Healthcare today is the prerogative of teams rather than of individuals. In acute care domains such as anaesthesia, intensive care, and emergency medicine, the work is complex and fast-paced, and the team members are diverse and interdependent. Three decades of research into the behaviours of high-performing teams provides us with clear guidance on team training, demonstrating positive effects on patient safety and staff wellbeing. Here we consider team performance through the lens of situation awareness. Maintaining situation awareness is an absolute requirement for safe and effective patient management. Situation awareness is a dynamic process of perceiving cues in the environment, understanding what they mean, and predicting how the situation may evolve. In the context of acute clinical care, situation awareness can be improved if the whole team actively contributes to monitoring the environment, processing information, and planning next steps. In this narrative review, we explore the concept of situation awareness at the level of the team, the conditions required to maintain team situation awareness, and the relationship between team situation awareness, shared mental models, and team performance. Our ultimate goal is to help clinicians create the conditions required for high-functioning teams, and ultimately improve the safety of clinical care.

We review the development of technology in anaesthesia over the course of the past century, from the invention of the Boyle apparatus to the modern anaesthetic workstation with artificial intelligence assistance. We define the operating theatre as a socio-technical system, being necessarily comprised of human and technological parts, the ongoing development of which has led to a reduction in mortality during anaesthesia by an order of four magnitudes over a century. The remarkable technological advances in anaesthesia have been accompanied by important paradigm shifts in the approach to patient safety, and we describe the inter-relationship between technology and the human work environment in the development of such paradigm shifts, including the systems approach and organisational resilience. A better understanding of emerging technological advances and their effects on patient safety will allow anaesthesia to continue to be a leader in both patient safety and in the design of equipment and workspaces.

At this centenary of the British Journal of Anaesthesia (BJA) in 2023, six of its 12 editors/editors-in-chief detail developments over the decades that have led to the BJA becoming a high-impact international scientific journal. As a charity, the BJA supports academic research and training in anaesthesia, critical care, and pain medicine including funding of research grants and postgraduate education. Building on this foundation, the BJA continues to innovate as it aims to become fully electronic, expand into open access publishing, and increase the diversity of its editorial board.

The authors regret that errors were present in the above article. On page 4, column 2, paragraph 3, in the paragraph entitled: Increasing Manuscript Submissions. The College of Anaesthesiologists of Ireland was incorrectly referred to as “The College of Anaesthetists of the Royal College of Surgeons of Ireland”. The authors would like to apologise for any inconvenience caused. The evolution of the British Journal of Anaesthesia: the first 100 yearsBritish Journal of AnaesthesiaVol. 130Issue 1PreviewAt this centenary of the British Journal of Anaesthesia (BJA) in 2023, six of its 12 editors/editors-in-chief detail developments over the decades that have led to the BJA becoming a high-impact international scientific journal. As a charity, the BJA supports academic research and training in anaesthesia, critical care, and pain medicine including funding of research grants and postgraduate education. Building on this foundation, the BJA continues to innovate as it aims to become fully electronic, expand into open access publishing, and increase the diversity of its editorial board. Full-Text PDF

Introduction: Split-thickness skin grafting is a widely used technique for post-traumatic wound management, however it may get complicated by delayed wound healing which leads to a considerable burden on patient and healthcare services in terms of increased treatment duration, costs and disability rates. One factor that may promote wound healing is the type of dressing applied over the skin graft. The use of negative pressure wound therapy over conventional dressings seems promising but evidence remains uncertain. Aims and Objectives: To compare the duration of hospital stay after negative pressure versus conventional dressings on skin graft for post-traumatic wound management. Materials and Methods: A prospective observational comparative study was conducted on 60 patients at a tertiary trauma care hospital. Patients with post-traumatic wounds awaiting skin grafting were included in the study.They were then divided into two equal groups on the basis of odd/even hospital registration number. Dressing was applied after the operative procedure, in a conventional way (Group CD) and by negative pressure technique (Group NPD). Graft take up evaluated on day 4, 7 & 10. The length of hospital stay and complications were noted from the discharge pro-forma. The data was analysed using SPSS software. Results: Demographic profile, size and site of wound area of two groups were comparable (p>0.05). The graft take up was much higher in groups NPD vs CD (p<0.05). Duration of hospital stay was statistically lower in group NPD vs CD (2.3±1.92 vs 5.6±4.23) (P=0.000). Complications such as infection and seroma formation were observed in 10% of patients in group CD. Conclusion: Negative pressure wound therapy provides better skin graft take up, shorter hospital stay and lesser complication rate over conventional method of dressing after grafting. Larger RCTs are recommended to prove effectiveness of this technique.

