Consent and anaesthetic risk

Minor postoperative complications related to anesthesia in elective gynecological and orthopedic surgical patients at a teaching hospital in Kingston, Jamaica

BACKGROUND AND OBJECTIVES

Minor postoperative anesthetic complications may increase patient discomfort and dissatisfaction and delay recovery. This paper sought to determine the frequency of minor complications in the first 48 hours postoperatively reported by elective gynecological and orthopedic surgical patients at the University Hospital of the West Indies, Jamaica. Overall satisfaction with anesthetic care and possible risk factors for developing complications were also assessed.

METHODS

A prospective, descriptive cohort study was undertaken with patient interviews 24 to 48 hours after anesthesia. Data were analyzed using SPSS version 12 and assessed using the χ(2)-square test and multiple logistic regression models.

RESULTS

Five hundred and five (505) patients were included, with 374 females (74%). Most were ASA I (55%) or ASA II (38%) and had general anesthesia (80%). A total of 419 (83%) patients reported at least one complication postoperatively. The most frequently reported complications were sore throat (44%), nausea (30%), vomiting (24%), and thrombophlebitis (20%). The mode of the Verbal Numerical Rating Score (VNRS) for each complication ranged between 2 and 5, suggesting that most did not cause severe distress. Age less than 45 years (OR 2.22, 95% CI 1.34-3.69, p=0.002) and female gender (OR 3.64, 95% CI 2.14-6.20, p<0.001) were identified as significant independent variables. Most patients regarded their anesthetic experience as excellent (51%) or very good (22%).

CONCLUSION

This study showed a comparatively high incidence of minor postoperative complications (83%), but low reported severity of symptoms and a high overall satisfaction rate. Special attention should be paid to reduce these minor complications through more meticulous anesthetic technique.

Cancer in older patients: an analysis of elderly oncology

Is it possible to define when someone is elderly? The worldwide population is growing not only in number but also in age; it is estimated that the population will increase to around 750 million by 2021. Two thirds of cancer occurs in the over 65 age groups. With an increasing elderly population, it can be derived that cancer will become a more prevalent condition. The burden of cancer on the medical profession will be even more apparent than before. In addition the elderly age group has different needs compared with younger oncology patients; there can be no ‘rule of thumb’ with the management of elderly illness. Factors such as frailty are significant when treating cancer in the older patients. The assessment of quality of life in older patients with cancer is also an important factor. Is it best for a patient to enjoy life as it is with cancer or aim for increased life expectancy by undertaking treatment with the threat of morbidity however severe during that period? The volume of scientific evidence currently available to support all the issues in geriatric oncology is greatly limited; almost all treatments designed for oncology are being tested in randomized clinical trials preferentially using younger cohorts of patients. Changes need to be made in order to further this field of medicine. Geriatric oncology is no longer a palliative field, as a healthy active life can now be expected by some older patients. The burden of oncology in the elderly will need to take a modern approach regarding the management of these patients.

Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists

OBJECTIVE

Thyrotoxicosis has multiple etiologies, manifestations, and potential therapies. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions and patient preference. This article describes evidence-based clinical guidelines for the management of thyrotoxicosis that would be useful to generalist and subspeciality physicians and others providing care for patients with this condition.

METHODS

The development of these guidelines was commissioned by the American Thyroid Association in association with the American Association of Clinical Endocrinologists. The American Thyroid Association and American Association of Clinical Endocrinologists assembled a task force of expert clinicians who authored this report. The task force examined relevant literature using a systematic PubMed search supplemented with additional published materials. An evidence-based medicine approach that incorporated the knowledge and experience of the panel was used to develop the text and a series of specific recommendations. The strength of the recommendations and the quality of evidence supporting each was rated according to the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group.

RESULTS

Clinical topics addressed include the initial evaluation and management of thyrotoxicosis; management of Graves' hyperthyroidism using radioactive iodine, antithyroid drugs, or surgery; management of toxic multinodular goiter or toxic adenoma using radioactive iodine or surgery; Graves' disease in children, adolescents, or pregnant patients; subclinical hyperthyroidism; hyperthyroidism in patients with Graves' ophthalmopathy; and management of other miscellaneous causes of thyrotoxicosis.

CONCLUSIONS

One hundred evidence-based recommendations were developed to aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice.

Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists

BACKGROUND

Thyrotoxicosis has multiple etiologies, manifestations, and potential therapies. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions and patient preference. This article describes evidence-based clinical guidelines for the management of thyrotoxicosis that would be useful to generalist and subspeciality physicians and others providing care for patients with this condition.

