Showing papers in "European Journal of Anaesthesiology in 2013"

Management of severe perioperative bleeding Guidelines from the European Society of Anaesthesiology

Abstract: The aims of severe perioperative bleeding management are three-fold. First, preoperative identification by anamesis and laboratory testing of those patients for whom the perioperative bleeding risk may be increased. Second, implementation of strategies for correcting preoperative anaemia and stabilisation of the macro- and microcirculations in order to optimise the patient’s tolerance to bleeding. Third, targeted procoagulant interventions to reduce the amount of bleeding, morbidity, mortality and costs. The purpose of these guidelines is to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthetists throughout Europe to integrate this knowledge into daily patient care wherever possible. The Guidelines Committee of the European Society of Anaesthesiology (ESA) formed a task force with members of scientific subcommittees and individual expert members of the ESA. Electronic databases were searched without language restrictions from the year 2000 until 2012. These searches produced 20 664 abstracts. Relevant systematic reviews with meta-analyses, randomised controlled trials, cohort studies, case-control studies and cross-sectional surveys were selected. At the suggestion of the ESA Guideline Committee, the Scottish Intercollegiate Guidelines Network (SIGN) grading system was initially used to assess the level of evidence and to grade recommendations. During the process of guideline development, the official position of the ESA changed to favour the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. This report includes general recommendations as well as specific recommendations in various fields of surgical interventions. The final draft guideline was posted on the ESA website for four weeks and the link was sent to all ESA members. Comments were collated and the guidelines amended as appropriate. When the final draft was complete, the Guidelines Committee and ESA Board ratified the guidelines.

The effect of transversus abdominis plane block or local anaesthetic infiltration in inguinal hernia repair: A randomised clinical trial

Abstract: CONTEXTThe analgesic effect of transversus abdominis plane (TAP) block after inguinal hernia repair is unclear.OBJECTIVEThe aim of this randomised and double-blind study was to evaluate the analgesic effect of a TAP block in patients scheduled for primary inguinal hernia repair. The TAP block was ev

Ultrasound-guided transversus abdominis plane block in children: A randomised comparison with wound infiltration

Abstract: CONTEXTThe transversus abdominis plane (TAP) block is a new regional anaesthesia technique applicable to infants and children.OBJECTIVE(S)The present study was designed to evaluate the analgesic efficacy of ultrasound-guided TAP block with high volume local anaesthetic (0.5 ml kg−1) during the first

Predictors of patient satisfaction with anaesthesia and surgery care: a cohort study using the Postoperative Quality of Recovery Scale.

Abstract: Context Previous research has shown that most patients are satisfied with their anaesthetic care. For those who are not the causes may be multifactorial including dissatisfaction with surgical outcomes. Objectives We aimed to identify whether quality of recovery after anaesthesia and surgery measured in multiple domains affects patient satisfaction. Design Sub-group analysis of previously published observational cohort study of quality of recovery after surgery (using the Postoperative Quality of Recovery Scale) was used to identify predictors of incomplete satisfaction 3 days after surgery. Setting Multicentre perioperative surgery. Patients Patients � 6 years old, undergoing a variety of operation types and all receiving general anaesthesia. Observations Of 701 patients, 573 completed the satisfaction question on day 3. Satisfaction was rated by a single fivepoint rating question. Patients were divided into two groups: 477 (83%) were completely satisfied and 96 (17%) were not completely satisfied. Multivariable logistic regression analysis was performed on preoperative and patient characteristics and recovery in five domains as follows: physiological, nociceptive (pain and nausea), emotive (anxiety and depression), activities of daily living and cognition. Recovery was defined as return to baseline values or better for all questions within each domain. Results Incomplete satisfaction was predicted by persistent pain or nausea at day 3 [OR 8.2 (95% CI 2.5 to 27), P <0.01] and incomplete satisfaction at day 1 [OR 28 (95% CI 10 to 77), P <0.01]. Paradoxically, incomplete satisfaction was less likely to occur if pain or nausea was present 15min after surgery [OR 0.34 (95% CI 0.11 to 0.99), P <0.05] or at day 1 [OR 0.30 (95% CI 0.10 to 0.91), P ¼0.03]. Incomplete recovery in the other domains did not influence satisfaction. Conclusion Of the recovery domains measured using the Postoperative Quality of Recovery Scale, only nociception (pain or nausea) contributed to incomplete satisfaction. Eur J Anaesthesiol 2012; 29:000–000

Analgesic efficacy of ultrasound-guided adductor canal blockade after arthroscopic anterior cruciate ligament reconstruction: a randomised controlled trial

Abstract: CONTEXTAnterior cruciate ligament (ACL) reconstruction surgery is associated with moderate to severe postoperative pain, which may be ameliorated by peripheral nerve blocks. The adductor canal block (ACB) is an almost exclusively sensory nerve block that has been demonstrated to reduce pain and opio

Comparison of Laryngeal Mask Airway Supreme and Laryngeal Mask Airway Proseal with respect to oropharyngeal leak pressure during laparoscopic cholecystectomy: a randomised controlled trial.

