The concept of peri-operative medicine to prevent major adverse events and improve outcome in surgical patients: A narrative review Peri-operative Medicine is the patient-centred and value-based multidisciplinary peri-operative care of surgical patients. Peri-operative stress, that is the collective response to stimuli occurring before, during and after surgery, is, together with pre-existing comorbidities, the pathophysiological basis of major adverse events. The ultimate goal of peri-operative medicine is to promote high quality recovery after surgery. Clinical scores and/or biomarkers should be used to identify patients at high risk of developing major adverse events throughout the peri-operative period. Allocation of high-risk patients to specific care pathways with peri-operative organ protection, close surveillance and specific early interventions is likely to improve patient-relevant outcomes, such as disability, health-related quality of life and mortality. Correspondence to Bernardo Bollen Pinto, MD, PhD, Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland Tel: +41 789401810; fax: +41 223727511; e-mail: bernardo.bollenpinto@hcuge.ch © 2019 European Society of Anaesthesiology

The distance between the glottis and cuff of a tracheal tube placed through three supraglottic airway devices in children: A randomised controlled trial BACKGROUND After tracheal tube insertion via various types of supraglottic airway devices, the distance from the tube cuff to the vocal cords has not been evaluated in children. OBJECTIVES The aim of this study was to evaluate the position of a tracheal tube cuff relative to the glottis in children when one of three supraglottic airway devices (I-gel, AuraGain and air-Q laryngeal airway) are used as intubation conduits. DESIGN A randomised controlled trial. SETTING Tertiary children's hospital. PATIENTS Children aged less than 7 years. INTERVENTION In vivo fibre-optic assessment and in vitro measurement. MAIN OUTCOME MEASURES The main outcome was the safety margin: the distance between the ventilation outlet of the supraglottic airway device and the beginning of the proximal cuff minus that from the ventilation outlet to the glottis. The maximum inner diameter of the cuffed tracheal tube that could be inserted, the fibre-optic view score and the oropharyngeal leak pressure were also evaluated. RESULTS The three devices exhibited significant differences in the distance from the ventilation outlet to the glottis (mean ± SD): I-gel 3.6 ± 0.6 cm, AuraGain 3.8 ± 0.7 cm, air-Q 2.8 ± 1.0 cm (P < 0.001). The safety margin was greatest with the air-Q and narrowest with the I-gel: I gel 1.9 ± 1.1 cm, AuraGain 4.4 ± 0.7 cm and air-Q 7.9 ± 1.1 cm. Using the AuraGain and air-Q, the cuffs of the tracheal tubes were predicted to be located below the glottis with one-size and two-size smaller tracheal tubes in all patients. However, using I-gel, the cuffs would be below the glottis in 69% (95% CI 49.6 to 84.5) and 29% (95% CI 14.0 to 48.4) of the patients with a one-size and two-size smaller tube, respectively. CONCLUSION The AuraGain and air-Q are well tolerated intubating conduits. The possibility of vocal cord damage is higher when the I-gel is used. TRIAL REGISTRATION www.clinicaltrials.gov (number: NCT03156166) Correspondence to Jin-Tae Kim, MD, PhD, Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, # 101 Daehakno, Jongnogu, Seoul 03080, Republic of Korea Tel: +82 2 2072 3295; fax: +82 2 745 5587; e-mail: jintae73@gmail.com © 2019 European Society of Anaesthesiology

Ipsilateral hemidiaphragmatic paresis after a supraclavicular and costoclavicular brachial plexus block: A randomised observer blinded study BACKGROUND The costoclavicular brachial plexus block (BPB) produces faster onset of sensory motor blockade than the lateral sagittal approach. However, the incidence of phrenic nerve palsy (PNP) after a costoclavicular BPB is not known. OBJECTIVES The current study compared the incidence of ipsilateral hemidiaphragmatic paresis, and thus PNP, between a supraclavicular and costoclavicular BPB. DESIGN Randomised observer blinded study. SETTING Operating room. PATIENTS Forty patients undergoing right-sided upper extremity surgery. INTERVENTION All patients received either a supraclavicular group or costoclavicular group BPB using 20 ml of an equal mixture of 0.5% bupivacaine and 2% lidocaine with 1 : 200 000 epinephrine. MAIN OUTCOME MEASURES Measurements included ipsilateral hemidiaphragmatic excursion and peak expiratory flow rate (PEFR) taken before and at 30 min after the BPB. Diaphragmatic excursion was measured using M-mode ultrasound during normal breathing, deep breathing and with the sniff manoeuvre. Ipsilateral PNP was defined as a reduction in hemidiaphragmatic excursion by at least 50% during deep breathing at 30 min after the BPB. RESULTS The incidence of ipsilateral PNP was lower (P = 0.008) in the costoclavicular group (5%) than in the supraclavicular group (45%). Fewer (P = 0.04) patients in the costoclavicular group [1(5%)] exhibited a positive sniff test, with paradoxical movement of the diaphragm, than in the supraclavicular group [7(35%)]. PEFRs were similar (P = 0.09) between the groups. When ipsilateral hemidiaphragmatic paresis was present, the median reduction in PEFR was 32% (interquartile range 23.6 to 45.5%). CONCLUSION Costoclavicular BPB produces a lower incidence of ipsilateral PNP than a supraclavicular BPB. NAME OF REGISTRY Clinical Trial Registry of India. IDENTIFIER CTRI/2017/09/009763. Correspondence to Indubala Maurya, Assistant Professor, Department of Anesthesiology Super Speciality Cancer Institute and Hospital, C.G. City, Lucknow, Uttar Pradesh, 226002, India E-mail: indubala.maurya@gmail.com © 2019 European Society of Anaesthesiology

