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Lyne TC, Everton HD, Barkley L, Blaise BJ. Limitations of the consent process in paediatric anaesthesia: the Death during Anaesthesia - Risk and Explanation (DARE) audit. Br J Anaesth 2024; 132:1001-1003. [PMID: 38514375 DOI: 10.1016/j.bja.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/05/2024] [Accepted: 02/10/2024] [Indexed: 03/23/2024] Open
Affiliation(s)
- Tom C Lyne
- Barnet Hospital, Royal Free London NHS Foundation Trust, Barnet, UK
| | - Harry D Everton
- Whittington Hospital, Whittington Foundation NHS Foundation Trust, London, UK
| | - Lisa Barkley
- Paediatric Psychology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Benjamin J Blaise
- Department of Paediatric Anaesthetics, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK; Center for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, St. Thomas' Hospital, London, UK.
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2
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Snell N. Medicinal Products and Environmental Pollution. Pharmaceut Med 2024; 38:5-7. [PMID: 37904074 DOI: 10.1007/s40290-023-00502-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 11/01/2023]
Affiliation(s)
- Noel Snell
- National Heart and Lung Institute, Imperial College London, London, UK.
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3
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Subramaniam J, Teh BL, Smith Q. Knowledge of local anaesthetic systemic toxicity and lipid emulsion therapy amongst healthcare providers in a stand-alone eye unit. Br J Anaesth 2023; 131:e123-e126. [PMID: 37541947 DOI: 10.1016/j.bja.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/29/2023] [Accepted: 07/06/2023] [Indexed: 08/06/2023] Open
Affiliation(s)
- Jeevan Subramaniam
- Northern School of Anaesthesia & Intensive Care Medicine, Newcastle-upon-Tyne, UK.
| | - Boon Lin Teh
- Department of Ophthalmology, Sunderland Eye Infirmary, Sunderland, UK
| | - Quentin Smith
- Department of Anaesthesia, Sunderland Eye Infirmary, Sunderland, UK
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4
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Ní Eochagáin A, Athanassoglou V, Cumberworth A, Morris O, Corbett S, Jefferson H, O'Sullivan EP, Pandit JJ. Assessing a novel second generation laryngeal mask airway using the 'ADEPT' approach: results from the LMA® Protector™ observational study. J Clin Monit Comput 2023; 37:517-524. [PMID: 36063277 PMCID: PMC9441326 DOI: 10.1007/s10877-022-00910-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 08/17/2022] [Indexed: 12/02/2022]
Abstract
To address the problem of lack of clinical evidence for airway devices introduced to the market, the Difficult Airway Society (UK) developed an approach (termed ADEPT; Airway Device Evaluation Project Team) to standardise the model for device evaluation. Under this framework we assessed the LMA Protector, a second generation laryngeal mask airway. A total of 111 sequential adult patients were recruited and the LMA Protector inserted after induction of general anaesthesia. Effective insertion was confirmed by resistance to further distal movement, manual ventilation, and listening for gas leakage at the mouth. The breathing circuit was connected to the airway channel and airway patency confirmed with manual test ventilation at 20 cm H20 (water) pressure for 3 s. Data was collected in relation to the time for placement, intraoperative performance and postoperative performance of the airway device. Additionally, investigators rated the ease of insertion and adequacy of lung ventilation on a 5-point scale. The median (interquartile range [range]) time taken to insertion of the device was 31 (26-40[14-780]) s with the ability to ventilate after device insertion 100 (95% CI 96.7- 100)%. Secondary endpoints included one or more manoeuvres 60.3 (95% CI 50.6-69.5)% cases requiring to assist insertion; a median ease of insertion score of 4 (2-5[3-5]), and a median adequacy of ventilation score of 5 (5-5[4-5]). However, the first time insertion rate failure was 9.9% (95% CI 5.1-17.0%). There were no episodes of patient harm recorded, particularly desaturation. The LMA Protector appears suitable for clinical use, but an accompanying article discusses our reflections on the ADEPT approach to studying airway devices from a strategic perspective.
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Affiliation(s)
- A Ní Eochagáin
- Consultant Anaesthetist St. James's Hospital, Dublin, Ireland
| | - V Athanassoglou
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A Cumberworth
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - O Morris
- Consultant Anaesthetist St. James's Hospital, Dublin, Ireland
| | - S Corbett
- Consultant Anaesthetist St. James's Hospital, Dublin, Ireland
| | - H Jefferson
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - E P O'Sullivan
- Consultant Anaesthetist St. James's Hospital, Dublin, Ireland
| | - J J Pandit
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
- University of Oxford, Oxford, UK.
- St John's College, Oxford, OX1 3JP, UK.
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5
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Kane AD, Soar J, Armstrong RA, Kursumovic E, Davies MT, Oglesby FC, Cortes L, Taylor C, Moppett IK, Agarwal S, Cordingley J, Dorey J, Finney SJ, Kunst G, Lucas DN, Nickols G, Mouton R, Nolan JP, Patel B, Pappachan VJ, Plaat F, Scholefield BR, Smith JH, Varney L, Cook TM. Patient characteristics, anaesthetic workload and techniques in the UK: an analysis from the 7th National Audit Project (NAP7) activity survey. Anaesthesia 2023; 78:701-711. [PMID: 36857758 DOI: 10.1111/anae.15989] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2023] [Indexed: 03/03/2023]
Abstract
Detailed contemporary knowledge of the characteristics of the surgical population, national anaesthetic workload, anaesthetic techniques and behaviours are essential to monitor productivity, inform policy and direct research themes. Every 3-4 years, the Royal College of Anaesthetists, as part of its National Audit Projects (NAP), performs a snapshot activity survey in all UK hospitals delivering anaesthesia, collecting patient-level encounter data from all cases under the care of an anaesthetist. During November 2021, as part of NAP7, anaesthetists recorded details of all cases undertaken over 4 days at their site through an online survey capturing anonymous patient characteristics and anaesthetic details. Of 416 hospital sites invited to participate, 352 (85%) completed the activity survey. From these, 24,177 reports were returned, of which 24,172 (99%) were included in the final dataset. The work patterns by day of the week, time of day and surgical specialty were similar to previous NAP activity surveys. However, in non-obstetric patients, between NAP5 (2013) and NAP7 (2021) activity surveys, the estimated median age of patients increased by 2.3 years from median (IQR) of 50.5 (28.4-69.1) to 52.8 (32.1-69.2) years. The median (IQR) BMI increased from 24.9 (21.5-29.5) to 26.7 (22.3-31.7) kg.m-2 . The proportion of patients who scored as ASA physical status 1 decreased from 37% in NAP5 to 24% in NAP7. The use of total intravenous anaesthesia increased from 8% of general anaesthesia cases to 26% between NAP5 and NAP7. Some changes may reflect the impact of the COVID-19 pandemic on the anaesthetic population, though patients with confirmed COVID-19 accounted for only 149 (1%) cases. These data show a rising burden of age, obesity and comorbidity in patients requiring anaesthesia care, likely to impact UK peri-operative services significantly.
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Affiliation(s)
- A D Kane
- Royal College of Anaesthetists, Red Lion Square, UK.,Department of Anaesthesia, James Cook University Hospital, South Tees NHS Foundation Trust, Middlesbrough, UK
| | - J Soar
- Department of Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - R A Armstrong
- Royal College of Anaesthetists, Red Lion Square, UK.,Department of Anaesthesia, Severn Deanery, Bristol, UK
| | - E Kursumovic
- Royal College of Anaesthetists, Red Lion Square, UK.,Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - M T Davies
- Department of Critical Care and Anaesthesia, North West Anglia NHS Trust, UK
| | - F C Oglesby
- University Hospitals Bristol and Weston NHS Foundation Trust, UK
| | - L Cortes
- Royal College of Anaesthetists, Red Lion Square, UK
| | - C Taylor
- Royal College of Anaesthetists, Red Lion Square, UK
| | - I K Moppett
- Royal College of Anaesthetists, Red Lion Square, UK.,University of Nottingham, UK
| | - S Agarwal
- Department of Anaesthesia, Manchester University Hospitals Foundation Trust, Manchester, UK
| | - J Cordingley
- Department of Critical Care and Anaesthesia, Barts Health NHS Trust, UK
| | - J Dorey
- Royal College of Anaesthetists, Red Lion Square, UK
| | - S J Finney
- Department of Critical Care and Anaesthesia, Barts Health NHS Trust, UK
| | - G Kunst
- Department of Cardiovascular Anaesthesia, Kings College London, UK
| | - D N Lucas
- Department of Anaesthesia, London North West University Healthcare NHS Trust, UK
| | - G Nickols
- Department of Anaesthesia, North Bristol NHS Trust, Bristol, UK
| | - R Mouton
- Department of Anaesthesia, North Bristol NHS Trust, Bristol, UK
| | - J P Nolan
- Resuscitation Medicine, Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - B Patel
- Royal College of Anaesthetists, Red Lion Square, UK
| | - V J Pappachan
- Southampton Children's Hospital, NIHR Biomedical Research Centre, Department of Paediatric Anaesthesia and Intensive Care Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - F Plaat
- Department of Anaesthesia, Imperial College Healthcare NHS Trust, London, UK
| | - B R Scholefield
- Institute of Inflammation and Ageing, University of Birmingham, UK
| | - J H Smith
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
| | - L Varney
- Department of Anaesthesia, University College London Hospitals, London, UK
| | - T M Cook
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK.,University of Bristol, UK
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6
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Li Y, Li Y, Chen Q, Hua H, Jiao J, Zhang L, Chen L, Huang S. The effect of first trimester body mass index on the changes in the upper lip bite test classification before and after delivery: A prospective observational study. Front Med (Lausanne) 2022; 9:969862. [PMID: 36186764 PMCID: PMC9515353 DOI: 10.3389/fmed.2022.969862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe difficult airway (DA) assessment and management of pregnant woman has always brought specific challenges. The aim of this study was to investigate the effect of labor on the airway by assessing changes in the upper lip bite test (ULBT) classes and to explore its correlation with the first trimester's body mass index (BMI).MethodsAccording to the BMI of the first trimester, 354 full-term women were divided into low BMI group, normal BMI group and high BMI group. The ULBT class and pregnancy outcome were recorded and compared at early labor, after delivery, and 48 h after delivery.ResultsThe ULBT class was increased in 75(21.1%) patients after delivery. Compared to the normal BMI group, the high BMI group had a higher probability of increasing (34.8 vs. 17.5%; P = 0.002). The number of women with ULBT class 2–3 increased to 157, which was 1.48 times that of early labor. The number of women with ULBT class 3 increased from 4 to 16, of which 7 (53.8%) were from the high BMI group. Binary logistic regression analysis showed that first trimester's BMI was associated with a significant increase in ULBT class after delivery (adjusted odds ratio [aOR] = 2.13 [0.91–4.98], P = 0.02). The ULBT classes of the three groups tended to return to their initial level 48 h after delivery (P > 0.05).ConclusionLabor results in an approximately one-fifth increase in ULBT class. Being overweight or obese in the first trimester is associated with an increased risk of DA during labor.Trial registrationThis study was registered in the Chinese Clinical Trial Registry (http://www.chictr.org.cn) on September 26, 2020. Registration number ChiCTR2000038643.