Abstract: CONTEXT A comparison of the efficacy and safety of the Laryngeal Mask Airway (LMA) Supreme (LMAS) versus the LMA Proseal (LMAP) in elective laparoscopic cholecystectomy. OBJECTIVES To compare the LMAS with LMAP in terms of ventilatory efficacy, airway leak pressure (airway protection), ease-of-use and complications. DESIGN Prospective, single-blind, randomised, controlled study. SETTING The Hospital del Sureste and Hospital Ramon y Cajal, Madrid, between May 2009 and March 2011. The Hospital del Sureste is a secondary hospital and Hospital Ramon y Cajal is a tertiary hospital. PATIENTS Patients undergoing elective laparoscopic cholecystectomy were studied following informed consent. Inclusion criteria were American Society of Anesthesiologists physical status I to III and age 18 or more. Exclusion criteria were BMI more than 40 kg m, symptomatic hiatus hernia or severe gastro-oesophageal reflux. INTERVENTIONS Anaesthesiologists experienced in the use of LMAP and LMAS participated in the trial. One hundred twenty-two patients were randomly allocated to LMAS or LMAP. MAIN OUTCOME MEASURES Our primary outcome measure was the oropharyngeal leak pressure (OLP). Secondary outcomes were the time and number of attempts for insertion, ease of insertion of the drain tube, adequacy of ventilation and the incidence of complication. Patients were interviewed postoperatively to evaluate the presence of sore throat, dysphagia or dysphonia. RESULTS Two patients were excluded when surgery changed from laparoscopic to open. A total of 120 patients were finally included in the analysis. The mean OLP in the LMAP group was significantly higher than that in the LMAS group (30.7 ± 6.2 versus 26.8 ± 4.1 cmH2O;P < 0.01). This was consistent with a higher maximum tidal volume achieved with the LMAP compared to the LMAS (511 ± 68 versus 475 ± 55 ml; P = 0.04). The success rate of the first attempt insertion was higher for the LMAS group than the LMAP group (96.7 and 71.2%, respectively; P < 0.01). The time taken for insertion, ease of insertion of the drain tube, complications and postoperative pharyngolaryngeal adverse events were similar in both groups. CONCLUSION The LMAP has a higher OLP and achieves a higher maximum tidal volume compared to the LMAS, in patients undergoing elective laparoscopic cholecystectomy. The success of the first attempt insertion was higher for the LMAS.

Postoperative handover: characteristics and considerations on improvement – a systematic review

Abstract: Context Current research has identified numerous safety risks related to patient handovers including postoperative handovers. During the postoperative handover and the recovery period, the patient is at risk of potential complications of surgery or anaesthesia. Furthermore, patients are subject to a downscale in monitoring and observation, which makes them vulnerable to incidents and errors. Objectives To describe the characteristics and potential hazards to quality and patient safety during postoperative handover. To identify concrete recommendations for improvement in this process. Design A systematic review of the literature. Data sources Comprehensive search of electronic databases (Medline, Embase, Cochrane Library) in March 2012. Additional studies were obtained from bibliographies of retrieved reports. Eligibility criteria Studies analysing the characteristics of the postoperative handover and interventional studies with the aim of improving postoperative handover. Only original research was included. Results We identified 23 studies including descriptive and interventional studies. Postoperative handovers are described as a complex work process challenged by interruptions, time pressure and a lack of supporting framework. Interventional studies introduced standardised handover tools in combination with environmental changes, resulting in better flow of information in four out of five, better teamwork in two and less technical errors in two out of three studies. Conclusion Postoperative handover is a complex and dynamic situation. It is very important to analyse the challenges in the local setting and that solutions are customised to fit the specific context in which the postoperative handovers takes place. It is also important to acknowledge the role of non-technical skills in the work process with respect to patient safety. Implementation of new handover strategies must be considered carefully. To optimise the motivation for change among staff, the importance of improvement in postoperative handover in all settings must be outlined in future studies with more patient-specific outcomes.

