Anxiety frequently burdens patients before surgery, potentially leading to poorer recovery. However, standard assessment tools typically quantify the intensity of this distress without understanding its root cause. This often leaves clinicians unaware of the specific fears driving a patient's anxiety. We aimed to address this deficit by developing and validating a questionnaire designed to identify individual pre-operative concerns. An iterative development process resulted in a 14-item questionnaire: Concerns Over Peri-operative Events (COPE). We conducted a prospective evaluation of 52 patients having elective surgery, measuring the questionnaire's performance against the Amsterdam Pre-operative Anxiety and Information Scale. The questionnaire performed well on metrics of validity, reliability and acceptability. Severe pain was the most reported concern. The median (IQR [range]) total COPE score was 30 (22-44 [14-63]). There was a positive correlation between the Amsterdam Pre-operative Anxiety and Information Scale and COPE scores. A classification model to predict Amsterdam Pre-operative Anxiety and Information Scale-positive status demonstrated excellent discrimination with an area under the curve of 0.86. An optimal COPE score of ≥ 34 demonstrated 88% sensitivity and 81% specificity. While future research should focus on generalisability, this novel questionnaire of patient concerns facilitates the identification of specific drivers of pre-operative anxiety. By bridging the gap between clinicians' assumptions and patient experience, the COPE questionnaire may facilitate targeted therapies and improve informed consent.
Persistent fluid leakage following epidural catheter removal is rare in infants and may indicate cerebrospinal fluid leakage, with poorly described clinical manifestations. We report a case of a 10-month-old infant who developed persistent fluid leakage from the epidural insertion site and position-dependent changes in consciousness after the removal of a thoracic epidural catheter following right hepatectomy. Brain computed tomography excluded acute intracranial pathology, and the clinical course suggested intracranial hypotension secondary to suspected cerebrospinal fluid leakage. Bed rest, pressure dressings and intravenous fluids were unsuccessful in improving the leakage or the neurological symptoms. An epidural blood patch was performed by injecting 2.5 ml (0.31 ml.kg-1) of autologous venous blood into the epidural space. No further leakage was observed from the epidural insertion site and the patient's neurological status rapidly returned to baseline. This case highlights the diagnostic challenges of suspected intracranial hypotension in infants and describes the clinical course following the performance of an epidural blood patch.
This retrospective single-centre service evaluation describes double-lumen tube one-lung ventilation as a respiratory motion-control strategy for hepatic histotripsy in 26 adults in Hong Kong. Histotripsy is a non-invasive, non-thermal focused ultrasound technique requiring precise targeting, challenged by respiratory-induced liver motion. High-frequency jet ventilation has been used to minimise motion but carries practical and physiological limitations. All procedures were performed under general anaesthesia with intended double-lumen tube one-lung ventilation. Successful double-lumen tube placement without modification was achieved in 81% of cases; overall, 92% of patients received one-lung ventilation using either double-lumen tube or bronchial blockers. Transient intra-operative desaturation occurred in 29% of one-lung ventilation cases but was managed with standard ventilatory adjustments. Technical success was achieved in 92% of cases. No major airway or respiratory complications or unplanned critical care admissions occurred and all patients were discharged within 2 days postoperatively. These findings suggest that double-lumen tube one-lung ventilation is a feasible and safe alternative to high-frequency jet ventilation for respiratory motion control during hepatic histotripsy, using widely available thoracic anaesthesia techniques. The retrospective design, small sample size and absence of comparator group highlight the need for future prospective trials to evaluate efficacy, safety and cost-effectiveness relative to high-frequency jet ventilation.
Transradial access is widely used for percutaneous coronary intervention because it reduces bleeding complications and speeds recovery. Severe radial artery spasm, however, can entrap catheters or sheaths, and forceful extraction may cause major vascular injury. This report describes the atraumatic removal of an entrapped radial artery sheath assited by ultrasound-guided supraclavicular brachial plexus block during primary percutaneous coronary intervention.
