The practice of preoperative assessment in 24 departments of anaesthesia in Great Britain and Ireland was surveyed. Most departments had no rigid policies governing assessment, and many served several hospitals. There was little evidence that admission procedures of patients scheduled for surgery or the organisation of operating lists took account of the problems encountered by anaesthetists undertaking preoperative assessment. From the participating departments 415 anaesthetists completed a questionnaire of their individual practice. Most (57%) visited at least 80% of their patients preoperatively, but 22% saw less than 50% of patients. The detection of potential anaesthetic problems and the establishment of rapport with patients were highly rated reasons for conducting such visits. Failure to visit was often related to organisational defects within the hospital service, and anaesthetists saw little prospect of improving these defects. The demands created by the needs of preoperative assessment on the one hand, and the need for a rapid turnover of surgical patients and financial stringency on the other, conflict, and this conflict is not easily reconciled.
Review of 489 "anaesthetic deaths" reported to procurators-fiscal over 10 years disclosed only 30 that were thought to justify such reporting. Most of the remainder occurred in patients so desperately ill at the time of operation that death was expected. Postmortem examinations ordered by the Crown authorities in nearly all cases were probably largely unrewarding and mostly unnecessary. The results suggest that the present regulation on reporting should be revised to focus more attention on the few deaths that occur in patients who have no apparent contraindication to anaesthesia or operation.
Ten anaesthetists were asked to make judgments on fitness for elective operation on data derived from 200 patients. The extent of their agreement was measured using a kappa statistic, and clusters of anaesthetists who agreed well with each other were identified. Using an alternative technique, the "true" fitness category of each patient was estimated using a maximum likelihood method which estimated the error involved in making judgments on limited amounts of information. It was possible to compare the performance of each anaesthetist against the consensus and to measure deviation on an "optimism--pessimism" continuum. A simple questionnaire predicted fitness for operation by all 10 anaesthetists in 96% of cases.
A prospective study was carried out in one District Health Authority over a twelve month period to investigate the principal reasons for the postponement of operations on the advice of anaesthetic staff. A mean of 1.4% of all cases listed for general anaesthesia were postponed. The clinical indications for this are described and possible methods for reducing this figure are discussed.
To test the predictive validity of a selection system for Senior House Officers (SHOs) and registrars in anaesthetics, 140 doctors short-listed from 635 applications between 1980 and 1987 were assessed by a semi-structured interview assessed and a personality questionnaire (Cattell 16PFQ-form C). The 62 doctors selected were followed up for between 3 and 8 years. Future performance was predicted from the psychological tests and by the interviewers. Academic, clinical, behavioural, and overall performance were used as criteria of outcome. Correlation coefficients between prediction and outcome measures were statistically highly significant (P < 0.01). Using multiple regression, equations could be derived from five of the Cattell personality factors to predict overall performance. Personality measures discriminated significantly between the best and poorest performers. Interview predictions were also statistically significant (P < 0.01). The method provides a blueprint for the effective selection of junior anaesthetists. Wastage in terms of those leaving the specialty was 16%.
OBJECTIVES: To assess the effect of a preprinted form in ensuring an improved and sustained quality of documentation of clinical data in compliance with the national guidelines for sedation by non-anaesthetists. DESIGN: The process of retrospective case note audit was used to identify areas of poor performance, reiterate national guidelines, introduce a post-sedation advice sheet, and demonstrate improvement. SETTING: Emergency Department, Musgrove Park Hospital, Taunton. SUBJECTS: Forty seven patients requiring sedation for relocation of a dislocated shoulder or manipulation of a Colles' fracture between July and October 1996 and July and October 1997. MAIN OUTCOME MEASURES: Evidence that the following items had been documented: consent for procedure, risk assessment, monitored observations, prophylactic use of supplementary oxygen, and discharging patients with printed advice. Case note review was performed before (n = 23) and after (n = 24) the introduction of a sedation audit form. Notes were analysed for the above outcome measures. The monitored observations analysed included: pulse oximetry, respiratory rate, pulse rate, blood pressure, electrocardiography, and conscious level. RESULTS: Use of the form significantly improved documentation of most parameters measured. CONCLUSIONS: Introduction of the form, together with staff education, resulted in enhanced documentation of data and improved conformity with national guidelines. A risk management approach to preempting critical incidents following sedation, can be adopted in this area of emergency medicine.
