Often conventional Inhalational agents are used for maintenance of anaesthesia in spine surgery. This study was undertaken to compare propofol with isoflurane anaesthesia with regard to haemodynamic stability, early emergence, postoperative nausea and vomiting (PONV) and early assessment of neurological functions.
Patients & Methods:
Eighty ASA grade I &II adult patients were randomly allocated into two groups. Patients in study group received inj propofol for induction as well as for maintenance along with N2O+O2 and the control group patients received inj thiopentone for induction and N2O+O2+isoflurane for maintenance. BIS monitoring was used for titrating the anaesthetic dose adjustments in all patients. All patients received fentanyl boluses for intraoperative analgesia and atracurium as muscle relaxant. Statistical data containing haemodynamic parameters, PONV, emergence time, dose of drug consumed & quality of surgical field were recorded and compared using student t' test and Chi square test.
The haemodynamic stability was coparable in both the groups. The quality of surgical field were better in study group. Though there was no significant difference in the recovery profile (8.3% Vs 9.02%) between both the groups, the postoperative nausea and vomiting was less in propofol group than isoflurane group (25%Vs60%). The anaesthesia cost was nearly double for propofol than isoflurane anaesthesia.
Haemodynamic stability was comparable in both the groups. There was no significant difference in the recovery time between intravenous and inhalational group. Patients in propofol group were clear headed at awakening and were better oriented to place than inhalational group.
Propofol; Isoflurane anaesthesia; spine surgery
Desflurane's short emergence time supports fast track anaesthesia. Data on the rate of upper airway complications and emergence time when desflurane is used with laryngeal mask airway (LMA) are controversial and limited.
To compare recovery time variables and the rates of upper airway adverse events in patients with an LMA undergoing general surgery with desflurane, sevoflurane, isoflurane or propofol anaesthesia.
A systematic review and meta-analysis of randomised controlled trials (RCTs).
A systematic search for eligible RCTs in Embase (Elsevier) and in PubMed (National Library of Medicine) databases up to September 2013.
RCTs investigating the rates of cough overall, cough at emergence, laryngospasm, time to eye opening, time to removal of the LMA, time to respond to command and time to state date of birth in patients with an LMA, during emergence from desflurane, sevoflurane, isoflurane or propofol anaesthesia.
Thirteen RCTs were included and analysed. We found a strong interstudy variability. There was no difference in the rates of upper airway events between desflurane and sevoflurane or between desflurane and a control group consisting of all the other anaesthetics combined. Comparing desflurane (n = 284) with all other anaesthetic groups (n = 313), the risk ratio [95% confidence interval (95% CI)] was 1.12 (0.63 to 2.02, P = 0.70). Cough at emergence was only measured in patients receiving desflurane (n = 148) and sevoflurane (n = 146): the risk ratio (95% CI) was 1.49 (0.55 to 4.02, P = 0.43). Laryngospasm was rare and there was no significant difference in its incidence when desflurane (n = 262) was compared with all other anaesthetics combined (n = 289; risk ratio 1.03; 95% CI 0.33 to 3.20, P = 0.96). The times of all emergence variables were significantly faster in the desflurane group than in all other groups.
When using an LMA, upper airway adverse reactions in association with desflurane anaesthesia were no different from those noted with sevoflurane, isoflurane or propofol anaesthesia. Emergence from general anaesthesia with desflurane is significantly faster than all the other anaesthetics. Due to interstudy variations and the small size of the trials, further large-scale, multicentre studies are required to confirm or refute the results of this meta-analysis.
Methods: Survey of resident/attending emergency physicians working in a tertiary care medical centre.
Results: Of 68 physicians, 46 responded: 98% believed that awake and alert patients find NGT insertion uncomfortable/painful; 93% used measures to reduce this, most commonly lubricant gel, topical anaesthetic spray, lidocaine gel, and distraction/use of a child life worker; 28% believed these provided adequate pain control and 37% believed they were inadequate. Topical anaesthetic spray, lidocaine gel, and nebulised/atomised anaesthetics were believed the most practical to administer and 44% actually used these. Nebulised/atomised anaesthetics, systemic anxiolytics, and topical anaesthetic spray were believed the most effective at pain control but only 24% actually used these. While 39% of respondents were satisfied with their current practice, 46% were dissatisfied: 91% would change their practice if new literature were to show a convenient way to effectively reduce this pain.
