BJA Podcast Episodes
British Journal of Anaesthesia Podcasts from the British Journal of Anaesthesia and Oxford Journals
- ‘Fit to fly’: overcoming barriers to preoperative haemoglobin optimization in surgical patients
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.
June 2015 || Volume 115 - Issue 1 || 27 Minutes
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- Fluid Thinking with Professor Monty Mythen
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 intérieur. 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.
April 2015 || Volume 114 - Issue 5 || 26 Minutes
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- They tried to make me go to prehab...
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.
February 2015 || Volume 114 - Issue 2 || 27 Minutes
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- Pregabalin use in the perioperative period: indications, dosage and the current evidence
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.
January 2015 || Volume 114 - Issue 1 || 22 Minutes
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- Repercussions: post-operative morbidity and the mortality hangover
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.
December 2014 || Volume 113 - Issue 6 || 28 Minutes
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- Fifth National Audit Project on Accidental Awareness during General Anaesthesia
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.
October 2014 || Volume 113 - Issue 4 || 36 Minutes
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- Expiratory flow control: a novel mode of ventilation for the injured lung
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.
September 2014 || Volume 113 - Issue 3 || 22 Minutes
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- Pre-hospital Anaesthesia
Emergency airway management in trauma patients is a complex and somewhat contentious issue, with opinions varying on both the timing and delivery of interventions. London's Air Ambulance is a service specialising in the care of the severely injured trauma patient at the scene of an accident, and has produced one of the largest data sets focusing on pre-hospital rapid sequence induction. Professor David Lockey, a consultant with London's Air Ambulance, talks to the BJA about LAA's approach to advanced airway management, which patients benefit from pre-hospital anaesthesia and the evolution of RSI algorithms. Professor Lockey goes on to discuss induction agents, describes how to achieve a 100% success rate for surgical airways and why too much choice can be a bad thing, as he gives us an insight into the exciting world of pre-hospital emergency care.
August 2014 || Volume 113 - Issue 2 || 35 Minutes
- Needle Phobia - A Psychological Perspective
For anaesthetists, intravenous cannulation is the gateway procedure to an increasingly complex and risky array of manoeuvres, and as such becomes more a reflex arc than a planned motor act. For some patients however, that initial feeling of needle penetrating epidermis, dermis and then vessel wall is a dreaded event, and the cause of more anxiety than the surgery itself. Needle phobia can be a deeply debilitating disease causing patients not to seek help even under the most dire circumstances. Dr Kate Jenkins, a hospital clinical psychologist describes both the psychology and physiology of needle phobia, what we as anaesthetists need to be aware of, and how we can better serve out patients for whom 'just a small scratch' may be their biggest fear.
July 2014 || Volume 113 - Issue 1 || 32 Minutes
- Kidney donation after circulatory death: review and regional variation
Successful kidney transplants have been shown to improve quality of life for the recipients and dramatically reduce the cost of caring for patients with end stage renal failure. However, there is still a significant shortfall in the number of donor organs available, particularly in the UK. This is in part being addressed by an increase in donation after circulatory death (DCD), where organs are recovered from patients whose death is determined according to cardiorespiratory criteria after planned withdrawal of life-sustaining treatments within a critical care setting. For this podcast, Mr Dominic Summers, a transplant surgeon from the University of Cambridge, talks about the process and challenges of DCD, as well as the opportunities to improve donation rates highlighted by the accompanying paper looking at regional variations for renal DCD within the UK.
June 2014 || Volume 112 - Issue 6 || 26 Minutes
- Fluid responsiveness: an evolution in our understanding
Fluid therapy is a central tenet of both anaesthetic and intensive care practice, and has been a solid performer in the medical armamentarium for over 150 years. However, mounting evidence from both surgical and medical populations is starting to demonstrate that we may be doing more harm than good by infusing solutions of varying tonicity and pH into the arms of our patients. As anaesthetists we arguably monitor our patient's response to fluid-based interventions more closely than most, but in emergency departments and on intensive care units this monitoring me be unavailable or misleading. For this podcast Dr Paul Marik, Professor and Division Chief of Pulmonary Critical Care at Eastern Virginia Medical Center delivers a masterclass on the physiology of fluid optimisation, tells us which monitors to believe and importantly under which circumstances, and reviews some of the current literature and thinking on fluid responsiveness.