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7
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Huepe-Artigas D, Singh P, Weinberg L, Kanaan RAA. Anaesthesia and the development of functional neurological disorder: A systematic review and case series. Gen Hosp Psychiatry 2022; 78:72-79. [PMID: 35930973 DOI: 10.1016/j.genhosppsych.2022.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE There are reports of functional neurological disorder (FND) developing after anaesthesia, though separating any aetiological role from other possible factors is challenging. We aimed to systematically review all published cases of post-anaesthetic FND to see if any common factors supported an anaesthetic role. We also aimed to identify all cases of post-anaesthetic FND arising in our FND clinic, to obtain an estimate of its frequency. METHODS For the review, a systematic search for published cases of FND developing within 48 h of anaesthesia was conducted in June 2022. For the case series, the medical records of all patients attending an FND clinic in Melbourne between 2017 and 2019 were examined, and all cases with FND within 48 h of anaesthesia extracted. RESULTS 36 published cases were identified for the review. Sixteen described preceding stressors and 16 psychiatric diagnoses, including 8 with previous FND. Thirty-two (92%) had undergone general anaesthesia, most commonly for obstetric procedures. Motor/sensory loss was the most common presentation, followed by seizures and coma. Most (80.5%) developed symptoms immediately on induction or cessation of anaesthesia. For the case series, 8 of 107 clinic patients (7.5%), developed FND within 48 h of anaesthesia. All had previous psychiatric diagnoses, including 3 with previous FND. Three underwent general anaesthesia and 3 procedural sedation, with seizures the most common presentation. All developed symptoms immediately on induction or cessation of anaesthesia. CONCLUSION These cases provide some support for an aetiological role for anaesthesia: there is evidence for an anaesthetic 'model' for the symptoms of FND that arise, they largely arise with the onset or termination of anaesthesia, and they arise most frequently during general anaesthesia or sedation.
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Affiliation(s)
- Daniela Huepe-Artigas
- Melbourne School of Psychological Sciences, University of Melbourne, VIC 3010, Australia.
| | | | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, Heidelberg, VIC 3084, Australia; The University of Melbourne, Department of Surgery, Austin Health, Heidelberg, VIC 3084, Australia.
| | - Richard A A Kanaan
- The University of Melbourne, Department of Psychiatry, Austin Health, Heidelberg, VIC 3084, Australia; The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC 3084, Australia.
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8
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Togioka BM, Schenning KJ. Optimizing Reversal of Neuromuscular Block in Older Adults: Sugammadex or Neostigmine. Drugs Aging 2022; 39:749-761. [PMID: 35934764 DOI: 10.1007/s40266-022-00969-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2022] [Indexed: 11/03/2022]
Abstract
Residual neuromuscular paralysis, the presence of clinically significant weakness after administration of pharmacologic neuromuscular blockade reversal, is associated with postoperative pulmonary complications and is more common in older patients. In contemporary anesthesia practice, reversal of neuromuscular blockade is accomplished with neostigmine or sugammadex. Neostigmine, an acetylcholinesterase inhibitor, increases the concentration of acetylcholine at the neuromuscular junction, providing competitive antagonism of neuromuscular blocking drug and facilitating muscle contraction. Sugammadex, a modified gamma-cyclodextrin, antagonizes neuromuscular blockade by encapsulating rocuronium and vecuronium in a one-to-one ratio for renal clearance, a pharmacokinetic property that led to the recommendation that sugammadex not be administered to those with end-stage renal disease. While data are limited, reports suggest sugammadex is efficacious and well tolerated in individuals with reduced renal function. Sugammadex provides a more rapid and complete reversal of neuromuscular blockade than neostigmine. There is also accumulating evidence that sugammadex may provide a protective effect against the development of postoperative pulmonary complications, nausea, and vomiting, and that it may have beneficial effects on the rate of bowel and bladder recovery after surgery. Accordingly, sugammadex administration is beneficial for most older patients undergoing surgery.
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Affiliation(s)
- Brandon M Togioka
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA. .,Department of Obstetrics and Gynecology, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Mail Code: UHN-2, Portland, OR, 97239-3098, USA.
| | - Katie J Schenning
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
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9
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Shrimpton AJ, Brown JM, Cook TM, Penfold CM, Reid JP, Pickering AE. Quantitative evaluation of aerosol generation from upper airway suctioning assessed during tracheal intubation and extubation sequences in anaesthetized patients. J Hosp Infect 2022; 124:13-21. [PMID: 35276282 PMCID: PMC9172909 DOI: 10.1016/j.jhin.2022.02.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/17/2022] [Accepted: 02/28/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Open respiratory suctioning is defined as an aerosol generating procedure (AGP). Laryngopharyngeal suctioning, used to clear secretions during anaesthesia, is widely managed as an AGP. However, it is uncertain whether upper airway suctioning should be designated as an AGP due to the lack of both aerosol and epidemiological evidence. AIM To assess the relative risk of aerosol generation by upper airway suctioning during tracheal intubation and extubation in anaesthetized patients. METHODS This prospective environmental monitoring study was undertaken in an ultraclean operating theatre setting to assay aerosol concentrations during intubation and extubation sequences, including upper airway suctioning, for patients undergoing surgery (N=19). An optical particle sizer (particle size 0.3-10 μm) sampled aerosol 20 cm above the patient's mouth. Baseline recordings (background, tidal breathing and volitional coughs) were followed by intravenous induction of anaesthesia with neuromuscular blockade. Four periods of laryngopharyngeal suctioning were performed with a Yankauer sucker: pre-laryngoscopy, post-intubation, pre-extubation and post-extubation. FINDINGS Aerosol was reliably detected {median 65 [interquartile range (IQR) 39-259] particles/L} above background [median 4.8 (IQR 1-7) particles/L, P<0.0001] when sampling in close proximity to the patient's mouth during tidal breathing. Upper airway suctioning was associated with a much lower average aerosol concentration than breathing [median 6.0 (IQR 0-12) particles/L, P=0.0007], and was indistinguishable from background (P>0.99). Peak aerosol concentrations recorded during suctioning [median 45 (IQR 30-75) particles/L] were much lower than during volitional coughs [median 1520 (IQR 600-4363) particles/L, P<0.0001] and tidal breathing [median 540 (IQR 300-1826) particles/L, P<0.0001]. CONCLUSION Upper airway suctioning during airway management was not associated with a higher aerosol concentration compared with background, and was associated with a much lower aerosol concentration compared with breathing and coughing. Upper airway suctioning should not be designated as a high-risk AGP.
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Affiliation(s)
- A J Shrimpton
- Anaesthesia, Pain and Critical Care, School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK.
| | - J M Brown
- Department of Anaesthesia and Intensive Care Medicine, North Bristol NHS Trust, Bristol, UK
| | - T M Cook
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital NHS Trust, Bath, UK
| | - C M Penfold
- Bristol Biomedical Research Centre, University of Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - J P Reid
- School of Chemistry, University of Bristol, Bristol, UK
| | - A E Pickering
- Anaesthesia, Pain and Critical Care, School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
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10
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Metodiev Y, Lucas D. The role of total intravenous anaesthesia for caesarean delivery. Int J Obstet Anesth 2022; 51:103548. [DOI: 10.1016/j.ijoa.2022.103548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/23/2022] [Accepted: 04/04/2022] [Indexed: 11/27/2022]
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11
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Cumberworth A, Lewith H, Sud A, Jefferson H, Athanassoglou V, Pandit JJ. Major complications of airway management: a prospective multicentre observational study. Anaesthesia 2022; 77:640-648. [PMID: 35254669 DOI: 10.1111/anae.15668] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2021] [Indexed: 12/12/2022]
Abstract
We conducted an observational study of serious airway complications, using similar methods to the fourth UK National Audit Project (NAP4) over a period of 1 year across four hospitals in one region in the UK. We also conducted an activity survey over a week, using NAP4 methods to yield an estimate for relevant denominators to help interpret the primary data. There were 17 serious airway complications, defined as: failed airway management leading to cancellation of surgery (eight); airway management in recovery (five); unplanned intensive care admission (three); and unplanned emergency front of neck access (one). There were no reports of death or brain damage. This was an estimate of 0.028% (1 in 3600) complications using the denominator of 61,000 general anaesthetics per year in the region. Complications in patients with 'predicted easy' airways were rare (approximately 1 in 14,200), but 45 times more common in those with 'predicted difficult' airways (approximately 1 in 315). Airway management in both groups was similar (induction of anaesthesia followed by supraglottic airway or tracheal tube). Use of awake/sedation intubation, videolaryngoscopy and high-flow nasal oxygenation were uncommon even in the predicted difficult airway patients (in 2.7%, 32.4% and 9.5% of patients, respectively). We conclude that the incidence of serious airway complications is at least as high as it was during NAP4. Despite airway prediction being used, this is not informing subsequent management.
