on the project, talks to us about the physiological rationale for flow-controlled expiration and in simple terms, how they were able to achieve it. Dr Schumann then goes on to describe their experiments in a porcine lung injury model and the encouraging results produced by this nascent technology.

Expiratory flow control: a novel mode of ventilation for the injured lung

The BJAs free podcasts will take listeners on a tour of the world of anaesthesia; interviews with authors and commentaries from key experts on featured articles, plus hot topics in anaesthesia research and practice will be published with each issue.

hubhopper

BJA: British Journal of Anaesthesia

hubhopper