Anesthesiology

Background: Perioperative pain after abdominal surgery is difficult to manage. Despite the advent of multimodal analgesia techniques, the opioids remain the cornerstone of treatment. Since the opioids' adverse effects are of concern immediate postoperatively, music as a modality that would influence human behavior, is of interest as an adjunct for acute pain management. Our hypothesis was that listening to instrumental music during the perioperative period reduces the pain level and decreases the use of opioids within the first 23 hours after the surgery. Methods: The study was designed as randomized clinical trial, including 54 males who underwent abdominal surgery under general anesthesia. One group was allocated to music therapy intra and postoperatively (G1), and the other was the control group (G2), without music therapy. The statistical analysis for each of the response variable, blood pressure, heart rate, oxygen saturation, visual analogue scale (VAS) score and morphine equivalents (ME), was based on a linear regression analysis accounting for group and time differences and adjusting for covariates (age, height, weight) if necessary (statistically significant). Results: Our study results show a statistically significant difference regarding the mean VAS measurements between the two groups before and after music therapy on arrival in the Postanesthesia Care Unit (PACU) [ 2.4; CI 95% 1.39-3.35 versus 4.1 CI 95% 2.77-5.53], 30 minutes [ 3; CI95% 2.21-3.87 vs 5.48; CI95% 4.34-6.62] and 23 hours later [2.15; CI95% 1.38-2.91 vs 4.37;CI 95% 3.51-5.24] , respectively (Table 2). There was no statistically significant difference in blood pressure (systolic and diastolic), heart rate, oxygen saturation (SpO2), and opioid consumption between the two groups at the three points in time when measurements were done. Conclusions: In this study, a short perioperative exposure to music was effective in reducing the pain perception (as measured by VAS method) but not the opioid consumption in the first 23 hours in male patients after abdominal surgery.

Purpose of the Review-The present review is intended to give an overview of fibromyalgia for the anesthesiologist. While the basics of the treatment of fibromyalgia are included, the intent is to provide context to discuss the potential implications in perioperative management. Recent Findings-One of the most important changes in the last year is the new criteria established by the American College of Rheumatology for the diagnosis of fibromyalgia. Instead of a combination of self-report and a tender point examination, there is a new self-report questionnaire that is now used diagnose fibromyalgia. This tool incorporates aspects of widespread body pain and some of the known comorbid symptoms. A score of 0-31 is given, which allows for the disease to be viewed as a continuum of sensitivity and symptomatology, instead of as a binary diagnosis. This continuum has been termed "fibromyalgia-ness." This article also reviews the advances in understanding of the pathophysiology and emerging therapies. Little is known about the impact of fibromyalgia in the perioperative period. Summary-The impact of fibromyalgia on anesthesia care is not known. Years of quality research have clearly demonstrated multiple pathophysiologic changes that could impact anesthesia care and future study is needed.

Different definitions of cancellation exist in the international literature .Some authors define 'cancellation' as only those procedures that were cancelled on the day on which surgery was scheduled [8], whereas others also include those that were cancelled on the previous day [9, 10]. The Modernization Agency Theatre Programme (National Health Service (NHS), UK) appears to define cancellations as those that occur after the patient has been

With the growing requirement of echocardiography in the perioperative management, the anesthesiologists need to be well trained in transthoracic echocardiography (TTE). Lack of formal, structured teaching program precludes the same. The present article reviews the expanding domain of TTE, simulation-based TTE training, the advancements, current limitations, and the importance of simulation-based training for the anesthesiologists.

Background. The aim of this study was to explore difficulties at work from anaesthetists' own perspective and to examine how anaesthetists handle and cope with situations that are perceived as difficult and potentially stressful. Methods. Two sets of interviews were conducted with 19 specialist anaesthetists in Sweden. The first set of interviews aimed at finding how the anaesthetists experienced difficulties at work. It consisted of in-depth interviews based on one open-ended question. We analysed the interviews with a phenomenological method, looking for themes in anaesthetists' descriptions of difficulties at work. In the second set, the interviews were semi-structured with open-ended questions, based on themes found in the first interview set. These interviews aimed at exploring how the interviewees described their ways of handling difficulties and how they coped with potentially stressful situations. Results. Analysis of the first set of interviews resulted in five themes, describing how the anaesthetists experienced difficulties at work. All interviewees talked about difficulties related to more than one of the themes. The second set of interviews revealed two main categories of ways of handling difficulties. First, problem solving consisted of descriptions of methods for handling difficult situations which aimed at solving problems, and second, coping strategies described ways of appraising potentially stressful situations that minimized stress, despite the problem not being solved. Conclusions. The anaesthetists interviewed in this study maintained that they enjoyed work and could see no external obstacles to doing a good job. They had arrived at a reconciliation of their work with its inherent difficulties and problems. Getting access to their coping strategies might help young anaesthetists to come to terms with their work.