METHODS

The development of these guidelines was commissioned by the American Thyroid Association in association with the American Association of Clinical Endocrinologists. The American Thyroid Association and American Association of Clinical Endocrinologists assembled a task force of expert clinicians who authored this report. The task force examined relevant literature using a systematic PubMed search supplemented with additional published materials. An evidence-based medicine approach that incorporated the knowledge and experience of the panel was used to develop the text and a series of specific recommendations. The strength of the recommendations and the quality of evidence supporting each was rated according to the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group.

RESULTS

Clinical topics addressed include the initial evaluation and management of thyrotoxicosis; management of Graves' hyperthyroidism using radioactive iodine, antithyroid drugs, or surgery; management of toxic multinodular goiter or toxic adenoma using radioactive iodine or surgery; Graves' disease in children, adolescents, or pregnant patients; subclinical hyperthyroidism; hyperthyroidism in patients with Graves' ophthalmopathy; and management of other miscellaneous causes of thyrotoxicosis.

CONCLUSIONS

One hundred evidence-based recommendations were developed to aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice.

Computed tomographic angiography: assessing outcomes

Perforator flaps are preferable for breast reconstruction after mastectomy in many patients. Preoperative imaging of the perforators and source vessels is desirable to reduce surgeon stress, limit donor and recipient site complications, and minimize operative time and associated costs. Computed tomographic angiography (CTA) has been shown to provide highly accurate representations of vascular anatomy with excellent spatial resolution. A critical review of the currently available literature was performed to identify the benefits of preoperative imaging (specifically CTA) in perforator flap reconstruction.

Informed Consent for Anaesthesia in Australia and New Zealand

The legal and ethical requirements related to an anaesthetist's communication with patients in preparing them for anaesthesia, assisting them in making appropriate decisions and obtaining consent in a formal sense are complex. Doing these things well takes time, skill and sensitivity. The primary focus should be to adequately prepare patients for surgery and to ensure that they are sufficiently well informed to make the choices that best meet their own needs. This is just an affirmation of the importance of patient-centred care.

General anaesthesia for external electrical cardioversion of atrial fibrillation: experience of an exclusively cardiological procedural management

AIMS

External electrical cardioversion (EC) usually requires brief general anaesthesia involving anaesthetists. The aim of this study was to evaluate the feasibility and safety of inducing anaesthesia for EC of atrial fibrillation (AF) exclusively by the cardiologic team with anaesthetists on-hand.

METHODS AND RESULTS

A retrospective analysis of 624 elective EC, over a 6-year period, was made. No patients were excluded due to the severity of pathology or comorbidities. The protocol of the intravenous anaesthesia was 5 mg bolus of midazolam and subsequent increasing doses of propofol starting from 20 mg to achieve the desired sedation level. After delivering DC shock, a direct observation period followed in order to assess the post-sedation recovery and to detect the procedure-related complications. Electrical cardioversion was effective in 98.9% of the cases. General anaesthesia was effective in 100% of cases with a dosage of propofol, ranging between 20 mg to a maximum of 80 mg, after 5 mg of midazolam was administered. All patients generally showed a fast recovery waking up in a few minutes. The anaesthesiology team was never called for assistance. All the procedures were carried out by the cardiologic team as planned. No thrombo-embolic and allergic complications were observed. Arrhythmic complications were uncommon and essentially bradyarrhythmias.

CONCLUSION

A general anaesthesia for outpatient EC of AF can be safely handled by a cardiologist having adequate experience with anaesthetical agents. Moreover, the association of midazolam and a very small dosage of propofol, given their synergic action, is effective and safe in inducing anaesthesia. Arrhythmic complications are rare and limited to bradyarrhythmias.

Perioperative management of the patient with cardiac disease

The overall incidence of perioperative death is relatively low. However, patients with coronary artery disease are at higher than average risk of perioperative cardiac complications. Thus, preoperative testing for cardiac disease should be done in certain patients in an effort to reduce postoperative mortality and morbidity. Patients who require emergent orthopaedic surgery are at greater risk of perioperative cardiac events than are those who undergo elective procedures. Certain modalities, such as beta blockers, statins, and alpha-2 agonists, may be started or continued in the postoperative period to further enhance cardiac function. We review the current recommendations for preoperative cardiac testing in orthopaedic patients and for perioperative management of orthopaedic patients with known cardiac disease.

