Showing papers in "BJA: British Journal of Anaesthesia in 2000"

Qualitative research in health care.

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Patient satisfaction after anaesthesia and surgery: results of a prospective survey of 10,811 patients.

Abstract: Patient satisfaction after anaesthesia is an important outcome of hospital care. We analysed our anaesthetic database to identify potentially modifiable factors associated with dissatisfaction. At the time of analysis, our database contained information on 10,811 in-patients interviewed on the first day after operation. The major subjective outcome measure was patient satisfaction. We also measured other predetermined outcomes, such as nausea, vomiting, pain and complications. The overall level of satisfaction was high (96.8%); 246 (2.3%) patients were 'somewhat dissatisfied' and 97 (0.9%) were 'dissatisfied' with their anaesthetic care. After adjustment for patient and surgical factors, there was a strong relation between patient dissatisfaction and: (i) intraoperative awareness (odds ratio (OR) 54.9, 95% confidence intervals (CI) 15.7-191); (ii) moderate or severe postoperative pain (OR 3.94, 95% CI 3.16-4.91); (iii) severe nausea and vomiting (OR 4.09, 95% CI 3.18-5.25); and (iv) any other postoperative complications (OR 2.04, 95% CI 1.61-2.56). Several factors associated with dissatisfaction may be preventable or better treated.

Validity and reliability of a postoperative quality of recovery score: the QoR-40.

Abstract: Quality of recovery after anaesthesia is an important measure of the early postoperative health status of patients. We attempted to develop a valid, reliable and responsive measure of quality of recovery after anaesthesia and surgery. We studied 160 patients and asked them to rate postoperative recovery using three methods: a 100-mm visual analogue scale (VAS), a nine-item questionnaire and a 50-item questionnaire; the questionnaires were repeated later on the same day. From these results, we developed a 40-item questionnaire as a measure of quality of recovery (QoR-40; maximum score 200). We found good convergent validity between QoR-40 and VAS (r = 0.68, P

The LMA ‘ProSeal’—a laryngeal mask with an oesophageal vent

Abstract: We describe a new laryngeal mask airway (LMA) that incorporates a second tube placed lateral to the airway tube and ending at the tip of the mask. The second tube is intended to separate the alimentary and respiratory tracts. It should permit access to or escape of fluids from the stomach and reduce the risks of gastric insufflation and pulmonary aspiration. It can also determine the correct positioning of the mask. A second posterior cuff is fitted to improve the seal. A preliminary crossover comparison with the standard mask in 30 adult female patients showed no differences in insertion, trauma or quality of airway. At 60 cm H2O intracuff pressure, the new LMA gave twice the seal pressure of the standard device (P

Efficacy of ginger for nausea and vomiting: a systematic review of randomized clinical trials.

Abstract: Ginger (Zingiber officinale) is often advocated as beneficial for nausea and vomiting. Whether the herb is truly efficacious for this condition is, however, still a matter of debate. We have performed a systematic review of the evidence from randomized controlled trials for or against the efficacy of ginger for nausea and vomiting. Six studies met all inclusion criteria and were reviewed. Three on postoperative nausea and vomiting were identified and two of these suggested that ginger was superior to placebo and equally effective as metoclopramide. The pooled absolute risk reduction for the incidence of postoperative nausea, however, indicated a non-significant difference between the ginger and placebo groups for ginger 1 g taken before operation (absolute risk reduction 0.052 (95% confidence interval -0.082 to 0.186)). One study was found for each of the following conditions: seasickness, morning sickness and chemotherapy-induced nausea. These studies collectively favoured ginger over placebo.

General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials.

Abstract: Hip fracture surgery is common and the population at risk is generally elderly. There is no consensus of opinion regarding the safest form of anaesthesia for these patients. We performed a meta-analysis of 15 randomized trials that compare morbidity and mortality associated with general or regional anaesthesia for hip fracture patients. There was a reduced 1-month mortality and incidence of deep vein thrombosis in the regional anaesthesia group. Operations performed under general anaesthesia had a reduction in operation time. No other outcome measures reached a statistically significant difference. There was a tendency towards a lower incidence of myocardial infarction, confusion and postoperative hypoxia in the regional anaesthetic group, and cerebrovascular accident and intra-operative hypotension in the general anaesthetic group. We conclude that there are marginal advantages for regional anaesthesia compared to general anaesthesia for hip fracture patients in terms of early mortality and risk of deep vein thrombosis.

