Recommendations for standards of monitoring during anaesthesia and recovery 2021: Guideline from the Association of Anaesthetists

Pharmacokinetic and Pharmacodynamic Changes in the Older Adults: Impact on Anesthetics

Anesthesiologists are increasingly required to care for frail older adults patients. A detailed knowledge of the influence of age on the pharmacokinetics and dynamics of the anesthetic drugs is essential for optimal safety and care. For most of the anesthetic drugs, the older adults need lower doses to achieve the same plasma concentrations, and at any given plasma and effect-site concentration, they will have more profound clinical effects than younger patients. Caution is required, with close monitoring of clinical effects and active titration of dose administration to achieve the desired level of effect, ideally following the "start low, go slow" principle.

Optimizing neuromuscular block monitoring and reversal: A large-scale quality improvement initiative in a diverse healthcare setting

BACKGROUND

Residual neuromuscular block (NMB) after anesthesia poses significant risk to patients, which can be reduced by adhering to evidence-based practices for the dosing, monitoring, and reversal of NMB. Incorporation of best practices into routine clinical care remains uneven across providers and institutions, prompting the need for effective implementation strategies.

METHODS

An interdisciplinary quality improvement initiative aimed to optimize NMB reversal practices across a large multi-campus urban medical center. Using the Institute for Healthcare Improvement (IHI) framework, interventions were designed to increase Train-of-Four (TOF) monitoring and promote evidence-based and cost-effective use of the NMB reversal agents. Process and outcome measures were tracked through Plan-Do-Study-Act (PDSA) cycles. Qualitative interviews provided insights into clinician perspectives.

RESULTS

The study encompassed 35,198 surgical cases utilizing NMB agents. The interventions led to a sustained increase in TOF monitoring from 42 % to 83 %. Significant increases were also observed in TOF ratio documentation and utilization of sugammadex. Postoperative respiratory complication rates decreased by 41 % (RR 0.59, 95 % CI 0.32-0.96) over the course of the initiative. The most pronounced increases in TOF monitoring were associated with financial incentives for the achievement of department-wide target monitoring rate.

CONCLUSION

This initiative demonstrates successful large-scale integration of quantitative TOF monitoring and evidence based NMB management across a diverse medical center, while highlighting important barriers in implementation. These findings contribute to the broader discussion on translating evidence into practice, offering insights for improving patient care and safety through tailored implementation strategies.

Prevention of accidental awareness under general anaesthesia: A regional service evaluation

The United Kingdom's Fifth National Audit Project investigated the incidence and causes of accidental awareness during general anaesthesia. Subsequently, guidelines produced by the Association of Anaesthetists of Great Britain and Ireland provide key recommendations to minimise awareness. These include using processed electroencephalogram for patients receiving total intravenous anaesthesia while paralysed and using audible low end-tidal anaesthetic concentration alarms. The Southcoast Perioperative Audit and Research Collaboration undertook a five-day regional service evaluation, assessing the measures in place to minimise awareness and conducting a practitioner survey. Eight hospitals participated with 382 theatre attendances were analysed. Processed electroencephalograph monitoring for patients receiving total intravenous anaesthesia with neuromuscular blockade has been widely adopted into regional practice, from 23% of cases in the Fifth National Audit Project, to 85% in this snapshot. During volatile anaesthesia, age-adjusted low end-tidal anaesthetic concentration alarms were used in 34% cases. The range was 0-97% at different hospitals, suggesting heterogeneity in practice. Seventy-six per cent of anaesthetists rarely alter the default anaesthetic machine alarm settings. Therefore, instigating default low end-tidal anaesthetic concentration alarms could improve compliance with guidelines and reduce the risk of awareness for patients.

Intrathecal catheter placement after inadvertent dural puncture in the obstetric population: management for labour and operative delivery. Guidelines from the Obstetric Anaesthetists' Association

BACKGROUND

Anaesthetists of all grades who work on a labour ward are likely to be involved in the insertion or management of an intrathecal catheter after inadvertent dural puncture at some point in their careers. Although the use of intrathecal catheters after inadvertent dural puncture in labour has increased in popularity over recent decades, robust evidence on best practice has been lacking.

METHODS

The Obstetric Anaesthetists' Association set up an expert working party to review the literature. A modified Delphi approach was used to produce statements and recommendations on insertion and management of intrathecal catheters for labour and operative delivery following inadvertent dural puncture during attempted labour epidural insertion. Statements and recommendations were graded according to the US Preventive Services Task Force grading methodology.

RESULTS

A total of 296 articles were identified in the initial literature search. Further screening identified 111 full text papers of relevance. A structured narrative review was produced which covered insertion of an intrathecal catheter; initial dosing; maintenance of labour analgesia; topping-up for operative delivery; safety features; complications; and recommended follow-up. The working party agreed on 17 statements and 26 recommendations. These were generally assigned a low or moderate level of certainty. The safety of mother and baby were a key priority in producing these guidelines.

CONCLUSIONS

With careful management, intrathecal catheters can provide excellent labour analgesia and may also be topped-up to provide anaesthesia for caesarean or operative vaginal delivery. The use of intrathecal catheters, however, also carries the risk of significant drug errors which may result in high- or total-spinal anaesthesia, or even cardiorespiratory arrest. It is vital that all labour wards have clear guidelines on the use of these catheters, and that staff are educated as to their potential complications.

Best practice recommendations for medically assisted reproduction in patients with known cardiovascular disease or at high risk of cardiovascular disease

Increasing numbers of people are seeking assisted conception. In people with known cardiac disease or risk factors for cardiac disease, assisted conception may carry increased risks during treatment and any subsequent pregnancy. These risks should be assessed, considered and minimized prior to treatment.

Depth of anesthesia monitoring: an argument for its use for patient safety

PURPOSE OF REVIEW

There have been significant advancements in depth of anesthesia (DoA) technology. The Anesthesia Patient Safety Foundation recently published recommendations to use a DoA monitor in specific patient populations receiving general anesthesia. However, the universal use of DoA monitoring is not yet accepted. This review explores the current state of DoA monitors and their potential impact on patient safety.