Medical air is essential for the safe delivery of anaesthesia, critical care and emergency care. We report a hospital-wide medical air contamination event caused by failure of ageing desiccant dryers. Water was detected in the intensive care unit medical air outlets, before moisture contamination was confirmed within the medical air pipeline system and operating theatre pendants. This resulted in shutdown of the central medical air plant, suspension of non-urgent surgery, surgical bypass and a 5-day disruption to normal hospital services. The principal clinical challenges were the loss of reliable medical air supplied via the pipeline system, potential moisture exposure of anaesthetic ventilators and other equipment, limited capacity to provide ventilatory support and initial inability to use available medical air cylinders with anaesthetic workstations because of pressure regulator incompatibility. Management required immediate cessation of use of the medical air pipeline system, use of alternative medical air supplies, liaison with the anaesthetic machine manufacturer, installation of a temporary dehydrator, moisture removal and compliance testing. This case highlights that visible water at a medical gas outlet is a serious infrastructure failure requiring urgent escalation and multidisciplinary management. The primary educational message is that medical air-drying systems require proactive maintenance, lifecycle replacement and continuous dew-point monitoring linked to hospital alarm systems. Secondary lessons include the importance of tested backup medical air plans, equipment-compatible regulators and staff education to recognise moisture ingress as a high-risk patient safety event.
Submental intubation is an alternative to nasotracheal intubation or tracheostomy in maxillofacial surgery when unobstructed access to the oral cavity is required. Reinforced tracheal tubes are considered the standard for this technique to avoid kinking during the procedure. Removal of the fixed standard 15 mm connector is required to perform the original Altemir's technique, which is the most used technique of submental intubation. Disconnecting the glued connector is a modification developed by clinicians, not endorsed by manufacturers and may expose patients to unforeseen risks. We report the management of a patient undergoing surgical repair of complex facial fractures with planned submental intubation. After repeated disconnections during tube repositioning, mechanical ventilation became difficult due to an intraluminal obstruction. Obstruction was caused by a polyvinyl chloride flap originating from the reinforced tracheal tube at the level of the forcibly removed connector. Removal of the flap restored normal ventilation and the remainder of the procedure was uneventful. To our knowledge, this is the first report of such a complication during submental intubation. It highlights material-related risk and underscores the importance of careful handling and inspection of the tracheal tube after removing the connector. Preventive strategies and alternative airway devices should be considered to enhance airway safety during submental intubation.
Videolaryngoscopy is increasingly important in airway management, but optimal training methods remain unclear. Artificial intelligence may enhance procedural skill acquisition through real-time feedback and guidance. This high-fidelity simulation pilot study characterised the learning curve of artificial intelligence-assisted videolaryngoscopy using the LarynGuide™ system in a mixed cohort of medical students, anaesthesia residents and qualified anaesthetists with limited or no prior experience of videolaryngoscopy. Ninety-nine healthcare practitioners (medical students, medical doctors, anaesthesia residents and specialists) performed 10 intubation attempts on a high-fidelity simulator with artificial intelligence-assisted real-time feedback. Optimal intubation was defined a priori as ≥90% probability of time to intubation <30 s combined with a percentage of glottic opening >90%. Tracheal intubation success, defined as completion of tracheal tube placement, irrespective of the number of laryngoscopy passes, was achieved in 951 of 990 attempts (96%), with mean (SD) time to intubation of 16 (13) s. At the group level, basic procedural competency (≥90% cumulative success rate, assessed using cumulative sum analysis) was reached at the fourth attempt. Success rates plateaued thereafter, time to intubation continued to fall until the seventh attempt, and the percentage of glottic opening continued to improve through the tenth attempt. Exploratory modelling estimated that more than 10 attempts would be required to reach a 90% probability of optimal intubation. Anaesthesia residents performed better than participants with no prior intubation experience: higher success rate (98% versus 93%, p = 0.003), better glottic visualisation (mean percentage of glottic opening 90% versus 78%, p < 0.001) and shorter time to intubation (14 s versus 18 s, p = 0.021). Participants with prior video game experience reached optimal intubation thresholds four attempts earlier than non-gamers (p = 0.018). Outcomes were worse in the 60- to 70-year subgroup (n = 3, p < 0.001), while the participants' sex had no influence. Satisfaction ratings were high, with ease of use reported as 9/10. Artificial intelligence-assisted videolaryngoscopy facilitated rapid acquisition of basic competency within four attempts in this pilot simulation cohort. Exploratory modelling suggests differences from historical benchmarks which warrant further investigation.