Analgesic efficacy of ultrasound-guided interscalene block vs. supraclavicular block for ambulatory arthroscopic rotator cuff repair: A randomised noninferiority study BACKGROUND Ultrasound-guided interscalene block (ISB) is the reference technique for pain control after ambulatory upper limb surgery, but supraclavicular block (SCB) is an alternative. OBJECTIVES The aim of this study was to compare the efficacy of SCB vs. ISB in patients undergoing ambulatory arthroscopic rotator cuff repair (ARCR), with the hypothesis of noninferiority of SCB analgesia compared with ISB. DESIGN A randomised, single-blind, noninferiority study. SETTING Hôpital Privé Jean Mermoz, Centre Paul Santy, Lyon, France. PATIENTS Ambulatory ARCR patients. INTERVENTION Patients were randomly allocated (1 : 1) to receive a single injection SCB or ISB, as well as general anaesthesia. All patients received a postoperative analgesic prescription for home use before leaving hospital (including fast-acting oral morphine sulphate). Patients completed a telephone questionnaire on days 1 and 2 postsurgery. MAIN OUTCOME MEASURES Primary endpoint was oral morphine consumption (mg) during the first 2 days postsurgery. If the difference between mean morphine consumption in the SCB vs. ISB group was less than 30 mg, noninferiority of SCB compared with ISB would be demonstrated. Secondary evaluation criteria included pain scores (numerical rating scale), duration of motor and sensory blockade, and satisfaction with treatment. RESULTS The per-protocol cohort included 103 patients (SCB = 52, ISB = 51) (57% men, median age 58 years). Mean morphine consumption in the 48 h postsurgery was 9.4 vs. 14.7 mg in the SCB and ISB groups, respectively (difference −5.3, P < 0.001). The upper limit of the 95% CI was less than 30 mg, demonstrating noninferiority of SCB compared with ISB. No difference was observed between the two groups in terms of pain scores or the duration of motor or sensory blockade. Overall, 98% of patients in the SCB group vs. 90% in the ISB group were satisfied with their treatment. CONCLUSION SCB is as effective as ISB in terms of postoperative analgesia based on oral morphine consumption in patients undergoing ambulatory ARCR. Trial registration: EudraCT number: 2016-A00747-47. Correspondence to Julien Cabaton, MD, Department of Anaesthesiology, Hôpital Privé Jean Mermoz, Centre Paul Santy, 24, avenue Paul Santy, Lyon 69008, France E-mail: cabaton.md@orthosanty.fr This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 © 2019 European Society of Anaesthesiology