RECENT FINDINGS

We reviewed the current evidence for using a DoA monitor and its potential role in preventing awareness and preserving brain health by decreasing the incidence of postoperative delirium and postoperative cognitive dysfunction or decline (POCD). We also explored the evidence for use of DoA monitors in improving postoperative clinical indicators such as organ dysfunction, mortality and length of stay. We discuss the use of DoA monitoring in the pediatric population, as well as highlight the current limitations of DoA monitoring and the path forward.

SUMMARY

There is evidence that DoA monitoring may decrease the incidence of awareness, postoperative delirium, POCD and improve several postoperative outcomes. In children, DoA monitoring may decrease the incidence of awareness and emergence delirium, but long-term effects are unknown. While there are key limitations to DoA monitoring technology, we argue that DoA monitoring shows great promise in improving patient safety in most, if not all anesthetic populations.

Intravenous Ketamine to Facilitate Transport of Agitated Patients to the ECT Clinic

OBJECTIVES

Electroconvulsive therapy (ECT) can be effective for a variety of psychiatric conditions, including for some patients who are very psychotic or agitated. Transferring such patients from the psychiatric ward to the ECT clinic can pose significant challenges for treating teams, as they try to minimize the use of restraint.

METHODS

We developed a protocol for safe transfer of such patients using sedation with ketamine. An intravenous cannula is inserted on the ward in a low stimulus environment with gentle supportive holds. Intravenous ketamine is given in a bolus at 0.5-2.0 mg/kg. The patient is transported on a transfer bed to the ECT clinic within a few minutes, and usual ECT process is immediately followed.

RESULTS

We describe 6 patients who were given between 1 and 11 ECT treatments using this method. All of them finished ECT courses without the need for ketamine sedation. Five of them regained capacity, provided informed consent for further ECTs, and eventually reached remission.

CONCLUSIONS

Ketamine can be used to manage risk and transfer agitated patients to an ECT clinic for treatment.

Clinical practice guidelines for the care of patients with a chronic subdural haematoma: multidisciplinary recommendations from presentation to recovery

INTRODUCTION

A chronic subdural haematoma (cSDH) is an encapsulated collection of fluid and blood degradation products in the subdural space. It is increasingly common, affecting older people and those living with frailty. Currently, no guidance exists to define optimal care from onset of symptoms through to recovery. This paper presents the first consensus-built recommendations for best practice in the care of cSDH, co-designed to support each stage of the patient pathway.

METHODS

Guideline development was led by a multidisciplinary Steering Committee with representation from diverse clinical groups, professional associations, patients, and carers. Literature searching to identify relevant evidence was guided by core clinical questions formulated through facilitated discussion with specially convened working groups. A modified Delphi exercise was undertaken to build consensus on draft statements for inclusion in the guideline using survey methodology and an in-person meeting. The proposed guideline was subsequently endorsed by the Society for British Neurological Surgeons, Neuroanaesthesia and Critical Care Society, Association of Anaesthetists, British Association of Neuroscience Nurses, British Geriatric Society, and Centre for Perioperative Care.

RESULTS

We identified that high quality evidence was generally lacking in the literature, although randomised controlled trial (RCT) data were available to inform specific recommendations on aspects of surgical technique and use of corticosteroids. The final guideline represents the outcome of synthesising available evidence, consensus-built expert opinion and patient involvement. The guideline comprises 67 recommendations across eight major themes, covering: presentation and diagnosis, neurosurgical triage and shared decision-making, non-operative management, perioperative management (including anticoagulation), timing of surgery, intraoperative and postoperative care, rehabilitation and recovery.

CONCLUSIONS

We present the first multidisciplinary guideline for the care of patients with cSDH. The recommendations reflect a paradigm shift in the care of cSDH, recognising and formalising the need for multidisciplinary and collaborative clinical management, communication and decision-making delivered effectively across secondary and tertiary care.

Residual neuromuscular block in the postanaesthesia care unit: a single-centre prospective observational study and systematic review

BACKGROUND

Concerns regarding residual neuromuscular block (RNMB) have persisted since the introduction of neuromuscular blocking agents, with reported incidences in the 21st century up to 50%. Advances in neuromuscular transmission (NMT) monitoring and the introduction of sugammadex have addressed this issue, but the impact of these developments remains unclear.

METHODS

This prospective observational study evaluated RNMB in 500 surgical patients in a large Dutch teaching hospital with readily available quantitative NMT monitoring and reversal agents. The anaesthetic technique and intraoperative NMT monitoring were independently chosen by the attending anaesthesiologist. Acceleromyography was performed upon arrival in the PACU for patients who received nondepolarising neuromuscular blocking agents. RNMB was defined as a train-of-four ratio (TOFR) <0.9. A systematic review was conducted to analyse trends in RNMB in contemporary practice.

RESULTS

Out of 500 patients, 11 (2.2%) had a TOFR <0.9. Intraoperative NMT monitoring was performed in 77.6% of patients, and sugammadex was administered to 38% of patients. No patient received neostigmine. The only difference was an automatically recorded TOFR ≥0.9 at the end of surgery in 61.1% in the non-RNMB group compared with 18.2% in the RNMB group (P=0.009). Our systematic review identified incidences ranging from 3.5% to 53.3% since 2000, with a decreasing trend in Europe and North America.

CONCLUSIONS

The incidence of residual neuromuscular block in the PACU was 2.2%. This suggests significant improvement in the prevention of residual neuromuscular block and stresses the importance of rigorous neuromuscular transmission monitoring and adequate use of reversal agents.

Awake Tracheal Intubation: An Update

Awake tracheal intubation (ATI) remains the "gold standard" technique in securing a definitive airway in conscious, self-ventilating patients with predicted or known difficult airways and the procedure is associated with a low failure rate. Since its inception a variety of techniques to achieve ATI have emerged and there have been accompanying advancements in pharmaceuticals and technology to support the procedure. In recent years there has been a growing focus on the planning, training and human factors involved in performing the procedure. The practice of ATI, does however, remain low around 1% to 2% of all intubations despite an increase in those with head and neck pathology. ATI, therefore, presents a skill that is key for the safety of patients but may not be practised with regularity by many anesthetists. In this article we therefore aim to highlight relevant guidance, recent literature and provide an update on the practical methods fundamental for successful ATI. We also discuss the crucial aspects of a safe airway culture and how this can help to embed training and maintenance of skills.