Effect of dexamethasone on prevention of postoperative nausea, vomiting and pain after caesarean section: a randomised, placebo-controlled, double-blind trial.

Abstract: ContextSpinal morphine is a common form of postoperative analgesia after caesarean section, but it is associated with postoperative nausea and vomiting.ObjectiveTo evaluate the hypothesis that dexamethasone reduces nausea and vomiting in patients undergoing caesarean section under spinal anaesthesia

Sevoflurane, but not propofol, reduces the lung inflammatory response and improves oxygenation in an acute respiratory distress syndrome model: a randomised laboratory study.

Abstract: CONTEXTAcute respiratory distress syndrome is characterised by activation of the inflammatory cascade. The only treatment that reduces the mortality rate associated with this syndrome is lung protective ventilation, which requires sedation of patients. Sedation in critical care units is usually indu

Assessing preoperative anxiety using a questionnaire and clinical rating: a prospective observational study.

Abstract: Background Preoperative anxiety and need for information can be detected during preoperative consultation via structured and standardised screening by the Amsterdam Preoperative Anxiety and Information Scale (APAIS) questionnaire. Objective To identify the prevalence of preoperative anxiety and need for information, with regard to influencing factors such as age, sex, previous operation and grade of surgery, and to examine the level of agreement between patients' self-rating and physicians' ratings. Design Prospective observational study. Setting Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Germany. Patients Two hundred seventeen patients scheduled for elective surgery. Interventions The patients completed questionnaires prior to the interaction with the anaesthesiologist. Physicians were blinded to the patients' ratings and provided their subjective ratings about patients' anxiety and need for information immediately after seeing the patient. Main outcome measure Degree of anxiety and need for information, agreement of patients' self-reports and physician's rating. Results 18.9% of patients were classified as 'anxiety cases' (31.8% in women and 10.6% in men). The grade of the intended surgery but no other investigated factor was related to patients' anxiety. Age (older patients) was correlated with information requirement (r = 0.21, P = 0.002). Analysis of agreement showed only weak correlations between patients' self-reports and physicians' ratings, demonstrated in low weighted Kappa-coefficients (0.12 to 0.32). Conclusion The APAIS is a useful instrument to assess the level of patients' preoperative anxiety and the need for information. Given the relationship between preoperative anxiety and postoperative outcome, it seems justified to incorporate this approach into the preoperative consultation. Trial registration German Clinical Trials Register DRKS00003084.

The effect of deep vs. awake extubation on respiratory complications in high-risk children undergoing adenotonsillectomy: a randomised controlled trial

Abstract: CONTEXTThere is ongoing debate regarding the optimal timing for tracheal extubation in children at increased risk of perioperative respiratory adverse events, particularly following adenotonsillectomy.OBJECTIVETo assess the occurrence of perioperative respiratory adverse events in children undergoin

Pre-interventional haemostatic assessment: Guidelines from the French Society of Anaesthesia and Intensive Care.

Abstract: Recently the French Society of Anaesthesia and Intensive Care (Societe Francaise d'Anesthesie et de Reanimation [SFAR]) issued recommendations for the prescription of routine preoperative testing before a surgical or non-surgical procedure, requiring any type of anaesthesia. Thirty clinical specialists performed a systematic analysis of the literature, and recommendations were then developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. One part of these guidelines is dedicated to haemostatic assessment. The goal of pre-anaesthetic screening for congenital or acquired haemostatic disorders is to prevent perioperative haemorrhagic complications through appropriate medical and surgical management. Preoperative assessment of bleeding risk requires a detailed patient interview to determine any personal or family history of haemorrhagic diathesis, and a physical examination is necessary in order to detect signs of coagulopathy. Laboratory investigation of haemostasis should be prescribed, not systematically, but depending on clinical evaluation and patient history. Standard tests (prothrombin time, activated partial thromboplastin time, platelet count) have a low positive predictive value for bleeding risk in the general population. Patients with no history of haemorrhagic diathesis and no conditions liable to interfere with haemostasis should not undergo pre-interventional haemostasis testing. Conversely, the existence of a positive history or a disease that could interfere with haemostasis should be an indication for clinically appropriate testing.

Implementation of a structured information transfer checklist improves postoperative data transfer after congenital cardiac surgery.