Peden CJ, Stephens T, Martin G, et al.; the EPOCH trial group. A national quality improvement programme to improve survival after emergency abdominal surgery: the EPOCH stepped-wedge cluster RCT. Southampton (UK): NIHR Journals Library; 2019 Sep.(Health Services and Delivery Research, No. 7.32.)

Introduction: Malnutrition is common in patients with acute kidney injury (AKI), particularly in those requiring renal replacement therapy (RRT). Use of RRT removes metabolic waste products and toxins, but it will inevitably also remove useful molecules such as micronutrients, which might aggravate malnutrition. The RRT modalities vary in mechanism of solute removal; for example, intermittent hemodialysis (IHD) uses diffusion, continuous veno-venous hemofiltration (CVVH) uses convection, and sustained low-efficiency diafiltration (SLEDf) uses a combination of these. Methods: We assessed micronutrient and amino acid losses in 3 different RRT modalities in patients with AKI (IHD, n = 27; SLEDf, n = 12; CVVH, n = 21) after correction for dialysis dose and plasma concentrations. Results: Total losses were affected by modality; generally CVVH >> SLEDf > IHD (e.g., amino acid loss was 18.69 +/- 3.04, 8.21 +/- 4.07, and 5.13 +/- 3.1 g, respectively; P < 0.001). Loss of specific trace elements (e.g., copper and zinc) during RRT was marked, with considerable heterogeneity between RRT types (e.g., +849 and +2325 mu g/l lost during SLEDf vs. IHD, respectively), whereas effluent losses of copper and zinc decreased during CVVH (effect size relative to IHD, -3167 and -1442 mu g/l, respectively). B vitamins were undetectable in effluent, but experimental modeling estimated 40% to 60% loss within the first 15 minutes of RRT. Conclusion: Micronutrient and amino acid losses are marked during RRT in patients with AKI, with variation between RRT modalities and micronutrients.

BackgroundEmergency abdominal surgery can result in poor outcomes for patients. Around 30,000 patients have this surgery each year in the NHS and 1 in 10 will die within 30 days. There are wide variations in care between hospitals, and researchers have already studied the effect of quality improvement (QI) programmes to encourage the use of routine treatments known to help these patients. These studies suggest improved patient survival, but most used poor-quality research designs, which could produce misleading results.

Peden CJ, Stephens T, Martin G, et al.; the EPOCH trial group. A national quality improvement programme to improve survival after emergency abdominal surgery: the EPOCH stepped-wedge cluster RCT. Southampton (UK): NIHR Journals Library; 2019 Sep.(Health Services and Delivery Research, No. 7.32.)

There is limited information on the occurrence of respiratory events in postoperative patients after discharge from the postanesthesia care unit. We studied the respiratory rate (RR) of 68 patients aged 60 years and above during the first 6 hours following elective surgery under general anesthesia to assess the frequency of respiratory events in the care unit and on the ward. RR was derived from the continuous RR counter RespiR8, measuring RR by quantifying the humidity of exhaled air. One-minute-averaged RRs were collected and analyzed to assess the frequency of postoperative bradypnea (RR 1-6 breaths/minute) and apnea (cessation of inspiratory flow ≥60 seconds). Values were median (interquartile range) or mean (SD). The median RR was 13 (10-15) breaths/minute. In the 6-hour postoperative period, 78% and 57% of patients experienced at least one bradypnea or apnea event, respectively. A median of ten (3.5-24) bradypnea and three (1-11) apnea events were detected per patient. The occurrence of respiratory events in the postanesthesia care unit (PACU) was a predictor of events on the ward (bradypnea, r2=0.4, P<0.001; apnea, r2=0.2, P<0.001). Morphine consumption correlated weakly with respiratory events in the PACU, but not on the ward. Patients with apnea had significantly larger neck circumference than patients without (39.6 [0.7] versus 37.4 [0.8] cm, P<0.05). Bradypneic or apneic respiratory events are frequent in postoperative elderly patients and even occur relatively late after surgery. Continuous respiratory monitoring on the ward, especially in patients with risk factors, such as early occurrence of events, opioid use, and larger neck circumference, is likely warranted.