Intraoperative Ventilation/Perfusion Mismatch and Postoperative Pulmonary Complications after Major Noncardiac Surgery: A Prospective Cohort Study

BACKGROUND

Postoperative pulmonary complications can increase hospital length of stay, postoperative morbidity, and mortality. Although many factors can increase the risk of postoperative pulmonary complications, it is not known whether intraoperative ventilation/perfusion (V/Q) mismatch can be associated with an increased risk of postoperative pulmonary complications after major noncardiac surgery.

METHODS

This study enrolled patients undergoing general anesthesia for noncardiac surgery and evaluated intraoperative V/Q distribution using the automatic lung parameter estimator technique. The assessment was done after anesthesia induction, after 1 h from surgery start, and at the end of surgery. Demographic and procedural information were collected, and intraoperative ventilatory and hemodynamic parameters were measured at each timepoint. Patients were followed up for 7 days after surgery and assessed daily for postoperative pulmonary complication occurrence.

RESULTS

The study enrolled 101 patients with a median age of 71 [62 to 77] years, a body mass index of 25 [22.4 to 27.9] kg/m2, and a preoperative Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score of 41 [34 to 47]. Of these patients, 29 (29%) developed postoperative pulmonary complications, mainly acute respiratory failure (23%) and pleural effusion (11%). Patients with and without postoperative pulmonary complications did not differ in levels of shunt at T1 (postoperative pulmonary complications: 22.4% [10.4 to 35.9%] vs. no postoperative pulmonary complications:19.3% [9.4 to 24.1%]; P = 0.18) or during the protocol, whereas significantly different levels of high V/Q ratio were found during surgery (postoperative pulmonary complications: 13 [11 to 15] mmHg vs. no postoperative pulmonary complications: 10 [8 to 13.5] mmHg; P = 0.007) and before extubation (postoperative pulmonary complications: 13 [11 to 14] mmHg vs. no postoperative pulmonary complications: 10 [8 to 12] mmHg; P = 0.006). After adjusting for age, ARISCAT, body mass index, smoking, fluid balance, anesthesia type, laparoscopic procedure and surgery duration, high V/Q ratio before extubation was independently associated with the development of postoperative pulmonary complications (odds ratio, 1.147; 95% CI, 1.021 to 1.289; P = 0.02). The sensitivity analysis showed an E-value of 1.35 (CI, 1.11).

CONCLUSIONS

In patients with intermediate or high risk of postoperative pulmonary complications undergoing major noncardiac surgery, intraoperative V/Q mismatch is associated with the development of postoperative pulmonary complications. Increased high V/Q ratio before extubation is independently associated with the occurrence of postoperative pulmonary complications in the first 7 days after surgery.

EDITOR’S PERSPECTIVE

Survey-based qualitative exploration of user perspectives on the philips visual patient avatar in clinical situation management

Philips Visual Patient Avatar is an innovative approach to patient monitoring. Computer-based simulation studies have shown that it can improve diagnostic accuracy and confidence while reducing perceived workload. Following its integration into clinical practice, we conducted a single-centre qualitative study at the University Hospital Zurich to explore the views of anaesthesia, post-anaesthesia and intensive care providers on their experience with the technology. We used an online survey to assess its contributions in different clinical situations. We analysed the data thematically to identify key themes. Of the 510 healthcare providers contacted, 131 (25.7%) completed the survey and 154 comments were collected. Key themes included the detection of specific vital sign changes, focusing on temperature and oxygen saturation (41.9%, 34/81 comments in the operating room; 38.6%, 17/44 comments in the intensive care unit; 10.3%, 3/29 comments in the post-anaesthesia care unit). Additionally, the technology was perceived to support daily routines and situational awareness (28.4%, 23/81 comments in the OR; 9.1%, 4/44 comments in the ICU; 10.3%, 3/29 comments in the PACU). The study provides early, but strong evidence that the Philips Visual Patient Avatar assists healthcare providers in specific clinical situations in the perioperative and critical care settings.

A comparative analysis of elevated endotracheal tube cuff pressure incidence in laparoscopic abdominal surgery: saline versus air inflation

BACKGROUND

Endotracheal intubation is a frequently performed procedure in anesthesia practice, and ensuring the correct inflation of the cuff is essential for maintaining the airway seal. Overinflation of endotracheal tube (ETT) cuffs can lead to complications, such as postoperative sore throat. This study aimed to compare the incidence of elevated ETT cuff pressure between saline and air inflation in elective laparoscopic abdominal surgery.

METHODS

The study involved 60 participants ranging in age from 18 to 65, with American Society of Anesthesiologists physical status levels 1-2, who underwent laparoscopic abdominal surgery. We randomly assigned patients to two groups: Group A (air-filled ETT cuffs, N.=30) and Group S (saline-filled ETT cuffs, N.=30). Intra-cuff pressure was recorded before and after CO2 insufflation, as well as during changes in patient position. The number of interventions to restore intra-cuff pressure to 18 mmHg was documented. Peak airway pressure, plateau pressure, and positive end-expiratory pressure (PEEP) were measured at 15-minute intervals.

RESULTS

The number of interventions needed to maintain intra-cuff pressure was significantly lower in the saline group compared to the air group. All patients started with initial cuff pressures above 20 mmHg. After insufflation, the first-minute cuff pressures were higher in the air group (P=0.001). Both groups experienced a significant increase in intra-cuff pressure with the Trendelenburg position, and after moving to the reverse Trendelenburg position (saline and air groups, P=0.001 and 0.012, respectively), the air group had higher intra-cuff pressure than the saline group (P=0.002). There were no significant differences between groups in peak airway pressure, plateau pressure, and PEEP.