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Affiliation(s)
- A Cumberworth
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - H Lewith
- Department of Anaesthetics, Kingston Hospital NHS Foundation Trust, Kingston, UK
| | - A Sud
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - H Jefferson
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - V Athanassoglou
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,University of Oxford, Oxford, UK
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12
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Müller J, Plöchl W, Mühlbacher P, Graf A, Kramer AM, Podesser BK, Stimpfl T, Hamp T. Ethanol reduces the minimum alveolar concentration of sevoflurane in rats. Sci Rep 2022; 12:280. [PMID: 34997177 PMCID: PMC8741959 DOI: 10.1038/s41598-021-04364-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/17/2021] [Indexed: 11/30/2022] Open
Abstract
A high number of trauma patients are under the influence of alcohol. Since many of them need immediate surgical procedures, it is imperative to be aware of the interaction of alcohol with general anesthesia. To counter challenges that arise from clinical studies, we designed an animal experiment in which 48 adult Wistar rats either received 1 g · kg-1 ethanol, 2 g · kg-1 ethanol or placebo via intraperitoneal application. Subsequently, they were anesthetized with an individual concentration of sevoflurane. The minimum alveolar concentration (MAC) of the different groups was assessed using Dixon's up-and-down design and isotonic regression methods. The bootstrap estimate of the MAC of sevoflurane in the placebo group was 2.24 vol% (95% CI 1.97-2.94 vol%). In the low dose ethanol group, the bootstrap estimate was 1.65 vol% (95% CI 1.40-1.98 vol%), and in the high dose ethanol group, it was 1.08 vol% (95% CI 0.73-1.42 vol%). We therefore report that intraperitoneal application of 1 g · kg-1 or 2 g · kg-1 ethanol both resulted in a significant reduction of the MAC of sevoflurane in adult Wistar rats: by 26.3% and 51.8% respectively as compared to placebo.
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Affiliation(s)
- Johannes Müller
- Department of Anaesthesia, Intensive Care and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria.
| | - Walter Plöchl
- Department of Anaesthesia, Intensive Care and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Paul Mühlbacher
- Department of Anaesthesia, Intensive Care and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Alexandra Graf
- Institute for Medical Statistics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | | | - Bruno Karl Podesser
- Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Thomas Stimpfl
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Thomas Hamp
- Department of Anaesthesia, Intensive Care and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
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13
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Shrimpton AJ, Gregson FKA, Brown JM, Cook TM, Bzdek BR, Hamilton F, Reid JP, Pickering AE. A quantitative evaluation of aerosol generation during supraglottic airway insertion and removal. Anaesthesia 2021; 76:1577-1584. [PMID: 34287820 DOI: 10.1111/anae.15542] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2021] [Indexed: 12/30/2022]
Abstract
Many guidelines consider supraglottic airway use to be an aerosol-generating procedure. This status requires increased levels of personal protective equipment, fallow time between cases and results in reduced operating theatre efficiency. Aerosol generation has never been quantitated during supraglottic airway use. To address this evidence gap, we conducted real-time aerosol monitoring (0.3-10-µm diameter) in ultraclean operating theatres during supraglottic airway insertion and removal. This showed very low background particle concentrations (median (IQR [range]) 1.6 (0-3.1 [0-4.0]) particles.l-1 ) against which the patient's tidal breathing produced a higher concentration of aerosol (4.0 (1.3-11.0 [0-44]) particles.l-1 , p = 0.048). The average aerosol concentration detected during supraglottic airway insertion (1.3 (1.0-4.2 [0-6.2]) particles.l-1 , n = 11), and removal (2.1 (0-17.5 [0-26.2]) particles.l-1 , n = 12) was no different to tidal breathing (p = 0.31 and p = 0.84, respectively). Comparison of supraglottic airway insertion and removal with a volitional cough (104 (66-169 [33-326]), n = 27), demonstrated that supraglottic airway insertion/removal sequences produced <4% of the aerosol compared with a single cough (p < 0.001). A transient aerosol increase was recorded during one complicated supraglottic airway insertion (which initially failed to provide a patent airway). Detailed analysis of this event showed an atypical particle size distribution and we subsequently identified multiple sources of non-respiratory aerosols that may be produced during airway management and can be considered as artefacts. These findings demonstrate supraglottic airway insertion/removal generates no more bio-aerosol than breathing and far less than a cough. This should inform the design of infection prevention strategies for anaesthetists and operating theatre staff caring for patients managed with supraglottic airways.
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Affiliation(s)
- A J Shrimpton
- Pain and Critical Care Sciences and School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
| | - F K A Gregson
- School of Chemistry, University of Bristol, Bristol, UK
| | - J M Brown
- Department of Anaesthesia and Intensive Care Medicine, North Bristol NHS Trust, Bristol, UK
| | - T M Cook
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital NHS Trust, Bath, UK
| | - B R Bzdek
- School of Chemistry, University of Bristol, Bristol, UK
| | - F Hamilton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - J P Reid
- School of Chemistry, University of Bristol, Bristol, UK
| | - A E Pickering
- Pain and Critical Care Sciences and School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
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14
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Bratch R, Pandit JJ. An integrative review of method types used in the study of medication error during anaesthesia: implications for estimating incidence. Br J Anaesth 2021; 127:458-469. [PMID: 34243941 DOI: 10.1016/j.bja.2021.05.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 12/20/2022] Open
Abstract
To meet the WHO vision of reducing medication errors by 50%, it is essential to know the current error rate. We undertook an integrative review of the literature, using a systematic search strategy. We included studies that provided an estimate of error rate (i.e. both numerator and denominator data), regardless of type of study (e.g. RCT or observational study). Under each method type, we categorised the error rate by type, by classification used by the primary studies (e.g. wrong drug, wrong dose, wrong time), and then pooled numerator and denominator data across studies to obtain an aggregate error rate for each method type. We included a total of 30 studies in this review. Of these, two studies were national audit projects containing relevant data, and for 28 studies we identified five discrete method types: retrospective recall (6), self-reporting (7), observational (5), large databases (7), and observing for drug calculation errors (3). Of these 28 studies we included 22 for a numerical analysis and used six to inform a narrative review. Drug error is recalled by ~1 in 5 anaesthetists as something that happened over their career; in self-reports there is an admitted rate of ~1 in 200 anaesthetics. In observed practice, error is seen in almost every anaesthetic. In large databases, drug error constitutes ~10% of anaesthesia incidents reported. Wrong drug or dose form the most common type of error across all five study method types (especially dosing error in paediatric studies). We conclude that medication error is common in anaesthetic practice, although we were uncertain of the precise frequency or extent of harm. Studies concerning medication error are very heterogenous, and we recommend consideration of standardised reporting as in other research domains.
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Affiliation(s)
- Ravinder Bratch
- Pharmacy Department, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Jaideep J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals, Oxford, UK.
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15
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Kursumovic E, Cook TM, Vindrola-Padros C, Kane AD, Armstrong RA, Waite O, Soar J. The impact of COVID-19 on anaesthesia and critical care services in the UK: a serial service evaluation. Anaesthesia 2021; 76:1167-1175. [PMID: 34005837 PMCID: PMC8222939 DOI: 10.1111/anae.15512] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 12/02/2022]
Abstract
Between October 2020 and January 2021, we conducted three national surveys to track anaesthetic, surgical and critical care activity during the second COVID‐19 pandemic wave in the UK. We surveyed all NHS hospitals where surgery is undertaken. Response rates, by round, were 64%, 56% and 51%. Despite important regional variations, the surveys showed increasing systemic pressure on anaesthetic and peri‐operative services due to the need to support critical care pandemic demands. During Rounds 1 and 2, approximately one in eight anaesthetic staff were not available for anaesthetic work. Approximately one in five operating theatres were closed and activity fell in those that were open. Some mitigation was achieved by relocation of surgical activity to other locations. Approximately one‐quarter of all surgical activity was lost, with paediatric and non‐cancer surgery most impacted. During January 2021, the system was largely overwhelmed. Almost one‐third of anaesthesia staff were unavailable, 42% of operating theatres were closed, national surgical activity reduced to less than half, including reduced cancer and emergency surgery. Redeployed anaesthesia staff increased the critical care workforce by 125%. Three‐quarters of critical care units were so expanded that planned surgery could not be safely resumed. At all times, the greatest resource limitation was staff. Due to lower response rates from the most pressed regions and hospitals, these results may underestimate the true impact. These findings have important implications for understanding what has happened during the COVID‐19 pandemic, planning recovery and building a system that will better respond to future waves or new epidemics.