Background: Simulation has been used to investigate clinical questions in anesthesia, surgery, and related disciplines, but there are few data demonstrating that results apply to clinical settings. We asked "would results of a simulation-based study justify the same principal conclusions as those of a larger clinical study?"Methods: We compared results from a randomized controlled trial in a simulated environment involving 80 cases at three centers with those from a randomized controlled trial in a clinical environment involving 1,075 cases. In both studies, we compared conventional methods of anesthetic management with the use of a multimodal system (SAFERsleep (R); Safer Sleep LLC, Nashville, Tennessee) designed to reduce drug administration errors. Forty anesthesiologists each managed two simulated scenarios randomized to conventional methods or the new system. We compared the rate of error in drug administration or recording for the new system versus conventional methods in this simulated randomized controlled trial with that in the clinical randomized controlled trial (primary endpoint). Six experts were asked to indicate a clinically relevant effect size.Results: In this simulated randomized controlled trial, mean (95% CI) rates of error per 100 administrations for the new system versus conventional groups were 6.0 (3.8 to 8.3) versus 11.6 (9.3 to 13.8; P = 0.001) compared with 9.1 (6.9 to 11.4) versus 11.6 (9.3 to 13.9) in the clinical randomized controlled trial (P = 0.045). A 10 to 30% change was considered clinically relevant. The mean (95% CI) difference in effect size was 27.0% (-7.6 to 61.6%).Conclusions: The results of our simulated randomized controlled trial justified the same primary conclusion as those of our larger clinical randomized controlled trial, but not a finding of equivalence in effect size.

INTRODUCTION:Osteoarthritis (OA) pain is a major cause of long-term disability and chronic pain in the adult population. One in five patients does not receive satisfactory pain relief, which reflects the complexity of chronic pain and the current lack of understanding of mechanisms of chronic pain. Recently, duloxetine has demonstrated clinically relevant pain relief, but only in half of treated patients with OA. Here, the aim is to investigate the neural mechanisms of pain relief and neural signatures that may predict treatment response to duloxetine in chronic knee OA pain. METHODS AND ANALYSIS:This is an ongoing single-centre randomised placebo-controlled mechanistic study (2:1 (placebo) allocation), using a multimodal neuroimaging approach, together with psychophysiological (quantitative sensory testing), genetics and questionnaire assessments. Eighty-one subjects with chronic knee OA pain are planned to power for between-group comparisons (placebo, duloxetine responder and duloxetine non-responder). Participants have a baseline assessment and, following 6 weeks of duloxetine (30 mg for 2 weeks, then 60 mg for 4 weeks), a follow-up evaluation. Brain imaging is performed at 3T with blood-oxygen-level dependent functional MRI at rest and during pin-prick nociceptive stimulation for main outcome assessment; arterial spin labelling and structural imaging (T1-weighted) for secondary outcome assessment. Questionnaires evaluate pain, negative affect, quality of sleep and cognition. ETHICS AND DISSEMINATION:The study has been approved by the East Midlands, Nottingham and is being carried out under the principles of the Declaration of Helsinki (64th, 2013) and Good Clinical Practice standards. Results will be disseminated in peer-reviewed journals and at scientific conferences. TRIAL REGISTRATION NUMBER:This trial is registered at ClinicalTrials.gov (NCT02208778).This work was supported by Arthritis Research UK (Grant 18769).