CONCLUSIONS

Inflating ETT cuffs with saline instead of air during laparoscopic abdominal surgeries led to a reduced requirement for interventions in maintaining pressure. This indicates that the use of saline inflation may significantly lower the risk of high cuff pressure and related complications.

Patient Safety in Anesthesiology: Progress, Challenges, and Prospects

Anesthesiology is considered a complex medical specialty. Its history has been marked by radical advances and profound transformations, owing to technical and pharmacological developments and innovations in the field, enabling us over the years to improve patient outcomes and perform longer, more complex surgical procedures on more fragile patients. However, anesthesiology has never been safe and free of challenges. Despite the advances made, it still faces risks associated with the practice of anesthesia, for both patients and healthcare professionals, and with some of the specific challenges encountered in low and middle-income countries. In this context, certain actions and initiatives must be carried out collaboratively. In addition, recent technologies and innovations such as simulation, genomics, artificial intelligence, and robotics hold promise for further improving patient safety in anesthesiology and overcoming existing challenges, making it possible to offer safer, more effective, and personalized anesthesia. However, this requires rigorous monitoring of ethical aspects and the reliability of the studies to reap the full benefits of the new technology. This literature review presents the evolution of anesthesiology over time, its current challenges, and its promising future. It underlines the importance of the new technologies and the need to pursue efforts and strengthen research in anesthesiology to overcome the persistent challenges and benefit from the advantages of the latest technology to guarantee safe, high-quality anesthesia with universal access.

Management of Muscle Relaxation With Rocuronium and Reversal With Neostigmine or Sugammadex Guided by Quantitative Neuromuscular Monitoring

BACKGROUND

The optimal pharmacological reversal strategy for neuromuscular blockade remains undefined even in the setting of strong recommendations for quantitative neuromuscular monitoring by several national and international anesthesiology societies. We evaluated a protocol for managing rocuronium blockade and reversal, using quantitative monitoring to guide choice of reversal agent and to confirm full reversal before extubation.

METHODS

We conducted a prospective cohort study and enrolled 200 patients scheduled for elective surgery involving the intraoperative use of rocuronium. Providers were asked to adhere to a protocol that was similar to local practice recommendations for neuromusculalr block reversal that had been used for >2 years; the protocol added quantitative monitoring that had not previously been routinely used at our institution. In this study, providers used electromyography-based quantitative monitoring. Pharmacological reversal was accomplished with neostigmine if the train-of-four (TOF) ratio was 0.40 to 0.89 and with sugammadex for deeper levels of blockade. The primary end point was the incidence of postoperative residual neuromuscular blockade (PRNB), defined as TOF ratio <0.9 at time of extubation. We further evaluated the difference in pharmacy costs had all patients been treated with sugammadex.

RESULTS

A total of 189 patients completed the study: 66 patients (35%) were reversed with neostigmine, 90 patients (48%) with sugammadex, and 33 (17%) patients recovered spontaneously without pharmacological reversal. The overall incidence of residual paralysis was 0% (95% CI, 0-1.9). The total acquisition cost for all reversal drugs was United States dollar (USD) 11,358 (USD 60 per patient) while the cost would have been USD 19,312 (USD 103 per patient, 70% higher) if sugammadex had been used in all patients.

CONCLUSIONS

A protocol that includes quantitative monitoring to guide reversal with neostigmine or sugammadex and to confirm TOF ratio ≥0.9 before extubation resulted in the complete prevention of PRNB. With current pricing of drugs, the selective use of sugammadex reduced the total cost of reversal drugs compared to the projected cost associated with routine use of sugammadex for all patients.

Bispectral Index Monitoring Effect on Delirium Occurrence and Nursing Quality Improvement in Post-anesthesia Care Unit Patients Recovering From General Anesthesia: A Randomized Controlled Trial

BACKGROUND

The effect of intraoperative anesthesia depth monitoring on delirium occurrence and improvement of nursing quality in the post-anesthesia care unit (PACU) remains unclear. We aimed to explore the effect of intraoperative anesthesia bispectral index (BIS) monitoring on delirium occurrence and improvement of nursing quality in the PACU for patients recovering from general anesthesia.

METHODS

 This randomized controlled trial included 120 patients, aged 20-80 years, classified as grades I-III according to the American Society of Anesthesiologists. The BIS-guided group (group B) underwent intraoperative monitoring of BIS anesthesia depth (maintained within the anesthetic range (40-60)). The depth of anesthesia was not monitored in the non-BIS-guided group (group C). The patient's vital signs were recorded at the beginning of the operation (T0), upon entering the PACU (T1), 15 min after extubation (T2), and after leaving the PACU (T3). Delirium score, emergence period (extubation and PACU observation times), and adverse events in the PACU were monitored. The nursing activity score (NAS) was used to evaluate the quality of care.

RESULTS

Group B exhibited significantly lower heart rate and mean arterial pressure at T1 and T2, shorter time to extubation and PACU observation time, and a significantly lower incidence of adverse events than group C. Group B had significantly lower Ricker sedation-agitation scores and a lower incidence of delirium than group C. The NAS was significantly lower for group B than for group C. Patients aged 60-80 years in group C experienced agitation, requiring 30% more frequent assistance from one or two nurses than those in group B.

CONCLUSION

Intraoperative BIS monitoring can reduce the incidence of adverse events in the PACU, diminish the incidence of delirium during the recovery period in elderly patients, lessen the nursing workload, improve nursing quality, and promote patient rehabilitation, thus meriting clinical application.

Navigating challenges in anesthesia for robotic urological surgery: a comprehensive guide

Robotic surgery has emerged as a cornerstone in urological interventions, offering effectiveness and safety for patients. For anesthesiologists, this technological advancement presents a myriad of new challenges, spanning from patient selection and assessment to intraoperative dynamics and post-surgical pain management. This article aims to elucidate these challenges and provide guidance for anesthesiologists in navigating the complexities of anesthesia administration in robotic urological procedures. Through a detailed exploration of patient optimization, team coordination, intraoperative adjustments, and post-surgical care, this article serves as a valuable resource for ensuring the success of such interventions.