Conclusions: Emergency physicians do not actually use the measures they believe are most practical/most effective at reducing the pain associated with NGT insertion. Thus, there may be a barrier to the use of these measures. Improvement in procedural anaesthesia for NGT insertion in emergency departments is needed and desired by emergency physicians.
The postoperative cognitive function is impaired in elderly patients after general anaesthesia. The fast recovery after xenon anaesthesia was hypothesized to be advantageous in this scenario. We compared early postoperative cognitive function after xenon and sevoflurane anaesthesia in this study.
The study was approved by the local ethics committee and written informed consent was obtained from each patient. Patients aged 65-75 years (ASA I-III) scheduled for elective surgery (duration 60-180 min) were enrolled. Investigators performing cognitive testing and patients were blinded towards allocation to either xenon or sevoflurane anaesthesia. Baseline assessment of cognitive function was carried out 12-24 h before the operation. The results were compared to follow-up tests 6-12 and 66-72 h after surgery. Primary outcome parameter was the subtest "Alertness" of the computerized Test of Attentional Performance (TAP). Secondary outcome parameters included further subtests of the TAP, several Paper-Pencil-Tests, emergence times from anaesthesia, modified Aldrete scores and patients' well-being.
40 patients were randomized and equally allocated to both groups. No significant differences were found in the TAP or the Paper-Pencil-Tests at 6-12 and 66-72 h after the operation. All emergence times were faster after xenon anaesthesia. The modified Aldrete scores were significantly higher during the first hour in the xenon group. No difference in well-being could be detected between both groups.
The results show no difference in the incidence of postoperative cognitive dysfunction (POCD) after xenon or sevoflurane anaesthesia. Emergence from general anaesthesia was faster in the xenon group.
Emergence agitation (EA), although well documented in the clinical literature, still has uncertainties and confusion abound on this subject because of the absence of a clear definition and lack of reliable and valid assessment tools.
To compare the incidence and severity of EA and recovery characteristics in paediatric patients under isoflurane, sevoflurane or desflurane anaesthesia and evaluate the effect of age and duration of anaesthesia on the incidence of EA.
Settings and Design:
Randomized prospective double-blinded study.
Seventy-five American Society of Anaesthesiologists I and II patients, aged between 4 months and 7 years, were included in the study. Patients were induced with sevoflurane and oxygen. Anaesthesia was maintained with O2 + N2O and isoflurane, sevoflurane or desflurane according to randomization. Caudal block and paracetamol suppository was administered before the surgical incision. In the Post-Anesthesia Care Unit (PACU), degree of agitation was assessed using the Paediatric Anaesthesia Emergence Delirium Scale. Aldrette score, Face, Legs, Activity, Cry, Consolability score and any adverse events were noted.
Chi-square/Fischer exact test was applied for categorical variables; for continuous variables, the analysis of variance/non-parametric Kruskall–Wallis test was applied. Two-sample t-test/non-parametric Wisconsin Mann–Whitney test was applied between the two groups. Statistical significance was determined at P<0.05.
Incidence and intensity of EA were comparable in all three groups. Age and duration of anaesthesia do not appear to have any bearing on the incidence of EA. Rapid emergence with sevoflurane and desflurane did not translate into early discharge from PACU.
EA is a multifactorial syndrome. More well-conducted studies using validated scales and standardized protocols should be carried out to better understand this phenomenon.
Emergence agitation; desflurane; isoflurane; paediatrics; sevoflurane
Emergence agitation (EA) is frequently observed in children undergoing general anaesthesia. This study tested whether the addition of an intra-operative low-dose infusion of dexmedetomidine to fentanyl treatment reduced the incidence of emergence delirium following desflurane anesthesia in children undergoing strabismus surgery.
Materials and Methods
A total of 96 children (1-5 years old) undergoing strabismus surgery were enrolled. Anaesthesia was induced with propofol and maintained with desflurane. After induction, fentanyl (1 µg/kg) was administered to all children. During surgery, patients were infused with 0.2 µg/(kg·h)-1 dexmedetomidine (Group FD, n=47) or normal saline (Group F, n=47). Postoperative objective pain score (OPS), Paediatric Agitation and Emergence Delirium (PAED) score, and EA score were documented every 10 minutes in the post-anaesthesia care unit.
