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Summary: While videolaryngoscopy has resulted in better overall success rates of tracheal intubation, airway assessment is still an important prerequisite for safe airway management. This study aimed to create an artificial intelligence model to identify difficult videolaryngoscopy using a neural network. Baseline characteristics, medical history, bedside examination and seven facial images were included as predictor variables. ResNet‐18 was introduced to recognise images and extract features. Different machine learning algorithms were utilised to develop predictive models. A videolaryngoscopy view of Cormack‐Lehane grade of 1 or 2 was classified as 'non‐difficult', while grade 3 or 4 was classified as 'difficult'. A total of 5849 patients were included, of whom 5335 had non‐difficult and 514 had difficult videolaryngoscopy. The facial model (only including facial images) using the Light Gradient Boosting Machine algorithm showed the highest area under the curve (95%CI) of 0.779 (0.733–0.825) with a sensitivity (95%CI) of 0.757 (0.650–0.845) and specificity (95%CI) of 0.721 (0.626–0.794) in the test set. Compared with bedside examination and multivariate scores (El‐Ganzouri and Wilson), the facial model had significantly higher predictive performance (p < 0.001). Artificial intelligence‐based facial analysis is a feasible technique for predicting difficulty during videolaryngoscopy, and the model developed using neural networks has higher predictive performance than traditional methods. [ABSTRACT FROM AUTHOR]

Summary: It is essential that academic publishing complies with the highest standards in terms of ethics, research conduct and manuscript preparation. This protects the rights and welfare of research participants, ensures the integrity of study results and aids the communication and dissemination of novel findings into clinical practice. This position statement outlines the current policies and practices of the Editors of Anaesthesia and Anaesthesia Reports in relation to academic medical publishing. [ABSTRACT FROM AUTHOR]

Summary: The amount of aerosol generation associated with the use of positive pressure ventilation via a supraglottic airway device has not been quantified. We conducted a two‐group, two‐centre, prospective cohort study in which we recruited 21 low‐risk adult patients scheduled for elective surgery under general anaesthesia with second‐generation supraglottic airway devices. An optical particle sizer and an isokinetic sampling probe were used to record particle concentrations per second at different size distributions (0.3–10 μm) during use as well as baseline levels during two common activities (conversation and coughing). There was a median (IQR [range]) peak increase of 2.8 (1.5–4.5 [1–28.1]) and 4.1 (2.0–7.1 [1–18.2]) times background concentrations during SAD insertion and removal. Most of the particles generated during supraglottic airway insertion (85.0%) and removal (85.3%) were < 3 μm diameter. Median (IQR [range]) aerosol concentration generated by insertion (1.1 (0.6–5.1 [0.2–22.3]) particles.cm−3) and removal (2.1 (0.5–3.0 [0.1–18.9]) particles.cm−3) of SADs were significantly lower than those produced during continuous talking (44.5 (28.3–70.5 [2.0–134.5]) particles.cm−3) and coughing (141.0 (98.3–202.8 [4.0–296.5]) particles.cm−3) (p < 0.001). The aerosol levels produced were similar with the two devices. The proportion of easily inhaled and small particles (<1 μm) produced during insertion (57.5%) and removal (57.5%) was much lower than during talking (99.1%) and coughing (99.6%). These results suggest that the use of supraglottic airway devices in low‐risk patients, even with positive pressure ventilation, generates fewer aerosols than speaking and coughing in awake patients. [ABSTRACT FROM AUTHOR]

Summary: Propfol‐remifentanil‐based total intravenous anaesthesia has dominated recent clinical practice due to its favourable pharmacokinetic profile. Interruption in remifentanil supply has presented an opportunity to diversify or even avoid the use of opioids and consider adjuncts to propofol‐based total intravenous anaesthesia. Propofol, while a potent hypnotic, is not an effective analgesic. The administration of opioids, along with other adjuncts such as α‐2 adrenoceptor agonists, magnesium, lidocaine, ketamine and nitrous oxide provide surgical anaesthesia and avoids large doses of propofol being required. We provide an overview of both target‐control and manual infusion regimes for the alternative opioids: alfentanil, sufentanil and fentanyl. The optimal combination of hypnotic‐opioid dose, titration sequence and anticipated additional postoperative analgesia required depend on the chosen combination. In addition, we include a brief discussion on the role of non‐opioid adjuncts in total intravenous anaesthesia, suggested doses and expected reduction in propofol dose. [ABSTRACT FROM AUTHOR]

There is a need to prioritise equity, diversity and inclusion within anaesthesia and medicine as a whole. This position statement outlines the Anaesthesia Editors' current policies and practices aiming to achieve equity, represent the diversity of our specialty and actively include people engaged with this journal and beyond. We will define, promote and embed principles of equity, diversity and inclusion across all our work. We will monitor and report author and editor characteristics and ensure recruitment practices are transparent and adhere to our principles on equity, diversity and inclusion. We will attempt to remove systemic barriers restricting those from under-represented groups from progressing into leadership roles within anaesthesia. We will respond to threats and barriers to the principles and practices we set. With these principles and specific actions we undertake, we aim to be pro-active rather than reactive. We commit to embracing and embedding equity, diversity and inclusion in all our practices and regularly reviewing, improving and updating our policies and practices. [ABSTRACT FROM AUTHOR]