Diamedica Draw-over Vaporiser: bench testing the UK Defence Anaesthesia System in the deployed environment

INTRODUCTION

The Diamedica Draw-over Vaporiser 2 (DDV2) is the sevoflurane vaporiser used by the UK Defence Medical Services to provide deployed volatile general anaesthesia. The Defence Anaesthesia System employs the DDV2 with a turbine-driven ventilator as a 'push-over' vaporiser, a modification from the manufacturer's design. We investigated sevoflurane delivery at varying minute volumes (MVs), vaporiser settings and temperatures in this configuration.

METHODS

A range of DDV2 settings (1%, 2%, 3%, 4% and induction) and MVs (2, 4, 6 and 8 L/min at 12 ventilations per minute) were tested at two ambient temperatures (20 and 30±3°C) over 30 min. A supplemental experiment, simulating anaesthesia during damage control surgery, was also completed, where he DDV2 was set to 2% with a 6 L/min MV for 90 min.

RESULTS

In both experiments, two distinct phases of sevoflurane delivery were noted, a 'wash-in phase' followed by a 'maintenance period'. The wash-in phase normally lasted less than 5 min. During the maintenance period at low MVs and vaporiser settings the DDV2 delivered a constant output, while at higher MVs and settings vapour output fell predictably. At 20±3°C, using DDV2 settings likely to be encountered in clinical practice, sevoflurane delivery was within 20% of that set. Higher vaporiser settings, MVs and temperatures resulted in greater variation between vaporiser setting and agent delivery. This variation is explained by the incomplete temperature compensation of the DDV2.

CONCLUSIONS

The DDV2 functions predictably at a range of settings, MVs and temperatures. Anaesthetic delivery in the defence anaesthesia configuration is like that previously described in the draw-over configuration. The equipment was found to be reliable and robust. This experimental work supports the continued use of the Defence Anaesthesia System for the delivery of and training in deployed general anaesthesia.

The evaluation of a non-invasive respiratory monitor in ards patients in supine and prone position

PURPOSE

The Prone positioning in addition to non invasive respiratory support is commonly used in patients with acute respiratory failure. The aim of this study was to assess the accuracy of an impedance-based non-invasive respiratory volume monitor (RVM) in supine and in prone position.

METHODS

In sedated, paralyzed and mechanically ventilated patients in volume-controlled mode with acute respiratory distress syndrome scheduled for prone positioning it was measured and compared non-invasively tidal volume and respiratory rate provided by the RVM in supine and, subsequently, in prone position, by maintaining unchanged the ventilatory setting.

RESULTS

Forty patients were enrolled. No significant difference was found between measurements in supine and in prone position either for tidal volume (p = 0.795; p = 0.302) nor for respiratory rate (p = 0.181; p = 0.604). Comparing supine vs. prone position, the bias and limits of agreements for respiratory rate were 0.12 bpm (-1.4 to 1.6) and 20 mL (-80 to 120) for tidal volume.

CONCLUSIONS

The RVM is accurate in assessing tidal volume and respiratory rate in prone compared to supine position. Therefore, the RVM could be applied in non-intubated patients with acute respiratory failure receiving prone positioning to monitor respiratory function.

Haemodynamic monitoring during noncardiac surgery: past, present, and future

During surgery, various haemodynamic variables are monitored and optimised to maintain organ perfusion pressure and oxygen delivery - and to eventually improve outcomes. Important haemodynamic variables that provide an understanding of most pathophysiologic haemodynamic conditions during surgery include heart rate, arterial pressure, central venous pressure, pulse pressure variation/stroke volume variation, stroke volume, and cardiac output. A basic physiologic and pathophysiologic understanding of these haemodynamic variables and the corresponding monitoring methods is essential. We therefore revisit the pathophysiologic rationale for intraoperative monitoring of haemodynamic variables, describe the history, current use, and future technological developments of monitoring methods, and finally briefly summarise the evidence that haemodynamic management can improve patient-centred outcomes.

Enhancing Drug Management, Cost Savings, and Staff Satisfaction in Anesthesiology: A Quality Improvement Project in a Chinese Tertiary Hospital

INTRODUCTION

In alignment with China's national directive for improved drug management in anesthesiology, the Affiliated Hospital of Qingdao University initiated a quality improvement project, aiming to tackle the prevailing challenges of inefficiencies in drug administration, escalating drug costs, and the notable communication gap between pharmacists and anesthesiologists.

METHODS

We employed a Plan-Do-Study-Act methodology to establish a pharmacy team and execute a multidimensional pharmaceutical intervention. The interventions included the formulation of standard procedures, guidelines and regulations, assistance from an information system (including automatic dispensing cabinets and prospective prescription review system), communication feedback (via WeChat groups), and education for anesthesiology staff. The intervention spanned from April to September 2023, focusing on optimizing medication management, achieving cost savings, and enhancing the satisfaction of anesthesia team members, with an additional observation from October to December 2023.

RESULTS

Following the interventions, improvements were observed in drug management practices. These enhancements included increased compliance with accounting procedures, more rigorous registration of controlled substances, and more effective disposal of liquid residues. There was no adverse events related to high-alert medications or look-alike drug usage errors. The introduction of automatic dispensing cabinets and a prospective prescription review system markedly improved work efficiency. The utilization of a WeChat group facilitated effective communication about unreasonable prescriptions and drug-related issues. Among the 29,061 patients who underwent surgery both before and after the interventions, significant reductions were observed both in the drug proportion and the per capita drug costs (P = 0.03, P = 0.014, respectively). The per capita drug cost decreased by 20.82%, from ¥723.43 to ¥572.78, consistently remaining below ¥600 throughout the 9-month observation period. The per capita cost of monitoring drugs including dezocine, butorphanol, haemocoagulase agkistrodon, penehyclidine, and ulinastatin experienced a significant reduction (P < 0.05). Additionally, in the satisfaction questionnaires returned, a remarkable 94.44% of anesthesiology staff expressed high satisfaction with the comprehensive pharmaceutical interventions.