There were no significant differences between the two groups in demographic characteristics and haemodynamic changes. The mean values of maximum EA, maximum PAED, and maximum OPS score were significantly lower in Group FD than in Group F at 0, 10, and 20 minutes after arrival at the post-anaesthesia care unit (p<0.001). The frequency of fentanyl rescue was lower in Group FD than in Group F (p<0.001). The incidence of severe EA was significantly lower in Group FD than in Group F (12.8% vs. 74.5%, p<0.001).
Intra-operative low-dose infusion of dexmedetomidine in addition to fentanyl reduces EA following desflurane anaesthesia in children undergoing strabismus surgeries.
Dexmedetomidine; emergence agitation; objective pain score; pediatrics
To review the anaesthetic management and outcome for emergency laparotomy for paediatric intestinal obstruction in the University of Nigeria Teaching Hospital, Enugu, Nigeria.
The anaesthetic charts and folders of pediatric patients that had emergency laparotomy for intestinal obstruction in the general operating theatre of the University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria, from October 2007 – September 2008 were reviewed. The records were examined for anaesthetic technique, patient primary diagnosis, intra-operative events, blood and fluid therapy and patient outcome. Patients above thirteen years were excluded.
Forty-four out of 285 (15.7%) paediatric patients underwent emergency laparotomy for intestinal obstruction in the general operating theatre. There were 29 males and 15 females. The average age of the patients was 3.75 years. There were a total of 1674 anesthetics in the general operating theatre during the study. The leading causes of intestinal obstruction in this study were typhoid peritonitis (14 or 31.8%), intussusceptions (14 or 31.8%) and congenital anomalies (11 or 25%). Six patients (13%) had a preoperative packed cell volume of less than 30%, while ten patients received intra-operative blood transfusion (21.7%). There was one anesthetic death to give a case mortality rate of 2.2%.
The mortality rate in this study shows the importance and relevance of trained providers of anaesthesia managing paediatric patients in the developing world. Early presentation of patients allowed time for resuscitation and fewer complications before surgery.
Emergence from general anaesthesia has been a process characterized by large individual variability. Delayed emergence from anaesthesia remains a major cause of concern both for anaesthesiologist and surgeon. The principal factor for delayed awakening from anaesthesia is assumed to be the medications and anaesthetic agents used in the perioperative period. However, sometimes certain non-anaesthetic events may lead to delayed awakening or even non-awakening from general anaesthesia. We report the non-anaesthetic cause (acute intracerebral haemorrhage) for non-awakening following ventriculo-peritoneal shunt surgery.
Intracerebral haemorrhage; non-awakening from anaesthesia; ventriculo-peritoneal shunt
Both sevoflurane and desflurane have shorter emergence times compared to isoflurane based anaesthesia. Because of its pharmacological properties, desflurane appears to yield a rapid early and intermediate recovery compared with sevoflurane. The aim of this study was to assess the maintenance and emergence characteristics after anaesthesia with sevoflurane or desflurane. One hundred female patients scheduled to undergo daycare laparoscopic gynaecological surgery were enrolled for this prospective study. Patients were randomised into two groups to receive either desflurane [group I (D); n = 50] or sevoflurane [group II (S); n = 50] for maintenance of anaesthesia. The demographic data and the duration of procedure were comparable in both the groups. The early recovery time was shorter after maintenance of anaesthesia with desflurane compared with sevoflurane. However, this faster early recovery failed to lead to early readiness for home discharge. The intraoperative haemodynamic characteristics were comparable with both sevoflurane and desflurane. Both sevoflurane and desflurane provide a similar time to home readiness despite a faster early recovery with desflurane. The intraoperative haemodynamics are similar with both the agents.
Desflurane; outpatient; recovery; sevoflurane
In the present study, we compared isoflurane with sevoflurane in day care surgeries in order to determine the suitability of each agent for anaesthesia with Classical laryngeal mask airway (LMA).
The aim of this study has been to compare isoflurane and sevoflurane as maintenance anaesthetic agents in day care surgeries with respect to intraoperative haemodynamics, recovery profile, time of first postoperative analgesia and pain score, adverse effects when used with classical LMA.
Settings and Design:
This open - level, prospective randomized study was carried out on 60 patients who were admitted on a day care basis for elective short surgical procedures.
The patients were randomly assigned to one of the two study groups of 30 patients each. First group was maintained on isoflurane and second on sevoflurane as inhalational agent.
The observations obtained in both the groups were recorded and tabulated. Statistical analysis was carried out using the Student t test, Chi-square test, Mann-Whitney test.
