Chairman of the BJA Board, University Department of Anaesthesia, Liverpool L69 3GA, UK
E-mail: bja{at}liv.ac.uk
It is not enough to have a good mind; the main thing is to use it well.Descartes, 1639
This Postgraduate Issue is based on a scientific meeting held in Hinckley, Leicestershire in 2004 to celebrate the significant and longstanding contribution made to the British Journal of Anaesthesia (BJA) by Professor Graham Smith. This Postgraduate Issue on The Recovery Period is dedicated to him. The one-day meeting was attended by over 300 anaesthetists and was well received. The Board of the BJA plans to continue to hold such meetings annually in various parts of the UK and mainland Europe, in conjunction with The Royal College of Anaesthetists, to contribute to continuing postgraduate education in anaesthesia.
Professor Smith was Postgraduate Editor of the BJA from 1983 to 1987, and would have been responsible for producing these annual issues at that time. As a senior lecturer in Glasgow with Professor Alastair Spence (the sixth editor of the BJA), and before that in the University of Leeds, Graham Smith had developed an interest in postoperative pain relief. These two editors were the first to report the beneficial respiratory effects of continuous epidural analgesia using bupivacaine compared with intramuscular opioids for pain relief after upper abdominal surgery.1 This paper is well quoted: it is in the list of BJA top 50 citation classics over the period 19481998. It was therefore apposite that a session at the meeting on the recovery period was dedicated to postoperative analgesia. Three reviews in this issue cover postoperative pain relief in adults2 and children3 and discuss the methods by which anaesthetic and analgesic techniques can improve outcome after surgery.4 A surgical viewpoint is provided on the treatment of chronic postoperative pain after inguinal herniorrhaphy by Aasvang and Kehlet.5 At an early stage in the development of the subspeciality of acute pain relief and of acute pain teams, Graham Smith identified the need for close cooperation with surgical colleagues to obtain an optimal outcome. Much of Professor Smith's more recent clinical research has been based on the relief of acute pain after gynaecological surgery, and this work has been done in close association with gynaecologists.6 7
It is well recognized that anaesthesia and analgesia produce side-effects and, in particular, contribute to postoperative nausea and vomiting (PONV), the treatment of which has been a persistent challenge to anaesthetists. Despite multimodal approaches, PONV still occurs after at least 20% of general anaesthetics. Thirteen years ago, Professor Smith and David Rowbotham edited a very successful supplement of the BJA devoted to this subject.8 It is appropriate that Professor Rowbotham, who has taken on the professorial mantle in Leicester, has reviewed one aspect of PONV in this issue of the BJA.9 He reminds us that acupuncture may be effective in preventing it with, not surprisingly, very few side-effects. Some acupuncture techniques are easy to learn and not time-consuming. They can be as efficacious as pharmacological therapy for PONV.
Another area of clinical research interest for Professor Smith has been the cardiovascular response to anaesthesia, including the stress response to intubation.10 This area of clinical research has expanded rapidly in recent years. Our understanding of how to protect the myocardium, especially if it is ischaemic, from an adverse event in the perioperative period is becoming established. This subject has been comprehensively reviewed in this issue by Professor H.-J. Priebe.11
When Professor Smith was Editor-in-Chief of the BJA (19871997), he urged its Board to expand their membership to include non-UK, European members. Professor Priebe was the first such appointment, and his contribution to the BJA Board had proved unique. He was soon joined by Professor D. R. Spahn, whose knowledge of blood transfusion and clotting problems in the perioperative period has been of special benefit to this journal. He and Dr Madjdpour summarize the latest approaches to these haematological challenges in this issue.12 The insidious problems of renal dysfunction in the perioperative period are summarized in an excellent review by a long-standing member of the BJA Board, Professor John Sear, in his usual analytical, thorough and scientific manner.13 Much can be learnt by reading this interesting review.