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Affiliation(s)
- E Kursumovic
- Department of Anaesthesia, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK.,Royal College of Anaesthetists, London, UK
| | - T M Cook
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath.,of Anaesthesia, University of Bristol, Bristol, UK
| | - C Vindrola-Padros
- Department of Targeted Intervention, University College London, London, UK.,NIAA Health Services Research Centre, Royal College of Anaesthetists, London, UK
| | - A D Kane
- Royal College of Anaesthetists, London, UK.,Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK
| | - R A Armstrong
- Royal College of Anaesthetists, London, UK.,Department of Anaesthesia, Severn Deanery, UK
| | - O Waite
- Health Services Research Centre, Royal College of Anaesthetists, London, UK
| | - J Soar
- Department of Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
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Cunningham A, McPolin O, Fallis R, Coyle C, Best P, McKenna G. A systematic review of the use of virtual reality or dental smartphone applications as interventions for management of paediatric dental anxiety. BMC Oral Health 2021; 21:244. [PMID: 33962624 PMCID: PMC8103574 DOI: 10.1186/s12903-021-01602-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 04/29/2021] [Indexed: 11/28/2022] Open
Abstract
Background Virtual reality (VR) has been used successfully in medicine both as a distraction tool during procedures, and as an acclimatisation tool to prepare for a procedure or experience. It has not yet become widely used in dentistry, but could theoretically have a role in exposure-based acclimatisation for dental experiences. Methods To examine the use of VR or bespoke dental smartphone applications pre- or perioperatively in dentistry, to decrease anxiety in a paediatric population attending for dental examination or treatment, compared with children/adolescents who receive no intervention, or more conventional behavioural management techniques. Searches were made of eight electronic databases: the Cochrane Oral Health Group’s Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE(PubMed), EMBASE, PsycINFO, CINAHL, Scopus and Web of Science. Further searches reference cross‐checks were performed to identify studies that were not discovered online. Results Systematic reviews and randomised control trials have demonstrated the successful use of VR to both distract patients perioperatively during medical procedures, and also preoperatively to prepare them for these interventions. However, to date, VR has only been applied to dentistry in a very limited number of studies. Three studies using virtual reality in a dental setting demonstrated decreased pain and anxiety compared with no intervention. All three of these studies were carried out in the perioperative period. A fourth study used a bespoke dental app and imagery to prepare patients with Autism Spectrum Disorder (ASD) for dental treatment, finding statistically significant decreases in both the number of appointments and number of attempts required to carry out a procedure. Conclusion VR is a promising tool which to date has been under-utilised in dentistry. High quality, clinical studies are required to assess the use of preoperative VR and smartphone applications to prepare patients for dental examination and procedures under local or general anaesthetic.
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Affiliation(s)
| | - Orlagh McPolin
- Centre for Dentistry, Queen's University Belfast, Belfast, UK
| | - Richard Fallis
- Queen's University Belfast Medical Library, Queen's University Belfast, Belfast, UK
| | - Catherine Coyle
- Centre for Dentistry, Queen's University Belfast, Belfast, UK
| | - Paul Best
- School of Social Sciences, Education and Social Work, Queen's University Belfast, Belfast, UK
| | - Gerald McKenna
- Centre for Public Health, Institute of Clinical Sciences Block B, Royal Victoria Hospital, Queen's University Belfast, Belfast, UK.
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The effect of oral Δ-9-tetrahydrocannabinol on the minimal alveolar concentration of sevoflurane: A randomised, controlled, observer-blinded experimental study. Eur J Anaesthesiol 2021; 38:58-63. [PMID: 32833854 DOI: 10.1097/eja.0000000000001295] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Cannabis has increasingly been used for medical and recreational purposes. The main pharmacological compound in cannabis is tetrahydrocannabinol (THC), which has sedative, anxiolytic and analgesic effects. In some animal models, THC has also been shown to reduce the minimum alveolar concentration (MAC) of halothane and cyclopropane, but its effect on sevoflurane, currently the most commonly used inhalational anaesthetic agent, has not been investigated. OBJECTIVE To investigate the effect of THC on the MAC of sevoflurane in rats. METHODS Observer-blinded, randomised controlled trial. SETTING Centre for Biomedical Research of the Medical University of Vienna, 2019. INDIVIDUALS Thirty-eight adult Wistar rats. INTERVENTIONS The rats were allocated randomly into one of two groups. Group A received THC 10 mg kg and group B received the corresponding volume of placebo via gastric gavage (administration through a tube placed in the distal oesophagus). The rats were then individually anaesthetised in an airtight sevoflurane-flooded chamber, and the MAC in both groups was determined using Dixon's up-and-down method. Blood samples were drawn to measure serum concentrations of THC. MAIN OUTCOME MEASURES The primary outcome was the MAC of sevoflurane in Groups A and B. RESULTS The bootstrap estimate of the MAC of sevoflurane was 2.1 (95% confidence interval 1.8 to 2.4) vol% in the THC group and 2.8 (95% confidence interval 2.7 to 2.9) vol% in the placebo group, corresponding to a significant MAC reduction of 26% in response to THC. CONCLUSION Gastric administration of THC 10 mg kg significantly reduced the MAC of sevoflurane by 26%. TRIAL REGISTRATION Not applicable.
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18
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Staben M, Raiten J, Lane-Fall M, Scott M. Development of an Anesthesiology Disaster Response Plan. Anesthesiol Clin 2021; 39:245-253. [PMID: 34024428 PMCID: PMC8053004 DOI: 10.1016/j.anclin.2021.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Mac Staben
- Department of Anesthesiology and Critical Care, Perelman School of Medicine of the University of Pennsylvania, 3400 Spruce Street, Dulles 6, Philadelphia, PA 19104, USA
| | - Jesse Raiten
- Department of Anesthesiology and Critical Care, Perelman School of Medicine of the University of Pennsylvania, 3400 Spruce Street, Dulles 6, Philadelphia, PA 19104, USA.
| | - Meghan Lane-Fall
- Department of Anesthesiology and Critical Care, Perelman School of Medicine of the University of Pennsylvania, 3400 Spruce Street, Dulles 6, Philadelphia, PA 19104, USA
| | - Michael Scott
- Department of Anesthesiology and Critical Care, Perelman School of Medicine of the University of Pennsylvania, 3400 Spruce Street, Dulles 6, Philadelphia, PA 19104, USA
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19
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Gaya da Costa M, Kalmar AF, Struys MMRF. Inhaled Anesthetics: Environmental Role, Occupational Risk, and Clinical Use. J Clin Med 2021; 10:1306. [PMID: 33810063 PMCID: PMC8004846 DOI: 10.3390/jcm10061306] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/14/2021] [Accepted: 03/18/2021] [Indexed: 12/17/2022] Open
Abstract
Inhaled anesthetics have been in clinical use for over 150 years and are still commonly used in daily practice. The initial view of inhaled anesthetics as indispensable for general anesthesia has evolved during the years and, currently, its general use has even been questioned. Beyond the traditional risks inherent to any drug in use, inhaled anesthetics are exceptionally strong greenhouse gases (GHG) and may pose considerable occupational risks. This emphasizes the importance of evaluating and considering its use in clinical practices. Despite the overwhelming scientific evidence of worsening climate changes, control measures are very slowly implemented. Therefore, it is the responsibility of all society sectors, including the health sector to maximally decrease GHG emissions where possible. Within the field of anesthesia, the potential to reduce GHG emissions can be briefly summarized as follows: Stop or avoid the use of nitrous oxide (N2O) and desflurane, consider the use of total intravenous or local-regional anesthesia, invest in the development of new technologies to minimize volatile anesthetics consumption, scavenging systems, and destruction of waste gas. The improved and sustained awareness of the medical community regarding the climate impact of inhaled anesthetics is mandatory to bring change in the current practice.
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Affiliation(s)
- Mariana Gaya da Costa
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, 9713GZ Groningen, The Netherlands;
| | - Alain F. Kalmar
- Department of Anesthesia and Intensive Care Medicine, Maria Middelares Hospital, 9000 Ghent, Belgium;
- Department of Basic and Applied Medical Sciences, Ghent University, 9000 Ghent, Belgium
| | - Michel M. R. F. Struys
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, 9713GZ Groningen, The Netherlands;
- Department of Basic and Applied Medical Sciences, Ghent University, 9000 Ghent, Belgium
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20
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Analysis of anaesthesia services to calculate national need and supply of anaesthetics in Switzerland during the COVID-19 pandemic. PLoS One 2021; 16:e0248997. [PMID: 33740018 PMCID: PMC7978279 DOI: 10.1371/journal.pone.0248997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/09/2021] [Indexed: 11/19/2022] Open
Abstract
Background In Switzerland, details of current anaesthesia practice are unknown. However, they are urgently needed to manage anaesthesia drug supply in times of drug shortages due to the pandemic. Methods We surveyed all Swiss anaesthesia institutions in April 2020 to determine their annual anaesthesia activity. Together with a detailed analysis on anaesthetic drug use of a large, representative Swiss anaesthesia index institution, calculations and projections for the annual need of anaesthetics in Switzerland were made. Only those drugs have been analysed that are either being used very frequently or that have been classified critical with regard to their supply by the pharmacy of the index institution or the Swiss Federal Office of Public Health. Results The response rate to our questionnaire was 98%. Out of the present 188 Swiss anaesthesia institutions, 185 responded. In Switzerland, the annual number of anaesthesias was 1’071’054 (12’445 per 100’000 inhabitants) with a mean anaesthesia time of 2.03 hours. Teaching hospitals (n = 54) performed more than half (n = 572’231) and non-teaching hospitals (n = 103) provided almost half of all anaesthesias (n = 412’531). Thereby, private hospitals conducted a total of 290’690 anaesthesias. Finally, office-based anaesthesia institutions with mainly outpatients (n = 31) administered 86’292 anaesthesias. Regarding type of anaesthesia provided, two thirds were general anaesthesias (42% total intravenous, 17% inhalation, 8% combined), 20% regional and 12% monitored anaesthesia care. Projecting for example the annual need for propofol in anaesthesia, Switzerland requires 48’573 L of propofol 1% which corresponds to 5’644 L propofol 1% per 100’000 inhabitants every year. Conclusions To actively manage anaesthesia drug supply in the context of the current pandemic, it is mandatory to have a detailed understanding of the number and types of anaesthesias provided. On this basis, the Swiss annual consumption of anaesthetics could be projected and the replenishment organized.