Emergence from Sevoflurane was significantly quicker as compared to isoflurane. Sevoflurane group also showed earlier discharge time from the post anaesthesia care unit (PACU)-1 as compared to isoflurane group, but discharge time was same from the PACU-1. Isoflurane has more incidences of mild airway hyper reactivity when compared to sevoflurane.
It can be concluded that both isoflurane and sevoflurane are suitable for day care anaesthesia. Sevoflurane has little advantages of less airway hyper reactivity and quicker emergence and discharge from PACU-1.
Anaesthesia; classical laryngeal mask airway; day care surgery; isoflurane; sevoflurane
High-risk obstetric patients in the immediate postpartum period are frequently admitted to the intensive care unit, but the necessity of this practice has recently been doubted. Herein we describe the efficiency of utilizing the post-anaesthesia care unit (PACU) as an intermediate intensive care facility for those patients.
Material and methods
We retrospectively described the reasons for admission, duration of stay, the anaesthetic used, main interventions and outcome for all obstetric admissions in the PACU during a period of 4 years in a university hospital.
During the 4-year period 47 women were admitted to the PACU after delivery. The frequency of admission to the PACU was 15.3 per 1000 deliveries, while obstetric cases represented 4.4 per 1000 admissions to the PACU. The majority represented caesarean sections (81%). The main reasons for admission to the PACU were haemorrhage (49%), cardiovascular problems (19%) and preeclampsia/eclampsia (17%). Mean length of stay in the PACU was 14.5 ±11.6 h, being significantly less in women having received epidural anaesthesia (8.2 ±5.6 h) compared to those who delivered with general anaesthesia (19.0 ±13.6 h, p < 0.05). General anaesthesia was used in 85% of cases in which emergency delivery was indicated, but only in 27% of cases without emergency indications for delivery (p < 0.01). No death or admission to the intensive care unit occurred during the study period.
The PACU can offer an intermediate intensive care facility for high-risk obstetric patients, thus reducing unnecessary admissions to the intensive care unit.
maternal morbidity and mortality; complications of pregnancy
Eclampsia remains a problem in the developing countries despite improvements in antenatal care and emergency obstetric facilities. It is an important cause of maternal morbidity and mortality in Nigeria. A 26-year-old primipara, residing in an urban city in Nigeria with antenatal care facilities, booked for antenatal care at 36 weeks of gestation and was then diagnosed with severe pre-eclampsia. She initially refused therapy and was later booked for an emergency cesarean section. She had eclamptic fits during cesarean section under spinal anesthesia, and the seizure was aborted with intravenous diazepam. The postoperative period was uneventful. Progression of pre-eclampsia to eclampsia during cesarean section under spinal anesthesia is rare, but it can occur. Early booking for antenatal care to enable an early diagnosis and treatment are necessary to prevent the progression of pre-eclampsia to eclampsia. There is need to educate the populace on the importance of ante natal care so as to improve its utilization.
Antenatal care; cesarean section; eclampsia; spinal anesthesia
This paper provides a detailed overview and discussion of anaesthesia in patients with mucopolysaccharidosis (MPS), the evaluation of risk factors in these patients and their anaesthetic management, including emergency airway issues. MPS represents a group of rare lysosomal storage disorders associated with an array of clinical manifestations. The high prevalence of airway obstruction and restrictive pulmonary disease in combination with cardiovascular manifestations poses a high anaesthetic risk to these patients. Typical anaesthetic problems include airway obstruction after induction or extubation, intubation difficulties or failure [can’t intubate, can’t ventilate (CICV)], possible emergency tracheostomy and cardiovascular and cervical spine issues. Because of the high anaesthetic risk, the benefits of a procedure in patients with MPS should always be balanced against the associated risks. Therefore, careful evaluation of anaesthetic risk factors should be made before the procedure, involving evaluation of airways and cardiorespiratory and cervical spine problems. In addition, information on the specific type of MPS, prior history of anaesthesia, presence of cervical instability and range of motion of the temporomandibular joint are important and may be pivotal to prevent complications during anaesthesia. Knowledge of these risk factors allows the anaesthetist to anticipate potential problems that may arise during or after the procedure. Anaesthesia in MPS patients should be preferably done by an experienced (paediatric) anaesthetist, supported by a multidisciplinary team (ear, nose, throat surgeon and intensive care team), with access to all necessary equipment and support.