April 2014 || Volume 112 - Issue 4 || 43 Minutes
- Post-operative Cognitive Decline
Post-operative cognitive decline (POCD) has been detected in some studies in up to 50% patients undergoing major surgery. With an ageing population and an increasing number of elective surgeries, POCD may represent a major public health problem. However POCD research is complex and difficult to perform, and the current literature may not tell the full story. Dr Rob Sanders from the Wellcome Department of Imaging Neuroscience at UCL talks to us about the methodological limitations of previous studies and the important concept of a cognitive trajectory. In addition, Dr Sanders discusses the risk factors and role of inflammation in causing brain injury, and reveals the possibility that certain patients may in fact undergo post-operative cognitive improvement (POCI).
March 2014 || Volume 112 - Issue 3 || 20 Minutes
- Incident Reporting Systems
Widely regarded as champions of patient safety, it was anaesthetists who first pioneered incident reporting systems within hospital medicine. Signed in 2010, the Helsinki declaration for patient safety in anaesthesiology requires members to contribute to national reporting systems, and this podcast accompanies a paper surveying reporting systems within member countries. Professor Andy Smith from the Lancaster Patient Safety Research Unit talks to us about why incident reporting is such a vital component of patient safety, how we should be reporting anaesthesia incidents in the UK, and the future of incident reporting in the wake of the Mid-Staffordshire enquiry.
March 2014 || Volume 112 - Issue 3 || 20 Minutes
- A new player in an old debate
Opinions remain divided on the best form of post-operative analgesia following lower abdominal surgery, with an even split between those favouring epidural anaesthesia versus patient-controlled intravenous infusion. Many variations and combinations have attempted to refine and unify these two techniques without clear-cut success. In Sweden, one group has spent several years pioneering intra-abdominal local anaesthetic infusion delivered via intraperitoneal catheters. Talking about their latest paper introducing a patient-controlled bolus version of this technique is Dr Davide Perniola. Dr Perniola reviews the evolution of intra-abdominal local anaesthesia for post-operative pain, its efficacy and potential benefits. Dr Perniola goes on to describe the results of the randomised controlled trial carried in this issue of the BJA, and the several mechanisms by which intra-abdominal bupivicaine may provide impressive post-operative analgesia.
February 2014 || Volume 112 - Issue 2 || 25 Minutes
- How effective is simulation training in anaesthesia?
As a speciality, anaesthesia has long been a champion of simulation training. But whilst ever increasing numbers of simulation based courses are available, what evidence exists for the proposed advantages of this learning modality? For this podcast Dr Ryan Brydges, an educational academic from the University of Toronto, talks to us about his meta-anaylsis on the topic published in this issue of the BJA. Dr Brydges takes us through the current state of the literature, highlighting the areas and domains where simulation appears to be most useful as an educational tool. Dr Brydges and Dr Thomas discuss outcome metrics, comparators, and explore some of the less intuitive findings with regard to crisis resource management training and high fidelity simulators.
February 2014 || Volume 112 - Issue 2 || 28 Minutes
- An Introduction to Functional MRI
Functional MRI is an exciting but complex imaging modality that is being used with increasing frequency in anaesthesia and pain research. Understanding and interpreting studies requires some knowledge of the fundamentals of fMRI, together with the nuances of study design and statistical analysis. Dr Kyle Pattinson, Consultant Anaesthetist at the John Radcliffe in Oxford and MRC clinician scientist fellow talks us through the basics of fMRI, some of its uses (both potential and realised) and the pitfalls associated with the analysis of multiple repeat tests.
December 2013 || Volume 111 - Issue 6 || 13 Minutes
- Three simple steps to instantly improve patient satisfaction
Whilst the vast majority of big number patient research focuses on physiological outcomes, few studies have attempted to investigate the factors that patients perceive to be indicative of quality anaesthesia. A group from Sir Charles Gairdner Hospital in Perth, Western Australia have developed and validated a simple patient survey that has demonstrated the facets of an anaesthetist and the delivery of anaesthesia that patients value. Data collected from over 7000 patients was used as the basis for departmental education and feedback with striking results. Dr Bill Weightman talks to the BJA about this impressive piece of work and reveals the three things that dramatically improve patients' perception of their anaesthesia care.