The ethics of anaesthesia learning curves

While the concept of the 'learning curve' is widely accepted and understood in medical education, the ethical appreciation of what this involves for patients has been under-represented in medical journals. Advances in medical technology have produced an armoury of diagnostic and therapeutic invasive procedures, which must be perfected by anaesthetists for the benefit of patients. Anaesthetic training involves practice using patients, which potentially exposes patients to excess procedural risk. However, such risk can be minimised through close supervision of trainees and the development of non-patient training aids. Most importantly, for training to be ethical, it must involve the patient: it is for patients to decide whether they consent to taking part in training and their consent should always be sought where possible.

Neurolinguistic programming used to reduce the need for anaesthesia in claustrophobic patients undergoing MRI

The purpose of this study was to assess the success of neurolinguistic programming in reducing the need for general anaesthesia in claustrophobic patients who require MRI and to consider the financial implications for health providers. This was a prospective study performed in 2006 and 2007 at a teaching hospital in England and comprised 50 adults who had unsuccessful MR examinations because of claustrophobia. The main outcome measures were the ability to tolerate a successful MR examination after neurolinguistic programming, the reduction of median anxiety scores produced by neurolinguistic programming, and models of costs for various imaging pathways. Neurolinguistic programming allowed 38/50 people (76%) to complete the MR examination successfully. Overall, the median anxiety score was significantly reduced following the session of neurolinguistic programming. In conclusion, neurolinguistic programming reduced anxiety and subsequently allowed MRI to be performed without resorting to general anaesthesia in a high proportion of claustrophobic adults. If these results are reproducible, there will be major advantages in terms of patient safety and costs.

Safety and feasibility of day case patent foramen ovale (PFO) closure facilitated by intracardiac echocardiography

Ultrasound guided patent foramen ovale (PFO) closure has traditionally utilized transoesophageal echocardiography (TOE) under general anaesthesia. Some centres use fluoroscopic guidance alone to facilitate day case PFO closure. Intracardiac echocardiography (ICE) is performed via femoral vein access using an 11 Fr sheath providing accurate guidance without the necessity for general anaesthesia. The safety and feasibility of PFO closure using ICE guidance as a day case procedure have not been documented. We present a consecutive series of patients undergoing planned day case PFO closure under ICE guidance with transthoracic echocardiogram (TTE) follow up. Patients excluded from day case PFO closure were those with early pregnancy or unfavourable social circumstances. 53 consecutive adult patients (44.2+/-11.0 years; 24 males) were planned for day case PFO closure facilitated by ICE. Referral indications were stroke or TIA (n=39), peripheral embolism (n=6), decompression sickness (n=7) and severe migraine (n=1). All 53 patients underwent ICE, with 9/53 (17%) having an atrial septal aneurysm. In 5 patients no PFO was found. In the remaining 48 patients, PFO closure was achieved using the HELEX occluder (n=47) or the Amplatzer device (n=1). Mean procedure and fluoroscopy times were 31.0+/-12.4 and 5.3+/-3.9 min respectively. One patient failed same day discharge due to groin haematoma. There were no other complications. At 3 month follow up, 45/48 (94%) had no residual shunt, with 3 patients having small residual shunts on colour flow Doppler. In conclusion, percutaneous PFO closure as a day case procedure is safe and feasible when facilitated by ICE.

Major complications of epidural analgesia after surgery: results of a six-year survey

We performed a retrospective case note review to identify the major complications of epidural analgesia occurring after surgery at our hospital. By cross-referencing the radiology, microbiology and patient information management system databases, we identified patients who had undergone either spinal magnetic resonance imaging or a lumbar puncture within 60 days of surgery in the period from January 2000 to December 2005. Review of these case notes identified six cases of epidural abscess, three of meningitis and three of epidural haematoma. Symptoms of epidural abscess or meningitis developed a median of 5 days after epidural catheter removal. Methicillin-resistant Staphylococcus aureus was the predominant pathogen. Epidural haematoma symptoms developed while the epidural catheter was in place. These symptoms were initially attributed to the epidural infusion. Diagnostic delays contributed to adverse neurological outcome in three patients. This study suggests that leg weakness is a critical monitor of spinal cord health. A national database is needed to establish a more accurate estimate of the incidence of major complications and to identify relevant risk factors.

Outcomes in day surgery

PURPOSE OF REVIEW

To summarize and examine the updated published results on the outcome measures that can be used to assess the quality of ambulatory surgery and anesthesia.