P2X receptors in sensory neurones.

Abstract: P2X receptors are a family of ligand-gated ion channels responsive to ATP. Seven subtypes have been identified which form homo-multimeric or hetero-multimeric pores. P2X3 receptors are selectively expressed predominantly on small-diameter nociceptive sensory neurones in the dorsal root, trigeminal and nodose ganglia, particularly the non-peptidergic subpopulations labelled with the lectin IB4. P2X2/3 labelling is also present in inner lamina II of the spinal cord and in sensory nerve projections to skin and viscera, but few receptors are present in skeletal muscle. P2X3 receptors are down-regulated after peripheral nerve injury and their expression can be regulated by glial cell-derived neurotrophic factor. P2X receptor activation of sensory neurones has been demonstrated in in vivo pain models, including the rat hindpaw and knee-joint preparations, as well as in inflammatory models. P2X4 and/or P2X6 receptors in the CNS also seem to be involved in pain pathways. Non-nociceptive P2 receptors on sensory nerves are present in muscle and on sensory endings in the heart and lung that initiate reflex activity involving vagal afferent and efferent nerve fibres. The sources of ATP involved in nociception and non-nociceptive sensory nerve stimulation are discussed as well as a novel hypothesis about purinergic mechanosensory transduction.

Sedation and general anaesthesia in children undergoing MRI and CT: adverse events and outcomes†

Abstract: Quality assurance data were collected prospectively for children who were sedated (n=922) or given general anaesthesia (n=140) for magnetic resonance imaging (MRI) or computerized tomography (CT). The data included patient characteristics, concurrent medication, adequacy of sedation, adverse events and requirement for escalated care. The quality of scans was evaluated. Reasons for preselection of general anaesthesia included previously failed sedation (28%), potential for failed sedation (32%) and perceived medical risk (14%). Hypoxaemia occurred in 2.9% of sedated children, and was more common in children classified as ASA III or IV. Sedation was inadequate for 16% of children and failed in 7%. Failed sedation was associated with greater age (P=0.009), higher ASA status (P=0.04) and use of benzodiazepines as sole sedatives (P

Thermoregulation, mild perioperative hypothermia and post-anaesthetic shivering

Abstract: The maintenance of normothermia is an important function Physiology of the autonomic nervous system in homeothermic mammals Thermoregulation is achieved by a physiological control such as man, as cellular and tissue dysfunction become system consisting of peripheral and central thermoreceptors, evident at even minor deviations from normal core body an integrating control centre and efferent response systems temperature. 48 53 113 In man, core temperature is normally which take compensatory action. 113 Afferent thermal input maintained within narrow limits of 36.5–37.5°C, 48 even in comes from anatomically distinct cold and warmth recepthe presence of an adverse environmental temperature, by tors, which may be peripheral or central. 53 The central a combination of behavioural and physiological responses. control mechanism, situated in the hypothalamus, deterAnaesthesia abolishes behavioural mechanisms and has mines mean body temperature by integrating thermal signals the potential to disrupt the physiological mechanisms of from peripheral and core structures, and comparing mean thermoregulation. Adverse postoperative outcomes, includ- body temperature with a pre-determined ‘set-point’ ing wound infection, increased surgical bleeding and morbid temperature. 48 In man, the efferent response to effect change in body heat content as required is by behavioural and cardiac events are being associated with mild perioperative autonomic means. The latter involves control of cutaneous hypothermia (33.0–36.4°C). 21 22 26 42–44 52 74 80 84 85 90 109

Central Nervous System Complications of Cardiac Surgery

Abstract: The neurological complications of cardiac surgery are associated with significantly increased mortality, morbidity and resource utilization. The use of new surgical techniques, introduction of wider indications for surgery and increased public expectation has led to an increase in the average age of cardiac surgical patients and an increased incidence of repeat procedures. With these changes has come an increased risk of neurological complications. The likelihood of perioperative stroke varies between 1% and 5% in most published series and is dependent on a multitude of risk factors. Of these, patient age, aortic atheroma, symptomatic cerebrovascular disease, diabetes mellitus and the type of surgery appear to be most important. Cognitive deterioration after cardiac surgery is far more common, affecting as many as 80% of patients a few days after surgery and persisting in one-third. Despite an increase in the age of the cardiac surgical population, the reported incidence of cognitive dysfunction after cardiac surgery seems to have fallen in recent years. Whether this is a real phenomenon or the result of changes in the use of psychometric testing and the definition of cognitive decline remains unclear. Recognition that certain equipment, surgical practices and patient factors contribute to neurological morbidity has prompted 'neuroprotective' interventions. Some of these (e.g. arterial line filtration and alpha-stat management) have been shown to improve outcome. Despite these measures, a small number of patients will inevitably sustain cerebral injury during otherwise successful cardiac surgery. Although pharmacological neuroprotection may, in the future, offer some of these patients an improved outcome, it is unlikely that any single agent will prevent neurological injury. In the meantime, the CNS complications of cardiac surgery remain a fertile area of research.