Electronic supplementary material
The online version of this article (doi:10.1007/s10545-012-9563-1) contains supplementary material, which is available to authorized users.
Eight patients with ruptured aneurysms during induction anaesthesia and endotracheal intubation underwent an emergency "rescue clipping" of their lesion. Three patients died. Of the five survivors three made a good final recovery, one patient was moderately disabled and one remained in coma. Conservative management of this crisis is doomed to failure but the comparatively good outcome of the operative cases supports emergency "rescue clipping".
Critical incident monitoring is useful in detecting new problems, identifying ‘near misses’ and analyzing factors or events leading to mishaps, which can be instructive for trainees. This study was aimed at investigating potential risk factors and analyze events leading to peri-operative critical incidents in order to develop a critical incident reporting system. We conducted a one year prospective analysis of voluntarily reported 24- hour-perioperative critical incidents, occurring in patients subjected to anaesthesia. During a one year period from December 2006 to December 2007, 14,134 anaesthetics were administered and 112(0.79%) critical incidents were reported with complete recovery in 71.42%(n=80) and mortality in 28.57% (n=32) cases. Incidents occurred maximally in 0-10 years age (23.21%), ASA 1(61.61%), in general surgery patients (43.75%), undergoing emergency surgery (52.46%) and during day time (75.89%). Incidence was more in the operating theatre (77.68%), during maintenance (32.04%) and post-operative phase (25.89%) and in patients who received general anaesthesia (75.89%). Critical incidents occurred clue to factors related to anaesthesia (42.85%), patient (37.50%) and surgery (16.96%). Among anaesthesia related critical incidents (42.85% n=48/112), respiratory events were maximum (66.66%) mainly at induction (37.5%) and emergence (43.75%), and factors responsible were human error (85.41%), pharmacological factors (10.41%) and equipment error (4.17%). Incidence of mortality was 22.6 per 10, 000 anaesthetics (32/14,314), mostly attributable to risk factors in patient (59.38%) as compared to anaesthesia (25%) and surgery (9.38%). There were 8 anaesthesia related deaths (5.6 per 10, 000 anaesthetics) where human error (75%) attributed to lack of judgment (67.50%) was an important causative factor. We conclude that critical incident reporting system may be a valuable part of quality assurance to develop policies to prevent recurrence and enhance patient safety measures.
Critical incidents; Critical incident reporting; Human error; Mortality; Anaesthesia related mortality
Introduction. Suxamethonium, a deepolarizing muscle relaxant, increases intraocular pressure. It is therefore advised to be avoided in open globe surgery, for fear of extruding ocular contents. Several anecdotal reports support this fear. Some workers however, dispute this claim. There is as yet no formal case report in the literature on the subject. Case Presentation. A 34-year old Nigerian male, was involved in a road traffic accident. He presented at the Accident & Emergency Unit of our hospital about 2 hours after the accident. Clinical examination revealed right corneal laceration (with intact ocular contents) and intra-abdominal visceral injury. Emergency laparotomy was scheduled, to be followed with corneal repair. Anaesthesia was induced with 10 mg midazolam, 100 mg ketamine, and 100 mg suxamethonium given intravenously in sequence. After laparotomy, the ophthalmologists reported for the corneal repair, only to find that the vitreous humour has been extruded. Conclusion. The fear about the use of suxamethonium in open globe situations is real. It will be good clinical judgment to use alternative drugs and techniques to effect rapid muscle relaxation, in the anaesthetic management of the open globe patient. This would be of interest to anaesthetists, ophthalmologists and clinical pharmacologists among others.
Objective To clinically evaluate a new patented multimodal system (SAFERSleep) designed to reduce errors in the recording and administration of drugs in anaesthesia.
Design Prospective randomised open label clinical trial.
Setting Five designated operating theatres in a major tertiary referral hospital.
Participants Eighty nine consenting anaesthetists managing 1075 cases in which there were 10 764 drug administrations.
Intervention Use of the new system (which includes customised drug trays and purpose designed drug trolley drawers to promote a well organised anaesthetic workspace and aseptic technique; pre-filled syringes for commonly used anaesthetic drugs; large legible colour coded drug labels; a barcode reader linked to a computer, speakers, and touch screen to provide automatic auditory and visual verification of selected drugs immediately before each administration; automatic compilation of an anaesthetic record; an on-screen and audible warning if an antibiotic has not been administered within 15 minutes of the start of anaesthesia; and certain procedural rules—notably, scanning the label before each drug administration) versus conventional practice in drug administration with a manually compiled anaesthetic record.