We read with interest the study by Scavone et al. 1 that demonstrates the absence of efficacy of a prophylactic epidural blood patch after inadvertent dural puncture. We suggest that two factors could have influenced the negative result of this trial. First, inadvertent dural puncture could have been overdiagnosed, namely when loss of resistance to saline was used to locate epidural space. This could explain the lower incidence of post-dural puncture headache and less frequent realization of therapeutic epidural blood patch reported in this study compared with others. 2,3 Second, 20 ml may not be the adequate blood volume to test a prophylactic epidural blood patch. This volume has tended to increase over time to 20 ml or more, 23 Ϯ 5 ml in a study by Safat-Tisseront et al. 3 The optimal blood volume may be the volume at which pain in the back, buttocks, or legs occurs, which was only achieved for seven patients in the study of Scavone et al. This higher volume may lead to either a larger patch over the dural tear or a significantly higher increase in lumbar and intracranial pressure, leading to reduced cerebral vasodilation.

The anaesthetist plays a key role in the management of high-risk pregnancies, and must be a member of the multidisciplinary team that is required to care for the critically ill obstetric patient. Anaesthetists are trained in advanced life support and resuscitation. They are experienced in the management of the critically ill, and provide anaesthesia, sedation and pain management. The obstetric anaesthetist should undertake education of medical and midwifery staff in the early recognition, monitoring and treatment of the sick mother, resuscitation training, running 'skills drills' for emergency simulations, risk management and audit of maternal morbidity on the labour ward. To date, there is little evidence to inform the anaesthetic management of the critically ill obstetric patient; most recommendations and guidelines are based on the management of non-obstetric, critically ill patients. Management must be adapted to encompass the physiological changes of pregnancy. Evidence-based guidelines on management of the critically ill woman with specific obstetric conditions are also lacking.

Background: Recurrent complex regional pain syndrome I is not rare in the pediatric population. The authors conducted this study to evaluate the efficacy of continuous peripheral nerve blocks with elastomeric disposable pumps associated with initial Bier blocks for the treatment of recurrent complex regional pain syndrome I in children.

F ROM its origins as a modified ureteral catheter, the epidural catheter has evolved into versions made with silk, rubber, plastic, and coiled stainless steel. These changes resulted from a growing recognition that particular design elements could potentially influence catheter performance. This article reviews the history of epidural catheter design, focusing on how modifications in the materials used, tip design, and orifice number and arrangement may have affected analgesic and anesthetic outcomes, and provides a summary of the comparative studies that evaluate the clinical performance of distinct epidural catheter design features. History The most consistent entry into the epidural space for the administration of anesthesia occurred at the turn of the 20th century when the French physicians Jean A. Sicard, M.D.

Abstract: A total of 13 cadavers (12 men and 1 women) of different age group were used for the study with the purpose to determine the prevalence of femoral vein duplication. Lower limb regions (26 sides) were carefully dissected as per the standard dissection procedure. Femoral vein (unitruncular) was found in 96.15% of specimen. Bitruncular configurations (total bifidity) was found in a male cadaver of 75 years of age (3.85%). In the right lower limb, 6.5 cms below the inguinal ligament the femoral vein - lateral ramus received the lateral circumflex femoral vein, and the medial circumflex femoral vein, and the lateral and medial ramii formed a common venous trunk. Knowledge of the truncular venous variations is important to recognize and avoid potential errors in diagnosis of deep venous thrombosis of the femoral vein, in the case of an occluded duplicated trunk.

Different modes of death are described in selected populations, but few data report the characteristics of death in a general intensive care unit population. This study analyzed the causes and characteristics of death of critically ill patients and compared anticipated death patients to unexpected death counterparts. An observational multicenter cohort study was performed in 96 intensive care units. During 1 yr, each intensive care unit was randomized to participate during a 1-month period. Demographic data, characteristics of organ failures (Sequential Organ Failure Assessment subscore greater than or equal to 3), and organ supports were collected on all patients who died in the intensive care unit. Modes of death were defined as anticipated (after withdrawal or withholding of treatment or brain death) or unexpected (despite engagement of full-level care or sudden refractory cardiac arrest). A total of 698 patients were included during the study period. At the time of death, 84% ha...