CONCLUSION

The quality improvement project has yielded remarkable positive outcomes, serving as a model worthy of reference and replication in similar healthcare settings.

Non-traumatic complete cervical spine dislocation with severe fixed kyphosis: successful multidisciplinary approach to a challenging case

BACKGROUND

To our knowledge, there is no previous report in the literature of non-traumatic neglected complete cervical spine dislocation characterized by anterior spondyloptosis of C4, extreme head drop, and irreducible cervicothoracic kyphosis.

CASE PRESENTATION

We report the case of a 33-year-old Caucasian man with a 17-year history of severe immune polymyositis and regular physiotherapy who presented with severe non-reducible kyphosis of the cervicothoracic junction and progressive tetraparesia for several weeks after a physiotherapy session. Radiographs, computed tomography, and magnetic resonance imaging revealed a complete dislocation at the C4-C5 level, with C4 spondyloptosis, kyphotic angulation, spinal cord compression, and severe myelopathy. Due to recent worsening of neurological symptoms, an invasive treatment strategy was indicated. The patient's neurological status and spinal deformity greatly complicated the anesthetic and surgical management, which was planned after extensive multidisciplinary discussion and relied on close collaboration between the orthopedic surgeon and the anesthetist. Regarding anesthesia, difficult airway access was expected due to severe cervical angulation, limited mouth opening, and thyromental distance, with high risk of difficult ventilation and intubation. Patient management was further complicated by a theoretical risk of neurogenic shock, motor and sensory deterioration, instability due to position changes during surgery, and postoperative respiratory failure. Regarding surgery, a multistage approach was carefully planned. After a failed attempt at closed reduction, a three-stage surgical procedure was performed to reduce displacement and stabilize the spine, resulting in correct spinal realignment and fixation. Progressive complete neurological recovery was observed.

CONCLUSION

This case illustrates the successful management of a critical situation based on a multidisciplinary collaboration involving radiologists, anesthesiologists, and spine surgeons.

Intraoperative EEG-based monitors: are we looking under the lamppost?

PURPOSE OF REVIEW

While electroencephalogram (EEG)-based depth of anesthesia monitors have been in use clinically for decades, there is still a major debate concerning their efficacy for detecting awareness under anesthesia (AUA). Further utilization of these monitors has also been discussed vividly, for example, reduction of postoperative delirium (POD).It seems that with regard to reducing AUA and POD, these monitors might be applicable, under specific anesthetic protocols. But in other settings, such monitoring might be less contributive and may have a 'built-it glass ceiling'.Recent advances in other venues of electrophysiological monitoring might have a strong theoretical rationale, and early supporting results, to offer a breakthrough out of this metaphorical glass ceiling. The purpose of this review is to present this possibility.

RECENT FINDINGS

Following previous findings, it might be concluded that for some anesthesia protocols, the prevailing depth of anesthesia monitors may prevent incidences of AUA and POD. However, in other settings, which may involve other anesthesia protocols, or specifically for POD - other perioperative causes, they may not. Attention-related processes measured by easy-to-use real-time electrophysiological markers are becoming feasible, also under anesthesia, and might be applicable for more comprehensive prevention of AUA, POD and possibly other perioperative complications.

SUMMARY

Attention-related monitoring might have a strong theoretical basis for the prevention of AUA, POD, and potentially other distressing postoperative outcomes, such as stroke and postoperative neurocognitive disorder. There seems to be already some initial supporting evidence in this regard.

Independent sector and peri-operative cardiac arrest as reported to the 7th National Audit Project of the Royal College of Anaesthetists

The 7th National Audit Project (NAP7) of the Royal College of Anaesthetists studied peri-operative cardiac arrest including those that occurred in the independent healthcare sector, which provides around 1 in 6 NHS-funded care episodes. In total, 174 (39%) of 442 independent hospitals contacted agreed to participate. A survey examining provider preparedness for cardiac arrest had a response rate of 23 (13%), preventing useful analysis. An activity survey with 1912 responses (from a maximum of 45% of participating hospitals) showed that, compared with the NHS caseload, the independent sector caseload was less comorbid, with fewer patients at the extremes of age or who were severely obese, and with a large proportion of elective orthopaedic surgery undertaken during weekday working hours. The survey suggested suboptimal compliance rates with monitoring recommendations. Seventeen reports of independent sector peri-operative cardiac arrest comprised 2% of NAP7 reports and underreporting is likely. These patients were lower risk than NHS cases, reflecting the sector's case mix, but included cases of haemorrhage, anaphylaxis, cardiac arrhythmia and pulmonary embolus. Good and poor quality care were seen, the latter including delayed recognition and treatment of patient deterioration, and poor care delivery. Independent sector outcomes were similar to those in the NHS, though due to the case mix, improved outcomes might be anticipated. Assessment of quality of care was less often favourable for independent sector reports than NHS reports, though assessments were often uncertain, reflecting poor quality reports. Overall, NAP7 is unable to determine whether peri-operative care relating to cardiac arrest is more, equally or less safe than in the NHS.

Practice Guidelines for Monitoring Neuromuscular Blockade-Elements to Change to Increase the Quality of Anesthesiological Procedures and How to Improve the Acceleromyographic Method

Neuromuscular blocking agents are a crucial pharmacological element of general anesthesia. Decades of observations and scientific studies have resulted in the identification of many risks associated with the uncontrolled use of neuromuscular blocking agents during general anesthesia or an incomplete reversal of neuromuscular blockade in the postoperative period. Residual relaxation and acute postoperative respiratory depression are the most serious consequences. Cyclic recommendations have been developed by anesthesiology societies from many European countries as well as from the United States and New Zealand. The newest recommendations from the American Society of Anesthesiologists and the European Society of Anesthesiology were published in 2023. These publications contain very detailed recommendations for monitoring the dosage of skeletal muscle relaxants in the different stages of anesthesia-induction, maintenance and recovery, and the postoperative period. Additionally, there are recommendations for various special situations (for example, rapid sequence induction) and patient populations (for example, those with organ failure, obesity, etc.). The guidelines also refer to pharmacological drugs for reversing the neuromuscular transmission blockade. Despite the development of several editions of recommendations for monitoring neuromuscular blockade, observational and survey data indicate that their practical implementation is very limited. The aim of this review was to present the professional, technical, and technological factors that limit the implementation of these recommendations in order to improve the implementation of the guidelines and increase the quality of anesthesiological procedures and perioperative safety.