Abstract: BACKGROUND: During one hospital stay, a patient can be cared for by five different units. With patient transfer from one unit to another, it is of prime importance to convey a complete picture of the patient's situation to minimise the risk of medical errors and to provide optimal patient care.OBJECTIVE(S): This study was designed to test the hypothesis that the implementation of a standardised checklist used during verbal patient handover could improve postoperative data transfer after congenital cardiac surgery.DESIGN: Prospective, pre/postinterventional clinical study.SETTING: Cardiac centre of a university hospital.PATIENTS: Forty-eight patients younger than 16 years undergoing heart surgery.INTERVENTIONS: A standardised checklist was developed containing all data that, according to the investigators, should be communicated during the handover of a paediatric cardiac surgery patient from the operating room to the ICU.MAIN OUTCOME MEASURES: Data transfer during the postoperative handover before and after implementation of the checklist was evaluated. Duration of handover, number of interruptions, number of irrelevant data and number of confusing pieces of information were noted. Assessment of the handover process by ICU medical and nursing staff was quantified.RESULTS: After implementation of the information transfer checklist, the overall data transfer increased from 48 to 73% (P<0.001). The duration of data transfer decreased from a median (range) of 6 (2 to 16) to 4min (2 to 19) (P=0.04). The overall handover assessment by the intensive care nursing staff improved significantly after implementation of the checklist.CONCLUSION: Implementation of an information transfer checklist in postoperative paediatric cardiac surgery patients resulted in a more complete transfer of information, with a decrease in the handover duration.

Perioperative pain therapy in opioid abuse.

Abstract: Opioid addiction represents an exaggerated organic and psychological comorbidity and should be regarded as a high-risk problem. Particular features seen perioperatively are tolerance, hyperalgesia and higher analgesic requirement together with physical and psychological withdrawal symptoms. Adequate pain management should have a high priority even for these patients.This review deals with the specific problems of addiction or opioid tolerance in this vulnerable patient group in the perioperative period. In this group are opioid-tolerant chronic pain patients on long-term therapy, addicts with long-term substitution therapy, those currently addicted and those with a previous history of addiction, mainly to heroin. This article intends to simplify the management of drug-dependent patients and offers strategies for perioperative analgesia that include stabilisation of physical dependency by substitution with methadone or μ-agonists; avoidance of stress; use of regional techniques in combination with non-opioids or opioids with higher doses than those used in non-addicts; avoidance of inadequate analgesic dosing; effective use of the opioid-sparing effect of different co-analgesics; and psychological support wherever appropriate.Those caring for abstinent patients should note that an inadequate dosage of analgesics can potentially reactivate addiction. After successful withdrawal of opioids and prolonged abstinence, opioid therapy can result in an exaggerated response.

Incidence of postoperative residual neuromuscular blockade in the postanaesthesia care unit: an observational multicentre study in Portugal.

Abstract: Context Residual neuromuscular blockade still presents despite the use of intermediate duration muscle relaxants and is a risk factor for postoperative morbidity. Objective To determine the incidence of incomplete postoperative neuromuscular recovery from anaesthesia in a postanaesthesia care unit. Design Multicentre observational study. Setting Public Portuguese hospitals. Patients Adult patients scheduled for elective surgery requiring general anaesthesia with neuromuscular blocking agents. Main outcome measures An independent anaesthesiologist measured neuromuscular transmission by the TOF-Watch SX acceleromyograph. Train-of-four ratios at least 0.9 and less than 0.9 were assessed as complete and incomplete neuromuscular recovery following general anaesthesia, respectively. Results The study population consisted of 350 patients [134 men and 216 women, mean (SD) age 54.3 (15.9) years]. Ninety-one patients had a train-of-four ratio less than 0.9 on arrival in the postanaesthesia care unit, an incidence of residual neuromuscular blockade of 26% [95% confidence interval (CI) 21 to 31%]. The most frequent neuromuscular blockers were rocuronium (44.2%) and cisatracurium (32%). A neuromuscular block reversal agent was used in 66.6% of the patients (neostigmine in 97%). The incidence of residual neuromuscular blockade in patients receiving reversal agents was 30% (95% CI 25 to 37%). There were no statistically significant differences in the occurrence of residual blockade relating to the neuromuscular blocker used, although higher percentages were observed for cisatracurium (32.4%) and vecuronium (32%) compared with atracurium (23.6%) and rocuronium (20.8%). Incomplete neuromuscular recovery was significantly more frequent among patients who had received a reversal agent (30.5 vs. 17.1%, P = 0.01). Incomplete neuromuscular recovery was more frequent in patients given propofol than in those exposed to sevoflurane (26.2 vs. 14.3%). Conclusion The incidence of incomplete neuromuscular recovery of 26% confirms that it is relatively frequent in the postoperative period and calls attention to the dimension of this problem in Portugal.