Professor Smith was always quick to recognize developing areas of interest in clinical anaesthesia; no doubt his long experience as an editor sharpened his antennae in this respect. Thus, it is not surprising that one of the first members of Professor Smith's university department when he moved to Leicester, Dr C. D. Hanning, became an expert on cognitive dysfunction in the postoperative period. Dr Hanning clearly summarizes the often confusing literature on this subject in this issue in his usual eloquent fashion.14 The development of postoperative critical care areas and outreach teams was also recognized early by Professor Smith, and it is therefore apt that David Goldhill, who was one of the first to publish on outreach teams in the UK,15 has summarized these recent developments here too.16
One mark of a truly successful academic must be the creation of another generation of academics to secure the survival of their specialitylocally, nationally and internationally. This is well demonstrated in the final contribution to this issue, by Professor Alan Aitkenhead from Nottingham.17 Now internationally recognized for his expertise in medicolegal issues in anaesthesia, Professor Aitkenhead was with Dr Hanning, one of Professor Smith's first senior lecturers in Leicester. There can be no finer tribute to Professor Smith than Professor Aitkenhead's exposition, published in this issue, on injuries associated with anaesthesia.17
It is now hard to appreciate fully that the development of 24-h postoperative recovery rooms has occurred only in Professor Smith's professional lifetime. We take them for granted and fail to appreciate their research potential. Throughout his career, Professor Smith's clinical research has concentrated on immediate postoperative care. His contribution to anaesthesia, and indeed to the BJA, cannot be summarized in one issue of the journal. By dedicating this issue to him, we acknowledge his outstanding contribution to academic anaesthesia, research and scholarship. On his retirement, we thank him for this immense contribution and wish him all that is well.
References
1 Spence AA, Smith G. Postoperative analgesia and lung function: a comparison of morphine with extradural block. Br J Anaesth 1971; 43: 1448[ISI][Medline]
2 Power I. Recent advances in postoperative pain therapy. Br J Anaesth 2005; 95: 4351
3 Lönnqvist P-A, Morton NS. Postoperative analgesia in infants and children. Br J Anaesth 2005; 95: 5968
4 Bonnet F, Marret E. Influence of anaesthetic and analgesic techniques on outcome after surgery. Br J Anaesth 2005; 95: 528
5 Aasvang E, Kehlet H. Chronic postoperative pain: the case of inguinal herniorrhaphy. Br J Anaesth 2005; 95: 6976
6 Ng A, Parker J, Toogood L, Cotton BR, Smith G. Does the opioid-sparing effect of rectal diclofenac following total abdominal hysterectomy benefit the patient? Br J Anaesth 2002; 88: 7146
7 Ng A, Smith G, Davidson AC. Analgesic effects of parecoxib following total abdominal hysterectomy. Br J Anaesth 2003; 90: 7469
8 Smith G, Rowbotham DJ, eds. Supplement on postoperative nausea and vomiting. Br J Anaesth 1992; 69 (7 Suppl. 1): 1S68S
9 Rowbotham DJ. Recent advances in the non-pharmacological management of postoperative nausea and vomiting. Br J Anaesth 2005; 95: 7781
10 Shribman AJ, Smith G, Achola KJ. Cardiovascular and catecholamine responses to laryngoscopy with and without tracheal intubation. Br J Anaesth 1987; 59: 2959[Abstract]
11 Priebe H-J. Perioperative myocardial infarctionaetiology and prevention. Br J Anaesth 2005; 95: 319
12 Madjdpour C, Spahn DR. Allogeneic red blood cell transfusions: efficacy, risks, alternatives and indications. Br J Anaesth 2005; 95: 3342
13 Sear JW. Kidney dysfunction in the postoperative period. Br J Anaesth 2005; 95: 2032
14 Hanning CD. Postoperative cognitive dysfunction. Br J Anaesth 2005; 95: 827
15 Goldhill DR, Worthington L, Mulcahy A, Tarling M, Sumner A. The patient-at-risk team: identifying and managing seriously ill ward patients. Anaesthesia 1999; 54: 85360[CrossRef][ISI][Medline]
16 Goldhill DR. Preventing surgical deaths: critical care and intensive care outreach services in the postoperative period. Br J Anaesth 2005; 95: 8894
17 Aitkenhead AR. Injuries associated with anaesthesia. A global perspective. Br J Anaesth 2005; 95: 95109