The aged cardiovascular risk patient

Abstract: It is mostly acknowledged that 'normal' or 'healthy' ageing of the cardiovascular system is distinct from the increasing incidence and severity of cardiovascular disease with advancing age (e.g. hypertension, ischaemic heart disease and congestive heart failure). It is also recognized that chronological and biological age may differ considerably. Nevertheless, even in the absence of overt coexisting disease, advanced age is always accompanied by a general decline in organ function, and specifically by alterations in structure and function of the heart and vasculature that will ultimately affect cardiovascular performance. Actual biological age is thus the net result of the interaction between age-related and concomitant disease-associated changes in organ function. As cardiovascular performance at a given moment is the net result of interactions between heart rate, intrinsic contractility, diastolic and systolic function, ventricular afterload and coronary perfusion, it is important to be aware of the age-related changes in each of these variables, independent of disease, as they determine cardiac performance at rest and its response to stress in the elderly. The most relevant age-related changes in cardiovascular performance for perioperative management are the stiffened myocardium and vasculature, blunted beta-adrenoceptor responsiveness and impaired autonomic reflex control of heart rate. These changes are of little clinical relevance at rest, but may have considerable consequences during superimposed cardiovascular stress. Such stress can take the form of increased flow demand (as in exercise or postoperatively), demand for acute autonomic reflex control (as in change of posture) or severe disease (as during myocardial ischaemia, tachyarrhythmias or uncontrolled hypertension). It may interfere with diastolic relaxation (i.e. ventricular filling), systolic contraction (i.e. ventricular emptying) and vasomotor control (i.e. arterial pressure homeostasis). Three factors contribute most of the increased perioperative risk related to advanced age. First, physiological ageing is accompanied by a progressive decline in resting organ function. Consequently, the reserve capacity to compensate for impaired organ function, drug metabolism and added physiological demands is increasingly impaired. Functional disability will occur more quickly and take longer to be cured. Second, ageing is associated with progressive manifestation of chronic disease which further limits baseline function and accelerates loss of functional reserve in the affected organ. Some of the age-related decline in organ function (e.g. impaired pulmonary gas exchange, diminished renal capacity to conserve and eliminate water and salt, or disturbed thermoregulation) will increase cardiovascular risk. The unpredictable interaction between age-related and disease-associated changes in organ functions, and the altered neurohumoral response to various forms of stress in the elderly may result in a rather atypical clinical presentation of a disease. This may, in turn, delay the correct diagnosis and appropriate treatment and, ultimately, worsen outcome. Third, related to the increased intake of medications and altered pharmacokinetics and pharmacodynamics, the incidence of untoward reactions to medications, anaesthetic agents, and medical and surgical interventions increases with advancing age. On the basis of various clinical studies and observations, it must be concluded that advanced age is an independent predictor of adverse perioperative cardiac outcome. It is to be expected that the aged cardiovascular risk patient carries an even higher perioperative cardiac risk than the younger cardiovascular risk patient. Although knowledge of the physiology of ageing should help reduce age-related complications, successful prophylaxis is hindered by the heterogeneity of age-related changes, unpredictable physiological and pharmacological interactions and diagnostic difficultie

The carina as a landmark in central venous catheter placement.

Abstract: Location of the tip of a central venous catheter (CVC) within the pericardium has been associated with potentially lethal cardiac tamponade. Because the pericardium cannot be seen on chest x-ray (CXR), an alternative radiographic marker is needed for correct placement of CVCs. The anatomy of the region was studied in 34 cadavers. The carina was a mean (SEM) distance of 0.4 (0.1) cm above the pericardial sac as it transverses the superior vena cava (SVC). In no case was the carina located below the pericardial sac. The carina is a reliable, simple anatomical landmark for the correct placement of CVCs. In almost all cases, the carina is radiologically visible even in poor quality, portable CXRs. CVC tips should be located in the SVC above the level of the carina in order to avoid cardiac tamponade.