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21
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Shelton CL, Sutton R, White SM. Desflurane in modern anaesthetic practice: walking on thin ice(caps)? Br J Anaesth 2020; 125:852-856. [DOI: 10.1016/j.bja.2020.09.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 01/20/2023] Open
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22
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Awareness with Recall After Neuromuscular Blockade—Lessons on Anesthetic Awareness from the UK and Ireland National Audit Project 5 (NAP5). CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00426-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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23
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Odor PM, Bampoe S, Moonesinghe SR, Andrade J, Pandit JJ, Lucas DN. General anaesthetic and airway management practice for obstetric surgery in England: a prospective, multicentre observational study. Anaesthesia 2020; 76:460-471. [PMID: 32959372 DOI: 10.1111/anae.15250] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2020] [Indexed: 02/06/2023]
Abstract
There are no current descriptions of general anaesthesia characteristics for obstetric surgery, despite recent changes to patient baseline characteristics and airway management guidelines. This analysis of data from the direct reporting of awareness in maternity patients' (DREAMY) study of accidental awareness during obstetric anaesthesia aimed to describe practice for obstetric general anaesthesia in England and compare with earlier surveys and best-practice recommendations. Consenting patients who received general anaesthesia for obstetric surgery in 72 hospitals from May 2017 to August 2018 were included. Baseline characteristics, airway management, anaesthetic techniques and major complications were collected. Descriptive analysis, binary logistic regression modelling and comparisons with earlier data were conducted. Data were collected from 3117 procedures, including 2554 (81.9%) caesarean deliveries. Thiopental was the induction drug in 1649 (52.9%) patients, compared with propofol in 1419 (45.5%). Suxamethonium was the neuromuscular blocking drug for tracheal intubation in 2631 (86.1%), compared with rocuronium in 367 (11.8%). Difficult tracheal intubation was reported in 1 in 19 (95%CI 1 in 16-22) and failed intubation in 1 in 312 (95%CI 1 in 169-667). Obese patients were over-represented compared with national baselines and associated with difficult, but not failed intubation. There was more evidence of change in practice for induction drugs (increased use of propofol) than neuromuscular blocking drugs (suxamethonium remains the most popular). There was evidence of improvement in practice, with increased monitoring and reversal of neuromuscular blockade (although this remains suboptimal). Despite a high risk of difficult intubation in this population, videolaryngoscopy was rarely used (1.9%).
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Affiliation(s)
- P M Odor
- Centre for Peri-operative Medicine, Research Department for Targeted Intervention, University College London Hospital, London, UK
| | - S Bampoe
- Centre for Peri-operative Medicine, Research Department for Targeted Intervention, University College London Hospital, London, UK
| | - S R Moonesinghe
- Centre for Peri-operative Medicine, Research Department for Targeted Intervention, University College London Hospital, London, UK
| | - J Andrade
- School of Psychology, University of Plymouth, Plymouth, UK
| | - J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Trust, Oxford, UK
| | - D N Lucas
- Department of Anaesthesia, Northwick Park Hospital, London, UK
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24
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Hewson DW, Hardman JG, Bedforth NM. Patient-maintained propofol sedation for adult patients undergoing surgical or medical procedures: a scoping review of current evidence and technology. Br J Anaesth 2020; 126:139-148. [PMID: 32917377 PMCID: PMC7844373 DOI: 10.1016/j.bja.2020.07.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/04/2020] [Accepted: 07/03/2020] [Indexed: 11/28/2022] Open
Abstract
Patient-maintained propofol sedation (PMPS) is the delivery of procedural propofol sedation by target-controlled infusion with the patient exerting an element of control over their target-site propofol concentration. This scoping review aims to establish the extent and nature of current knowledge regarding PMPS from both a clinical and technological perspective, thereby identifying knowledge gaps to guide future research. We searched MEDLINE, EMBASE, and OpenGrey databases, identifying 17 clinical studies for analysis. PMPS is described in the context of healthy volunteers and in orthopaedic, general surgical, dental, and endoscopic clinical settings. All studies used modifications to existing commercially-available infusion devices to achieve prototype systems capable of PMPS. The current literature precludes rigorous generalisable conclusions regarding the safety or comparative clinical effectiveness of PMPS, however cautious acknowledgement of efficacy in specific clinical settings is appropriate. Based on the existing literature, together with new standardised outcome reporting recommendations for sedation research and frameworks designed to assess novel health technologies research, we have made recommendations for future pharmacological, clinical, behavioural, and health economic research on PMPS. We conclude that high-quality experimental clinical trials with relevant comparator groups assessing the impact of PMPS on standardised patient-orientated outcome measures are urgently required.
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Affiliation(s)
- David W Hewson
- Department of Anaesthesia and Critical Care Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | - Jonathan G Hardman
- Department of Anaesthesia and Critical Care Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nigel M Bedforth
- Department of Anaesthesia and Critical Care Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Ratnayake G, El-Boghdadly K, Pandit JJ. An analysis of the academic capacity of anaesthesia in the UK by publication trends and academic units. Anaesthesia 2020; 76:500-513. [PMID: 32888196 DOI: 10.1111/anae.15247] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2020] [Indexed: 12/12/2022]
Abstract
Over a decade ago, bibliometric analysis predicted the disappearance of UK publishing in anaesthesia by 2020. We repeated this analysis to assess if this had turned out to be the case, searching PubMed for papers associated with UK consultant anaesthetists for 2017-2019 across 15 journals. Although the rate of decline has flattened using the same search filter, including a wider range of publication types shows that outputs still remain at half 1990s levels (381 papers for all 3 years combined), authored by 769 anaesthetists, 274 of whom are associated with an academic centre. There are now 11 identifiable academic units, and a further 15 places where anaesthetists have affiliations with academic centres as individuals. The majority of papers (71%) are in secondary analysis (observational, database and association studies, surveys and meta-analyses), rather than in primary research (clinical trials or laboratory studies). These data reflect the current academic capacity in terms of publications, academic units and staffing. We discuss how this information can be used to inform a new strategy for UK academic anaesthesia.
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Affiliation(s)
- G Ratnayake
- Department of Anaesthesia and Peri-operative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - K El-Boghdadly
- Department of Anaesthesia and Peri-operative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London
| | - J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Early Childhood General Anesthesia and Neurodevelopmental Outcomes in the Avon Longitudinal Study of Parents and Children Birth Cohort. Anesthesiology 2020; 133:1007-1020. [DOI: 10.1097/aln.0000000000003522] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background
Most common anesthetic agents have been implicated in causing neurodegeneration in the developing animal brain, leading to warnings regarding their use in children. The hypothesis of this study was that exposure to general anesthesia and surgery before 4 yr would associate with adverse neurodevelopmental outcomes at age 7 to 16 yr.
Methods
This cohort study comprised 13,433 children enrolled in the Avon Longitudinal Study of Parents and Children, a prospective, population-based birth cohort born between 1991 and 1993 in southwest England. Children were grouped by none, single, or multiple exposures to general anesthesia and surgery by 4 yr. Motor, cognitive, linguistic, educational, social, and behavioral developmental outcomes were evaluated at 7 to 16 yr using school examination results, validated parent/teacher questionnaires, or clinic assessments. Continuous outcomes were z-scored. P-value thresholds were corrected using false discovery rate procedures.
Results
This study compared 46 neurodevelopmental outcomes in 13,433 children: 8.3% (1,110) exposed singly and 1.6% (212) exposed multiply to general anesthesia and surgery. Of these, the following reached predefined levels of statistical significance (corrected P < 0.00652): dynamic balance scores were 0.3 SD (95% CI, 0.1, 0.5; P < 0.001) lower in multiply exposed children; manual dexterity performance was 0.1 SD (95% CI, 0.0, 0.2; P = 0.006) lower in singly and 0.3 SD (95% CI, 0.1, 0.4; P < 0.001) lower in multiply exposed children; and social communication scores were 0.1 SD (95% CI, 0.0, 0.2; P = 0.001) and 0.4 SD (95% CI, 0.3, 0.5; P < 0.001) lower in singly and multiply exposed children, respectively. General anesthesia and surgery were not associated with impairments in the remaining neurodevelopmental measures including: general cognitive ability; attention; working memory; reading, spelling, verbal comprehension and expression; behavioral difficulties; or national English, mathematics, and science assessments (all ≤0.1 SD; corrected P ≥ 0.00652).
Conclusions
Early childhood general anesthesia and surgery were not associated with a global picture of clinically and statistically significant neurodegenerative effects, providing reassurance about the neurotoxic potential of general anesthesia. Exposure to anesthesia and surgery was associated with significantly lower motor and social linguistic performance.