Comparison of the Airtraq and the Macintosh laryngoscope for double-lumen tube intubation: a randomised clinical trial.

Abstract: CONTEXTThe Airtraq is a disposable optical laryngoscope that is available in a double-lumen tube version. Inserting a double-lumen tube is generally more difficult compared to conventional endotracheal intubation, mainly due to its configuration.OBJECTIVEThe aim of this study was to compare the Airt

A multidisciplinary approach to improve preoperative understanding and reduce anxiety: a randomised study.

Abstract: BACKGROUNDEmotional factors may influence reception of information provided during informed consent leading to incomplete understanding and reduced satisfaction.OBJECTIVEThis study was designed to test the hypothesis that a multidisciplinary approach could improve understanding of the information pr

How can we best predict acute kidney injury following cardiac surgery?: a prospective observational study

Abstract: Background Several models for predicting acute kidney injury following cardiac surgery have been published, and various end-point definitions have been used. Objectives Our aim was to investigate how acute kidney injury following cardiac surgery could be most accurately predicted. Design Single-centre prospective observational study. Setting St Olav's University Hospital, Trondheim, Norway, from 2000 to 2007. Patients All 5029 adult patients undergoing cardiac surgery were considered eligible for participation. Patients who required preoperative dialysis and patients with missing information on preoperative or maximum postoperative serum creatinine concentration were excluded (n=51). A total of 4978 patients were entered into the statistical analyses. Main outcome measures Logistic regression with bootstrapping methods was applied for model development and validation, together with the area under the receiver operating characteristic curve and Hosmer-Lemeshow test. We tested different end-points, exchanged serum creatinine concentration with creatinine clearance or estimated glomerular filtration rate and added intraoperative variables. The main end-point was at least 50% increase in serum creatinine concentration, an increase in concentration by at least 26.4 μmol l(-1) (0.3 mg dl(-1)) or a new requirement for dialysis after surgery. Results The final model consisted of 11 preoperative predictors of acute kidney injury: age, BMI, lipid-lowering treatment, hypertension, peripheral vascular disease, chronic pulmonary disease, haemoglobin concentration, serum creatinine concentration, previous cardiac surgery, emergency operation and operation type. The area under the receiver operating characteristic curve was 0.819 (95% confidence interval 0.801 to 0.837), and the Hosmer-Lemeshow test P value was 0.17. Exchanging serum creatinine concentration with glomerular filtration rate or creatinine clearance slightly reduced model discrimination and the addition of intraoperative variables improved discrimination somewhat. Slight end-point definition changes had little impact. Conclusion The risk of acute kidney injury can be accurately predicted using preoperative variables. Serum creatinine concentration was more accurate than estimated glomerular filtration rate or creatinine clearance. Intraoperative variables slightly improved the model, but did not seem to outweigh the advantages of a preoperative model.

Lorazepam does not improve the quality of recovery in day-case surgery patients: a randomised placebo-controlled clinical trial.

Abstract: BACKGROUND: In day-case surgery, the effects of the anxiolytic lorazepam as premedication on the quality of postoperative recovery are unknown. OBJECTIVE: To evaluate whether lorazepam as a premedication beneficially affects quality of recovery (primary outcome) and psychological manifestations (secondary outcome) after day-case surgery. DESIGN: A randomised, double-blind, placebo-controlled clinical trial. SETTING: Single tertiary centre. PATIENTS: INCLUSION CRITERIA: day-case surgery; age at least 18 years. EXCLUSION CRITERIA: insufficient knowledge of the Dutch language; intellectual disability; ophthalmology surgery; extracorporeal shock wave lithotripsy; endoscopy; botulinum toxin A treatment; abortion; chronic pain treatment; preceding use of psychopharmaceuticals; contraindication to lorazepam. INTERVENTION: Lorazepam (1 to 1.5 mg) intravenously vs. NaCl 0.9% as a premedication prior to surgery. MAIN OUTCOME MEASURE: Quality of Recovery-40 (QoR-40) score. SECONDARY OUTCOMES: State-Trait Anxiety Inventory (STAI-State/Trait); State-Trait Anger Scale (STAS-State/Trait); Multidimensional Fatigue Inventory (MFI); Hospital Anxiety and Depression Scale (HADS). Timing of evaluation: T0: preoperatively (all scales); T1: before discharge (STAI-State/Trait); T2: first postoperative working day (QoR-40); T3: 7th day after surgery (all scales). Robust regression analysis was applied. Statistical analyses were adjusted for the corresponding baseline value and sex. RESULTS: Four hundred patients were randomised; 398 patients were analysed. Postoperative mean QoR-40 scores were similar in both groups at T2 (174.5 vs. 176.4, P = 0.34) and T3 (172.8 vs.176.3, P = 0.38). Postoperative mean STAI-State/Trait scores decreased less in the group with lorazepam at T1 (32.3 vs. 29.3, P < 0.0001; 32.7 vs. 30.8, P = 0.0002). STAI-Trait and HADS-Anxiety decreased less in the group with lorazepam at T3 (31.1 vs. 30.0; P = 0.03, 3.3 vs. 2.5, P = 0.003). STAS-State increased in the group with lorazepam at T3 (10.8 vs. 10.3, P = 0.04). CONCLUSION: In day-case surgery, lorazepam as a premedication did not improve quality of recovery. Furthermore, this premedication may delay the decrease in postoperative anxiety and aggression. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01441843.

