1 The formulation and introduction of a 'can't intubate, can't ventilate' algorithm into clinical practice. Heard et al. Anaesthesia. 2009 Jun;64(6):601-8.
This article details the framework for a unique and impressive airway training program which exists at Royal Perth Hospital. Over a period of 6 years, thousands of anaesthetised sheep have been used as subjects for CICV scenarios and testing of techniques including cannula cricothyroid puncture (CCP), scalpel bougie (SB), Melker cricothyroidotomy (MK), scalpel finger needle (SFN), surgical cricothyroidotomy (SC) and mini-trach techniques as well as simulation of difficult neck anatomy. This program has enabled the investigators to formulate an evidence based & validated ‘can’t intubate, can’t ventilate’ algorithm. The algorithm is simple and removes decision making from a stressful situation in an attempt to avoid fixation error. If the first attempt to access the cricothyroid membrane or trachea with a cannula is successful, it is followed by a seldinger technique to insert a Melker cuffed airway. If the CCP fails, the SB or SFN is recommended depending on whether neck anatomy is palpable. This article provides the best evidence that currently exists for management of this thankfully rare but undeniably catastrophic scenario.
Take home message: The appropriate CICV plan must include equipment that is rapidly accessible and familiar to the anaesthetist, enable rapid oxygenation of the patient and ultimately provide a secure airway. Every anaesthesia department is accountable for providing the equipment and training necessary to facilitate timely execution of this plan by each of their providers.
For related reading this month: - Kumar et al. Cardiff model for training in cricothyrotomy. Anaesthesia. 2009 Jun;64(6):695-6 -Soulsby et al. Teaching lifesaving procedures: the impact of model fidelity on acquisition and transfer of cricothyrotomy skills to performance on cadavers. Anesth Analg. 2009 Jun;108(6):1992
2 Can't intubate, can't ventilate! A survey of knowledge and skills in a large teaching hospital. Green L. Eur J Anaesthesiol. 2009 Jun;26(6):480-3.
This study aimed to assess the preparedness of anaesthetists to manage a CICV scenario. Widespread deficits in knowledge included: inability to locate airway trolley, lack of compliance with failed airway algorithms, unfamiliarity with equipment (airway access devices, jet ventilator connections) and prolonged procedural times. Although this was obviously a simulation, it is difficult to believe that any of these findings would be better in the time critical situation of a ‘real’ CICV situation.
Take home message: There is evidence that many anaesthetists are ill-prepared to manage a ‘can’t intubate, can’t ventilate’ scenario highlighting inadequate knowledge of equipment and lack of exposure and training for this rare crisis situation which is the most common cause of (preventable) hypoxic anaesthesia related mortality.
3 New airway equipment: opportunities for enhanced safety. Martin et al. Br J Anaesth. 2009 Jun;102(6):734-8.
This editorial gives a ‘cook’s tour’ of many of the new airway aids and devices that have become available. The discussion includes mention of optical stylets, the Bonfils retromolar intubation fibrescope, modified LMAs including the LMA CTrach, the Cobra PLA, laryngeal tubes and indirect videolaryngoscopes. The authors classify videolaryngoscopes into two categories depending on whether or not they are equipped with a guiding channel to direct the tracheal tube into the glottis. Examples of the former include the Airtraq and Pentax airway scope and examples of the latter include the Glidescope and the McGrath laryngoscopes. The brief overview also gives a summary of some the recent literature pertaining to each device discussed including the advantages and disadvantages that have become evident. The authors highlight the relevance of the potential contribution of new airway devices in the continuing quest to enhance the safety of airway management by quoting a recent review of adult and paediatric perioperative cardiac arrests which found: ‘airway management was the cause of just over half of anaesthesia-related cardiac arrests ‘.
Take home message: The authors of this editorial believe that when considering the many new airway devices that have recently become available: proficiency in using some of these devices and techniques, especially from the range of indirect video-laryngoscopes, should be among the competencies of every anaesthetist.’
For related reading this month: - Fiadjoe et al. The efficacy of the Storz Miller 1 video laryngoscope in a simulated infant difficult intubation. Anesth Analg. 2009 Jun;108(6):1783-6 -DeGregoris et al. Airtraq laryngoscope for bronchial blocker placement in a difficult airway. Anaesthesia. 2009 Jun;64(6):691 -Takenaka et al. Approach combining the airway scope and the bougie for minimizing movement of the cervical spine during endotracheal intubation. Anesthesiology. 2009 Jun;110(6):1335-40.