Residual curarization in the recovery room after vecuronium

Abstract: We have investigated residual block after anaesthesia which included the use of the neuromuscular blocking agent vecuronium but no anticholinesterase, in 568 consecutive patients on admission to the recovery room. The ulnar nerve was stimulated submaximally using TOF stimulation (30 mA). Postoperative residual curarization was defined as a TOF ratio

Prospective evaluation of a modified Early Warning Score to aid earlier detection of patients developing critical illness on a general surgical ward

Abstract: Admissions to the intensive care unit (ICU) from the wards have a higher mortality when compared to patients admitted from the operating theatres/recovery and accident and emergency department.1 Suboptimal care may contribute to morbidity and mortality of patients admitted from the ward.2 Failure to appreciate physiological derangements of breathing and mental status has been demonstrated in patients who subsequently suffered cardiac arrest, and these events may have been apparent up to 8 h prior to the event.3 4 The Early Warning Score (EWS) was developed as a simple scoring system to be used at ward level utilising routine observations taken by nursing staff.5 Deviations from the normal score points and a total is calculated. The EWS was evaluated prospectively for 1 month. The score was then modified to include urine output, to make temperature deviations less sensitive and to include normalised blood pressure (Table 8). We then evaluated this prospectively for 9 months. A total score of 4 or more resulted in the patient being reviewed by ward medical staff and help sought from the intensive care team if appropriate. Over a 9-month period 206 patients on two general surgical wards were put on the scoring system, of these 26 were admitted to the ICU. The APACHE II scores of these patients was 16.6 (± 7.3). Eleven patients were admitted to the ICU from the surgical ward who had not been monitored on the modified EWS and their admission APACHE II scores were 23.5 (± 4.1). This compares with admission APACHE II scores of 22.3 (± 5.5) in 43 patients admitted from surgical wards in the 9-month period prior to introduction of the system. The introduction of the system has appeared to lead to earlier referral to the intensive care unit.

Management of massive blood loss: a template guideline

Abstract: The management of acute massive blood loss is considered and a template guideline is formulated, supported by a review of the key literature and current evidence. It is emphasized that, if avoidable deaths are to be prevented, surgeons, anaesthetists, haematologists and blood-bank staff need to communicate closely in order to achieve the goals of secure haemostasis, restoration of circulating volume, and effective management of blood component replacement.

Mucosal pressure and oropharyngeal leak pressure with the ProSeal versus laryngeal mask airway in anaesthetized paralysed patients

Abstract: The ProSeal laryngeal mask airway (PLMA) is a new laryngeal mask device with a larger, wedge-shaped cuff and a drainage tube. We tested the hypothesis that directly measured mucosal pressure and oropharyngeal leak pressure (OLP) are higher for the PLMA compared with the laryngeal mask airway (LMA†). We also assess the mechanism of seal, and the reliability of cuff volume, in vivo intracuff pressure and calculated mucosal pressure (in vivo minus in vitro intracuff pressure) to predict directly measured mucosal pressure. Thirty-two anaesthetized, paralysed adult patients were randomly allocated to receive either a size 4 LMA or PLMA. Microchip sensors were attached at locations corresponding to: (a) base of tongue; (b) distal oropharynx; (c) hypopharynx; (d) lateral pharynx; (e) posterior pharynx; and (f) pyriform fossa. In vitro and in vivo intracuff pressures, OLP and directly measured mucosal pressure were documented at zero volume and after each 10 ml up to 40 ml. Directly measured mucosal pressure was similar between devices for a given cuff volume, but was lower for the PLMA for a given OLP. Directly measured mucosal pressure was highest in the distal oropharynx for both devices, but rarely (

Serum S100 protein as a marker of cerebral damage during cardiac surgery.