The effect of upper transabdominal plane block on diaphragm thickness in adult patients after laparoscopic cholecystectomy operation

INTRODUCTION

In this prospective and observational study, our objective was to examine the impact of subcostal transversus abdominis plane (SubTAP) block, along with intravenous analgesia techniques, on diaphragm thickness and post-operative pain following laparoscopic cholecystectomy.

PATIENTS AND METHODS

This study examined laparoscopic cholecystectomy patients aged 18-60 years with an American Society of Anesthesiologist score of 1-2. This study divided patients into Group 1 for SubTAP block and Group 2 for intravenous analgesia. This study had 67 patients, at least 30 from each group. Thus, diaphragm thicknesses and Visual Analogue Scale (VAS) values were compared between regional anaesthesia and intravenous analgesia groups.

RESULTS

Pre-operative data showed no statistically significant changes between the groups, although post-extubation inspiratory thickness was closer to baseline in Group 1 patients who received regional block. The groups had different outcomes after extubation and at the post-operative 30th min (P = 0.028 and P = 0.001, respectively). There was also a significant difference in post-operative oxygen saturation and VAS scores (P = 0.001). Our receiver operating characteristic analysis determined that the threshold values for VAS parameters of 2 or 3 were 0.28 cm in inspiration, 0.18 cm in expiration and 1.29 as i/e ratio. Significant discomfort was defined as diaphragm parameter values below these limits.

CONCLUSIONS

We found that the earlier return of diaphragmatic functions to baseline was associated with diaphragm thickness. According to the measurements made in the post-operative care unit, the regional block group effectively prevented the loss of diaphragm function.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Korean clinical practice guidelines for diagnostic and procedural sedation

Safe and effective sedation depends on various factors, such as the choice of sedatives, sedation techniques used, experience of the sedation provider, degree of sedation-related education and training, equipment and healthcare worker availability, the patient's underlying diseases, and the procedure being performed. The purpose of these evidence-based multidisciplinary clinical practice guidelines is to ensure the safety and efficacy of sedation, thereby contributing to patient safety and ultimately improving public health. These clinical practice guidelines comprise 15 key questions covering various topics related to the following: the sedation providers; medications and equipment available; appropriate patient selection; anesthesiologist referrals for high-risk patients; pre-sedation fasting; comparison of representative drugs used in adult and pediatric patients; respiratory system, cardiovascular system, and sedation depth monitoring during sedation; management of respiratory complications during pediatric sedation; and discharge criteria. The recommendations in these clinical practice guidelines were systematically developed to assist providers and patients in sedation-related decision making for diagnostic and therapeutic examinations or procedures. Depending on the characteristics of primary, secondary, and tertiary care institutions as well as the clinical needs and limitations, sedation providers at each medical institution may choose to apply the recommendations as they are, modify them appropriately, or reject them completely.

Anesthesia Patient Monitoring 2050

The monitoring of vital signs in patients undergoing anesthesia began with the very first case of anesthesia and has evolved alongside the development of anesthesiology ever since. Patient monitoring started out as a manually performed, intermittent, and qualitative assessment of the patient's general well-being in the operating room. In its evolution, patient monitoring development has responded to the clinical need, for example, when critical incident studies in the 1980s found that many anesthesia adverse events could be prevented by improved monitoring, especially respiratory monitoring. It also facilitated and perhaps even enabled increasingly complex surgeries in increasingly higher-risk patients. For example, it would be very challenging to perform and provide anesthesia care during some of the very complex cardiovascular surgeries that are almost routine today without being able to simultaneously and reliably monitor multiple pressures in a variety of places in the circulatory system. Of course, anesthesia patient monitoring itself is enabled by technological developments in the world outside of the operating room. Throughout its history, anesthesia patient monitoring has taken advantage of advancements in material science (when nonthrombogenic polymers allowed the design of intravascular catheters, for example), in electronics and transducers, in computers, in displays, in information technology, and so forth. Slower product life cycles in medical devices mean that by carefully observing technologies such as consumer electronics, including user interfaces, it is possible to peek ahead and estimate with confidence the foundational technologies that will be used by patient monitors in the near future. Just as the discipline of anesthesiology has, the patient monitoring that accompanies it has come a long way from its beginnings in the mid-19th century. Extrapolating from careful observations of the prevailing trends that have shaped anesthesia patient monitoring historically, patient monitoring in the future will use noncontact technologies, will predict the trajectory of a patient's vital signs, will add regional vital signs to the current systemic ones, and will facilitate directed and supervised anesthesia care over the broader scope that anesthesia will be responsible for.

The Effect of Warmed Serum on Shivering and Recovery Period of Patients Under General and Spinal Anesthesia: A Randomized Clinical Trial

PURPOSE

Postoperative hypothermia followed by shivering is a common phenomenon in patients undergoing surgery under anesthesia, and should be prevented and treated in postoperative patient care units. This study was conducted to investigate the effect of warmed serum injection on postoperative shivering and recovery period of patients operated under general and spinal anesthesia.

DESIGN

In this clinical trial, patients to be operated on under general and spinal anesthesia were randomly assigned into two groups of test and control. In the test group, patients received warmed intravenous fluids and blood products. All patients were monitored to record vital signs, incidences of hypothermia and shivering, and recovery period.

METHODS

The collected data were analyzed with repeated measures analysis of variance to detect significant differences between groups and significant changes within groups over time.

FINDINGS

The incidence of nausea, vomiting, and shivering in the intervention and control groups was (4.7%, 42%), (2.8%, 16.8%), and (6.6%, 43%), respectively. Patients in the intervention group had higher body temperature than the control group (<0.001). Also, patients under spinal anesthesia had higher body temperature than patients under general anesthesia (<0.001). Blood pressure reduction was also significantly higher in the control group than in the intervention group. The patients who received warm intravenous serum, and especially those who had received spinal anesthesia spent less time in the recovery room (<0.001).