Management of antithrombotic therapies in patients scheduled for eye surgery

Abstract: The large majority of patients undergoing ophthalmic surgery are elderly and take systemic medications on a regular basis, including antiplatelet and anticoagulant treatments. It is current practice for many physicians to discontinue antithrombotic treatment prior to surgery to reduce bleeding complications that may lead to retrobulbar haemorrhage and, ultimately, to loss of vision. However, discontinuation of antithrombotic treatment in such patients may lead to thromboembolic events with serious consequences. The present narrative review highlights the risk of thrombosis when discontinuing antithrombotic drugs and the risk of bleeding when continuing them. The published literature on this topic shows that discontinuation of antiplatelet or anticoagulant treatment leads to a substantially increased risk of arterial or venous thromboembolic events and related complications, especially in patients with atrial fibrillation, prosthetic heart valves or recent coronary stenting. This risk is distinctly higher than the risk of significant local haemorrhage. Ophthalmic bleeding events reported in the literature are usually minor, without serious consequences, even if antiplatelet or anticoagulant treatments are continued, provided that the anticoagulation level is within the therapeutic range. Thus, the current data are in favour of maintaining antiplatelet and anticoagulant drugs for most ophthalmic procedures, regardless of the anaesthetic techniques.

Pupillometry to detect pain response during general anaesthesia following unilateral popliteal sciatic nerve block: a prospective, observational study.

Abstract: CONTEXT Pupillary reflex dilation appears to be a reliable indicator of response to noxious stimulation even under general anaesthesia. The ability of pupillometry to detect the effects of extremity blocks during continuous infusion of opioids remains unknown. OBJECTIVE To explore the performance of pupillometry to detect differences in pupillary reflex dilation response to a standardised noxious stimulus applied to each leg following unilateral popliteal sciatic nerve block during continuous infusion of remifentanil. DESIGN Prospective, observational study. SETTING University hospital anaesthesia department, between June 2010 and December 2010. PATIENTS Twenty-four adult patients undergoing elective foot or ankle surgery under general anaesthesia who requested a peripheral nerve block. Unilateral popliteal sciatic nerve block with 0.75% ropivacaine and 1% lidocaine was performed awake. General anaesthesia was maintained with steady-state infusions of propofol and remifentanil. MAIN OUTCOME MEASURE Video-based pupillometer was used to determine pupillary reflex dilation during tetanic stimulation (60 m, 100 Hz) applied to the skin area innervated by the sciatic nerve for 5 s after the onset of general anaesthesia. RESULTS Sensory nerve block led to a blunted maximal pupillary reflex dilation response to noxious stimulation compared with the non-blocked leg: median (interquartile range) change from baseline 2% (1 to 4%) versus 17% (13 to 24%), respectively (P < 0.01). The differences in the response persisted throughout the 5-s stimulus and the recovery phase. CONCLUSION These results are a proof of concept. The effects of peripheral nerve block can be detected via the measurement of pupillary reflex dilation response to noxious stimulation of the skin in patients receiving remifentanil.

Emotional sequelae among survivors of critical illness: a long-term retrospective study.

Abstract: ContextTreatment in an ICU can be stressful and traumatic for patients, and can lead to various physical, psychological and cognitive sequelae.ObjectivesThe aim of the study was to assess the influence of the social, economic and working status of individuals in regard to long-term anxiety and depre

Epidural analgesia and postoperative orthostatic haemodynamic changes: observational study.