RECENT FINDINGS

Major morbidity and mortality following ambulatory surgery is exceedingly low. Cancellations and delays may have a negative impact on the patients, healthcare personnel and the organizations. Minor cardiovascular adverse events are the most common intraoperatively and are associated with preexisting cardiovascular diseases and elderly patients. Respiratory events postoperatively are associated with obesity, smoking and asthma. Also, pain is a common cause for longer postoperative stay, unanticipated admission and readmission. Postoperative nausea and vomiting occurs in 30% of patients and strongly affects patient satisfaction. Furthermore, prolonged stays are mainly caused by surgical factors, or minor symptoms like pain or nausea. Surgical factors are also the main causes of unanticipated hospital admission. The type of surgery and the 24 h postoperative symptoms may affect the degree of return to daily living function. Also, patient satisfaction affects the outcome of healthcare and the use of healthcare services.

SUMMARY

Ambulatory surgery, as currently practiced, provides quality care that is cost-effective. Minor adverse events such as pain and postoperative nausea and vomiting are still common, and improvement could be targeted in these areas.

Patient selection in ambulatory surgery

PURPOSE OF REVIEW

To evaluate the evidence regarding decisions made in the perioperative management of patients undergoing ambulatory surgery for the following: the elderly, hyper-reactive airways disease, coronary artery disease, diabetes, obesity, obstructive sleep apnea, the ex-premature infant and the child with an upper respiratory infection.

RECENT FINDINGS

Major morbidity and mortality following ambulatory surgery is exceedingly low. Minor adverse cardiac events during the intraoperative period are associated with hypertension and the elderly. Minor adverse respiratory events during the intraoperative period are associated with obesity. Respiratory events during the postoperative period are associated with obesity, smoking and asthma. Prolonged stays following ambulatory surgery are predominantly caused by surgical factors or minor symptoms such as pain or nausea. Surgical factors are also the main causes of unplanned admissions. Age greater than 85, significant co-morbidity and multiple admissions to hospital in the 6 months preceding ambulatory surgery, however, are associated with higher readmission rates.

SUMMARY

Evidence indicates that ambulatory anesthesia is currently very safe. Ambulatory surgery, however, is being offered to a population with increasing co-morbidity. As the population undergoing ambulatory surgery changes over time, the evidence regarding patient outcomes will need re-examination.

Four years experience of a nurse-led elective cardioversion service within a district general hospital setting

AIMS

External direct current cardioversion is an effective method of restoring sinus rhythm (SR) in patients with persistent atrial arrhythmias. Increasing demand for hospital beds, together with a reduction in junior doctors' hours, has adversely affected cardioversion provision. A regular nurse-led cardioversion service conducted in a dedicated hospital day-unit was introduced to resolve these constraints. There are limited data on the safety or efficacy of such a service.

METHODS AND RESULTS

All cardioversions between October 2000 and October 2004 were performed by an appropriately trained specialist nurse, under general anaesthesia. Patients attended a pre-assessment clinic. Energy requirements for initial and subsequent defibrillations were guided by a local protocol in accordance with the guidelines from American Heart Association, American College of Cardiology, and the European Society of Cardiology. Rectilinear biphasic defibrillation was introduced in January 2004 with an appropriate protocol amendment. In the absence of complications, the aim was to discharge patients the same day. A total of 578 cardioversions (475 monophasic; 103 biphasic) were performed on 464 patients [72.1% male, mean (+/- SD) age 67.8 +/- 9.4 years] with atrial fibrillation (AF) (89.7%) and atrial flutter (10.3%). SR was restored in 84.0 and 100% of patients with AF and atrial flutter, respectively, which increased to 90.2 and 100% following the introduction of biphasic defibrillation. Biphasic shocks cardioverted AF with less energy (163 +/- 22 vs. 289 +/- 81 J) and less cumulative energy (230 +/- 139 vs. 455+/-255 J) than monophasic (P < 0.001 for both), despite no difference in the duration of AF (P = 0.26) or patient age (P = 0.78). Two patients required hospital admission due to transient bradycardia; both were discharged within 72 h, without the need for permanent pacing. A total of 99.6% of patients was discharged home the same day; there were no deaths.

CONCLUSION

The provision of a nurse-led elective cardioversion service is feasible and effective, without compromising safety.