See also: March Journal Watch (5); April Journal Watch (1)
4 Transfusion management of trauma patients. Shaz et al. Anesth Analg. 2009 Jun;108(6):1760-8.
This review presents the recent evidence relating to optimal transfusion management of trauma patients. It begins by emphasizing that trauma remains a leading cause of death worldwide and 30-40% of patients with trauma die secondary to haemorrhage. The pathophysiology of early trauma-induced coagulopathy (ETIC) is discussed as well as the DIC-like state that results and is possibly related to enhanced activity of natural anticoagulants (activated protein C, hyperfibrinolysis) associated with tissue hypoperfusion. The secondary coagulopathy that develops is a result of dilutional and consumptive loss of factors in addition to hypothermia and acidosis. In order to address the triad of death (i.e. acidosis, hypothermia and coagulopathy), the authors propose a management plan that requires implementation of a massive transfusion protocol (MTP) to ensure early and aggressive coagulation factor therapy as well as to limit crystalloid infusion. In the absence of prospective RCTs, available evidence supports a high ratio of coagulation factor (plasma, platelet and cryoprecipitate) to RBC so MTPs attempt to ‘recapitulate’ whole blood by premixing components that resemble whole blood i.e. RBC:plasma:platelets in approximately a 1:1:1 ratio. The authors also mention that conventional coagulation tests are likely not clinically relevant in the event of a massive transfusion because they do not reflect the in vivo haemostatic capacity and the results are delayed, and therefore less relevant, for the acute situation. The main imitations of the evidence included in this review is that the conclusions are drawn from observational research and also the impact of survival bias due to the fact that patients who die early will receive fewer blood products than survivors.
Take home message: Current data regarding transfusion management of trauma patients show that earlier and more aggressive transfusion intervention in the form of a MTP as well as resuscitation with blood components that approximate whole blood (a target ratio of plasma:RBC:platelet transfusions of 1:1:1)
significantly decrease mortality.
See also: May Journal Watch (10)
5 Feasibility of Tobacco Interventions in Anesthesiology Practices: A Pilot Study. Warner et al. Anesthesiology. 2009 Jun;110(6):1223-8 [Article]
Editorial: Addressing Tobacco Use in Anesthesiology Practice: A Call to Action. Rigotti NA. Anesthesiology. 2009 Jun;110(6):1207-8 [Editorial]
This pilot study attempts to explore the potential role for anaesthetists in anti-tobacco interventions prior to elective surgery. The investigators are part of the US ASA Smoking Cessation Initiative Task Force. The investigators disseminated an educational program to 14 US practices which agreed to implement a simple Ask, Advise and Refer (AAR) strategy and then distributed a follow-up survey to the practices. They found that the majority of anaesthetists surveyed successfully implemented the AAR strategy, agreed that they were responsible for helping patients getting help to quit and planned to incorporate the AAR strategy into their routine practice. The discussion and accompanying editorial emphasize that, in contrast to the GP setting, the preoperative clinic interaction is a uniquely ‘teachable moment’ when the patient may seriously consider changing their behavior with the ultimate goal of optimizing their surgical outcome. The potential rewards for practioners are also emphasized by considering the possible impact of influencing the rate of tobacco use- currently the leading preventable cause of death worldwide. Unfortunately, the investigators don’t report the likely time investment required and there is no data available about the success of the strategy in ultimately reducing smoking rates. The other major limitations of the study are selection and response bias. If we can define our role in the anti-smoking campaign, then all that’s left to tackle is patient compliance with prescribed therapy, obesity, alcoholism & drug abuse…
Take home message: We are doing our patients a disservice if we don’t use our interaction in preoperative clinic to formally or informally encourage healthy behavioural modifications by asking, advising & making referrals if required
For related reading this year:
-Tønnesen et al. Smoking and alcohol intervention before surgery: evidence for best practice. Br J Anaesth. 2009 Mar;102(3):297-306. Review.
6 Editorial: Perioperative echocardiography for non-cardiac surgery: what is its role in routine haemodynamic monitoring? Ng et al. Br J Anaesth. 2009 Jun;102(6):731-4.