Virtual reality exposure before elective day care surgery to reduce anxiety and pain in children: A randomised controlled trial BACKGROUND Pre-operative anxiety in children is very common and is associated with adverse outcomes. OBJECTIVE The aim of this study was to investigate if virtual reality exposure (VRE) as a preparation tool for elective day care surgery in children is associated with lower levels of anxiety, pain and emergence delirium compared with a control group receiving care as usual (CAU). DESIGN A randomised single-blind controlled trial. SETTING A single university children's hospital in the Netherlands from March 2017 to October 2018. PATIENTS Two-hundred children, 4 to 12 years old, undergoing elective day care surgery under general anaesthesia. INTERVENTION On the day of surgery, children receiving VRE were exposed to a realistic child-friendly immersive virtual version of the operating theatre, so that they could get accustomed to the environment and general anaesthesia procedures. MAIN OUTCOME MEASURES The primary outcome was anxiety during induction of anaesthesia (modified Yale Preoperative Anxiety Scale, mYPAS). Secondary outcomes were self-reported anxiety, self-reported and observed pain, emergence delirium, need for rescue analgesia (morphine) and parental anxiety. RESULTS A total of 191 children were included in the analysis. During induction of anaesthesia, mYPAS levels (median [IQR] were similar in VRE, 40.0 [28.3 to 58.3] and CAU, 38.3 [28.3 to 53.3]; P = 0.862). No differences between groups were found in self-reported anxiety, pain, emergence delirium or parental anxiety. However, after adenoidectomy/tonsillectomy, children in the VRE condition needed rescue analgesia significantly less often (55.0%) than in the CAU condition (95.7%) (P = 0.002). CONCLUSION In children undergoing elective day care surgery, VRE did not have a beneficial effect on anxiety, pain, emergence delirium or parental anxiety. However, after more painful surgery, children in the VRE group needed rescue analgesia significantly less often, a clinically important finding because of the side effects associated with analgesic drugs. Options for future research are to include children with higher levels of anxiety and pain and to examine the timing and duration of VRE. TRIAL REGISTRATION Netherlands Trial Registry: NTR6116 (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6116). Correspondence to Elisabeth M.W.J. Utens, (Kp-2865), P.O. Box 2060, 3000 CB Rotterdam, the Netherlands E-mail: e.utens@erasmusmc.nl This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 © 2019 European Society of Anaesthesiology

Comparison of neostigmine vs. sugammadex for recovery of muscle function after neuromuscular block by means of diaphragm ultrasonography in microlaryngeal surgery: A randomised controlled trial BACKGROUND Postoperative residual neuromuscular blockade or curarisation (PORC) is a risk directly related to the use of neuromuscular blocking agents during surgical procedures. Acceleromyography is distressing for conscious patients when assessing PORC. Diaphragm ultrasonography could be a valid alternative. OBJECTIVES The primary objective was to achieve a 28% lower incidence of PORC in patients who, after rocuronium administration, received neostigmine or sugammadex at 30 min after surgery. To assess PORC, diaphragm ultrasonography was used, and thickening fractioning [the difference of thickness at the end of inspiration (TEI) and at the end of expiration (TEE), normalised for TEE (TEI − TEE/TEE)] was measured. PORC was defined as thickening fractioning of 0.36 or less. The secondary object was the comparison, in the two treatment groups, of the return to baseline thickening fractioning at 30 min after surgery (ΔTF30). DESIGN Prospective, double-blind, single-centre randomised study. SETTING University Hospital Careggi, Florence, Italy. PATIENTS Patients of American Society Anesthesiologists’ physical status 1 or 2, 18 to 80 years, receiving rocuronium during microlaryngeal surgery. INTERVENTIONS At the end of surgery participants were randomised to receive neostigmine (NEO group) or sugammadex (SUG group) as the reversal drug. Thickening fractioning and ΔTF30 were evaluated at baseline and at 0, 10 and 30 min after surgery. MAIN OUTCOME MEASURES TEE and TEI at each time point. RESULTS A total of 59 patients with similar demographic characteristics were enrolled. An association between lack of recovery (thickening fractioning ≤0.36) and drug treatment was only observed at 0 min (SUG vs. NEO, P < 0.05). Concerning ΔTF, at 30 min more patients in the SUG group returned to baseline than those in the NEO group (P < 0.001), after adjusting for side (P = 0.52), baseline thickening fractioning (P < 0.0001) and time of measurement (P < 0.01). CONCLUSION We found an early (0 min) but not long-lasting (30 min) association between diaphragm failure and treatment allocation; a full recovery in baseline diaphragm function was observed only in patients receiving sugammadex. We cannot exclude that further differences have not been found due to interpatients variability in assessing diaphragm contractility by ultrasonography. TRIAL REGISTRATION EudraCT Identifier: 2013-004787-62, Clinicaltrials.gov Identifier: NCT02698969. Correspondence to Iacopo Cappellini, Section of Anesthesiology and Intensive Care, Department of Health Sciences, University of Florence, Largo Brambilla 3, 50134 Florence, Italy E-mail: jacopocappellini@gmail.com © 2019 European Society of Anaesthesiology