Anaphylaxis is a potentially life-threatening hypersensitivity reaction, most typically caused by neuromuscular blocking agents or antibiotics in the peri-operative setting. Propofol is the most common induction agent used during anaesthesia, and the occurrence of anaphylaxis is rare. This is a case report of suspected propofol anaphylaxis after induction of anaesthesia for cerebral aneurysm clipping surgery in a 51-year-old man who had previously been exposed to propofol. Recognition of the early signs of anaphylaxis, prompt management and follow-up allergy skin testing are crucial for confirming the diagnosis.
Prehabilitation aims to improve physical, nutritional and psychological health before surgery. Despite its potential benefits, inequitable access remains a concern. The wider PARITY study aimed to identify and help address inequalities in prehabilitation before cancer surgery using a mixed-methods approach. This report describes the end-of-study prioritisation workshop, which brought together professional, public and patient participants to prioritise considerations to promote equity in prehabilitation services using a nominal group technique. Before the workshop, 42 considerations identified from preceding work, including co-design, Delphi, service mapping and case studies, were shared with participants for review. Participants (n = 15) discussed and prioritised these considerations according to perceived impact and feasibility of implementation. Considerations were ranked by perceived priority and categorised by level of implementation. Forty-two considerations were prioritised and categorised as system level (n = 15), service level (n = 22) and practitioner level (n = 5). The six highest-priority considerations relate to: understanding how prehabilitation and surgery may affect each patient's life; adapting delivery to individual needs; making services available at a system-wide level; contacting patients who are not engaging; providing interpreters where needed; and training care teams in equality and diversity issues. These findings provide consensus-based considerations to support more equitable prehabilitation before cancer surgery, at a time when prehabilitation is increasingly prominent in national guidance.
Awake craniotomy facilitates real-time assessment of neurological function and maximises the extent of tumour resection, reducing the risk of postoperative deficits. Awake craniotomy is uncommonly performed in young children. To our knowledge, we report the youngest case of awake craniotomy in medical literature, involving a 6-year-old child. He had a right frontoparietal tumour and a 4-year history of drug-resistant epilepsy. As the tumour was located in an eloquent brain area, an awake craniotomy was planned. Pre-operative preparation included psychological assessment, theatre environment simulation and interpreter-assisted counselling. An asleep-awake-asleep technique was employed. Maximum safe resection was achieved without haemodynamic instability. The patient remained neurologically intact postoperatively, with no speech or motor deficits. Postoperative magnetic resonance imaging demonstrated satisfactory resection. Psychological follow-up confirmed no distress or significant recall of the surgery. He was discharged seizure-free and without any deficit on postoperative day 4. This case shows that with thorough preparation and multidisciplinary teamwork, awake craniotomy is feasible and well tolerated even in very young paediatric patients.
We describe a pregnant patient who presented in labour with diffuse ST-segment elevation on electrocardiography and biochemical evidence of myocardial injury. Transthoracic echocardiography showed severe biventricular dysfunction. An urgent caesarean birth was indicated due to breech presentation and severe cardiac dysfunction. Intra-operatively, the ventricular function worsened requiring escalating vasopressor administration and the patient developed refractory monomorphic ventricular tachycardia. After delivery, she progressed to cardiogenic shock and required urgent veno-arterial extracorporeal membrane oxygenation cannulation with subsequent axillary Impella 5.5 (Abiomed, Johnson & Johnson MedTech; Danvers, MA, USA) placement for left ventricular unloading. She received immunosuppressive therapy for suspected fulminant myocarditis. Her haemodynamics improved and ventricular function normalised over 12 days of extracorporeal membrane oxygenation support. She was weaned from mechanical circulatory support, her trachea was extubated and an implantable cardioverter-defibrillator was placed. She was discharged home neurologically intact with complete biventricular recovery. The case emphasises the importance of early recognition of rapid haemodynamic decline and timely initiation of mechanical circulatory support in an acute setting.