Main outcome measures Primary: composite of errors in the recording and administration of intravenous drugs detected by direct observation and by detailed reconciliation of the contents of used drug vials against recorded administrations; and lapses in responding to an intermittent visual stimulus (vigilance latency task). Secondary: outcomes in patients; analyses of anaesthetists’ tasks and assessments of workload; evaluation of the legibility of anaesthetic records; evaluation of compliance with the procedural rules of the new system; and questionnaire based ratings of the respective systems by participants.
Results The overall mean rate of drug errors per 100 administrations was 9.1 (95% confidence interval 6.9 to 11.4) with the new system (one in 11 administrations) and 11.6 (9.3 to 13.9) with conventional methods (one in nine administrations) (P=0.045 for difference). Most were recording errors, and, though fewer drug administration errors occurred with the new system, the comparison with conventional methods did not reach significance. Rates of errors in drug administration were lower when anaesthetists consistently applied two key principles of the new system (scanning the drug barcode before administering each drug and keeping the voice prompt active) than when they did not: mean 6.0 (3.1 to 8.8) errors per 100 administrations v 9.7 (8.4 to 11.1) respectively (P=0.004). Lapses in the vigilance latency task occurred in 12% (58/471) of cases with the new system and 9% (40/473) with conventional methods (P=0.052). The records generated by the new system were more legible, and anaesthetists preferred the new system, particularly in relation to long, complex, and emergency cases. There were no differences between new and conventional systems in respect of outcomes in patients or anaesthetists’ workload.
Conclusions The new system was associated with a reduction in errors in the recording and administration of drugs in anaesthesia, attributable mainly to a reduction in recording errors. Automatic compilation of the anaesthetic record increased legibility but also increased lapses in a vigilance latency task and decreased time spent watching monitors.
Trial registration Australian New Zealand Clinical Trials Registry No 12608000068369.
A 14-year-old boy underwent emergency debridement surgery of right foot under spinal anaesthesia. Four hours after the surgery, the patient developed symptoms of cauda equina syndrome (CES). Postoperative magnetic resonance imaging of the patient's spine suggested underlying tubercular arachnoiditis. The boy was started on intravenous methylprednisolone and antitubercular therapy. He responded to the therapy and recovered completely in 2 weeks without any residual neurological deficits. We suggest that underlying pathological changes in the subarachnoid space due to tubercular arachnoiditis contributed to maldistribution of the local anaesthetic drug leading to CES.
Cauda equina syndrome; spinal anaesthesia; tubercular arachnoiditis
Cardiac transplantation has become the standard therapy for idiopathic dilated cardiomyopathy and end-stage ischaemic heart disease. With the introduction of newer immunosuppressants, together with better patient selection, improved perioperative monitoring and care, the overall survival of recipients has improved. An increasing number of patients who received a transplant present for either elective or emergency non-cardiac surgery. We hereby discuss the perioperative management of such a patient who came to our set-up for bipolar haemiarthroplasty.
Anaesthesia; cardiac transplant; graft function; immunosuppressants; non-cardiac surgery
It is unknown whether resources necessary to implement the Surviving Sepsis Campaign guidelines and sepsis bundles are available in Africa. This self-reported, continent-wide survey compared the availability of these resources between African and high-income countries, and between two African regions (Sub-Sahara Africa vs. South Africa, Mauritius and the Northern African countries).
The study was conducted as an anonymous questionnaire-based, cross-sectional survey among anaesthesia providers attending a transcontinental congress. Based on the respondents' country of practice, returned questionnaires were grouped into African and high-income countries. The questionnaire contained 74 items and evaluated all material resources required to implement the most recent Surviving Sepsis Campaign guidelines. Group comparisons were performed with the Chi2, Fisher's Exact or Mann Whitney U test, as appropriate.