Neuraxial labour analgesia is associated with a reduced risk of maternal depression at 2 years after childbirth: A multicentre, prospective, longitudinal study BACKGROUND Severe labour pain is an important risk factor of postpartum depression, and early depression is associated with an increased risk of long-term depression; whereas the use of epidural analgesia during labour decreases the risk of postpartum depression. OBJECTIVE To investigate whether neuraxial labour analgesia was associated with a decreased risk of 2-year depression. DESIGN This was a multicentre, prospective, longitudinal study. SETTING The study was performed in Peking University First Hospital, Beijing Obstetrics and Gynecology Hospital and Haidian Maternal and Child Health Hospital in Beijing, China, between 1 August 2014 and 25 April 2017. PATIENTS Five hundred ninety-nine nulliparous women with single-term cephalic pregnancy preparing for vaginal delivery were enrolled. MAIN OUTCOME MEASURE Depressive symptoms were screened with the Edinburgh Postnatal Depression Scale at delivery-room admission, 6-week postpartum and 2 years after childbirth. A score of 10 or higher was used as the threshold of depression. The primary endpoint was the presence of depression at 2 years after childbirth. The association between the use of neuraxial labour analgesia and the development of 2-year depression was analysed with a multivariable logistic regression model. RESULTS Five hundred and eight parturients completed 2-year follow-up. Of these, 368 (72.4%) received neuraxial analgesia during labour and 140 (27.6%) did not. The percentage with 2-year depression was lower in those with neuraxial labour analgesia than in those without (7.3 [27/368] vs. 13.6% [19/140]; P = 0.029). After correction for confounding factors, the use of neuraxial analgesia during labour was associated with a significantly decreased risk of 2-year depression (odds ratio 0.455, 95% confidence interval 0.230 to 0.898; P = 0.023). CONCLUSION For nulliparous women with single-term cephalic pregnancy planning for vaginal delivery, the use of neuraxial analgesia during labour was associated with a reduced risk of maternal depression at 2 years after childbirth. TRIAL REGISTRATION www.chictr.org.cn: ChiCTR-OCH-14004888 and ClinicalTrials.gov: NCT02823418. Correspondence to Dong-Xin Wang, MD, PhD, Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No. 8 Xishiku Street, Beijing 100034, China Tel: +86 10 83572784; fax: +86 10 66551057; e-mail: wangdongxin@hotmail.com Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 © 2019 European Society of Anaesthesiology

Guidewire-assisted vs. direct radial arterial cannulation in neonates and infants: A randomised controlled trial BACKGROUND Cannulation of the radial artery is challenging to perform in neonates and infants because of the small vessel size. OBJECTIVE To compare guidewire-assisted with direct radial artery cannulation in neonates and infants. DESIGN A randomised controlled study. SETTING A tertiary university hospital from 7 August 2017 to 4 July 2018. PATIENTS Ninety neonates and infants who required radial artery cannulation during general anaesthesia. INTERVENTIONS All patients were allocated randomly into the guidewire group (guidewire-assisted cannulation, n=45) or control group (direct cannulation, n=45). Radial artery cannulation was performed under general anaesthesia. The contralateral radial artery was used if the arterial cannulation was not successful within two attempts. After the second failure in the contralateral radial artery, the case was considered a failure. MAIN OUTCOME MEASURES The primary outcome was the first-attempt success rate of radial artery cannulation. The secondary outcomes included the overall success rate, overall procedure time, number of attempts and use of the contralateral radial artery for radial artery cannulation. RESULTS The guidewire group showed a higher first-attempt success rate [76 vs. 56%; P = 0.046; odds ratio (OR) 2.47, 95% confidence interval (CI) of odds 1.01 to 6.08] and overall success rate (96 vs. 76%; P = 0.007; OR 6.96; 95% CI 1.44 to 33.52) than the control group. The overall procedure time was not significantly different between the guidewire group (median [IQR] 36 [28.0 to 70.5] s) and control group (98 [23.5 to 465.0] s; P = 0.400). There was no difference in the median number of attempts between the two groups (P = 0.454). However, use of the contralateral radial artery was significantly lower in the guidewire group (17.8%) than in the control group (40%; P = 0.020; OR 0.324, 95% CI 0.12 to 0.86). Kaplan–Meier analysis of the overall procedure time to successful radial artery cannulation showed that the overall success rate was significantly higher in the guidewire group than in the control group (P = 0.019). CONCLUSION For radial artery cannulation in neonates and infants, guidewire-assisted radial artery cannulation showed superiority over the direct technique in terms of first-attempt success rate and overall success rate without delaying the procedure time. TRIAL REGISTRATION Clinicaltrials.gov (identifier: NCT03217019). Correspondence to Prof Jin-Tae Kim, Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehakno, Jongnogu, Seoul 03080, Republic of Korea Tel: +82 2 2072 3295; fax: +82 2 745 5587; e-mail: jintae73@gmail.com © 2019 European Society of Anaesthesiology