This article discusses the practice of mixing injectable medications in anesthesia, which is not covered in recent guidelines on safe administration. The authors highlight the increasing prevalence of mixing medications, such as the components of total intravenous anesthesia (TIVA), antibiotics, anti-emetics, and analgesics. While guidelines do not endorse the mixing of propofol and remifentanil, there is emerging discourse within the anesthesia community on its acceptability. The article emphasizes the need for a stronger consensus on mixing injectable medications, considering factors like chemical compatibility and pharmacokinetic properties. The authors also mention the lack of a validated pharmacokinetic model for propofol and remifentanil admixtures, leading to complexities in dosing recommendations. The article suggests that separate guidance may be needed for adult and pediatric anesthesia, and highlights the risks and responsibilities associated with using unlicensed ad-hoc admixtures. [Extracted from the article]

Summary: Various techniques have been explored to prolong the duration and improve the efficacy of local anaesthetic nerve blocks. Some of these involve mixing local anaesthetics or adding adjuncts. We did a literature review of studies published between 01 May 2011 and 01 May 2021 that studied specific combinations of local anaesthetics and adjuncts. The rationale behind mixing long‐ and short‐acting local anaesthetics to hasten onset and extend duration is flawed on pharmacokinetic principles. Most local anaesthetic adjuncts are not licensed for use in this manner and the consequences of untested admixtures and adjuncts range from making the solution ineffective to potential harm. Pharmaceutical compatibility needs to be established before administration. The compatibility of drugs from the same class cannot be inferred and each admixture requires individual review. Precipitation on mixing (steroids, non‐steroidal anti‐inflammatory drugs) and subsequent embolisation can lead to serious adverse events, although these are rare. The additive itself or its preservative can have neurotoxic (adrenaline, midazolam) and/or chondrotoxic properties (non‐steroidal anti‐inflammatory drugs). The prolongation of block may occur at the expense of motor block quality (ketamine) or block onset (magnesium). Adverse effects for some adjuncts appear to be dose‐dependent and recommendations concerning optimal dosing are lacking. An important confounding factor is whether studies used systemic administration of the adjunct as a control to accurately identify an additional benefit of perineural administration. The challenge of how best to prolong block duration while minimising adverse events remains a topic of interest with further research required. [ABSTRACT FROM AUTHOR]

With different pharmacokinetics in a drug mixture, a decision must be made to guide the infusion by one of the drugs with the potential risk of over- or under-dosing the other. The Medicines and Healthcare products Regulatory Agency in the UK and the US Food and Drug Administration have not approved the use of other medications including ketamine, remifentanil and dexmedetomidine but these practices have gained popularity. In some circumstances, there may be persuasive reasons for mixing two or more parenteral drug solutions, such as difficult intravenous access or in palliative care syringe drivers, but most of these situations are not applicable to routine intra-operative drug administration. Keywords: pharmacokinetics: pharmacodynamics; pharmacology; safety EN pharmacokinetics: pharmacodynamics pharmacology safety 260 263 4 02/07/22 20220301 NES 220301 The development and refinement of anaesthetic drugs and their administration have markedly increased safety and titratability while decreasing morbidity. [Extracted from the article]

Patients with Parkinson's disease are at higher risk of peri-operative medical and surgical complications. Multidisciplinary management, early recognition of potential complications, specialised care of medications and intra-operative protection of the vulnerable brain are all important aspects of the peri-operative management of patients with Parkinson's disease. Advances in continuous dopaminergic treatment, development of a peri-operative Parkinson's disease pathway and application of telemedicine are starting to play a role in improving peri-operative care. Management of patients with advanced Parkinson's disease is also evolving, with potential for incorporation of integrated care and changes in the anaesthetic management for deep brain stimulation surgery. There are new methods for localisation of target nuclei and increasing insight on the effects of anaesthetic drugs on microelectrode recordings and clinical outcomes. Parkinson's disease is a progressive disease, but management is improving with better peri-operative care for patients. [ABSTRACT FROM AUTHOR]

Surgery and anaesthesia subject the brain to considerable stress in the peri-operative period. This may be caused by potentially neurotoxic anaesthetic drugs, impaired cerebral perfusion and reperfusion injury related to surgery or thromboembolic events. Patient monitoring using electroencephalogram and cerebral oximetry can assist in optimising depth of anaesthesia and assessment of cerebral metabolic activity. However, research findings have been contradictory as to whether these monitors can help ameliorate peri-operative neurocognitive complications. In this narrative review, we will discuss recent evidence in the use of electroencephalography and cerebral oximetry and the underlying scientific principles. It is important to appreciate the raw electroencephalographic changes under anaesthesia and those associated with ageing, in order to interpret depth of anaesthesia indices correctly. Cerebral oximetry is useful not only for the detection of cerebral desaturation but also to identify those patients who are particularly vulnerable to injury, for better risk stratification. An algorithm-based approach may be most effective in managing the episodes of cerebral desaturation. [ABSTRACT FROM AUTHOR]