This editorial explores the evolving role of perioperative TOE and TTE in non-cardiac surgery on the background of more anaesthetists becoming interested in echocardiography. The discussion revolves around an assessment of clinical validity, clinical usefulness, safety, education and economics. Indications for use are broad and can extend from preoperative assessment, assisting routine anaesthetic decision-making i.e. administration of fluids and vasoactive drugs (inotropes, dilators, pressors, beta blockers), as well as guide diagnosis and management of major complications: unexplained hypotension, myocardial ischaemia, tamponade, thromboembolism and hypovolaemia. Available evidence for TOE for cardiac assessment is better than evidence for TOE in assessment of major vessel pathology (PE, atherosclerosis). The evidence for TTE is less established although likelihood ratios for prediction of a cardiac event are better for stress echo compared to thallium imaging. Obviously, stress echo is performed by cardiologists. Quality of the evidence available is not optimal for either modality with very little data from cohort studies or RCTs. The authors emphasise that a monitor is useful only if the information that it provides is of high quality and interpreted correctly, and with respect to perioperative echocardiography, significant training is required before sufficient expertise and consistency can be attained. As such, because TTE is non-invasive, the major risk of its use is misdiagnosis. Four levels of competency are proposed: basic competency enables the practitioner to perform a focused emergency scan, level 1 achieves some diagnostic skill, level 2 achieves advanced diagnostic skill and level 3 enables specialized and research-based examinations. Adequate training, experience & credentialing will obviously be a vital component of the increased use of perioperative echocardiography.
Take home question: Will perioperative echocardiography ultimately become a best practice anaesthesia monitor?
7 Hypoxemia during One-lung Ventilation: Prediction, Prevention, and Treatment. Karzai et al. Anesthesiology. 2009 Jun;110(6):1402-11.
This article presents an update about the current evidence for prevention & management of hypoxaemia during OLV. The discussion begins with predictors of hypoxaemia including preoperative lung function-assessed by PaO2 (rather than FEV1), side of operation & distribution of perfusion (depends on pathology, surgical approach & positioning). Prevention of perioperative hypoxaemia requires monitoring of DLT position and consideration of the best ventilation strategy: avoiding atelectasis in ventilated lung, minimization of shunt fraction & avoiding strategies that may contribute to acute lung injury (high FiO2, high TV/airway pressures). The authors recommend PCV (peak pressure 20-25 cm H20) & moderate TV (6-8m ml/kg) + PEEP ≤5 cm H20, in preference to high TV (10-12 ml/kg) +ZEEP to achieve these objectives. Emphasis is placed upon the fact that some patients will develop auto-PEEP in association with their underlying obstructive airways disease. A simple strategy to monitor for auto-PEEP is assessment of the flow-time trace on the ventilation monitoring module (the Aisys module defaults to ETvolatile but is easily changed to flow-time from the ‘main menu’ button) and respond appropriately: modify expiration time, RR, total PEEP. Advantages of CPAP (5-10 cm H20) to the non-dependent lung include improved oxygenation & potentially reducing ALI but it may not be tolerated by all surgeons especially during VATS and may mask sub-optimal ventilation or DLT mal-position. The article states that type of anaesthesia (TIVA vs volatile) has minimal clinical impact on oxygenation, despite traditional teaching relating to inhibition of HPV. Strategies such as high FiO2, intermittent ventilation of operative lung & recruitment maneuvers are reserved for treatment of hypoxaemia & the author claims that with the use of sound clinical practice, this should occur in less than 5% of patients.
Take home message: Optimal management of hypoxaemia during OLV requires simultaneous treatment (increased FiO2, ventilation/CPAP to non-dependent lung) as well as diagnosis of the contributing factors (correct position of DLT, removal of secretions/blood, most appropriate ventilation strategy).
For related reading this month: - De Conno et al. Anesthetic-induced Improvement of the Inflammatory Response to One-lung Ventilation. Anesthesiology. 2009 Jun;110(6):1316-26.
For related reading this year:
-Grichnik et al. Update on one-lung ventilation: the use of continuous positive airway pressure ventilation and positive end-expiratory pressure ventilation--clinical application. Curr Opin Anaesthesiol. 2009 Feb;22(1):23-30.
8 The association of perioperative red blood cell transfusions and decreased long-term survival after cardiac surgery. Surgenor et al. Anesth Analg. 2009 Jun;108(6):1741-6.