We are pleased to provide this special issue of the British Journal of Anaesthesia (BJA) in association with the PostGraduate Assembly (PGA) of the New York State Society of Anesthesiologists (NYSSA). The PGA is one of the largest international gatherings of anaesthesiologists, with a strong clinical and educational focus. The BJA in collaboration with the PGA continues its strong commitment to innovative approaches to education by once again producing this special issue of the BJA to correspond with the meeting based on a selection of clinically relevant lectures from the 70th Annual PostGraduate Assembly held in New York City, December 9–13, 2016. This is the eighth special issue published to coincide with the PGA. This year's special issue is published online only and is available free to registrants of the PGA through links available on the PGA website (http://www.nyssa-pga.org/pga-meeting) and provided at registration, as well as to regular subscribers of the BJA through their subscriptions. The PGA is the premiere international annual meeting, with >6000 attendees, of whom >30% are from outside the USA. This collaborative international project thus represents an opportunity to enhance the educational missions of both the PGA and the BJA in bringing clinically relevant topical reviews to meeting attendees and international readers of the BJA. The BJA is also sponsoring a scientific panel of international experts on a timely topic at this year's meeting. The BJA panel this year is on perioperative brain injury and protection, moderated by Hugh C. Hemmings, Jr, MD, PhD, an editor of the BJA, incoming editor-in-chief of the BJA, and an expert in anaesthetic neuropharmacology. This panel will be presented on Sunday, December 11, 2016. The BJA, published since 1923, has the highest journal impact factor of all anaesthesia journals (5.616 in 2015) and a global distribution to >6400 institutional subscribers in 50 countries worldwide. It is affiliated with the Royal College of Anaesthetists, the College of Anaesthetists of Ireland, the Hong Kong College of Anaesthesiologists, and the Faculty of Intensive Care Medicine. The BJA publishes clinical and laboratory studies with ∼11% of submissions from North America; in 2015 the BJA published 488 papers originating from 34 countries. Online usage is global, with >350,000 monthly downloads, one-third coming from North America. The BJA, as well as publishing cutting-edge research, has a strong interest in continuing medical education (CME) and also publishes BJA Education (http://bjaed.oxfordjournals.org), a journal supporting the CME and professional development of specialists in anaesthesia, critical care medicine and pain management. Each issue contains one or two review articles that have CME questions online (http://bja.oxfordjournals.org). This common ground between the NYSSA, PGA and BJA of providing high-quality clinical updates and education further strengthens our association. The six educational review articles for the 2016 BJA/PGA special issue, selected from the extensive programme offered at the PGA to complement recent publications in the BJA, are presented by respected experts in the subspecialties of anaesthesiology, perioperative medicine, pain, and critical care. The following contributors to the PGA have kindly agreed to provide detailed reviews of their lectures to supplement their oral presentations (the relevant lectures are indicated by the BJA logo in the PGA programme). Meng and Heerdt1Meng L Heerdt PM Perioperative goal-directed haemodynamic therapy based on flow parameters: a concept in evolution.Br J Anaesth. 2016; 117: iii3-ii17Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar provide a cardiovascular review focusing on the physiological basis of goal-directed haemodynamic therapy. There are two reviews relevant to perioperative bleeding and coagulation. Ghadimi and Welby2Ghadimi K Levy JH Welsby IJ Perioperative management of the bleeding patient.Br J Anaesth. 2016; 117: iii18-iii30Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar discuss recent developments in the management of bleeding in the perioperative period, while Simmons3Simmons JW Powell MF Acute traumatic coagulopathy: pathophysiology and resuscitation.Br J Anaesth. 2016; 117: iii31-iii43Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar discusses the pathophysiology of and resuscitation from acute traumatic coagulopathy. These reviews complement the 2014 review by Waters4Waters JH Role of the massive transfusion protocol in the management of haemorrhagic shock.Br J Anaesth. 2014; 113: ii3-ii8Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar on massive transfusion protocols and the management of haemorrhagic shock. Also in the critical care section, Nunnaly5Nunnally ME Sepsis for the anaesthetist.Br J Anaesth. 2016; 117: iii44-iii51Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar updates current concepts relevant to perioperative sepsis. Brown and Deiner6Brown IV, C Deiner S Perioperative cognitive protection.Br J Anaesth. 2016; 117: iii52-iii61Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar discuss perioperative cognitive protection in a neurosciences and neuroanaesthesia review based on Deiner's lecture in the BJA panel on perioperative brain injury and protection. Following the four reviews published in 2015 based on last year's BJA panel entitled Improving Outcomes with Regional Anaesthesia,7Hopkins PM Does regional anaesthesia improve outcome?.Br J Anaesth. 