Abstract: The identification of a serum marker to assist in the diagnosis of cerebral injury after cardiac surgery is potentially useful. S100 protein is an early marker of cerebral damage. It is released after cardiac surgery performed under cardiopulmonary bypass (CPB). Its level is correlated with the duration of CPB, deep circulatory arrest and aortic cross-clamping. Increased levels of S100 protein are correlated with the age of the patient and the number of microemboli, especially during aortic cannulation. Perioperative cerebral complications such as stroke, delayed awakening and confusion are associated with increased levels of S100 protein directly after bypass and from 15 to 48 h after it. In addition, increased levels of S100 protein are related to neuropsychological dysfunction after cardiac surgery. S100 protein has early and late release patterns after CPB; the early pattern may be due to sub-clinical brain injury. The late release pattern may be due to perioperative cerebral complications. Patients undergoing intracardiac operations combined with coronary artery bypass surgery are more susceptible to brain injury and have higher levels of S100 after CPB. Furthermore, adults and children undergoing deep circulatory arrest are more susceptible to brain injury, in terms of higher S100 protein release after CPB. Serum S100 protein levels are reduced after using arterial line filtration and covalent-bonded heparin to coat the inner surface of the CPB circuit.

Oral preanaesthetic medication for children: double-blind randomized study of a combination of midazolam and ketamine vs midazolam or ketamine alone.

Abstract: Anxiolysis and sedation with oral midazolam are common practice in paediatric anaesthesia. However, good or excellent results are seen in only 50-80% of cases. For this reason, we investigated if addition of a low dose of oral ketamine (MIKE: ketamine 3 mg kg-1, midazolam 0.5 mg kg-1) resulted in better premedication compared with oral midazolam 0.5 mg kg-1 or ketamine 6 mg kg-1 alone, in a prospective, randomized, double-blind study. We studied 120 children (mean age 5.7 (range 2-10) yr) undergoing surgery of more than 30 min duration. After oral premedication in the ward and transfer, the child's condition in the induction room was evaluated by assigning 1-4 points to the quality of anxiolysis, sedation, behaviour at separation from parent and during venepuncture (transfer score). On days 1 and 7 after operation, parents were interviewed for changes in behaviour (eating, sleep, dreams, toilet training), recollection and satisfaction, using a standardized questionnaire. The groups were similar in age, sex, weight, intervention and duration of anaesthesia. The transfer score was significantly better in the MIKE group (12.5 (95% confidence interval (CI) 11.9-13.1)) than in the ketamine or midazolam groups (10.6 (9.8-11.4) and 11.5 (10.7-12.3), respectively). Success rates for anxiolysis and behaviour at separation were greater than 90% with the combination, approximately 70% with midazolam and only 51% with ketamine alone. The incidence of salivation, excitation and psychotic symptoms was low in all groups. Vertigo and emesis before induction were significantly more frequent after ketamine premedication. During recovery, there were no differences in sedation or time of possible discharge. After 1 week, parents reported nightmares (ketamine five, midazolam three, MIKE one), restless sleep (five/four/four) or negative memories (three/four/one). There were no major or continuing disturbances in behaviour or development. In summary, significantly better anxiolysis and separation were observed with a combination of ketamine and midazolam, even in awake children (sedation was not successful according to the preset criteria), than with midazolam or ketamine alone. Duration of action and side effects of the combination were similar to those of midazolam. The combination of both drugs in strawberry flavoured glucose syrup (pH 4.5 approximately) is chemically stable for 8 weeks.

Gastrointestinal luminal PCO2 tonometry: an update on physiology, methodology and clinical applications.