This prospective observational study of patients undergoing first-time elective CABG, valve or CABG/valve surgery (n=9079) examined the outcome of those patients who were exposed to 1-2 units PRBC (n=3254) compared to patients not exposed to transfusion. Patients who required 3 or more units of PRBC were excluded. The focus of the analysis was on patients who were transfused as treatment for stable perioperative anaemia so exclusion of patients requiring more than 2 units of PRBC was designed to limit the potential impact of confounding medical indications such as RTOR for active haemorrhage. After adjustment for patient and disease characteristics, patients exposed to 1-2 units RBCs had a 16% higher long-term mortality risk (adjusted HR=1.16, CI: 1.01-1.34) after 5 years. If the early phase (surgery-6 months) was considered, differences were even more marked: adjusted HR 1.67, CI: 1.21-2.28. The adverse impact on 5 year survival after exposure to RBC transfusion was confirmed using propensity score analysis: HR 1.16 (CI 1-1.34), although it can be seen that the CI includes 1. The major limitation of this study is the observational study design and the fact that statistical adjustment of covariates is always going to be imperfect. However, this study adds to other evidence (including the RCT by Herbert, NEJM, 1999) which suggests that a decision to transfuse patients without active haemorrhage, is not an innocuous one and that increasing emphasis should be placed on perioperative blood conservation strategies to avoid unwarranted RBC transfusions and potentially reduce a patient’s risk of short and long-term mortality.
Take home message: There is mounting evidence to suggest the decision to transfuse patients for the treatment of stable perioperative anaemia may be putting patients at significant risk and potentially increasing mortality rates.
See also: March Journal Watch (2)
9 Preoperative cardiovascular assessment in noncardiac surgery: an update. De Hert SG. Eur J Anaesthesiol. 2009 Jun;26(6):449-57.
This article attempts to provide an overview of preoperative cardiovascular assessment with reference to 2007 ACC/AHA guidelines. The author emphasizes that optimal preoperative preparation of the patient with cardiovascular disease entails risk stratification and intervention as appropriate. In addition, consideration of perioperative monitoring and administration of medical therapy (beta blockers, statins, aspirin) is required. In high- risk patients post-operative event surveillance may be appropriate especially in view of the fact that postoperative MI is often silent, non-Q-wave and preceded by ST depression.
Take home message: Despite existence of well-defined guidelines, many patients at high risk of perioperative cardiovascular events don’t receive ‘best practice’ management.
For related reading this month: - Scott et al. Perioperative myocardial protection. Contin Educ Anaesth Crit Care Pain 2009 Jun;9(3): 97-101
-Stone et al. Beta-blockers: must we throw the baby out with the bath water? Anesth Analg. 2009 Jun;108(6):1987-90
See also: May Journal Watch (12);
10 Risks and side-effects of intrathecal morphine combined with spinal anaesthesia: a meta-analysis. Review. Gehling et al. Anaesthesia. 2009 Jun;64(6):643-51.
This meta-analysis looked at intrathecal morphine in combination with spinal anaesthesia only. Therefore procedures analysed were limited to LUSCS, haemorrhoidectomy, tubal ligation, TURP, gynaecological surgery and orthopaedics. The endpoints studied were frequency of N&V, pruritus, urinary retention and respiratory depression. For nausea, there were 644 patients in the IT group and 431 in the systemic opioid group included for analysis and the authors found an increase in nausea in the IT group with RR=1.3 (1.1-1.5). For vomiting, there were 504 patients in the IT group and 336 in the systemic opioid group included for analysis and the authors found an increase in nausea in the IT group with RR=1.6 (1.1-2.2). For pruritus there were 700 patients in the IT group and 434 in the systemic opioid group included for analysis and the authors found an increase in the IT group with RR=2 (1.6-2.4) and a dose response was identified. For urinary retention there were 223 patients in the IT group and 177 in the systemic opioid group included for analysis and the authors found no increase in the IT group (all patients had spinals). For respiratory depression there were 327 patients in the IT group and 255 in the systemic opioid group included for analysis and the authors found no increase in the IT group if dose was <0.3 mg morphine. Of note, the definition of respiratory depression ranged from 8-12 breaths per minute. The authors concluded that patients receiving either systemic opioids or IT morphine require continuous observation of respiratory function. Unfortunately, these results cannot be extrapolated to procedures requiring general anaesthesia because the side-effect profile is different. It is possible that patients would require higher doses of systemic opioid analgesia in the absence of a neuraxial block.