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
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27
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White SM, Shelton CL. Abandoning inhalational anaesthesia: a reply. Anaesthesia 2020; 75:1258-1259. [DOI: 10.1111/anae.15148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2020] [Indexed: 11/28/2022]
Affiliation(s)
- S. M. White
- Brighton and Sussex University Hospitals NHS Trust Brighton UK
| | - C. L. Shelton
- Manchester University NHS Foundation Trust Manchester UK
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Dixon T, Bhatia K, Columb M. The SARS-CoV-2 effect: an opportunity to reduce general anaesthesia rates for Caesarean section? Br J Anaesth 2020; 125:e324-e326. [PMID: 32624184 PMCID: PMC7303628 DOI: 10.1016/j.bja.2020.06.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 01/13/2023] Open
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Competitive Interactions between Halothane and Isoflurane at the Carotid Body and TASK Channels. Anesthesiology 2020; 133:1046-1059. [DOI: 10.1097/aln.0000000000003520] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background
The degree to which different volatile anesthetics depress carotid body hypoxic response relates to their ability to activate TASK potassium channels. Most commonly, volatile anesthetic pairs act additively at their molecular targets. We examined whether this applied to carotid body TASK channels.
Methods
We studied halothane and isoflurane effects on hypoxia-evoked rise in intracellular calcium (Ca2+i, using the indicator Indo-1) in isolated neonatal rat glomus cells, and TASK single-channel activity (patch clamping) in native glomus cells and HEK293 cell line cells transiently expressing TASK-1.
Results
Halothane (5%) depressed glomus cell Ca2+i hypoxic response (mean ± SD, 94 ± 4% depression; P < 0.001 vs. control). Isoflurane (5%) had a less pronounced effect (53 ± 10% depression; P < 0.001 vs. halothane). A mix of 3% isoflurane/1.5% halothane depressed cell Ca2+i response (51 ± 17% depression) to a lesser degree than 1.5% halothane alone (79 ± 15%; P = 0.001), but similar to 3% isoflurane alone (44 ± 22%; P = 0.224), indicating subadditivity. Halothane and isoflurane increased glomus cell TASK-1/TASK-3 activity, but mixes had a lesser effect than that seen with halothane alone: 4% halothane/4% isoflurane yielded channel open probabilities 127 ± 55% above control, versus 226 ± 12% for 4% halothane alone (P = 0.009). Finally, in HEK293 cell line cells, progressively adding isoflurane (1.5 to 5%) to halothane (2.5%) reduced TASK-1 channel activity from 120 ± 38% above control, to 88 ± 48% (P = 0.034).
Conclusions
In all three experimental models, the effects of isoflurane and halothane combinations were quantitatively consistent with the modeling of weak and strong agonists competing at a common receptor on the TASK channel.
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
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30
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Protocol for direct reporting of awareness in maternity patients (DREAMY): a prospective, multicentre cohort study of accidental awareness during general anaesthesia. Int J Obstet Anesth 2020; 42:47-56. [DOI: 10.1016/j.ijoa.2020.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 01/29/2020] [Accepted: 02/09/2020] [Indexed: 11/18/2022]
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McGuire B, Lucas DN. Planning the obstetric airway. Anaesthesia 2020; 75:852-855. [DOI: 10.1111/anae.14987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2019] [Indexed: 12/16/2022]
Affiliation(s)
- B. McGuire
- Department of Anaesthesia Ninewells Hospital Dundee UK
| | - D. N. Lucas
- Department of Anaesthesia Northwick Park Hospital Middlesex UK
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32
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Davies A, Corbett L, Kelly FE, Cook TM. An audit of intravenous access visibility and bispectral (BIS) use during total intravenous anaesthesia. Are we compliant with guidelines? Anaesthesia 2020; 75:411-412. [DOI: 10.1111/anae.14954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A. Davies
- Royal United Hospitals Bath NHS Foundation Trust Bath UK
| | - L. Corbett
- Royal United Hospitals Bath NHS Foundation Trust Bath UK
| | - F. E. Kelly
- Royal United Hospitals Bath NHS Foundation Trust Bath UK
| | - T. M. Cook
- Royal United Hospitals Bath NHS Foundation Trust Bath UK
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Claridge H, Williams BD, Copeland CS. A deadly trend in fentanyl fatalities (England, 1998-2017). Br J Clin Pharmacol 2020; 86:437-444. [PMID: 31663152 DOI: 10.1111/bcp.14135] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/22/2019] [Accepted: 08/29/2019] [Indexed: 02/06/2023] Open
Abstract
AIM To identify trends in drug-related deaths associated with fentanyl and its derivatives, including novel variants, in England, 1998-2017. METHODS Case reports from the National Programme on Substance Abuse Deaths (NPSAD) where a pharmaceutical fentanyl or non-pharmaceutical fentanyl derivative (NPFD) was found at post-mortem and/or implicated in the death were extracted for analysis. RESULTS NPSAD has received case reports detailing 298 deaths in England from 1998-2017 where a fentanyl was found at post-mortem and/or implicated in the death. Hospital administered fentanyl is "very safe", whereas pharmaceutical fentanyls in the community, procured either legitimately via prescription or illegitimately, carry high risk of unintentional death. Deaths involving NPFDs, which possess extreme potencies in comparison to morphine, have drastically risen over the past three years, and correlate with an increasing number of available compounds. Males, and those with existing opioid abuse disorders, are particularly susceptible to death related to NPFD intake. CONCLUSIONS The increasing availability of both pharmaceutical fentanyls and NPFDs represents a serious risk to public health. Unintentional misuse of these compounds in England is contributing to the exponential increase in fentanyl-associated deaths that is being observed at the global scale.
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Affiliation(s)
- Hugh Claridge
- Population Health Research Institute, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Bryn D Williams
- Anaesthetics Department, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
| | - Caroline S Copeland
- Population Health Research Institute, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK
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Walkden GJ, Pickering AE, Gill H. Assessing Long-term Neurodevelopmental Outcome Following General Anesthesia in Early Childhood: Challenges and Opportunities. Anesth Analg 2019; 128:681-694. [PMID: 30883414 PMCID: PMC6436726 DOI: 10.1213/ane.0000000000004052] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neurodegeneration has been reported in young animals after exposure to all commonly used general anesthetic agents. The brain may be particularly vulnerable to anesthetic toxicity during peak synaptogenesis (in gestation and infancy). Human studies of long-term neurodevelopmental outcome following general anesthesia in early childhood report contradictory findings. This review assesses the strengths and deficiencies in human research methodologies to inform future studies. We identified 76 studies, published between 1990 and 2017, of long-term neurodevelopmental outcome following early childhood or in utero general anesthesia exposure: 49 retrospective, 9 ambidirectional, 17 prospective cohort studies, and 1 randomized controlled trial. Forty-nine studies were explicitly concerned with anesthetic-induced neurotoxicity. Full texts were appraised for methodological challenges and possible solutions. Major challenges identified included delineating effects of anesthesia from surgery, defining the timing and duration of exposure, selection of a surgical cohort and intervention, addressing multiple confounding life course factors, detecting modest neurotoxic effects with small sample sizes (median, 131 children; interquartile range, 50–372), selection of sensitive neurodevelopmental outcomes at appropriate ages for different developmental domains, insufficient length of follow-up (median age, 6 years; interquartile range, 2–12 years), and sample attrition. We discuss potential solutions to these challenges. Further adequately powered, multicenter, prospective randomized controlled trials of anesthetic-induced neurotoxicity in children are required. However, we believe that the inherent methodological challenges of studying anesthetic-induced neurotoxicity necessitate the parallel use of well-designed observational cohort studies.
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Affiliation(s)
- Graham J Walkden
- From the School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom.,Bristol Anaesthesia, Pain and Critical Care Sciences, Translational Health Sciences, Bristol Medical School, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Anthony E Pickering
- From the School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom.,Bristol Anaesthesia, Pain and Critical Care Sciences, Translational Health Sciences, Bristol Medical School, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Hannah Gill
- From the School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom.,Bristol Anaesthesia, Pain and Critical Care Sciences, Translational Health Sciences, Bristol Medical School, Bristol Royal Infirmary, Bristol, United Kingdom.,Department of Paediatric Anaesthesia, Bristol Royal Hospital for Children, Bristol, United Kingdom
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35
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What’s in a number? Communicating risk through real-world examples. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2019.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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36
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Pandit JJ, Odor PM. Author's reply: the 5th National Audit Project Handbook and the realities of the dynamic phases of (dys)anaesthesia and
EEG
limitations. Anaesthesia 2019; 74:1333-1334. [DOI: 10.1111/anae.14801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J. J. Pandit
- Oxford University Hospitals NHS Foundation Trust OxfordUK
| | - P. M. Odor
- University College London Hospital London UK
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37
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Raju M, Pandit JJ. Re-awakening the carotid bodies after anaesthesia: managing hypnotic and neuromuscular blocking agents. Anaesthesia 2019; 75:301-304. [PMID: 31421004 DOI: 10.1111/anae.14789] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2019] [Indexed: 12/11/2022]
Affiliation(s)
- M Raju
- Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - J J Pandit
- Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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38
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Berwick RJ, Gauntlett W, Silverio SA, Wallace H, Mercer S, Brown JM, Sandars JE, Morton B, Groom P. A mixed-methods pilot study to evaluate a collaborative anaesthetic and surgical training package for emergency surgical cricothyroidotomy. Anaesth Intensive Care 2019; 47:357-367. [DOI: 10.1177/0310057x19861978] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In a ‘can’t intubate, can’t oxygenate’ scenario, success of emergency front-of-neck access is dependent upon a clinician’s skill, competence and confidence to initiate the procedure. Surgical cricothyroidotomy is an important airway skill, as it can be employed as both the primary method of emergency front-of-neck access or as a rescue approach if a needle technique should fail. We designed a collaborative surgical and anaesthetic training package to address perceived anaesthetic reluctance to perform surgical cricothyroidotomy and undertook a pilot study of the package using a mixed-methods approach. The package consisted of three elements: theory teaching, surgical experience and repeated high-fidelity simulation. Ten anaesthetic trainees were trained using the package. Training comprised face-to-face tuition on the 2015 Difficult Airway Society guidelines, the Vortex cognitive aid, manikin-based surgical cricothyroidotomy instruction and surgical experience gained from an elective surgical tracheostomy. A standardised, high-fidelity in situ ‘can’t intubate, can’t oxygenate’ simulation was used to assess performance at baseline and at two weeks and six months after training. Participants scored their self-efficacy, underwent qualitative semi-structured interviews and had their performance quantitatively assessed to evaluate this training. Six months following training, participants’ performance had improved. They reported significantly increased self-efficacy and demonstrated significantly reduced deliberation time to initiate surgical cricothyroidotomy in the simulated ‘can’t intubate, can’t oxygenate’ emergency. Thematic framework analysis of interview transcripts revealed that reluctance to perform surgical cricothyroidotomy was related to fear and anxiety in regard to performing the procedure. These results support wider adoption of collaborative educational training packages, including hands-on surgical teaching, to improve trainees’ efficacy and confidence with surgical cricothyroidotomy and front-of-neck access in an emergency ‘can’t intubate, can’t oxygenate’ scenario.