Abstract: Context In thoracic and abdominal surgery, epidural analgesia provides excellent pain relief, but associated postural hypotension can delay mobilisation. Objectives To assess postoperative orthostatic haemodynamic changes in patients receiving epidural analgesia after major surgery. Design Prospective observational study. Physiological intervention. Settings Montreal General Hospital tertiary teaching hospital. Patients or other participants Patients scheduled for thoracic or abdominal surgery with thoracic epidural analgesia using a mixture of bupivacaine 0.1% and fentanyl 3 μg ml(-1). Intervention(s) Arterial blood pressure and heart rate were measured in supine, sitting and standing position before surgery and daily for the first 3 postoperative days. Main outcome measure Orthostatic hypotension, defined as a drop in SBP of more than 20 mmHg during the orthostatic tests, was investigated as a predictor of inability to mobilise during the postoperative period. Results One hundred and sixty-one patients were enrolled in the study. Hypotension was detected in 59 (37%) of the patients on postoperative day 1, 20 (12%) on day 2 and four (2.5%) on day 3. On day 1, 43% of the patients walked, 39% only sat and 17% were bedridden. Supine SBP less than 90 mmHg, haemodynamic changes during the orthostatic tests, dizziness or nausea, did not predict inability to walk. Only blood loss more than 500 ml and supine mean BP less than 70 mmHg were negative predictors of mobilisation on day 1. Conclusion Epidural analgesia is associated with arterial hypotension in the postoperative period. However, haemodynamic assessment does not predict inability to walk after thoracic and abdominal surgery. Early mobilisation should be tried irrespective of BP or orthostatic changes in postoperative patients with epidural analgesia.

Low-dose neostigmine to antagonise shallow atracurium neuromuscular block during inhalational anaesthesia: A randomised controlled trial.

Abstract: BACKGROUNDEven shallow residual neuromuscular block [i.e. train-of-four (TOF) ratio around 0.6] is harmful. It can be effectively antagonised by small doses of neostigmine, but reports are limited to intravenous anaesthesia. Inhalational anaesthesia may enhance neuromuscular block and delay recovery

Hepatopulmonary syndrome: the anaesthetic considerations.

Abstract: Hepatopulmonary syndrome (HPS) is a pulmonary complication observed in patients with chronic liver disease and/or portal hypertension, attributable to an intrapulmonary vascular dilatation that induces severe hypoxaemia. Considering the favourable long-term survival of HPS patients as well as the reversal of the syndrome with a functional liver graft, HPS is now an indication for orthotopic liver transplantation (OLT). Consequently, blood gas analysis and imaging techniques should be performed when cirrhotic patients present with shortness of breath as well as when OLT candidates are placed on the transplant waiting list. If the arterial partial pressure of oxygen (PaO2) is more than 10.7 kPa when breathing room air, HPS can be excluded and no other investigation is needed. When the PaO2 when breathing room air is 10.7 kPa or less, contrast-enhanced echocardiography should be performed to exclude pulmonary vascular dilatation. Lung function tests may also help detect additional pulmonary diseases that can contribute to impaired oxygenation. When contrast-enhanced echocardiography is negative, HPS is excluded and no follow-up is needed. When contrast-enhanced echocardiography is positive and PaO2 less than 8 kPa, patients should obtain a severity score that provides them with a reasonable probability of being transplanted within 3 months. In mild-to-moderate HPS (PaO2 8 to 10.6 kPa), periodic follow-up is recommended every 3 months to detect any further deterioration in PaO2. Although no intraoperative deaths have been directly attributed to HPS, oxygenation may worsen immediately following OLT due to volume overload and postoperative infections. Mechanical ventilation is often prolonged with an extended stay in the ICU. A high postoperative mortality (mostly within 6 months) is observed in this group of patients in comparison to non-HPS patients. However, the recovery of an adequate PaO2 within 12 months after OLT explains the similar outcome of HPS and non-HPS patients following OLT over a longer time period.

A comparison of noninvasive bioreactance with oesophageal Doppler estimation of stroke volume during open abdominal surgery: an observational study.

Abstract: CONTEXTThe anaesthetist must maintain tissue perfusion by ensuring optimal perioperative fluid balance. This can be achieved using less invasive cardiac output monitors such as oesophageal Doppler monitoring (ODM). Other less invasive cardiac output monitors using bio-impedence technology (noninvasi

Sensitivities of rat primary sensory afferent nerves to magnesium: implications for differential nerve blocks.

Abstract: ContextContrasting findings have been published regarding the role of magnesium sulphate used as an additive to local anaesthetics in peripheral nerve blocks.ObjectiveTo clarify the effect of magnesium sulphate on nerve excitability.SettingC and Aβ compound action potentials were recorded extracellu

A simple epidural simulator: a blinded study assessing the 'feel' of loss of resistance in four fruits.