December 2013 || Volume 111 - Issue 6 || 28 Minutes
- ARDS: The difficulty with a definition
Despite being defined as a syndrome over 4 decades ago, current studies estimate that over half of patients diagnosed with acute respiratory distress syndrome do not in fact have the disease. In this podcast, Dr Stephen Frohlich explains the difficulties with defining this clinical syndrome and takes us through the new Berlin criteria, set to take over from the established AECC definition. Dr Frohlich and Dr Thomas examine alternate definitions and means of diagnosis with reference to a histological gold standard, and highlight the problems that diagnostic inaccuracy causes researchers examining novel therapies.
November 2013 || Volume 111 - Issue 5 || 19 Minutes
- Uncertainty and the art of systematic over-simplification
With the exponential expansion of the evidence base and increasing frequency of meta-analysis, clinical guidelines have become increasingly ubiquitous in all fields of medicine. Dr Georgina Imberger joins Dr Thomas to talk through the process of guideline generation from a developer's perspective, and question the way in which practising clinicians should apply wide-reaching recommendations to individual patients. Dr Imberger describes how a guideline is generated from clinical question through to recommendation, detailing the various stages and lending her unique insight into their relative degrees of reproducibility and subjectivity.
November 2013 || Volume 111 - Issue 5 || 23 Minutes
- Propofol use by non-anaesthetists in the Emergency Department
Opinions on the use of propofol by non-anaesthetists remain controversial and divided. In this podcast Dr Gavin Lloyd, an emergency physician from The Royal Devon and Exeter NHS Foundation Trust, gives his point of view and describes his experience developing a training program and governance framework for propofol use in the resus room. Dr Lloyd and Dr Thomas explore the relative risks and potential benefits of propofol use in the ED, discuss the results from the accompanying paper and look at the recently published College guidance for the sedation of adults in the ED.
October 2013 || Volume 111 - Issue 4 || 25 Minutes
- Mortality from Anaphylaxis under Anaesthesia
Anaphylaxis under anaesthesia is a dramatic and feared phenomenon. Whilst recognition and treatment has improved largely through awareness and training, the widely quoted mortality still lies between 3 and 9%. An unusual combination of legal obligation and comprehensive referral puts Western Australia in a unique position to audit these figures, which has yielded an unexpected result. Dr Neville Gibbs talks about this observation, its accuracy, and some of the theory and practice relating to anaphyalxis under anaesthesia.
October 2013 || Volume 111 - Issue 4 || 22 Minutes
- Perioperative Neuraxial Block - Safety, Outcomes and Statistics
As the the debate over perioperative neuraxial blockade rages on, more fuel is added to the fire in the form of a controversial secondary analysis carved from the original POISE data set. The authors have used propensity score matching to manipulate the POISE study group into those who received a perioperative neuraxial block and those who did not, with thought provoking results. In this podcast Professor Tim Cook talks about the complex statistical methods used in this paper, and guides us through his interpretation of this important piece of work.
September 2013 || Volume 111 - Issue 3 || 22 Minutes
- Sound Asleep
NAP5 and the recent controversial guidance from NICE are putting commercial depth of anaesthesia monitors under intense scrutiny. How do they work? Does their use correlate with a reduced incidence of awareness? What is the neurobiological basis for the relationship between EEG activity and depth of anaesthesia? A group from Glasgow have developed a new type of DOA monitor that is a radical departure from the conventional number generation box. Dr John Glenn and Dr Bernd Porr explain how their electroencephalophone (EEP) harnesses the power of the human ear as the system's signal processing unit. By transducing the EEG signal into a real time audible sound wave, the EEP produces a sound that can be used to distinguish between the anaesthetised and the awake patient. Drs Glenn and Porr discuss the potential advantages the EEP holds over traditional DOA monitors, future testing and research, and their open approach to development of this exciting new technology.