Take home message: This meta-analysis including only spinal anaesthetics found there were no more episodes of respiratory depression with a dose <0.3 mg intrathecal morphine than in placebo patients who received systemic opioid analgesia.
See also: Feb Journal Watch (2), (10)
11 Impaired upper airway integrity by residual neuromuscular blockade: increased airway collapsibility and blunted genioglossus muscle activity in response to negative pharyngeal pressure. Herbstreit et al. Anesthesiology. 2009 Jun;110(6):1253-60.
This study aimed to determine the impact of mild degrees of neuromuscular block on passive upper airway collapsibility by measuring the critical airway closing pressure (Pcrit) at baseline and then at different degrees of neuromuscular block. The very brave, healthy, awake German ‘volunteers’ for this study (n=15) had 0.1mg/kg bolus of rocuronium followed by an infusion (10-80 mg/hr) initially targeting a TOF ratio of 0.5, then 0.8 prior to termination of the infusion. The measurements taken at baseline, TOF 0.5/0.8 and recovery included airway pressures (via a nasal catheter), genioglossus electromyogram (hook-wire electrodes inserted submentally) and regular TOF measurements with supramaximal stimulation current! Local anaesthetic was used for the genioglossus EMG but there is no mention of any sedation/analgesia use (or volunteer satisfaction with the protocol). You would hope they were paid well. The investigators found that minimal residual neuromuscular blockade in the awake state, in the absence of anaesthetics and surgery, and to a degree insufficient to evoke respiratory symptoms markedly increased upper airway collapsibility and impaired the genioglossus muscle’s (upper airway dilator) compensatory response to pharyngeal negative pressure challenges. It is well recognized that quantitative neuromuscular transmission monitoring (acceleromyography NOT tactile assessment using a nerve stimulator) is not routinely applied (or even available), so this study highlights the lax standards under which many relaxant GAs are conducted. The authors state in the discussion: ‘reversal of residual neuromuscular blockade is an important goal for patients’ postoperative safety, and it is associated with a decreased risk of 24-h postoperative morbidity & mortality’ and that ‘even small degrees of neuromuscular blockade should be reversed, if waiting for spontaneous recovery is not considered reasonable.’ This is obviously paramount in higher risk patients, such as those with OSA, having major surgery who will also have residual effects of anaesthesia/sedation and analgesia to contend with prior to return of baseline respiratory function.
Take home message: Minimal residual neuromuscular blockade (equivalent to TOF 0.5-1) can be associated with markedly increased airway collapsibility, despite unaffected oxygenation & values for resting ventilation, potentially leading to postoperative respiratory complications.
For related reading this month: - Claudius et al. Is the performance of acceleromyography improved with preload and normalization? A comparison with mechanomyography. Anesthesiology. 2009 Jun;110(6):1261-70.
12 Preoperative electrocardiograms: patient factors predictive of abnormalities. Correll et al. Anesthesiology. 2009 Jun;110(6):1217-22
Preoperative electrocardiograms: obsolete or still useful? Editorial: De Hert SG. Anesthesiology. 2009 Jun;110(6):1205-6 [Editorial]
This study was designed to determine whether it is possible to target ECG ordering to patients most likely to have an abnormality that would affect management. The investigators reviewed 1,149 ECGs from all patients>50 yo presenting to preoperative clinic in a 2 month period. A group of cardiologists & anaesthetists devised an arbitrary list by consensus opinion of what constitutes a ‘significant’ abnormality on ECG: major q waves/ ST depression or elevation/t waves changes; mobitz type II or higher blockade, LBBB & AF. Eighty-nine (7.7%) of the sample had at least one abnormality considered significant. The patient parameters in order of increasing influence on the probability of having an abnormal ECG were: high cholesterol (OR 2.26), age >65 yo (OR 4.08), severe valvular disease (OR 4.8), Hx of AMI (OR 6.16) angina (OR 7.49), CCF (OR 12.18). The subsequent interventions in response to the abnormal ECG were: retrieval of old ECGs (24/89) or cardiac tests (32/89), ordering of new cardiac test (14/89), cardiology consult (3/89) and initiation of beta-blocker therapy (2/89). Correlating ECG abnormality with outcome was beyond the scope of this study. The accompanying editorial points out that the majority of the clinical variables found to be associated with an abnormal ECG are also those that according to the ACC/AHA guidelines should prompt for further cardiac evaluation, including a 12 lead ECG.
