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Cost-effectiveness research in Anesthesiology

Teja, B. et al. | Cost-Effectiveness Research in Anesthesiology | Anesthesia & Analgesia | published online ahead of print: March 21, 2018 


Perioperative interventions aimed at decreasing costs and improving outcomes have become increasingly popular in recent years. Anesthesiologists are often faced with a choice among different treatment strategies with little data available on the comparative cost-effectiveness.

We performed a systematic review of the English language literature between 1980 and 2014 to identify cost-effectiveness analyses of anesthesiology and perioperative medicine interventions. We excluded interventions related to critical care or pediatric anesthesiology, and articles on interventions not normally ordered or performed by anesthesiologists. Of the more than 5000 cost effectiveness analyses published to date, only 28 were applicable to anesthesiology and perioperative medicine and met inclusion criteria.

Multidisciplinary interventions were the most cost-effective overall; 8 of 8 interventions were “dominant” (improved outcomes, reduced cost) or cost-effective, including accelerated, standardized perioperative recovery pathways, and perioperative delirium prevention bundles.

Intraoperative measures were dominant in 3 of 5 cases, including spinal anesthesia for benign abdominal hysterectomy. With regard to prevention of perioperative infection, methicillin-resistant Staphylococcus aureus (MRSA) decolonization was dominant or cost-effective in 2 of 2 studies.

Three studies assessing various antibiotic prophylaxis regimens had mixed results. Autologous blood donation was not found to be cost-effective in 5 of 7 studies, and intraoperative cell salvage therapy was also not cost-effective in 2 of 2 reports.

Overall, there remains a paucity of cost-effectiveness literature in anesthesiology, particularly relating to intraoperative interventions and multidisciplinary perioperative interventions.

Based on the available studies, multidisciplinary perioperative optimization interventions such as accelerated, standardized perioperative recovery pathways, and perioperative delirium prevention bundles tended to be most cost-effective.

Our review demonstrates that there is a need for more rigorous cost-effective analyses in many areas of anesthesiology and that anesthesiologists should continue to lead collaborative, multidisciplinary efforts in perioperative medicine.

Full abstract available at Anesthesia & Analgesia

Welfare, morale and experiences of anaesthetists in training

A report on the welfare, morale and experiences of anaesthetists in training: the need to listen | The Royal College of Anaesthetists

Between December 2016 and January 2017, The Royal College of Anaesthetists (RCoA) conducted a survey of anaesthetists in training, to better understand their experiences of life on the frontline of UK hospital care. Well over half of all anaesthetists in training responded: 2,312 responses represent 58% of all anaesthetists in training across the UK.

Image source: http://www.rcoa.ac.uk

With over 1,000 free text comments, the survey provides a detailed picture of the issues faced by doctors training as anaesthe tists in today’s NHS.

Alongside these surveys and to better understand the results, throughout 2017 the RCoA held a series of Listening Events with anaesthetists in training across the UK. These events explored the emerging themes from the RCoA Survey. The feedback from over 200 anaesthetists in training who attended these events also informs the recommendations in this report.

Full publication: A report on the welfare, morale and experiences of anaesthetists in training: the need to listen

General anaesthetics do more than put you to sleep

A new understanding of the complex ways in which general anaesthetics act on the brain could eventually lead to improved drugs for surgery. | via Journal of Anaesthesia Practice

Although general anaesthesia is one of the most common medical procedures worldwide,  it remains unclear how general anaesthesia works. In this research article, Professor Bruno van Swinderen, says his team had overturned previous understanding of what general anaesthetics do to the brain, finding the drugs did much more than induce sleep.


Propofol is the most commonly used general anesthetic in humans. Our understanding of its mechanism of action has focused on its capacity to potentiate inhibitory systems in the brain. However, it is unknown whether other neural mechanisms are involved in general anesthesia.

Here, we demonstrate that the synaptic release machinery is also a target. Using single-particle tracking photoactivation localization microscopy, we show that clinically relevant concentrations of propofol and etomidate restrict syntaxin1A mobility on the plasma membrane, whereas non-anesthetic analogs produce the opposite effect and increase syntaxin1A mobility.

