Perioperative care and collaboration between surgeons and anaesthetists - it's about time

Noninvasive respiratory support in the perioperative setting: a narrative review

The application of preoperative noninvasive respiratory support (NRS) has been expanding with increasing recognition of its potential role in this setting as a physiological optimization for patients with a high risk of developing atelectasis and postoperative pulmonary complications (PPC). The increased availability of high-performance anesthesia ventilator machines providing an easy way for NRS support in patients with reduced lung function should not be under-evaluated. This support can reduce hypoxia, restore lung volumes and theoretically reduce atelectasis formation after general anesthesia. Therapeutic purposes should also be considered in the perioperative setting, such as preoperative NRS to optimize treatment of patients' pre-existing diseases, e.g., sleep-disordered breathing. Finally, the recent guidelines for airway management suggest preoperative NRS application before anesthesia induction in difficult airway management to prolong the time needed to secure the airway with an orotracheal tube. This narrative review aims to revise all these aspects and to provide some practical notes to maximize the efficacy of perioperative noninvasive respiratory support.

Professional Obstacles to Anaesthesiology Practice in Punjab, Pakistan: Qualitative Study of Consultant Anaesthesiologists' Perspectives

Limitations in the global anaesthesia workforce contribute to the emigration of skilled anaesthesiologists from lower-income to higher-income countries, jeopardizing workforce balance and patient outcomes in Pakistan. This study aimed to explore the challenges experienced by anaesthesiologists in Punjab, Pakistan's most populous province, and the potential changes to encourage their retention. We conducted a qualitative study, conducting semi-structured interviews with 25 purposively sampled consultant anaesthesiologists working in Punjab and analysing data thematically. Reported professional challenges and reasons consultant anaesthesiologists chose to work abroad differed between public and private sectors, each sector providing distinct challenges that compromised anaesthesia workforce numbers and quality. Key concerns were security, promotion/incentive structures, and gender inequalities in public hospitals versus inadequate salary and facilities, surgeon dependency, and the lack of out-of-theatre practice in private hospitals that minimized the scope and earnings of anaesthesiologists within Pakistan. Our findings help contextualise Pakistan's anaesthesia workforce crisis, indicating public-sector improvements could include increasing security in hospital premises, performance-based incentives, and qualification-dependent promotion, while private-sector improvements could include decreasing surgeon dependency, fixing salary percentages by surgical case, and encouraging direct patient-anaesthesiologist relationships. National and subnational interventions to promote anaesthesiology, along with public awareness campaigns, could additionally raise its profile and encourage retention.

Association of Race and Ethnicity with Pediatric Postoperative Pain Outcomes

INTRODUCTION

Inequitable variability in healthcare practice negatively affects patient outcomes. Children of color may receive different analgesic medications in the perioperative period, resulting in different outcomes.

METHODS

Medical records of children 0 to ≤ 18 years old from May 2014 to August 2019 were reviewed. The exposure was racial or ethnic groups: Asian, Black, Hispanic, Pacific Islander, and White non-Hispanic (reference).

PRIMARY OUTCOME

post-anesthesia care unit mean pain score.

SECONDARY OUTCOMES

inpatient mean pain score; opioid, antiemetic, and antipruritic administration in the post-anesthesia care unit and inpatient ward. The association of race or ethnicity with outcomes was modeled using multilevel logistic regression, adjusting for confounders and covariates.

RESULTS

Twenty-nine thousand six hundred fourteen cases are included. In the post-anesthesia care unit, Black, Hispanic, and Pacific Islander children had no significant difference in the odds of receiving opioids or having moderate-severe pain as compared to White non-Hispanic patients; Asian children had lower odds of receiving opioids and lower odds of having a moderate-severe mean pain score. In the inpatient setting, Black, Hispanic, and Pacific Islander children had no significant difference in the odds of receiving opioids or having moderate severe-pain as compared to White non-Hispanic children, but Asian children had lower odds of receiving opioids and of having a moderate-severe mean pain score.

CONCLUSIONS

Asian children had lower odds of receiving opioids and having moderate-severe pain postoperatively compared to the White non-Hispanic children. These differences may be a function of variation in patient/caregivers culture or healthcare provider care and warrant further investigation.

Laparoscopy in Gynecologic and Abdominal Surgery in Regional (Spinal, Peridural) Anesthesia, the Utility of the Technique during COVID-19 Pandemic

BACKGROUND

laparoscopic surgery is mainly performed in general anesthesia. Symptomatic patients infected with COVID-19 needing surgery are however at higher risk for COVID-19 complications in general anesthesia than in regional anesthesia. Even so, Covid transfection is a hazard to medical personnel during the intubation procedure and treatment drugs may be in shortage during a pandemic. Recovery and hospital stay are also shorter after laparoscopy. Laparoscopy performed in regional anesthesia may have several advantages in limiting Covid.