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Affiliation(s)
| | | | - Sergio A Silverio
- Department of Reproductive Health, Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Hilary Wallace
- Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Simon Mercer
- Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Jeremy M Brown
- Postgraduate Medical Institute, Faculty of Health and Social Care, Edge Hill University, Ormskirk, UK
| | - John E Sandars
- Postgraduate Medical Institute, Faculty of Health and Social Care, Edge Hill University, Ormskirk, UK
| | - Ben Morton
- Aintree University Hospital NHS Foundation Trust, Liverpool, UK
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Peter Groom
- Aintree University Hospital NHS Foundation Trust, Liverpool, UK
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39
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Sprinks J, Worcester F, Breedon P, Watts P, Hewson D, Bedforth N. A Prototype Patient-Maintained Propofol Sedation System Using Target Controlled Infusion for Primary Lower-Limb Arthroplasty. J Med Syst 2019; 43:247. [PMID: 31243603 PMCID: PMC6594991 DOI: 10.1007/s10916-019-1377-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 06/05/2019] [Indexed: 11/24/2022]
Abstract
Each year, many operations in the UK are performed with the patient awake, without the use of general anaesthesia. These include joint replacement procedures, and in order to reduce patient anxiety, the supervising anaesthetist delivers the sedative propofol intravenously using a target-controlled infusion (TCI) device. However, it is clinically challenging to judge the required effect-site concentration of sedative for an individual patient, resulting in patient care issues related to over or under-sedation. To improve the process, patient-maintained propofol sedation (PMPS), where the patient can request an increase in concentration through a hand-held button, has been considered as an alternative. However, due to the proprietary nature of modern TCI pumps, the majority of PMPS research has been conducted using prototypes in research studies. In this work, a PMPS system is presented that effectively converts a standard infusion pump into a TCI device using a laptop with TCI software. Functionally, the system delivers sedation analogous to a modern TCI pump, with the differences in propofol consumption and dosage within the tolerance of clinically approved devices. Therefore, the Medicines and Healthcare products Regulatory Agency (MHRA) has approved the system as a safe alternative to anaesthetist-controlled TCI procedures. It represents a step forward in the consideration of PMPS as a sedation method as viable alternative, allowing further assessment in clinical trials.
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Affiliation(s)
- James Sprinks
- Medical Engineering Design Research Group, Nottingham Trent University, Nottingham, UK
| | - Frank Worcester
- Medical Engineering Design Research Group, Nottingham Trent University, Nottingham, UK
| | - Philip Breedon
- Medical Engineering Design Research Group, Nottingham Trent University, Nottingham, UK.
| | - Paul Watts
- Medical Engineering Design Research Group, Nottingham Trent University, Nottingham, UK
| | - David Hewson
- Department of Anaesthesia and Critical Care, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nigel Bedforth
- Department of Anaesthesia and Critical Care, Nottingham University Hospitals NHS Trust, Nottingham, UK
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40
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Engel D, Furrer MA, Wuethrich PY, Löffel LM. Surgical safety in radical cystectomy: the anesthetist's point of view-how to make a safe procedure safer. World J Urol 2019; 38:1359-1368. [PMID: 31201522 DOI: 10.1007/s00345-019-02839-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 06/03/2019] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The aim of this review is to present an anesthesiological overview on surgical safety for radical cystectomy implementing the cornerstones of today's rapidly evolving field of perioperative medicine. METHODS This is a narrative review of current perioperative medicine and surgical safety concepts for major surgery in general with special focus on radical cystectomy. RESULTS The tendency for perioperative care and surgical safety is to consider it a continuous proactive pathway rather than a single surgical intervention. It starts at indication for surgery and lasts until full functional recovery. Preoperative optimization leads to superior outcome by mobilizing and/or increasing physiological reserve. Multidisciplinary teamwork involving all the relevant parties from the beginning of the pathway is crucial for outcome rather than an isolated specialist approach. This fact has gained importance in times of an ageing frail population and rising health care cost. We also present our 2019 Cystectomy Enhanced Recovery Approach for optimization of perioperative care for open radical cystectomy in a high caseload center. CONCLUSIONS With the implementation of in itself simple but crucial steps in perioperative medicine such as multimodal prehabilitation, safety checks, better perioperative monitoring and enhanced recovery concepts, even complex surgical procedures such as radical cystectomy can be performed safer. Emphasis has to be laid on a more global view of the patients' path through the perioperative process than on the surgical procedure alone.
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Affiliation(s)
- Dominique Engel
- Department of Anaesthesiology and Pain Medicine, Inselspital, University Hospital Bern, CH 3010, Bern, Switzerland
| | - Marc A Furrer
- Department of Urology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Patrick Y Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, University Hospital Bern, CH 3010, Bern, Switzerland
| | - Lukas M Löffel
- Department of Anaesthesiology and Pain Medicine, Inselspital, University Hospital Bern, CH 3010, Bern, Switzerland.
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41
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Frequency, variation and cost of dental extractions for adults in secondary care in Great Britain. Br Dent J 2019; 226:679-686. [DOI: 10.1038/s41415-019-0262-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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42
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Shelley BG, McCall PJ, Glass A, Orzechowska I, Klein AA. Association between anaesthetic technique and unplanned admission to intensive care after thoracic lung resection surgery: the second Association of Cardiothoracic Anaesthesia and Critical Care (ACTACC) National Audit. Anaesthesia 2019; 74:1121-1129. [PMID: 30963555 DOI: 10.1111/anae.14649] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2019] [Indexed: 12/19/2022]
Abstract
Unplanned intensive care admission is a devastating complication of lung resection and is associated with significantly increased mortality. We carried out a two-year retrospective national multicentre cohort study to investigate the influence of anaesthetic and analgesic technique on the need for unplanned postoperative intensive care admission. All patients undergoing lung resection surgery in 16 thoracic surgical centres in the UK in the calendar years 2013 and 2014 were included. We defined critical care admission as the unplanned need for either tracheal intubation and mechanical ventilation or renal replacement therapy, and sought an association between mode of anaesthesia (total intravenous anaesthesia vs. volatile) and analgesic technique (epidural vs. paravertebral) and need for intensive care admission. A total of 253 out of 11,208 patients undergoing lung resection in the study period had an unplanned admission to intensive care in the postoperative period, giving an incidence of intensive care unit admission of 2.3% (95%CI 2.0-2.6%). Patients who had an unplanned admission to intensive care unit had a higher mortality (29.00% vs. 0.03%, p < 0.001), and hospital length of stay was increased (26 vs. 6 days, p < 0.001). Across univariate, complete case and multiple imputation (multivariate) models, there was a strong and significant effect of both anaesthetic and analgesic technique on the need for intensive care admission. Patients receiving total intravenous anaesthesia (OR 0.50 (95%CI 0.34-0.70)), and patients receiving epidural analgesia (OR 0.56 (95%CI 0.41-0.78)) were less likely to have an unplanned admission to intensive care after thoracic surgery. This large retrospective study suggests a significant effect of both anaesthetic and analgesic technique on outcome in patients undergoing lung resection. We must emphasise that the observed association does not directly imply causation, and suggest that well-conducted, large-scale randomised controlled trials are required to address these fundamental questions.