The overall response rate was 74.3% (318/428). Three-hundred-seven questionnaires were analysed (African countries, n = 263; high-income countries, n = 44). Respondents from African hospitals were less likely to have an emergency room (85.5 vs. 97.7%, P = 0.03) or intensive care unit (73.8 vs. 100%, P < 0.001) than respondents from high-income countries. Drugs, equipment, and disposable materials required to implement the Surviving Sepsis Campaign guidelines or sepsis bundles were less frequently available in African than high-income countries. Of all African and Sub-Saharan African countries, 1.5% (4/263) and 1.2% (3/248) of respondents had the resources available to implement the Surviving Sepsis Campaign guidelines in entirety. The percentage of implementable recommendations was lower in African than in high-income countries (72.6 (57.7 to 87.7)% vs. 100 (100 to 100)%, P < 0.001) and lower in Sub-Saharan African countries than South Africa, Mauritius, and the Northern African countries (72.6 (56.2 to 86.3)% vs. 90.4 (71.2 to 94.5)%, P = 0.02).
The results of this self-reported survey strongly suggest that the most recent Surviving Sepsis guidelines cannot be implemented in Africa, particularly not in Sub-Saharan Africa, due to a shortage of required hospital facilities, equipment, drugs and disposable materials. However, availability of resources to implement the majority of strong Surviving Sepsis Campaign recommendations and the sepsis bundles may allow modification of current sepsis guidelines based on available resources and implementation of a substantial number of life-saving interventions into sepsis care in Africa.
The prevalence and nature of arrhythmias in horses following general anaesthesia and surgery is poorly documented. It has been proposed that horses undergoing emergency surgery for gastrointestinal disorders may be at particular risk of developing arrhythmias. Our primary objective was to determine the prevalence and nature of arrhythmias in horses following anaesthesia in a clinical setting and to establish if there was a difference in the prevalence of arrhythmias between horses with and without gastrointestinal disease undergoing surgery. Our secondary objective was to assess selected available risk factors for association with the development of arrhythmias following anaesthesia and surgery.
Horses with evidence of gastrointestinal disease undergoing an exploratory laparotomy and horses with no evidence of gastrointestinal disease undergoing orthopaedic surgery between September 2009 and January 2011 were recruited prospectively. A telemetric electrocardiogram (ECG) was fitted to each horse following recovery from anaesthesia and left in place for 24 hours. Selected electrolytes were measured before, during and after surgery and data was extracted from clinical records for analysis. Recorded ECGs were analysed and the arrhythmias characterised. Multivariable logistic regression was used to identify risk factors associated with the development of arrhythmias.
Sixty-seven horses with gastrointestinal disease and 37 without gastrointestinal disease were recruited. Arrhythmias were very common during the post-operative period in both groups of horses. Supra-ventricular and bradyarrhythmias predominated in both groups. There were no significant differences in prevalence of any type of arrhythmias between the horses with or without gastrointestinal disease. Post-operative tachycardia and sodium derangements were associated with the development of any type of arrhythmia.
This is the first study to report the prevalence of arrhythmias in horses during the post-operative period in a clinical setting. This study shows that arrhythmias are very common in horses following surgery. It showed no differences between those horses with or without gastrointestinal disease. Arrhythmias occurring in horses during the post-anaesthetic period require further investigation.
equine; post-anaesthetic; electrocardiography; arrhythmia
Approximately 90 haemoglobinopathies have been identified that result in abnormally high oxygen affinity. One of these is haemoglobinopathy York (HbY), first described in 1976. HbY causes an extreme leftward shift of the oxygen dissociation curve with the P50 value changing to 12.5 - 15.5 mmHg (normal value 26.7 mmHg), indicating that approximately half of the haemoglobin is not available as oxygen carrier. Patients with haemoglobinopathies with increased oxygen affinity could suffer from the risk developing ischaemic complications due to a lack of functional oxygen carriers. This is, to best of our knowledge, the first case report on a patient with HbY published in connection with anesthesia.
A 42-year-old female with a severe headache and Glasgow coma scale (GCS) of 15 was admitted to the neurosurgical intensive care unit with a ruptured, right sided ICA aneurysm with consecutive subarachnoid haemorrhage [Fisher III, World Federation of Neurosurgical Societies (WFNS) I)]. The medical history of the patient included an erythrocytosis (Hb 17.5 g/dl) on the base of a high-oxygen-affinity haemoglobinopathy, called Hb York (HbY). With no time available to take special preoperative precautions, rapid blood loss occurred during the first attempt to clip the aneurysm. General transfusion procedures, according to the guidelines based on haemoglobin and haematocrit values, could not be applied due to the uncertainty in the oxygen carrier reduction. To maintain tissue oxygen supply, clinical indicators of ischaemia were instead utilized to gauge the appropriate required blood products, crystalloids and colloids replacements. Despite this, the patient survived the neurosurgical intervention without any neurological deficit.
