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The origins of general anaesthesia for dentistry are inextricably linked to the dawn of anaesthesia as a specialty, and the availability of the very first inhalational anaesthetic agents. Its delivery, regulation and safety profile have evolved significantly since then, with its practice now conducted solely by trained anaesthetists in a hospital setting. Dental chair anaesthesia and nasal masks have largely been replaced by more modern techniques and equipment; nevertheless, the patients that necessitate these interventions present their own unique challenges.

Dental damage is the most common complication in anaesthesia. It negatively affects patients’ quality of life and is the most likely reason for complaint or litigation against anaesthetists. Major risk factors include poor premorbid dental status and prostheses, difficult airways and laryngoscopy. The maxillary incisors are most commonly affected, with enamel fractures and subluxation the most frequently reported injuries. All patients should have an individualized risk assessment, informed consent discussion and risk mitigation strategy in place.

Maxillofacial surgery involves procedures on the facial skeleton, oral cavity and soft tissues of the head and neck. These frequently require shared airway access and close collaboration between anaesthetic and surgical teams. These cases present distinct anaesthetic challenges including difficult airway management and complex perioperative planning. This review focuses on general principles relevant across maxillofacial anaesthesia, with a particular emphasis on ‘major’ surgery, including complex cancer resections and free flap reconstructive procedures.

Anaesthesia for orthognathic surgery requires thorough preoperative planning and multidisciplinary involvement. Patients are generally young and healthy, though there is an increasing trend in treatment of patients with obstructive sleep apnoea syndrome, associated with increased premorbid disease burden. Principles of perioperative management include close cooperation between surgeon and anaesthetist, a multifaceted approach to minimizing blood loss, multimodal analgesia, anti-emesis prophylaxis, and a carefully planned, communicated and executed airway management strategy.

Flexible bronchoscope-assisted tracheal intubation remains an indispensable technique in airway management – as the first-line approach in known or anticipated difficult airways or as a rescue technique in unanticipated difficulty. It can be performed in awake patients or following induction of general anaesthesia, dependent upon the individual patient's risk factors, physiological (in)stability and clinical circumstances. In the fourth National Audit Project of airway complications in the UK (2011), awake tracheal intubation was an under-utilized technique, such that it must be considered in the presence of predictors of difficulty.

Maxillofacial trauma is common and can cause significant physical and psychological morbidity. It can be extremely challenging managing patients with maxillofacial injuries, whether in the emergency setting or in the elective operating theatre environment. Airway management interventions should be carefully planned so that the safest and most effective technique is utilized. Advanced airway management techniques such as awake tracheal intubation, submental intubation or awake tracheostomy may be required.

Clinical audit and quality improvement are essential processes that help to ensure that patients receive safe, effective, and high-quality care. By participating in clinical audit and quality improvement initiatives, anaesthetists can gain a deeper understanding of the care provided to patients and identify areas for improvement. Ensuring good data quality is crucial for these processes, and can be achieved by following a systematic approach to data management, including training on data collection and management techniques, strict data validation procedures and regular data quality checks.

Safe airway management is a key component of anaesthesia, emergency medicine and critical care. Complications arising from airway management can be associated with serious morbidity and mortality. Prediction of difficulties during airway management, with the aim of facilitating better decision-making, planning and preparation, has historically been limited to the use of bedside tests that focus on identification of anatomical features that might impair direct laryngoscopy and tracheal intubation success.

Dental sedation enables the safe and effective treatment of adult and paediatric patients unable to tolerate minor procedures under local anaesthesia alone. Sedation exists along a continuum, ranging from anxiolysis to general anaesthesia, such that it can be challenging to achieve and maintain an optimal depth of sedation throughout procedures with fluctuating levels of surgical stimuli in varied and potentially demanding patient groups. Careful patient and technique selection, continuous monitoring and the ability to immediately manage complications are essential requirements.

Identification of the difficult airway

Clinical informatics, the interdisciplinary science of managing and applying health data, has undergone a profound transformation from a specialist domain into a core pillar of modern healthcare. This shift has profound implications for the perioperative and critical care clinician, moving beyond the simple digitization of records to the widespread implementation of advanced analytical systems and tools to support clinical decision-making, improve patient and systematic safety and reduce medical errors.

Burns, or tissue damage secondary to heat, high-voltage electricity or caustic chemical exposure, lead to an estimated 8,000 hospital admissions in the UK each year. Given the vast array of different causes and complications of these injuries, critically ill burns patients require multidisciplinary team input from the moment they arrive in hospital. From the perspective of the anaesthetist or the intensivist, burns patients present unique challenges in pre-hospital stabilization, operative management and in critical care.

A major incident is one that causes casualties on a scale beyond the emergency and healthcare services’ usual ability to manage. Major incident planning and rehearsal are vital to ensuring an appropriate response. Delivery of a major incident response requires command and coordination within and between emergency services, hospitals and specialist organizations. Casualty management will require the set-up of major incident infrastructure at the scene to effectively extricate, triage, treat and transport casualties to appropriate facilities.

This article explores the critical role of anaesthesia and advanced interventions in pre-hospital trauma care. It outlines a systematic, evidence-based approach for pre-hospital critical care teams, adapting the standard (C)ABCDE framework to address the unique challenges of the scene. The abstract highlights key clinical considerations, including the crucial management of catastrophic haemorrhage, the complexities of airway management in austere environments, and the importance of neuroprotective strategies for traumatic brain injury.

Plasma expanders are colloidal solutions that expand the circulating blood volume more than isotonic crystalloids. Though this physiologic effect is typically transient, colloids remain commonly though variably used in critical care and perioperative medicine worldwide. Our review of these agents begins by introducing the modified Starling model, which incorporates the fundamental physiologic role of the endothelial glycocalyx in transcapillary fluid movement. Next, we discuss each fluid's pharmacological properties and evidence base for use.

In the UK, the annual incidence of acute spinal cord injury (SCI) is 19 new cases per million population, contributing to an estimated 50,000 people who are currently living with SCI. Trauma is the most common cause of SCI, predominantly from falls and road traffic accidents. Damage to the spinal cord occurs both at the time of injury (primary) and in its aftermath (secondary). Effectively treating and preventing secondary cord injury, and managing complications associated with SCI, can make a significant improvement to patient outcomes.

Drowning is defined as respiratory impairment following submersion or immersion in liquid. It is recognized as a global public health crisis, and although death rates have declined, significant disparities remain, with the most socioeconomically deprived populations at greatest risk. Drowning is more common among males and individuals with pre-existing medical co-morbidities. It is a leading cause of death in younger people, often due to limited risk awareness, poor water safety skills, and lack of swimming ability.

Rib fractures commonly result from blunt chest wall trauma and are often associated with significant morbidity and mortality. Patients often develop a vicious cycle of pain, requirement for opioid analgesia, respiratory dysfunction, hypostatic pneumonia and ultimately respiratory failure. This is more common in those with high-risk features such as increasing age, respiratory co-morbidities and significant burden of injury. Poorly managed chest wall pain can lead to prolonged hospital stay, including critical care admission, invasive ventilation and increased likelihood of morbidity and death.