Editor's key points † The ASA physical status classification was designed as a measure of preoperative health status, not operative risk. † This study found good agreement with how different anaesthetists rate a patient's ASA classification. † This study used psychometric methods to show that the ASA classification is an indicator of perioperative risk.

Melatonin possesses sedative, hypnotic, analgesic, antiinflammatory, antioxidative, and chronobiotic properties that distinguish it as an attractive alternative premedicant. A qualitative systematic review of the literature concerning the perioperative use of melatonin as an anxiolytic or analgesic in adult patients was carried out using the recommended guidelines provided by the Cochrane Handbook for Systematic Reviews of Interventions. Nine of the 10 studies showed statistically significant reduction of preoperative anxiety with melatonin premedication compared with placebo. An opioid-sparing effect or reduced pain scores were evident in five studies whereas three studies were contradictory. Thus, melatonin premedication is effective in ameliorating preoperative anxiety in adults, but its analgesic effects remain controversial in the perioperative period. Additional well designed randomized controlled trials are necessary to compare melatonin premedication with other pharmacological interventions, investigate its effect on more varied surgical populations, and to delineate its optimal dosing regimen.

The anesthesiology profession may one day serve as a cautionary tale of how power, politics and privilege can perturb science and progress. Previous anesthesia practitioners possessed a superior understanding of physiology and pharmacology, but overenthusiastic CO2 supplementation with inadequate monitors and machines caused asphyxiation disasters that were improperly attributed to CO2 toxicity. Dr. Ralph Waters founded the anesthesiology profession on the basis of a practical new anesthetic tech- nique that introduced elective intubation and hyperventilation to eliminate CO2 toxicity, but mechanical hyperventilation dangerously depletes CO2 tissue reserves and exag- gerates morbidity and mortality. The bene ts of CO2 supplementation were forgotten, and consequent CO2 confusion has derailed research, discouraged opioid treatment, damaged patient safety, and disrupted professional progress. Anesthesiologists can no longer claim to provide superior service, and hospital administrators are replacing them with nurses. Professional membership is in decline, and professional survival is in ques- tion. Modern machines have eliminated asphyxiation, and modern monitoring enables safe and bene cial hypercarbia that complements opioid treatment and minimizes sur- gical morbidity and mortality. CO2 reform promises revolutionary advance but faces formidable opposition.

Incident Reporting Systems (IRS) continue to be an important influence
on improving patient safety. IRS can provide valuable insights
into how to prevent patients from being harmed at the
organizational level. But inadequate expectations and misuse, for
performance assessment, patient safety measurement or research,
have hindered the full IRS potential. Health care organizations
need to develop effective strategies built on trust and truth telling
to improve the impact of IRS. This requires strategies to address
the limited resources to analyse the near-misses or adverse events;
avoid the punitive drift through maintaining the anonymity and
protective legislation; integrating IRS and avoiding its confusion
with mandatory adverse event response systems; training data
analysts to focus on the system instead of the individual through a
balanced simple taxonomy; combine the analyses at the local level,
to reinforce effective and personalized feedback, with the potential
of a national or supranational learning platform.

Practice guidelines on weaning should be based on the results of several well-designed randomized studies performed over the last decade. One of those studies demonstrated that immediate extubation after successful trials of spontaneous breathing expedites weaning and reduces the duration of mechanical ventilation as compared with a more gradual discontinuation of ventilatory support. Two other studies showed that the ability to breathe spontaneously can be adequately tested by performing a trial with either T-tube or pressure support of 7 cmH 2 O lasting either 30 or 120 min. In patients with unsuccessful weaning trials, a gradual withdrawal for mechanical ventilation can be attempted while factors responsible for the ventilatory dependence are corrected. Two randomized studies found that, in difficult-to-wean patients, synchronized intermittent mandatory ventilation (SIMV) is the most effective method of weaning.

Purpose of review Patient care in the operating room is a dynamic interaction that requires cooperation among team members and reliance upon sophisticated technology. Most human factors research in medicine has been focused on analyzing errors and implementing system-wide changes to prevent them from recurring. We describe a set of techniques that has been used successfully by the aviation industry to analyze errors and adverse events and explain how these techniques can be applied to patient care.