Removing the interaction with the t-SNARE partner SNAP-25 abolishes propofol-induced syntaxin1A confinement, indicating that syntaxin1A and SNAP-25 together form an emergent drug target. Impaired syntaxin1A mobility and exocytosis under propofol are both rescued by co-expressing a truncated syntaxin1A construct that interacts with SNAP-25.

Our results suggest that propofol interferes with a step in SNARE complex formation, resulting in non-functional syntaxin1A nanoclusters.

Full reference: Bademosi, Adekunle T. et al. | Trapping of Syntaxin1a in Presynaptic Nanoclusters by a Clinically Relevant General Anesthetic | Cell Reports , Volume 22 , Issue 2 , 427 – 440


The effect of general anaesthesia on the developing brain

The head of the CU School of Medicine Department of Anesthesiology in Colorado, has written a review of scientific studies on the potentially adverse effects of exposing developing brains to general anaesthesia | Anesthesiology



Recently, the U.S. Food and Drug Administration issued an official warning to all practicing physicians regarding potentially detrimental behavioral and cognitive sequelae of an early exposure to general anesthesia during in utero and in early postnatal life.

The U.S. Food and Drug Administration concern is focused on children younger than three years of age who are exposed to clinically used general anesthetics and sedatives for three hours or longer.

Although human evidence is limited and controversial, a large body of scientific evidence gathered from several mammalian species demonstrates that there is a potential foundation for concern. Considering this new development in public awareness, this review focuses on nonhuman primates because their brain development is the closest to humans in terms of not only timing and duration, but in terms of complexity as well.

Full reference: Jevtovic-Todorovic, V | Exposure of Developing Brain to General Anesthesia: What Is the Animal Evidence? | Anesthesiology | Published ahead of print Dec 2017

The effects of fatigue on trainees in anaesthesia

McClelland, L. et al. | A national survey of the effects of fatigue on trainees in anaesthesia in the UK | Anaesthesia |2017; 72: 1069–77


Long shifts remain a major feature of working life for trainees in anaesthesia. Over the past 10 years, there has been an increase in awareness and understanding of the potential effects of fatigue on both the doctor and the patient. Despite the introduction of the European Working Time Directive into UK law, reducing the maximum hours worked by junior doctors, there is evidence that problems with inadequate rest and fatigue persist.


These authors conducted a national survey to assess the incidence and effects of fatigue among the 3772 anaesthetists in training within the UK.


A response rate of 59% was achieved, with data from 100% of NHS trusts. The results suggested that fatigue remains prevalent among junior anaesthetists, with 73.6% saying that it has effects on physical health, 71.2% that it affects psychological wellbeing and 67.9% that personal relationships are affected. The most problematic factor remains night shift work, with many respondents commenting on the absence of breaks, inadequate rest facilities and 57.0% stating that they had experienced an accident or near-miss when travelling home from night shifts.


The authors discuss potential explanations for the results, and present a plan to address the issues raised by their survey, aiming to change the culture around fatigue for the better.

Full article available via Wiley online Library

A survey of acute pain services in the UK

The organisational state of inpatient pain management in UK hospitals is difficult to determine. We sent an electronic questionnaire to 209 acute pain service leads throughout the UK | Anaesthesia

Questions were about staffing and service provision. We received 141 responses (67%); 47% of all UK hospitals.

Each service was responsible for a median (IQR [range]) of 566 (400–839 [120–2800]) beds. Each acute pain specialist nurse was responsible for 299 (238–534 [70–1923]) beds. The mean (SD) number of consultant hours per week was 5.54 (4.62), delivered by a median of 1.0 (1.0–2.5 [0.2–7.0]) consultant. Overnight cover was provided by 20 (15%) acute pain services, and weekend cover by 39 (29%).

Acute pain services commonly (in 50 (35%) hospitals) had roles in addition to acute pain management. Most teams (105, (77%)) reviewed medical patients and patients with chronic pain (in 131, (96%) teams). Half of the services (56, (49%)), reported that they were part of an integrated acute and chronic pain service, however, 83 (59%) did not have any members who work in chronic pain clinics. The majority (79, (70%)) were able to access a nominated chronic pain consultant for advice.

Provision of acute pain services throughout the UK is highly variable. The majority do not meet core UK standards.

Full reference: Rockett, M. et al. (2017) A survey of acute pain services in the UK. Anaesthesia. Vol. 72 (Issue 10) pp. 1237–1242.