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Affiliation(s)
- B G Shelley
- University of Glasgow Academic Unit of Anaesthesia, Pain and Critical Care Medicine, Glasgow, UK
| | - P J McCall
- University of Glasgow Academic Unit of Anaesthesia, Pain and Critical Care Medicine, Glasgow, UK
| | - A Glass
- University of Glasgow Academic Unit of Anaesthesia, Pain and Critical Care Medicine, Glasgow, UK
| | - I Orzechowska
- London School of Hygiene and Tropical Medicine, London, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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Özelsel TJP, Sondekoppam RV, Ip VHY, Tsui BCH. Re-defining the 3R’s (reduce, refine, and replace) of sustainability to minimize the environmental impact of inhalational anesthetic agents. Can J Anaesth 2018; 66:249-254. [DOI: 10.1007/s12630-018-01279-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 09/18/2018] [Accepted: 09/25/2018] [Indexed: 10/27/2022] Open
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Anesthesia Quality Improvement on Both Sides of the Atlantic. Int Anesthesiol Clin 2018; 57:131-143. [PMID: 30520753 DOI: 10.1097/aia.0000000000000211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hamp T, Baron-Stefaniak J, Krammel M, Reiter B, Langauer A, Stimpfl T, Plöchl W. Effect of intravenous S-ketamine on the MAC of sevoflurane: a randomised, placebo-controlled, double-blinded clinical trial. Br J Anaesth 2018; 121:1242-1248. [DOI: 10.1016/j.bja.2018.08.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 08/02/2018] [Accepted: 08/28/2018] [Indexed: 11/24/2022] Open
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Tasbihgou SR, Vogels MF, Absalom AR. Accidental awareness during general anaesthesia - a narrative review. Anaesthesia 2018; 73:112-122. [PMID: 29210043 DOI: 10.1111/anae.14124] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2017] [Indexed: 11/30/2022]
Abstract
Unintended accidental awareness during general anaesthesia represents failure of successful anaesthesia, and so has been the subject of numerous studies during the past decades. As return to consciousness is both difficult to describe and identify, the reported incidence rates vary widely. Similarly, a wide range of techniques have been employed to identify cases of accidental awareness. Studies which have used the isolated forearm technique to identify responsiveness to command during intended anaesthesia have shown remarkably high incidences of awareness. For example, the ConsCIOUS-1 study showed an incidence of responsiveness around the time of laryngoscopy of 1:25. On the other hand, the 5th Royal College of Anaesthetists National Audit Project, which reported the largest ever cohort of patients who had experienced accidental awareness, used a system to identify patients who spontaneously self-reported accidental awareness. In this latter study, the incidence of accidental awareness was 1:19,600. In the recently published SNAP-1 observational study, in which structured postoperative interviews were performed, the incidence was 1:800. In almost all reported cases of intra-operative responsiveness, there was no subsequent explicit recall of intra-operative events. To date, there is no evidence that this occurrence has any psychological consequences. Among patients who experience accidental awareness and can later remember details of their experience, the consequences are better known. In particular, when awareness occurs in a patient who has been given neuromuscular blocking agents, it may result in serious sequelae such as symptoms of post-traumatic stress disorder and a permanent aversion to surgery and anaesthesia, and is feared by patients and anaesthetists. In this article, the published literature on the incidence, consequences and management of accidental awareness under general anaesthesia with subsequent recall will be reviewed.
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Affiliation(s)
- S R Tasbihgou
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, the Netherlands
| | - M F Vogels
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, the Netherlands
| | - A R Absalom
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, the Netherlands
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Walker EMK, Bell M, Cook TM, Grocott MPW, Moonesinghe SR. Patient reported outcome of adult perioperative anaesthesia in the United Kingdom: a cross-sectional observational study. Br J Anaesth 2018; 117:758-766. [PMID: 27956674 DOI: 10.1093/bja/aew381] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Understanding the patient perspective on healthcare is central to the evaluation of quality. This study measured selected patient-reported outcomes after anaesthesia in order to identify targets for research and quality improvement. METHODS This cross-sectional observational study in UK National Health Service hospitals, recruited adults undergoing non-obstetric surgery requiring anaesthesia care over a 48 h period. Within 24 h of surgery, patients completed the Bauer questionnaire (measuring postoperative discomfort and satisfaction with anaesthesia care), and a modified Brice questionnaire to elicit symptoms suggestive of accidental awareness during general anaesthesia (AAGA). Patient, procedural and pharmacological data were recorded to enable exploration of risk factors for these poor outcomes. RESULTS 257 hospitals in 171 NHS Trusts participated (97% of eligible organisations). Baseline characteristics were collected on 16,222 patients; 15,040 (93%) completed postoperative questionnaires. Anxiety was most frequently cited as the worst aspect of the perioperative experience. Thirty-five per cent of patients reported severe discomfort in at least one domain: thirst (18.5%; 95% CI 17.8-19.1), surgical pain (11.0%; 10.5-11.5) and drowsiness (10.1%; 9.6-10.5) were most common. Despite this, only 5% reported dissatisfaction with any aspect of anaesthesia-related care. Regional anaesthesia was associated with a reduced burden of side-effects. The incidence of reported AAGA was one in 800 general anaesthetics (0.12%) CONCLUSIONS Anxiety and discomfort after surgery are common; despite this, satisfaction with anaesthesia care in the UK is high. The inconsistent relationship between patient-reported outcome, patient experience and patient satisfaction supports using all three of these domains to provide a comprehensive assessment of the quality of anaesthesia care.
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Affiliation(s)
- E M K Walker
- National Institute of Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, London, WC1R 4SG, UK
| | - M Bell
- Royal College of Anaesthetists, London, WC1R 4SG, UK
| | - T M Cook
- Royal United Hospital NHS Foundation Trust Bath, BA1 3NG, UK
| | - M P W Grocott
- Faculty of Medicine, University of Southampton, Southampton, SO17 1BJ, UK
| | - S R Moonesinghe
- National Institute of Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, London, WC1R 4SG, UK, and UCL/UCLH Surgical Outcomes Research Centre, Department of Anaesthetics and UCL Centre for Anaesthesia, University College Hospital, London, NW1 2BU, UK
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Morkane CM, McKenna H, Cumpstey AF, Oldman AH, Grocott MPW, Martin DS. Intraoperative oxygenation in adult patients undergoing surgery (iOPS): a retrospective observational study across 29 UK hospitals. Perioper Med (Lond) 2018; 7:17. [PMID: 30062007 PMCID: PMC6057104 DOI: 10.1186/s13741-018-0098-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 07/06/2018] [Indexed: 01/26/2023] Open
Abstract
Background Considerable controversy remains about how much oxygen patients should receive during surgery. The 2016 World Health Organization (WHO) guidelines recommend that intubated patients receive a fractional inspired oxygen concentration (FIO2) of 0.8 throughout abdominal surgery to reduce the risk of surgical site infection. However, this recommendation has been widely criticised by anaesthetists and evidence from other clinical contexts has suggested that giving a high concentration of oxygen might worsen patient outcomes. This retrospective multi-centre observational study aimed to ascertain intraoperative oxygen administration practice by anaesthetists across parts of the UK. Methods Patients undergoing general anaesthesia with an arterial catheter in situ across hospitals affiliated with two anaesthetic trainee audit networks (PLAN, SPARC) were eligible for inclusion unless undergoing cardiopulmonary bypass. Demographic and intraoperative oxygenation data, haemoglobin saturation and positive end-expiratory pressure were retrieved from anaesthetic charts and arterial blood gases (ABGs) over five consecutive weekdays in April and May 2017. Results Three hundred seventy-eight patients from 29 hospitals were included. Median age was 66 years, 205 (54.2%) were male and median ASA grade was 3. One hundred eight (28.6%) were emergency cases. An anticipated difficult airway or raised BMI was documented preoperatively in 31 (8.2%) and 45 (11.9%) respectively. Respiratory or cardiac comorbidity was documented in 103 (27%) and 83 (22%) respectively. SpO2 < 96% was documented in 83 (22%) patients, with 7 (1.9%) patients desaturating < 88% at any point intraoperatively. The intraoperative FIO2 ranged from 0.25 to 1.0, and median PaO2/FIO2 ratios for the first four arterial blood gases taken in each case were 24.6/0.5, 23.4/0.49, 25.7/0.46 and 25.4/0.47 respectively. Conclusions Intraoperative oxygenation currently varies widely. An intraoperative FIO2 of 0.5 currently represents standard intraoperative practice in the UK, with surgical patients often experiencing moderate levels of hyperoxaemia. This differs from both WHO’s recommendation of using an FIO2 of 0.8 intraoperatively, and also, the value most previous interventional oxygen therapy trials have used to represent standard care (typically FIO2 = 0.3). These findings should be used to aid the design of future intraoperative oxygen studies.
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Affiliation(s)
- Clare M Morkane
- 1Division of Surgery and Interventional Science (University College London) and Royal Free Perioperative Research Group, Department of Anaesthesia, Royal Free Hospital, 3rd Floor, Pond Street, London, NW3 2QG UK
| | - Helen McKenna
- 1Division of Surgery and Interventional Science (University College London) and Royal Free Perioperative Research Group, Department of Anaesthesia, Royal Free Hospital, 3rd Floor, Pond Street, London, NW3 2QG UK
| | - Andrew F Cumpstey
- University of Southampton/University Hospital Southampton and NIHR Biomedical Research Centre, Tremona Rd, Southampton, SO16 6YD UK
| | - Alex H Oldman
- 3University Hospital Southampton, Tremona Rd, Southampton, SO16 6YD UK
| | - Michael P W Grocott
- University of Southampton/University Hospital Southampton and NIHR Biomedical Research Centre, Tremona Rd, Southampton, SO16 6YD UK
| | - Daniel S Martin
- 1Division of Surgery and Interventional Science (University College London) and Royal Free Perioperative Research Group, Department of Anaesthesia, Royal Free Hospital, 3rd Floor, Pond Street, London, NW3 2QG UK
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Cross-sectional study of perioperative drug and allergen exposure in UK practice in 2016: the 6th National Audit Project (NAP6) Allergen Survey. Br J Anaesth 2018; 121:146-158. [DOI: 10.1016/j.bja.2018.04.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/01/2018] [Accepted: 04/16/2018] [Indexed: 12/20/2022] Open
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Cook T, Harper N, Farmer L, Garcez T, Floss K, Marinho S, Torevell H, Warner A, McGuire N, Ferguson K, Hitchman J, Egner W, Kemp H, Thomas M, Lucas D, Nasser S, Karanam S, Kong KL, Farooque S, Bellamy M, McGlennan A, Moonesinghe S. Anaesthesia, surgery, and life-threatening allergic reactions: protocol and methods of the 6th National Audit Project (NAP6) of the Royal College of Anaesthetists. Br J Anaesth 2018; 121:124-133. [DOI: 10.1016/j.bja.2018.04.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 03/29/2018] [Accepted: 04/05/2018] [Indexed: 12/20/2022] Open
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