Abstract: Complex epidural simulators are now available, but these are expensive and not widely available. Simple simulators using fruit have been described before. To ascertain which easily available fruit would best simulate the 'feel' of loss of resistance experienced in epidural insertion and be used as a teaching tool. A single blinded study using four different fruits housed in a purpose-built box to conceal the identities of the fruits. The fruits were labelled A, B, C and D. Two teaching hospitals in Glasgow, Scotland between 2006 and 2007. Fifty participants consisting of consultant anaesthetists, specialist registrars and senior house officers all with previous epidural experience. Insertion of a Tuohy needle into the four concealed fruits (orange, banana, kiwi and honeydew melon). Each participant then completed a questionnaire that included recording of the realism of the 'feel' of loss of resistance of each fruit. The 'feel' of loss of resistance for each fruit was scored on a 100-mm Visual Analogue Scale. A '0 mm' represented 'completely unrealistic feel' and '100 mm' represented 'indistinguishable feel from a real patient'. A total of 62.6% of participants recorded the banana as their first choice. This result was statistically significant after taking into account the grades of the participants, their years of experience, the needle gauge used and the participants' chosen technique. The banana is a cheap and easily available training tool to introduce novice anaesthetists to the feel of loss of resistance, which is best experienced before the first insertion of an epidural in a patient.

Minimised closed circuit coronary artery bypass grafting in the elderly is associated with lower levels of organ-specific biomarkers: a prospective randomised study.

Abstract: BACKGROUNDRestrictive fluid management may protect organ function and improve postoperative outcome in elderly coronary artery bypass grafting (CABG) patients.OBJECTIVEWe assessed organ-specific biomarker release to study the contribution of a fluid restrictive closed circuit concept to organ protec

Impact of haemoglobin concentration on cardiovascular outcome after vascular surgery: a retrospective observational cohort study.

Abstract: Background Although low preoperative haemoglobin (Hb) concentration is a well known risk factor for adverse outcome, little is known about decreases in Hb and postoperative Hb concentrations. Objectives The aim of this study was to evaluate the prognostic impact of both pre- and postoperative Hb concentrations (divided into low, intermediate and high tertiles) as well as Hb decrease, defined as preoperative minus postoperative Hb (g dl(-1)), on postoperative cardiovascular events in vascular surgery patients. Design A retrospective observational cohort study. Setting Erasmus University Medical Centre, Rotterdam, the Netherlands, from 1 January 2002 to 31 December 2011. Patients One thousand four hundred and eighty-four patients underwent elective open or endovascular abdominal aortic repair (aneurysm or stenosis), lower extremity arterial repair or carotid surgery. Patients for whom pre or postoperative Hb concentrations were not available were excluded. Main outcome measures The study endpoint was 30-day postoperative cardiovascular events, including myocardial infarction, heart failure, arrhythmias, stroke, asymptomatic troponin-T release and cardiovascular death. Results In 1041 patients, both pre and postoperative Hb concentrations were available. Thirty-day cardiovascular events occurred in 221 (21%) patients. Multivariable logistic regression analyses, adjusting for age, sex, Revised Cardiac Risk Index (high-risk surgery, coronary heart disease, heart failure, cerebrovascular disease, diabetes mellitus, renal insufficiency), hypertension and hypercholesterolaemia, demonstrated that low preoperative Hb (8.7 to 12.9 g dl(-1)) was associated with 30-day events [odds ratio (OR) 1.7; 95% confidence interval (CI) 1.1 to 2.5]. Intermediate (10.6 to 12.1 g dl(-1)) and low (7.4 to 10.5 g dl(-1)) postoperative Hb and Hb decrease were also associated with an independently increased risk of 30-day events (intermediate Hb: OR 1.7; 95% CI 1.1 to 2.7; low Hb: OR 3.1; 95% CI 2.0 to 4.8; and Hb decrease: OR 1.2; 95% CI 1.1 to 1.3, respectively). Sensitivity analyses excluding patients with transfusions (n=314) demonstrated that only postoperative Hb concentrations remained associated with a high risk of 30-day cardiovascular events (intermediate Hb: OR 1.8; 95% CI 1.0 to 3.3 and low Hb: OR 2.0; 95% CI 1.0 to 4.0). Conclusion Pre and postoperative Hb concentrations and Hb decrease are all related to 30-day cardiovascular events in elective vascular surgery patients. Postoperative Hb concentrations are the strongest predictor of 30-day cardiovascular events.