Differential attainment by protected characteristics is described in the setting of medical education, but its relevance to UK anaesthetic training is not well established. This study examined whether personal characteristics influence access to procedural and training opportunities among resident doctors (or doctors in training) and speciality anaesthetists practising in the UK. A national, cross-sectional, web-based survey was distributed via the Association of Anaesthetists, Regional Anaesthesia UK and social media between 01/06/2023 and 30/09/2023. Eligible respondents were resident doctors, speciality doctors, locally employed/trust doctors and clinical fellows practising in UK anaesthetic posts. We collected demographic data, protected characteristics, self-reported numbers of procedures performed, receipt of simulation training, self-reported confidence and self-declared supervision levels. Data were anonymised and analysed using mixed-effects proportional odds logistic regression models to identify associations between personal characteristics and outcomes, adjusting for potential confounders, including socio-economic deprivation. There were 874 respondents of whom 699 (80%) were resident doctors. Four hundred and twenty-seven (49%) identified as female, 414 (47%) as male and 17 (2%) as non-binary. The majority were White (66%) and worked in England (79%). After adjustment, female compared with male gender was associated with being in a lower category for number of procedures performed (OR 0.68, 95%CI 0.54-0.86), self-reported confidence (OR 0.48, 0.37-0.61) and supervision requirements (OR 0.49, 0.37-0.64). Older age was associated with greater procedural exposure and confidence. Compared with white ethnicity, Asian ethnicity was associated with higher confidence (OR 1.55, 1.15-2.11) and perceived need for more distant supervision (OR 1.63, 1.17-2.27), but not with greater procedural numbers. No significant adverse associations were found for disability, sexuality, less than full time training, religion, marital status, socio-economic background or carer status. Gender-based barriers were perceived by 43% of female respondents, compared with 3% of male respondents. Access to procedural training in UK anaesthesia appears broadly equitable across ethnicity, disability and training status. Significant gender disparities in procedural exposure, self-reported confidence and perceived need for supervision remain. These findings highlight the need for equitable training practices and further qualitative work to address underlying causes and promote diversity within the anaesthetic workforce.
Summary Pre‐operative anxiety is distressing for patients and is associated with peri‐operative complications, yet the relative effectiveness of available pharmacological and non‐pharmacological interventions remains unclear. We conducted a systematic review with network meta‐analysis to compare anxiolytic strategies in the pre‐operative setting. We searched six databases for randomised controlled trials in patients aged ≥ 16 years undergoing surgery, evaluating pharmacological or non‐pharmacological anxiolytic interventions. Study selection, data extraction and risk‐of‐bias assessment were performed in duplicate. We performed pairwise and network meta‐analysis for pre‐operative anxiety and secondary outcomes (postoperative pain, patient satisfaction, pre‐operative sedation and minor or major complications) and used the Grading of Recommendations Assessment, Development and Evaluation to rate certainty of evidence. A total of 350 studies were included. Data from 309 studies (27,218 patients) were analysed for the primary outcome (pre‐operative anxiety). Fifteen interventions reduced pre‐operative anxiety compared with placebo or sham or no intervention and usual care, including spiritual training standardised mean difference (95% CrI) −6.07 (−9.33 to −2.84), mirtazapine −3.37 (−5.55 to −1.17), binaural beats −2.99 (−5.00 to −0.97), benzodiazepines −1.27 (−1.67 to −0.86), gabapentinoids −1.13 (−1.78 to −0.48) and melatonin −0.90 (−1.65 to −0.16). Other interventions associated with lower anxiety included relaxation techniques, herbal medicines, massage, hydroxyzine, acupoint stimulation, audiovisual distraction, aromatherapy, clonidine and educational strategies. Five interventions improved peri‐operative patient satisfaction compared with placebo: parecoxib, acupoint stimulation, psychological intervention, audiovisual distraction and education. No significant differences were identified between interventions for postoperative pain, pre‐operative sedation or minor and major complications. Multiple pharmacological and non‐pharmacological interventions reduce pre‐operative anxiety and may improve peri‐operative patient satisfaction. No single intervention appears clearly superior and comparative safety differences remain uncertain.