Take home message: The main benefit of routinely perfuming a preoperative ECG is to provide a baseline reference in case the patient develops postoperative cardiac problems and it is possible to predict patients likely to have a ‘significantly’ abnormal ECG by the presence of active cardiac disease, risk factors for IHD or age>65.
Other articles of potential specific interest:
CARDIOVASCULAR ANAESTHESIA -Suk et al. Stress-induced cardiomyopathy following cephalosporin-induced anaphylactic shock during general anesthesia. Can J Anaesth. 2009 Jun;56(6):432-436 -Editorial: Bainbridge et al. Stress-induced cardiomyopathy in the perioperative setting. Can J Anaesth. 2009 Jun;56(6):397-401 -Durand et al. Pericardial tamponade. Can J Anaesth. 2009 Jun;56(6):443-8
REGIONAL ANAESTHESIA -Dolan et al. The Rectus Sheath Block: Accuracy of Local Anesthetic Placement by Trainee Anesthesiologists Using Loss of Resistance or Ultrasound Guidance. Reg Anesth Pain Med. 2009 May-Jun;34(3):247-50 -Hanna et al. Survey of the Utilization of Regional and General Anesthesia in a Tertiary Teaching Hospital. Reg Anesth Pain Med. 2009 May-Jun;34(3):224-2 -Balki et al. Ultrasound imaging of the lumbar spine in the transverse plane: the correlation between estimated and actual depth to the epidural space in obese parturients. Anesth Analg. 2009 Jun;108(6):1876-81. -Fowler SJ. Incidence of severe complications after central neuraxial block. Br J Anaesth. 2009 Jun;102(6):882 - Bigeleisen et al. Extraneural versus intraneural stimulation thresholds during ultrasound-guided supraclavicular block. Anesthesiology. 2009 Jun;110(6):1235 -43. -El-Dawlatly et al. Ultrasound-guided transversus abdominis plane block: description of a new technique and comparison with conventional systemic analgesia during laparoscopic cholecystectomy. Br J Anaesth. 2009 Jun;102(6):763-7.
GENERAL TOPICS -Tanoubi et al. Optimizing preoxygenation in adults. Can J Anaesth. 2009 Jun;56(6):449-466 -Ozcan et al. Same-patient reproducibility of state entropy: a comparison of simultaneous bilateral measurements during general anesthesia. Anesth Analg. 2009 Jun;108(6):1830-5.
RESEARCH -Greenfield et al. Improvement in the quality of randomized controlled trials among general anesthesiology journals 2000 to 2006: a 6-year follow-up. Anesth Analg. 2009 Jun;108(6):1916-21.
PAEDIATRICS -Bharti et al. Paediatric perioperative cardiac arrest and its mortality: database of a 60-month period from a tertiary care paediatric centre. Eur J Anaesthesiol. 2009 Jun;26(6):490-5.
PERIOPERATIVE MEDICINE -Chen et al. New therapeutic agents for diabetes mellitus: implications for anesthetic management. Anesth Analg. 2009 Jun;108(6):1803-10. -Hall et al. Current therapeutic drugs for type 2 diabetes, still useful after 50 years? Anesth Analg. 2009 Jun;108(6):1727-30.
NEUROANAESTHESIA -Audibert et al. Endocrine response after severe subarachnoid hemorrhage related to sodium and blood volume regulation. Anesth Analg. 2009 Jun;108(6):1922-8. -Bruder et al. Hyponatremia and subarachnoid hemorrhage: will that be one pinch or two of salt? Anesth Analg. 2009 Jun;108(6):1734-5
TRAUMA ANAESTHESIA -Thiboutot et al. Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial. Can J Anaesth. 2009 Jun;56(6):412-418
Written by Maryanne Balkin, June 2009
Feedback welcome: M.Balkin@alfred.org.au
Disclaimers:
1 Best attempts are made to include articles representative of recent publications but no attempt is made to include every important article.
2 Commentary & take home message is only one of many possible opinions/interpretations of the literature.
For other 2009 editions of journal watch: http://www.anaesthesiacases.com.au