September 2013 || Volume 111 - Issue 3 || 32 Minutes
- Challenges in experimental pain studies in human volunteers
This month the BJA features a volunteer study investigating the effects of low dose neuraxial clonidine from Stanford University. One of the authors of this paper, Dr Yehuda Ginosar, talks about the challenges surrounding the design and interpretation of volunteer studies in experimental pain. Dr Ginosar and Dr Thomas review the results and inferences from this particular study, and go on to discuss some of the general ethical considerations and practical issues with experimentation on human volunteers.
August 2013 || Volume 111 - Issue 2 || 19 Minutes
- Neurotoxicity and Neuroplasticity
Anaesthetic neurotoxicity is currently one of the hottest research topics in anaesthesia. In June 2012 the BJA sponsored a seminar in Salzburg Austria which saw experts from all over the world come together to discuss the current state of the evidence and future research directions in this important area. To accompany this special edition of the BJA, Professor Hugh Hemmings distils down the conference proceedings and summarises the current thinking on the mechanisms of anaesthetic neurotoxicity, translation to human subjects and the potential clinical implications.
July 2013 || Volume 110 - Supplement 1 || 27 Minutes
- Adam or Eve - who bears the burden of chronic pain?
Dr Sibtain Anwar interviews Professor Roger Fillingim on his work examining the differences in pain experienced between the sexes. Whilst a large body of quite disparate work has demonstrated a significant increase in pain reported by women, the scientific basis for this has yet to be elucidated. Prof Fillingim takes us through some of the proposed mechanisms, many of which have already been discounted, and signposts future avenues investigating this fascinating observation.
July 2013 || Volume 111 - Issue 1 || 25 Minutes
- Pain - recent advances, novel imaging and new challenges
Guest editor Dr Lesley Colvin introduces this special post-graduate issue of the BJA focusing on recent advances and new research in the field of pain medicine. Dr Colvin talks about the the importance and relevance of basic science in this rapidly advancing field and how new imaging techniques are redefining chronic pain as a disease. Also featuring in this podcast and issue are new pathways for clinicians from the British Pain Society, and thoughts on how academic pain research should be conducted in the future to improve the quality of data sets.
July 2013 || Volume 111 - Issue 1 || 20 Minutes
- The Irish are Coming
Dr Ellen O'Sullivan talks about the adoption of the BJA as the official journal of The College of Anaesthetists of Ireland. Together with Rik Thomas, Dr O'Sullivan celebrates some of Ireland's notable academic anaesthetists past, present and future, and discusses the nation's current research output. We hear about some of the College's current projects both at home, in collaboration with the UK and in the developing world.
June 2013 || Volume 110 - Issue 6 || 13 Minutes
- Vein visualisation with near-infrared technology
Definitely one for the tricky vein society; Dr Franklin Chiao talks us through his experience and research evaluating near-infrared devices for perpiheral venous cannulation. Dr Chiao explains the physics behind this new technology plus its potential uses and limitations. We run through the main findings from the scientific paper including the characterisation of patients with difficult venous access, and the potential cannulation advantage offered by the VueTek Veinsite.
June 2013 || Volume 110 - Issue 6 || 18 Minutes
- Human factors and patient safety in anaesthesia
The majority of morbidity and mortality due to anaesthesia is unfortunately caused by human error. In this podcast, Professors Alan Merry and Jennifer Weller gives us an introduction to human factors in anaesthesia, the types of errors that occur and strategies to prevent them. We explore communication failure within the operating theatre environment, the differences between a blame-free and just culture, and the anaesthetist's role in promoting patient safety.
May 2013 || Volume 110 - Issue 5 || 32 Minutes
Whether you relish the prospect of being on call from home or fear losing your job to a more consistently performing robot; automated anaesthesia delivery systems are increasing in their use and sophistication. In this podcast, Rik Thomas talks to Professor Thomas Hemmerling from the McGill University in Montreal and head of the Intelligent Technology in Anaesthesia Research Group about his recent paper describing the provision of anaesthesia to 20 patients undergoing thyroidectomy in Italy, while sat over 4000 miles away in Montreal. Professor Hemmerling describes the process, problems and future development of teleanaesthesia and the implications for practitioners and patients.