Family members of patients with HbY (and other haemoglobinopathies with increased oxygen affinity) should undergo clinical assessment, particularly if they are polycythaemic. If the diagnosis of HbY is confirmed, they should carry an "emergency anaesthesiology card" in order to avert perioperative risks arising from their "hidden" anemia.
Haemoglobinopathy; Hb York; Oxygen affinity; Neuroanaesthesia; Subarachnoid haemorrhage; Anaemia; Hypoxia
Background. Morbid obesity in a pregnancy is a great challenge to medical practice especially when the patient requires caesarean section. Case Summary. A 38-year-old unbooked gravida 3 Para 2+0 weight 195 kg, height 1.7 m with a blood pressure of 210/160 mmhg had spinal anaesthesia for emergency caesarean section which was technically difficult for severe preeclampsia at 32-week gestation. She had poor wound healing and spent 18 days postoperatively on hospital admission. Conclusion. Morbid obesity is a challenge to both obstetric and anaesthetic practice. Antenatal care is necessary in reducing both maternal morbidity and mortality.
Thoracoscopy with local anesthesia or medical thoracoscopy is an invasive method which is rather valuable not only for the approach of undiagnosed exudative pleural effusions but also for the treatment of symptomatic malignant effusions with the conduct of pleurodesis. This is a review of those patients who underwent medical thoracoscopy in the period May 2011 to September 2012 in the Pulmonary Department the Aristotle University of Thessaloniki.
Patients and methods
Thirty nine thoracoscopies were conducted in our Department since May 2011. Twenty nine patients with cytological test negative for malignancy underwent diagnostic thoracoscopy. Eleven of those procedures were diagnostic and positive for malignancy, while 12 were non-diagnostic and 2 with limited evidence of malignancy. The biopsy results of 2 thoracoscopies showed granulomatous infection and other 2 nonspecific chronic inflammation. Out of all the diagnoses which were positive for malignancy, 2 were related to mesothelioma, 5 to adenocarcinoma (4 of them originated from lungs and one of unknown primary origin) while 1 patient was diagnosed with metastatic papillary adenocarcinoma originated from the thyroid and another one with lymphoma. There were also patients carrying diagnosed illness intending pleurodesis in cases of malignant recrudescent pleural effusions in mesothelioma, lung adenocarcinoma and biliary carcinoma who underwent thoracoscopy. Another patient with recrudescent pneumothorax underwent pleurodesis with talc.
The major complications which emerged either during the procedure or after the thoracoscopy were two: one patient developed allergy in lidocaine intake for the local anesthesia having as a result to quit the procedure while another patient developed an empyema several weeks later.
Thoracoscopy with local anesthesia is a safe procedure, tolerable for the patient, which has a significant diagnostic value and only a small percentage of complications.
There is an increasing demand for intensive care in hospitals, which can lead to capacity limitations in the intensive care unit (ICU). Due to postponement of elective surgery or delayed admission of emergency patients, outcome may be negatively influenced. To optimize the admission process to intensive care, the post-anaesthesia care unit (PACU) was staffed with intensivist coverage around the clock. The aim of this study is to demonstrate the impact of the PACU on the structure of ICU-patients and the contribution to overall hospital profit in terms of changes in the case mix index for all surgical patients.
The administrative data of all surgical patients (n = 51,040) 20 months prior and 20 months after the introduction of a round-the-clock intensivist staffing of the PACU were evaluated and compared.
The relative number of patients with longer length of stay (LOS) (more than seven days) in the ICU increased after the introduction of the PACU. The average monthly number of treatment days of patients staying less than 24 hours in the ICU decreased by about 50% (138.95 vs. 68.19 treatment days, P <0.005). The mean LOS in the PACU was 0.45 (± 0.41) days, compared to 0.27 (± 0.2) days prior to the implementation. The preoperative times in the hospital decreased significantly for all patients. The case mix index (CMI) per hospital day for all surgical patients was significantly higher after the introduction of a PACU: 0.286 (± 0.234) vs. 0.309 (± 0.272) P <0.001 CMI/hospital day.
The introduction of a PACU and the staffing with intensive care staff might shorten the hospital LOS for surgical patients. The revenues for the hospital, as determined by the case mix index of the patients per hospital day, increased after the implementation of a PACU and more patients can be treated in the same time, due to a better use of resources.