Informed consent in medical practice is essential and a global standard that should be sought at all the times doctors interact with patients. Its intensity would vary depending on the invasiveness and risks associated with the anticipated treatment. To our knowledge there has not been any systematic review of consent practices to document best practices and identify areas that need improvement in our setting. The objective of the study was to evaluate the informed consent practices of surgeons at University teaching Hospitals in a low resource setting. A cross-sectional study conducted at three university teaching hospitals in Uganda. Self-guided questionnaires were left at a central location in each of the surgical departments after verbally communicating to the surgeons of the intention of the study. Filled questionnaires were returned at the same location by the respondents for collection by the research team. In addition, 20 in-depth interviews were held with surgeons and a rev...

To study the patients' characteristics, outcomes, contributory factors, factors minimizing the incidence and suggested corrective strategies for perioperative pulmonary aspiration in Thailand. This is a prospective descriptive research design. The relevant data was extracted from the incident reports on aspiration from 51 hospitals across Thailand during the study period between January 1 and June 30, 2007 from the Thai Anesthesia Incident Monitoring Study (Thai AIMS) database. Descriptive statistics was used. Each incident report was reviewed by three senior anesthesiologists. Any disagreement was discussed to achieve a consensus. From 1,996 incident reports, there were 28 reports (1.4%) that met the definition of pulmonary aspiration. Most of the incidents occurred in patients with ASA 1-2 (85.7%), during the official hour (64.3%) and the anesthesiologists were in charge (67.9%). Eleven incidents (39.3%) occurred during induction, seven (25%) during maintenance and seven (25%)...

Background and Objectives: The assessment and quantification of postoperative pain is more difficult in children than adults. Regional anesthesia and analgesia has shown to provide excellent analgesia and also provide benefits, which extend beyond the perioperative period. Caudal epidural block is a gold standard technique in paediatric lower abdominal surgeries. The aim of this study is to evaluate perioperative effect of caudal epidural block in children undergoing laparoscopic hernia repair surgeries regarding hemodynamic changes in intra-operative period, postoperative pain score, rescue analgesia requirement and any side effects.
Methods: Sixty children aged 2–12 years with ASA grade I or II scheduled for laparoscopic unilateral hernia repair were randomly allocated into two groups: group A (General anaesthesia with caudal block) and group B (General anaesthesia without caudal block). Postoperative pain scores, rescue analgesic requirement, intraoperative hemodynamic changes, any complication
related to caudal block were recorded.
Results: All children were comparable regarding demographic profile. There was no statistically significant difference in hemodynamic changes between both the groups. The mean postoperative pain score was significantly lower in group A (2.98 ± 1.08) as compared to group B (3.63 ± 1.49) (p = 0.002). Eleven (36%) subjects in group A and 25 (83%) subjects in group B needed rescue analgesic in postoperative period. The incidence of adverse effects was higher (30%) in group A than group B (13%).
Conclusion: We concluded that caudal bock with 0.2% ropivacaine in paediatric patients provides better analgesia, without significant intraoperative hemodynamic changes.

Successful and sustainable training and learning of the management of difficult and normal airway is essential for all clinically active anesthesiologists. We emphasize the importance of a continuously updated learning and training environment based on actual knowledge, best available equipment, standardized procedures, and educational theory. In the past, most of the training were based on 'learning by doing' under the supervision of superiors or experienced colleagues. This has been recognized as insufficient and training has evolved to its recent level by structuring it into technical, methodological, and behavioral components. Additionally, a large part of it has been shifted away from learning on patients to simulated scenarios in designated environments. The contents, structure, components, and succession of components have been refined according to the steadily evolving and available instruments. Increasingly, team interaction and behavioral aspects gained more attent...

There are many simulators available for use in anaesthetic-related education and research. Those who wish to purchase a simulator or to establish a simulation facility face a daunting task in understanding the differences between simulators. Recent reviews have focused on narrower areas of simulation, such as airway management or basic life support, or on the application of simulators. It would be difficult to deal in detail with every simulator ever made for anaesthesia, but in the present review we cover the spectrum of currently available anaesthetic simulators, provide an overview of different types of simulator, and discuss a selection of simulators of particular interest, including some of historical significance and some examples of 'home made' simulators. We have found no common terminology amongst authors for describing or classifying simulators, and propose a framework for describing (or classifying) them that is simple, clear and applicable to any simulator.

Many surgical patients are anxious while waiting to go to the operating theatre in spite of the best preparation with drugs, information and reassurance. It is possible that patients could be more comfortable if allowed a choice of activities before operations. The objective of this study was to find out how pre-operative patients might prefer to occupy their time. We distributed 200 questionnaires to elective surgery patients and 184 (92%) were available for analysis. Of the respondents, 54.1% wanted to be slightly sleepy, 72.0% preferred not to be fast asleep and 57.2% preferred not to be wide awake. Reading (56.8%), listening to music (57.1%) and chatting with other patients (39.9%) were preferred activities. It might be appropriate to ask patients how sedated they would wish to be before their surgery and perhaps have alternatives to sedation available.