Abstract: Gastrointestinal mucosal pH (pHi), calculated from tonosimilar to changes in gastrically determined tonometric variables. This may also apply to sepsis and shock, even if metrically measured PCO2 in the gastrointestinal lumen and the oxygen demands by the bowel wall increase,101 and to blood bicarbonate content using the Henderson–Hasselbalch cardiopulmonary bypass surgery, during which bowel wall equation, has been suggested to constitute an index of the oxygen demands may decrease following hypothermia and adequacy of splanchnic mucosal perfusion. This may relate increase during rewarming.3 11 29 53 106 110 111 129 Moreover, to the prognosis of critically ill patients, as bowel wall shock may result in early selective splanchnic vasoconstrichypoperfusion may result in tissue injury, increased pertion so that gastric tonometry may reveal an early indicator meability, endotoxin–bacterial translocation and a harmful of general hypoperfusion.33 36 46 55 101 134 The gastric tonoinflammatory (cytokine) response.11 12 26 30 37 54 61 68 71 73 98 metric PCO2 gradient proved an early, sensitive indicator of 106 114 122 130 131 The theory is that hypoperfusion below hypovolaemia during haemorrhage in healthy volunteers.55 a critical level causes tissue (mucosal) carbon dioxide An increase in the gastric PCO2 gradient and decrease in accumulation and acidosis. As carbon dioxide diffuses pHi during general hypoperfusion in humans may relate to easily across membranes, the PCO2 in the gut lumen also angiotensin II-induced selective splanchnic vasoconincreases, leading to widening of the tonometer–blood PCO2 striction.67 109 gradient. In fact, pHi has been used successfully to guide Experimental studies using vascular occlusion and repertreatment and to improve the outcome of critically ill fusion, induction of shock or pharmacological splanchnic patients.36 46 49 61 68 Nevertheless, tonometry has not yet vasoconstriction have revealed that changes in blood flow become a routine intensive care monitoring technique. to the gut wall, as measured by microspheres, laser Doppler, This may relate to uncertainties regarding its physiological electromagnetic or ultrasonic flow probes, or reflectance background, methodology and clinical usefulness.46 This spectrophotometry, were paralleled by concordant changes review will therefore update current thoughts on these in tonometric variables.2 57 70 73 82 84 101 108 115 117–119 125 131 aspects.36 46 134 A decrease in blood flow to less than 50% of baseline during incremental hypoperfusion leads to an increased Physiological background tonometric PCO2 relative to supplying (and draining) blood values. This results in a decrease in pHi, in parallel with Gastrointestinal hypoperfusion the decreasing blood flow and decrease in tissue PO2 and Several conditions may lead to altered gut perfusion (Table oxygen consumption.1 2 13 36 46 50 55 57 73 82 84 101 103 108 115 1). Haemorrhagic hypotension, cardiac tamponade, cardiac 117–119 125 134 This may result in tissue damage and increased bypass or vasopressin infusion for example, may lead to mucosal permeability.1 11 12 26 71 73 106 122 131 In critically ill, mucosal hypoperfusion along the entire gastrointestinal septic and mechanically ventilated patients, laser Doppler tract, and this may be assessed with the help of simultaneous (and reflectance spectroscopy) measurement of gastric tonometric measurements in various gastrointestinal segmucosal blood flow, hepatosplanchnic blood flow measured ments.1 82 84 101 117 118 134 In fact, the bowel PCO2 gradient by indocyanine green, or hepatic breakdown of injected lidocaine to monoethylglycinexylidide, were lower in may increase and pHi decrease during hypoperfusion states,

Randomized placebo-controlled trial to assess the effect of remifentanil and propofol on bispectral index and sedation.

Abstract: The effect of the combination of opiates and hypnotics on bispectral index (BIS) is unclear. This double-blind placebo-controlled trial investigated the effect on BIS and sedation of different infusion doses of remifentanil combined with a steady infusion of propofol. Forty patients initially received a target-controlled infusion of propofol 2 micrograms ml-1 for 15 min. They were then randomized to receive either placebo, 0.01, 0.05 or 0.1 microgram kg-1 min-1 remifentanil for a further 15 min. We found a significant correlation between the dose of remifentanil and the change of BIS after 15 min of infusion. The correlation between all the sedation scores and their corresponding BIS was also significant. We concluded that remifentanil, in combination with propofol, reduces BIS when used for sedation.

Self-citations in six anaesthesia journals and their significance in determining the impact factor.

Abstract: Self-citation of a journal may affect its impact factor. We investigated self-citations in the 1995 and 1996 issues of six anaesthesia journals by calculating the self-citing and self-cited rates for each journal. Self-citing rate relates a journal's self-citations to its total number of references. We defined self-cited rate as the ratio of a journal's self-citations to the number of times it is cited by the six anaesthesia journals. We also correlated self-citing rates with the impact factor of the six journals for 1997. Citations among the six journals differed significantly (P < 0.0001). Anesthesiology had the highest self-citing rate (57%). Anaesthesia, Anesthesia and Analgesia, British Journal of Anaesthesia, Canadian Journal of Anaesthesia and the European Journal of Anaesthesiology had self-citing rates of 28%, 28%, 30%, 11% and 4% respectively. The self-cited rates were 31%, 35%, 34%, 27%, 31% and 17% for Anaesthesia, Anesthesiology, Anesthesia and Analgesia, British Journal of Anaesthesia, Canadian Journal of Anaesthesia and the European Journal of Anaesthesiology, respectively. North America journals cited the North America literature. This also occurred, to a lesser extent, in the European anaesthesia journals. A significant correlation between self-citing rates and impact factors was found (r = 0.899, P = 0.015). A high self-citing rate of a journal may positively affect its impact factor.