Informed consent for anesthesia: survey of current practices in Japan

Anesthesia requires informed consent because it is an invasive procedure with certain risks. However, the state of informed consent for anesthesia in Japan remains unclear. The purpose of this survey was to examine the state of informed consent for anesthesia in Japan. A questionnaire was sent to all hospitals certified by the Japanese Society of Anesthesiologists (n = 854). The questionnaire consisted of four sections: explanation of the anesthesia, method of documentation, consent for anesthesia, and other information such as the hospital's size. A total of 504 (59.0%) questionnaires were completed and returned. At 96.7% of hospitals, an anesthesiologist would explain the scheduled anesthesia. Most departments provide an explanation of dental damage, malignant hyperthermia, and nausea/vomiting. Explanation of anesthesia was standardized at 59.0% of hospitals. A written description was handed out to patients routinely at 61.3% of hospitals. Although consent for anesthesia was obtained at more than 90% of departments, only 59.9% of departments would keep records of having obtained consent. This survey found that the explanation of anesthesia varied among hospitals and was not standardized in Japan. Further attention is needed on how to improve the documentation of informed consent.

The management of infants and children for painless imaging

The ability of a child to remain sufficiently immobile for painless imaging depends upon their behaviour and the imaging itself. Anaesthesia allows imaging to be optimised but it is expensive, scarce and inappropriate for many situations. Fortunately, sedation and behavioural techniques are sufficiently successful for the majority of scanning, and success rates are high provided that suitable children are selected. Sedation, however, administered by non-anaesthetists, may have catastrophic complications such as airway obstruction. Current UK recommendations demand that any sedation technique has a 'wide margin of safety', but in addition to this, safety is dependent on trained, skillful and experienced staff. Magnetic resonance imaging frightens many children and special planning is necessary for sedation and anaesthesia. When planning an imaging service for children, all the management techniques should be considered in order to achieve maximum efficiency, quality and safety.

What’s new and novel in obstetric anesthesia? Contributions from the 2003 scientific literature

THE PREGNANT PATIENT: Age; maternal disease; prophylactic antibiotics; gastroesophageal reflux; obesity; starvation; genotyping; coagulopathy; infection; substance abuse; altered drug responses in pregnancy; physiological changes of pregnancy. THE FETUS: Fetal monitoring; intrauterine surgery. THE NEWBORN: Breastfeeding; maternal infection, fever, and neonatal sepsis evaluation. OBSTETRIC COMPLICATIONS: Embolic phenomena; hemorrhage; preeclampsia; preterm delivery. OBSTETRIC MANAGEMENT: External cephalic version and cervical cerclage; elective cesarean delivery; fetal malpresentation; vaginal birth after cesarean delivery; termination of pregnancy. OBSTETRIC ANESTHESIA: Analgesia for labor and delivery; anesthesia for cesarean delivery; anesthesia for short obstetric operations; complications of anesthesia. MISCELLANEOUS: Consent; ethics; history; labor support; websites/books/leaflets/journal announcements.

Cardioversion and the use of sedation

Nurse led cardioversion services have achieved significant reductions in both cost and waiting time. However, the question of safety of the procedure raises several areas of concern.

Handover of responsibility for the anaesthetised patient - opinion and practice

Anaesthesia is a critical and complex process that extends from the pre-operative assessment through to the postoperative management of patients. Handover of responsibility for logistical as opposed to patient-orientated reasons may compromise that process of care. If such handover becomes inevitable with shift-based patterns of working, the implications need to be considered and procedures developed in order to minimise adverse consequences. This survey of national practice reveals little formalisation of procedure and a spectrum of opinion on the relevance of the key considerations. There is, however, a majority view amongst respondents that national guidelines would be of value and that professional defensibility would be aided by standardisation and documentation of any handover.

Informed consent: ethical implications in clinical practice

PURPOSE OF REVIEW

The concept of involving pediatric patients in medical decision-making, in both clinical and research anesthesia and surgical care, has support from specialists involved in pediatric care. Production pressure in the workplace creates conflict between ethical anesthesia practice - such as obtaining informed consent - and time efficiency. Specialized documentation of anesthesia consent may increase efficiency but could weaken the consent process. Concerns with cost containment have led to interventional quality improvement activities that may constitute research and therein require informed consent. This review discusses these three consent issues as they relate to anesthesia care.

RECENT FINDINGS

Children are more capable of participating in medical decision-making than previously thought. Despite the call for physicians to involve children in decision-making regarding their medical care, few physicians or parents do so. Quality improvement research potentially harmful to patients, achieved without patient knowledge or consent, may violate the Nuremberg Code. Opinions differ about the potential advantages and pitfalls of specific and separate anesthesia consent forms.

SUMMARY

Anesthesiologists have ethical obligations to involve children in the medical decision-making process as much as the child's capacity allows, and to place patient advocacy in the informed consent process above production pressures. While a specific and separate anesthesia informed consent form may be useful, it should not undermine the process of informed consent or relegate the consent process to non-physician personnel. The informed consent process for anesthesia care remains the province and responsibility of the individual anesthesiologist.