2015; 115: ii26-ii33Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 8Tedore T Regional anaesthesia and analgesia: relationship to cancer recurrence and survival.Br J Anaesth. 2015; 115: ii34-ii45Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar, 9McIsaac DI Cole ET McCartney CJL The impact of including regional anaesthesia in enhanced recovery protocols: a scoping review.Br J Anaesth. 2015; 115: ii46-ii56Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 10Cozowicz C Poeran J Memtsoudis SG Epidemiology, trends, and disparities in regional anaesthesia for orthopaedic surgery.Br J Anaesth. 2015; 115: ii57-ii67Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar we provide a review by Soffin and Yadeau11Soffin EM YaDeau JT Enhanced recovery after surgery for primary hip and knee arthroplasty: a review of the evidence.Br J Anaesth. 2016; 117: iii62-iii72Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar on the development of enhanced recovery approaches for joint replacement surgery. This year we add a new feature to the BJA/PGA special issue. The Resident Research Contest sponsored each year at the PGA attracts submissions from around the world that are the result of basic or clinical research accomplished during anaesthesiology residency and fellowship training. The contest attracts 20–30 submissions each year and the top abstracts are invited to present their research in moderated poster discussion format during the annual meeting. The abstracts of the six finalists for 2016 are published at the end of the 2016 special issue.12Abstracts from the PostGraduate Assembly Resident Research ContestBr J Anaesth. 2016; 117 (New York, NY, December 10, 2016): iii73-iii76Abstract Full Text PDF Google Scholar Our goal as in the seven previous BJA/PGA special issues13Twersky RS Hemmings Jr., HC Introduction: 2009 BJA/PGA Supplement: a selection of eight reviews.Br J Anaesth. 2009; 103: i1-i2Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 14Hemmings Jr, HC Rosenberg AD Reilly CS Hunter JM The 2010 BJA/PGA supplement: a selection of 10 educational reviews.Br J Anaesth. 2010; 105: i1-i2Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 15Rosenberg AD Hemmings Jr, HC Reilly CS Webster NR The 2011 BJA/PGA supplement: a selection of nine educational reviews.Br J Anaesth. 2011; 107: i1-i2Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 16Hemmings Jr, HC Rosenberg AD Mahajan RP Webster NR The 2012 BJA/PGA supplement: a selection of seven educational.Br J Anaesth. 2012; 109: i1-i2Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 17Hemmings Jr, HC Wlody D Mahajan R Webster NR The 2013 BJA/PGA special issue: a selection of nine educational reviews.Br J Anaesth. 2013; 111: i1-i2Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 18Hemmings Jr, HC Wlody D Mahajan R Webster NR The 2014 BJA/PGA special issue: a selection of six educational reviews.Br J Anaesth. 2014; 113: ii1-ii2Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 19Hemmings Jr, HC Wlody D Mahajan R Webster NR BJA/PGA special issue: a selection of nine educational reviews.Br J Anaesth. 2015; 115: ii1-ii2Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar is to provide the international anaesthesiology community with updated knowledge and skills that benefit you and your patients in clinical practice. We hope you again enjoy this special issue of clinically relevant reviews as an added bonus to this year's PGA. Once again, these articles will be made freely available online on the PGA and BJA websites. We thank the authors for these excellent educational review articles, as well as all involved in the preparation of this special issue, including Oxford University Press. H.C.H. wrote, edited, and approved the final version of this article. R.M., and N.R.W. revised and approved the final version of this article. H.C.H. is editor of the BJA and editor of Anesthesiology. R.M. is editor-in-chief of the BJA. N.R.W. is chairman of the BJA board. None of the authors have other relevant conflicts of interest.

There are fi ve core pillars that intuitively underpin the specialty of academic anaesthesia, but it is imperative to recognize that these ‘ big fi ve ’ [(i) teaching and learning (education); (ii) training (skills acquisition and protocol development); (iii) testing (of sys-tems, theories, and equipment); (iv) quality (innovation and excellence of care, which includes professionalism and superior ethical conduct); and (v) ongoing research (both basic and clinical) and its application to practice] are the tenets that guarantee and sustain the growth, relevance, success, excellence, respect-ability, and productivity of the specialty. Ensuring that these fi ve limbs are catered for can be made possible by the creation of Centres of Excellence and Innovation in Anaesthesia (CEIAs), an open source repository of knowledge, Skills Laboratories, and Simulation Centres (Fig 1).

The prevalence of malnutrition in acute kidney injury (AKI) is high. Patients with AKI may require renal replacement therapy (RRT), which could result in loss of water-soluble micronutrients. Little is known about these losses in RRT and whether they differ between types of RRT. This study aims to quantify micronutrient losses during RRT in patients with AKI and to compare them in three different RRT modalities: continuous venovenous haemofiltration (CVVH), intermittent haemodialysis (IHD) and sustained low-efficiency diafiltration (SLEDf).