May 2013 || Volume 110 - Issue 5 || 23 Minutes
- Do team processes really have an effect on clinical performance? A systematic literature review
In this podcast, Dr Tanja Manser talks about the recent explosion of research into non-technical skills, crew resource management and team processes. Dr Manser describes some of the core principles behind CRM, explains the complexities of performing psychological research in this area, and the difficulties in interpreting the disparate data sets produced.
April 2013 || Volume 110 - Issue 4 || 20 Minutes
- The National Audit Phenomenon
The RCoA national audit projects have enjoyed incredible success, both at home in the UK and internationally. Professor Tim Cook takes us through the national audit project process; from inception, through to execution and recommendation. Professor Cook and Dr Thomas discuss the strengths and weaknesses of the NAP system, how the program has evolved over time and the logistics of carrying out service evaluation on a mammoth scale.
April 2013 || Volume 110 - Issue 4 || 23 Minutes
- Perioperative medicine: the future of anaesthesia?
Dr Rupert Pearce talks about the ideas and concepts behind the rapidly evolving speciality of peri-operative medicine. Dr Pearce and Dr Thomas discuss why a speciality service is required and what it may look like, how it will benefit patients and most importantly for anaesthetists, who will be running it.
March 2013 || Volume 110 - Issue 3 || 16 Minutes
- Inconsistencies in NICE guidance on measuring depth of anaesthesia: limitations of EEG-based technology in detecting who is unconscious
Professor Jaideep Pandit, head of the Royal College's National Audit Project on accidental awareness under general anaesthesia, give us his views on the recent NICE guidelines on depth of anaesthesia monitoring. In the interview we explore the rationale and evidence behind the directive, as well as some of the more controversial issues with regards to the generation and implementation of national guidelines.
March 2013 || Volume 110 - Issue 3 || 27 Minutes
- Opioid-induced respiratory depression in paediatrics: a review of case reports
Professor Albert Dahan, head of the Anesthesia and Pain Research Unit at Leiden University Medical Centre, talks about why this common and dangerous phenomenon is under-reported in the literature and as a result, why he has taken this unusual investigative approach. Professor Dahan highlights the paper's main findings including the emerging importance of CYP2D6 genetic polymorphisms and future directions for research.
February 2013 || Volume 110 - Issue 2 || 17 Minutes
- Long-term quality of sleep after remifentanil-based anaesthesia: a randomized controlled trial
Dr Rik Thomas talks with Dr Manuel Wenk (lead author) about the inspiration and background behind this unusual randomised controlled trial. Dr Wenk summarises what we already know about the effects of opioids on sleep, and why remifentanil may differ in this respect. Dr Wenk goes on to explain his unexpected findings and the potential long-term effects remifentanil may have on sleep quality after surgery.
February 2013 || Volume 110 - Issue 2 || 16 Minutes
- Failed tracheal intubation in Obstetrics
Dr A. Quinn, from Leeds General Infirmary in the UK, lead author of a recent BJA paper on failed tracheal intubation in obstetric anaesthesia talks us through this important UK national prospective survey. Using the UK Obstetric Surveillance System (UKOSS) of data collection, Dr Quinn and colleagues confirm the expected incidence of failed tracheal intubation in obstetrics at one in 224, and that the incidence of failed intubations hasn't decreased in the last 20 years, despite advances in airway techniques. Age, BMI, and a recorded Mallampati score were significant independent predictors of failed tracheal intubation.
January 2013 || Volume 110 - Issue 1 || 20 Minutes
- Why do we need research in Anaesthesia?
This BJA podcast sees the Journal interview Dr J. P. van Besouw, President of the Royal College of Anaesthetists, UK for his thoughts on why more research is necessary in the field of anaesthesia.
January 2013 || Volume 110 - Issue 1 || 10 Minutes
- An academic trainee; have I got a future?
Professor M. Mythen, University College, London shares his perspective on training in academic anaesthesia in the UK.
January 2013 || Volume 110 - Issue 1 || 12 Minutes
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