Background: Patients with initial mild acute respiratory distress syndrome are often underrecognized and mistakenly considered to have low disease severity and favorable outcomes. They represent a relatively poorly characterized population that was only classified as having acute respiratory distress syndrome in the most recent definition. Our primary objective was to describe the natural course and the factors associated with worsening and mortality in this population. Methods: This study analyzed patients from the international prospective Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) who had initial mild acute respiratory distress syndrome in the first day of inclusion. This study defined three groups based on the evolution of severity in the first week: "worsening" if moderate or severe acute respiratory distress syndrome criteria were met, "persisting" if mild acute respiratory distress syndrome criteria were the most severe category, and "improving" if patients did not fulfill acute respiratory distress syndrome criteria any more from day 2. results: Among 580 patients with initial mild acute respiratory distress syndrome, 18% (103 of 580) continuously improved, 36% (210 of 580) had persisting mild acute respiratory distress syndrome, and 46% (267 of 580) worsened in the first week after acute respiratory distress syndrome onset. Global in-hospital mortality was 30% (172 of 576; specifically 10% [10 of 101], 30% [63 of 210], and 37% [99 of 265] for patients with improving, persisting, and worsening acute respiratory distress syndrome, respectively), and the median (interquartile range) duration of mechanical ventilation was 7 (4, 14) days (specifically 3 [2, 5], 7 [4, 14], and 11 [6, 18] days for patients with improving, persisting, and worsening acute respiratory distress syndrome, respectively). Admissions for trauma or pneumonia, higher nonpulmonary sequential organ failure assessment score, lower partial pressure of alveolar oxygen/fraction of inspired oxygen, and higher peak inspiratory pressure were independently associated with worsening. Conclusions: Most patients with initial mild acute respiratory distress syndrome continue to fulfill acute respiratory distress syndrome criteria in the first week, and nearly half worsen in severity. Their mortality is high, particularly in patients with worsening acute respiratory distress syndrome, emphasizing the need for close attention to this patient population.

T HE liver plays a key role in the synthesis of proteins, metabolism of toxins and drugs, and in modulation of immunity. In critically ill patients, hypoxic, toxic, and inflammatory insults can affect hepatic excretory, synthetic, and/or purification functions, leading to systemic complications such as coagulopathy, increased risk of infection, hypoglycemia, and acute kidney injury. In severe cases, hepatic encephalopathy or brain dysfunction (acute liver failure) may occur. Because of the lack of specificity of standard laboratory investigations, identifying liver injury or dysfunction in critically ill patients remains a significant challenge. In addition, the great heterogeneity of criteria used to define the consequences of liver insults increases the difficulties for the clinician to properly interpret hepatic biochemical abnormalities. In this review, we choose to define liver injury as an elevation in serum concentrations of routinely measured hepatic enzymes, including aminotransferases (aspartate aminotransferase [AST]; alanine aminotransferase, [ALT]), alkaline phosphatase (ALP), or ␥-glutamyl transpeptidase. Hepatic dysfunction refers to derangement of pathways related to synthetic or clearance function, including international normalized ratio (INR) and bilirubin. Hepatotoxicity refers to hepatic injury and dysfunction caused by a drug or another noninfectious agent. 1 Acute liver failure designates liver injury that results in life-threatening hepatic synthetic dysfunction and brain dysfunction (encephalopathy) ( ).

Chronic kidney disease is one of the leading co-morbidity at present. With the increasing prevalence of diabetes mellitus and hypertension, more and more peoples are developing diabetic and hypertensive nephropathy. As chronic kidney disease patient can present as an asymptomatic stable patient in one end and a multi-organ involved complicated end-stage disease in other ends, their management plan also varies. The serum creatinine levels of as low as 1.5 mg% have been linked to perioperative major cardiac events like myocardial infarction and arrest; these patients poses a challenge to the perioperative team. Moreover, a chance of developing acute kidney injury on the chronic kidney disease is also higher. These patients are also often elderly, with diabetes mellitus and/or hypertension. Therefore, accepting such patient for perioperative care needs systematic and meticulous approach. Preoperative assessment, risk stratification, and optimization play a great role. Both intraoperative and postoperative management needs a tailored approach. The present narrative review is prepared to give the current insight on these aspects.

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