Penicillin allergy labels are common in elective surgical patients, although most are incorrect. These labels often prevent the use of first-line surgical prophylaxis, and alternative antibiotic choices are associated with patient harm and antimicrobial resistance. There is a need for effective pre-operative penicillin allergy de-labelling services, but demand cannot be matched by allergists alone, making non-allergist-led approaches particularly important. Such services have been implemented in a range of health care settings, although their design, level of allergist supervision, implementation and clinical effectiveness vary. The elective surgical population is a promising cohort for these interventions, but has been studied less than inpatient groups. We aim to synthesise quantitative and qualitative evidence on non-allergist-led penicillin allergy de-labelling interventions in elective surgical populations. Studies involving penicillin allergy de-labelling by non-allergist healthcare professionals in the elective surgical setting will be eligible, including quantitative studies of clinical effectiveness and economic evaluations, and qualitative studies exploring experiences, perceptions or implementation factors. A mixed-methods systematic review will be conducted using a convergent segregated approach in line with Joanna Briggs Institute methodology. Systematic searches will be performed across MEDLINE, Embase, CINAHL, Web of Science, Scopus and ClinicalTrials.gov. Studies will be screened and data extracted independently by two reviewers. Quantitative and qualitative findings will be synthesised separately and then integrated to identify convergence, divergence and complementarity.
Erector spinae plane catheters are increasingly used for rib fracture analgesia, but the influence of catheter insertion technique on catheter position and analgesic effectiveness remains uncertain. In this case series, we describe 11 erector spinae plane catheters inserted using a catheter-through-needle technique for analgesia in patients with rib fractures who underwent chest computed tomography after catheter insertion. Catheter tip position outside the intended fascial plane was identified in six of 11 (55%) catheters. Previous studies of catheter-over-needle systems have reported displacement rates of up to 89%, but cross-study comparisons are limited by small sample sizes and differences in population, catheter techniques and imaging protocols. Interpretation of clinical impact is limited. Pain score recording and analgesic prescribing were not standardised, and patients frequently had multiple injuries requiring multimodal analgesia, making it difficult to isolate the contribution of erector spinae planes catheter position to pain relief. Furthermore, computed tomography demonstrates catheter location but may not reflect local anaesthetic spread or functional block efficacy. These findings highlight clinically relevant uncertainty regarding the relationship between catheter insertion technique, catheter position and patient-centred analgesic effectiveness. Further prospective studies are needed to determine whether insertion techniques affect catheter position, injectate spread and patient-centred analgesic outcomes.
Povidone-iodine solutions are used widely in clinical practice for a variety of antiseptic indications. In an era of increasing antibiotic resistance, they remain an essential tool in the treatment and prevention of wound infections. However, iodine species are easily absorbed systemically and there are reports of presumed iodine toxicity from povidone-iodine, including fatal outcomes. We present a case of a 64-year-old woman who suffered cardiovascular collapse after systemic absorption of iodine from wound packing during a revision hip arthroplasty. Features included hypotension, severe metabolic acidosis and renal injury associated with a urine iodine 413 times the upper limit of normal. Supportive care and high dose haemodiafiltration resulted in effective clearance of iodine, leading to full recovery. Thorough consideration and exclusion of other diagnoses are presented. This case highlights the under-recognised risk of systemic iodine absorption from the use of povidone-iodine. Further research is required to better understand the mechanisms of toxicity as well as the factors which influence systemic absorption of iodine and its effects.