Does programmed intermittent epidural bolus improve childbirth conditions of nulliparous women compared with patient-controlled epidural analgesia?: A multicentre, prospective, controlled, randomised, triple-blind study BACKGROUND Epidural analgesia may change the mechanics of childbirth. These changes are related to the concentration of the local anaesthetic used epidurally but probably also to its mode of delivery into the epidural space. OBJECTIVE To determine whether the administration of programmed intermittent epidural boluses (PIEB) improves the mechanics of second-stage labour compared with patient-controlled epidural analgesia (PCEA) with a background infusion. DESIGN Prospective, controlled, randomised, triple-blind study. SETTING Multicentre study including four level III maternity units, January 2014 until June 2016. PATIENTS A total of 298 nulliparous patients in spontaneous labour were randomised to a PIEB or PCEA group. INTERVENTION After epidural initiation with 15 ml of 0.1% levobupivacaine containing 10 μg of sufentanil, patients received either an hourly bolus of 8 ml (PIEB) or a continuous rate infusion of 8 ml h−1 (PCEA): the drug mixture used was levobupivacaine 0.1% and sufentanil 0.36 μg ml−1. MAIN OUTCOME MEASURES The primary outcome was a composite endpoint of objective labour events: a posterior occiput position in the second stage, an occiput position at birth, waiting time at full cervical dilatation before active maternal pushing more than 3 h, maternal active pushing duration more than 40 min, and foetal heart rate alterations. Vaginal instrumental delivery rates, analgesia and motor blockade scores were also recorded. RESULTS From the 298 patients randomised, data from 249 (124 PIEB, 125 PCEA) were analysed. No difference was found in the primary outcome: 48.0% (PIEB) and 45.5% (PCEA) of patients, P = 0.70. In addition, no difference was observed between the groups for each of the individual events of the composite endpoint, nor in the instrumental vaginal delivery rate, nor in the degree of motor blockade. Despite an equivalent volume of medication in the groups, a significantly higher analgesia score at full dilatation was observed in the PIEB group, odds-ratio = 1.9 (95% confidence interval, 1.0 to 3.5), P = 0.04. CONCLUSION The mechanics of the second stage did not differ whether PIEB or PCEA was used. Analgesic conditions appeared to be superior with PIEB, especially at full dilation. TRIAL REGISTRATION Clinical trial number: NCT01856166. Correspondence to Estelle Morau, CHU Arnaud de Villeneuve, 34295 Montpellier Cedex 5, France E-mail: estelle.morau@hotmail.fr © 2019 European Society of Anaesthesiology

Patient safety and the role of the Helsinki Declaration on Patient Safety in Anaesthesiology: A European survey BACKGROUND The Helsinki Declaration on Patient Safety was launched in 2010 by the European Society of Anaesthesiology and the European Board of Anaesthesiology. It is not clear how widely its vision and standards have been adopted. OBJECTIVE To explore the role of the Helsinki Declaration in promoting and maintaining patient safety in European anaesthesiology. DESIGN Online survey. SETIING A total of 38 countries within Europe. PARTICIPANTS Members of the European Society of Anaesthesiology who responded to an invitation to take part by electronic mail. MAIN OUTCOME MEASURES Responses from a 16-item online survey to explore each member anaesthesiologist's understanding of the Declaration and compliance with its standards. RESULTS We received 1589 responses (33.4% response rate), with members from all countries responding. The median [IQR] response rate of members was 20.5% [11.7 to 37.0] per country. There were many commonalities across Europe. There were very high levels of use of monitoring (pulse oximetry: 99.6%, blood pressure: 99.4%; ECG: 98.1% and capnography: 96.0%). Protocols and guidelines were also widely used, with those for pre-operative assessment, and difficult and failed intubation being particularly popular (mentioned by 93.4% and 88.9% of respondents, respectively). There was evidence of widespread use of the WHO Safe Surgery checklist, with only 93 respondents (6.0%) suggesting that they never used it. Annual reports of measures taken to improve patient safety, and of morbidity and mortality, were produced in the hospitals of 588 (37.3%) and 876 (55.7%) respondents, respectively. Around three-quarters of respondents, 1216, (78.7%) stated that their hospital used a critical incident reporting system. Respondents suggested that measures to promote implementation of the Declaration, such as a formal set of checklist items for day-to-day practice, publicity, translation and simulation training, would currently be more important than possible changes to its content. CONCLUSION Many patient safety practices encouraged by the Declaration are well embedded in many European countries. The data have highlighted areas where there is still room for improvement. Correspondence to Andrew F. Smith, Department of Anaesthetics, Royal Lancaster Infirmary, Lancaster LA1 4RP, UK Tel: +00 44 7768 226361; e-mail: andrew.f.smith@mbht.nhs.uk © 2019 European Society of Anaesthesiology