CONCLUSIONS

The use of warmed intravenous serum increased the patients' core temperature, reduced their postoperative shivering, and shortened their recovery period. Considering the potential risks associated with hypothermia, using such methods for hypothermia prevention can be highly effective in preventing shivering and prolongation of the recovery period and other potential complications. Anesthesia specialists and technicians are therefore encouraged to use this method as a preventive measure.

Atracurium-Induced Bronchospasm With Flat Capnograph at Induction of General Anaesthesia: A Case Report

Benzylisoquinolinium neuromuscular blocking agents can precipitate bronchospasm either through allergy/anaphylaxis or isolated stimulation of mast cell histamine release. This report presents a 75-year-old female who attended the day surgery unit for a rigid cystoscopy under general anaesthesia. She had a hyper-reactive airway history of mild historic asthma and sensitivity to aerosols. After administration of atracurium at induction of anaesthesia, ventilation became challenging with no chest rise and a flat CO2 trace. Repeat video laryngoscopy confirmed correct endotracheal tube position. The patient remained cardiovascularly stable with no mucocutaneous signs of anaphylaxis. Administration of high flow oxygen, sevoflurane, salbutamol and magnesium sulfate led to gradual improvement and normalisation of respiratory parameters. Surgery was postponed. This report highlights atracurium as an important trigger of bronchospasm at induction of anaesthesia, and illustrates that in rare cases a flat capnograph does not always indicate a mispositioned airway device. Several aspects of the anaesthetic plan for this patient were suboptimal given her respiratory history, namely, the choice of mode of anaesthesia and choice of neuromuscular blocking agent. These factors are discussed in the context of anaesthetic planning for patients presenting with features suggesting high bronchospastic risk.

The effect of sugammadex on patient morbidity and quality of recovery after general anaesthesia: a systematic review and meta-analysis

BACKGROUND

Residual neuromuscular block is associated with increased patient morbidity. Therefore prevention of residual neuromuscular block is an important component of general anaesthesia where neuromuscular blocking agents are used. Whereas sugammadex improves reversal based on neuromuscular twitch monitoring parameters, there have been no prospective, adequately powered definitive studies demonstrating that sugammadex is also associated with less patient morbidity.

METHODS

We performed a systematic review of randomised trials comparing sugammadex with anticholinesterase-based reversal or placebo reversal that reported important patient outcomes beyond the postanaesthesia care unit.

RESULTS

We identified 43 articles, including 5839 trial participants. Only one trial reported days alive and out of hospital to 30 days (DAOH-30), which showed that the number of DAOH-30 was similar in those allocated to sugammadex compared with neostigmine-based reversal (25 days [19-27] vs 24 days [21-27], median difference 0.00 [-2.15 to 2.15]). Pooled analyses of data from 16 trials showed an estimated odds ratio (OR) for postoperative pulmonary complications of 0.67 (95% confidence interval 0.47-0.95) with sugammadex use. Pooled analysis showed that pneumonia (eight trials OR 0.51 [0.24-1.01] with sugammadex use), hospital length of stay (23 trials, mean difference -0.31 [-0.84 to 0.22] with sugammadex use), and patient-reported quality of recovery (11 trials, varied depending on metric used) are similar in those allocated to sugammadex vs control. The difference seen in mortality (11 trials, OR 0.39 [0.15-1.01] with sugammadex use) would be considered to be clinically significant and warrants further investigation, however, the rarity of these events precludes drawing definitive conclusions.

CONCLUSION

Although few trials reported on DAOH-30 or important patient outcomes, sugammadex is associated with a reduction in postoperative pulmonary complications, however, this might not translate to a difference in hospital length of stay, patient-reported quality of recovery, or mortality.

CLINICAL TRIAL REGISTRATION

PROSPERO database (CRD42022325858).

Anaesthetic records: an evaluation of variation across England

We collected blank non-specialist anaesthetic records from 71 National Health Service Trusts in England. A data set was established by collating all data items found in an initial tranche of 28 records. All 71 records were subsequently analysed for each data item in this data set. We found significant variation: the most populated record included 216 data items and the least included 38 data items: a greater than five-fold variation. There was significant variation in the inclusion of data items commonly considered important to patient safety; 42% of records omitted documentation of fasting status, 72% omitted documentation of a discussion around the risk of accidental awareness during general anaesthesia, 92% omitted documentation of quantitative neuromuscular blockade monitoring and 63% omitted documentation for 'Stop Before You Block' when performing regional anaesthesia. The study highlights significant variability in the composition of anaesthetic records across England which may impact on its value as a data repository, an action trigger, a medicolegal account, and a tool to facilitate safe handover. Standardisation of the anaesthetic record or the establishment of standards of recording would help to allay potential risks to patient safety and assist in guiding future procurement of electronic solutions for anaesthetic records.

The Theatre Recovery and Anaesthetic nurse Capnography Education (TRACE) project

The Theatre Recovery and Anaesthetic Nurse Capnography Education (TRACE) project is a multidisciplinary quality improvement project. The overall aim is to educate anaesthetic and recovery nurses on the correct use of capnography and educate non-consultant hospital doctors on the guidelines on Preventing Unrecognised Oesophageal Intubation from the Project for Universal Management of Airways group. This project addresses technical aspects of task performance such as correct waveform identification and interpretation, troubleshooting abnormal waveforms and establishing routine checks of capnography both pre-induction and post-intubation. The pre-induction verification of the correct function of capnography is an essential component of this project. In addition, the project focuses on team aspects of task performance with an emphasis on team psychological safety, empowering nurses to speak up using graded assertiveness and flattening hierarchies. As a result of the project, our nurses' knowledge about capnography and waveform identification improved to over 80% correct answers six months after completion of the project. In addition, over 90% of participants reported feeling confident in speaking up to both consultants and non-consultant hospital doctors when a waveform was not present before induction of anaesthesia or after attempted tracheal intubation.