METHODS

international literature on the risk of COVID-19 complications development was searched. 3 topics concerning laparoscopic surgery were reviewed: (1) Achievements in laparoscopy; (2) Advantages of regional anesthesia compared to general anesthesia; (3) Feasibility to perform laparoscopy in regional anesthesia in COVID-19 pandemic. The authors reviewed abstracts and full-text articles concerning laparoscopic surgery, gynecology, anesthesia and COVID-19. Studies published in PubMed, Embase, Cochrane Library and found in Google Scholar before 1st FEB, 2021 were retrieved and analyzed.

RESULTS

a total of 83 studies were found, all of them written in English. 17 studies could be found in gynecology and in general surgery about laparoscopy with regional anesthesia. In Covid time only one study compared laparoscopic surgery in general anesthesia to laparotomy and another study laparotomy in general anesthesia to regional anesthesia. Laparoscopy showed no disadvantage compared to laparotomy in Covid pandemic and in another study laparotomy in general anesthesia was associated with higher mortality and more pulmonary complications. Trendelenburg position can be a threat if used by inexperienced personnel and can induce unintended anesthesia of breathing organs. On the other hand Trendelenburg position has advantages for cardiovascular and pulmonary functions. Pneumoperitoneum of low CO2 pressure is well tolerated by patients.

CONCLUSIONS

elective surgery should be postponed in symptomatic Covid patients. In inevitable emergency surgery intubation anesthesia in COVID-19 pandemic is as far as possible to be avoided. In COVID-19 pandemic, regional anesthesia is the preferred choice. The optimum may be the combination of laparoscopic surgery with regional anesthesia. Reducing the pneumoperitoneum is a good compromise for the comfort of patients and surgeons. A special case is gynecology, which needs to be performed in Trendelenburg position to free pelvic organs.

Academic Publication of Anesthesiology From a Bibliographic Perspective From 1999 to 2018: Comparative Analysis Using Subject-Field Dataset and Department Dataset

Background: Publication activity in the field of anesthesiology informs decisions that enhance academic advancement. Most previous bibliometric studies on anesthesiology examined data limited to journals focused on anesthesiology rather than data answerable to authors in anesthesia departments. This study comprehensively explored publication trends in the field of anesthesiology and their impact. We hypothesized that anesthesiology's bibliometric scene would differ based on whether articles in the same study period were published in anesthesiology-focused journals or were produced by authors in anesthesia departments but published in non-specialty journals.

Methods: This cross-sectional study used bibliometric data from the Science Citation Index Expanded database between 1999 and 2018. Two datasets were assembled. The first dataset was a subject-dataset (articles published in 31 journals in the anesthesiology category of InCites Journal Citation Reports in 2018); the second dataset was the department-dataset (articles published in the Science Citation Index Expanded by authors in anesthesia departments). We captured the bibliographical record of each article in both datasets and noted each article's Institute for Scientific Information code, publication year, title, abstract, author addresses, subject category, and references for further study.

Results: A total of 69,593 articles were published—cited 1,497,932 times—in the subject-dataset; a total of 167,501 articles were published—cited 3,731,540 times—in the department-dataset. The results demonstrate differences between the two datasets. First, the number of articles was stagnant, with little growth (average annual growth rate = 0.31%) in the subject-dataset; whereas there was stable growth (average annual growth rate = 4.50%) in articles in the department-dataset. Second, only 30.4% of anesthesia department articles were published in anesthesiology journals. Third, journals related to “pain” had the lowest department-subject ratio, which was attributable to a large portion of non-anesthesia department researchers' participation in related research.

Conclusions: This study showed that articles published in anesthesiology-focused and non-specialty journals demonstrate fundamentally different trends. Thus, it not only helps researchers develop a more comprehensive understanding of the current publication status and trends in anesthesiology, but also provides a basis for national academic organizations to frame relevant anesthesiology development policies and rationalize resource allocation.

The Perioperative Surgical Home, Enhanced Recovery After Surgery and how integration of these models may improve care for medically complex patients

Perioperative medicine is changing rapidly, and with this change comes the opportunity to improve upon current models of care delivery and integration within the health care system. Perioperative models of care are structured or conceptual arrangements for surgical patients before, during and after their surgery. Models of care such as the Perioperative Surgical Home and Enhanced Recovery After Surgery pathways are increasingly used to guide the structure of perioperative care delivery with an aim to improve patient outcomes and experience in Canadian settings. In this narrative review, we summarize the origins of these perioperative models of care. They are fundamentally different in scope and level of evidence. Both models have potential benefits and limitations to their broad implementation in our health care system. As currently developed, both models are limited in their application to patients with chronic disease. We discuss how these models of care can be used to develop integrated horizontal and vertical perioperative pathways in a Canadian setting. Such integration is a potential solution that will improve their applicability to patients with medically complex conditions and in times when health care systems are under pressure. We describe this approach using the example of patients with kidney failure receiving dialysis.