OBJECTIVE--To investigate the incidence of difficulties associated with parental presence during the induction of anaesthesia in children and the influence of premedication with special reference to vomiting after papaveretum. DESIGN--Mixed factual and multiple choice questionnaire completed by medical and nursing staff and parents during and after admission. SETTING--Teaching hospital with regional paediatric general surgical unit where parental presence during induction of anaesthesia is long established. PATIENTS--151 Children aged 1-14 years who had not previously undergone surgery attending with parents for day stay general surgical procedures. INTERVENTION--Children were randomly allocated to receive no premedication (group 1), oral diazepam elixir (0.3 mg/kg) (group 2), or intramuscular papaveretum with hyoscine (0.3 mg/kg with 0.006 mg/kg) (group 3). No other modification to established day stay routine was made. RESULTS--No major problems were associated with the presence of parents during the induction of anaesthesia. Only 10 of the 141 parents who accompanied their child caused some difficulty, and five became distressed. Premedication with both diazepam and papaveretum resulted in sedation but did not ease induction of anaesthesia. Papaveretum greatly reduced pain and distress immediately after the operation, pain and discomfort being observed in only 15% of children (7/48) compared with 66% (27/41) in group 1 and 49% (22/45) in group 2. Papaveretum, however, must be given intramuscularly, and nurses observed that the children preferred being given premedication orally to intramuscularly. In addition, the incidences of nausea and vomiting were significantly higher in the postoperative ward and at home with papaveretum, although no patient who had been given the drug was nauseous or vomited in the recovery area. The incidences of nausea in group 3 were 62% (31/50) and 57% (27/47) in the postoperative ward and at home, respectively, v 21% (7/33) and 14% (4/29) in group 1 and 13% (5/38) and 14% (5/37) in group 2; the incidences of vomiting in group 3 were 60% and 43% in the postoperative ward and at home, respectively, v 18% and 7% in group 1 and 11% and 11% in group 2. Finally, neither the administration or otherwise of premedication nor the drug given affected the children's or parents' perception of day care surgery. CONCLUSIONS--Difficulties with parents in anaesthetic rooms were not common or severe. Premedication provides preoperative sedation and papaveretum improves the immediate postoperative course but the incidences of nausea and vomiting after operation are higher with its use than without.
Upper gastrointestinal endoscopy is a valuable diagnostic tool, but for an endoscopy service to be effective it is essential that it is not overloaded with inappropriately referred patients. A joint working party in Britain has considered the available literature on indications for endoscopy, assessed standard practice through a questionnaire, and audited randomly selected cases using an independent panel of experts and an American database system. They used these data to produce guidelines on the appropriate and inappropriate indications for referral for endoscopy, although they emphasise that under certain circumstances there may be reasons to deviate from the advice given. The need for endoscopy is most difficult to judge in patients with dyspepsia, and this aspect is discussed in detail. Early endoscopy will often prove more cost effective than delaying until the indications are clearer.
Twelve patients with severe chronic obstructive lung disease undergoing 15 operations were assessed with preoperative lung function tests and blood gas estimations. Their operative and postoperative course was followed. There were no deaths or serious complications. Patients fell into three groups: those with low respiratory capacity but normal blood gases, who required no special respiratory treatment apart from physiotherapy and antibiotics; those with hypoxaemia but normal arterial carbon dioxide pressure, who needed more prolonged oxygen treatment after operation; and those with hypoxaemia and hypercapnia, who needed postoperative ventilatory support. While forced expiratory volume in one second (FEV) is a good screening test in preoperative assessment it should be supplemented by arterial blood gas estimations in patients with an FEV of less than 1 litre.
Background: Volatile anaesthetics are chemically related to organic solvents used in industry. Exposure to industrial solvents may increase the incidence of multiple sclerosis (MS).
Aim: To examine the risk among nurse anaesthetists of contracting MS.
Methods: Nurses with MS were identified by an appeal in the monthly magazine of the Swedish Nurse Union and a magazine of the Neurological Patients Association in Sweden. Ninety nurses with MS responded and contacted our clinic. They were given a questionnaire, which was filled in by 85 subjects; 13 of these were nurse anaesthetists. The questionnaire requested information about work tasks, exposure, diagnosis, symptoms, and year. The number of active nurse anaesthetists was estimated based on information from the National Board of Health and Welfare and The Nurse Union. Incidence data for women in the region of Gothenburg and Denmark were used as the reference to estimate the risk by calculation of the standardised incidence ratio (SIR).
Results: Eleven of the 13 nurse anaesthetists were exposed to anaesthetic gases before onset of MS. Mean duration of exposure before diagnosis was 14.4 years (range 4–27 years). Ten cases were diagnosed in the study period 1980–99, resulting in significantly increased SIRs of 2.9 and 2.8 with the Gothenburg and the Danish reference data, respectively.
Conclusion: Although based on crude data and a somewhat approximate analysis, this study provides preliminary evidence for an excess risk of MS in nurse anaesthetists. The risk may be even greater than observed, as the case ascertainment might have been incomplete because of the crude method applied. Further studies in this respect are clearly required to more definitely assess the risk.
Anxiety levels measured in patients who received preoperative reassurance about anaesthesia from a member of the hospital staff were significantly lower than those in a control group given no such support. Anxiety levels in patients who read a booklet designed to reassure about anaesthesia were less significantly reduced. Owing to the increasing work load in the operating theatre many anaesthetists can no longer afford the time to visit patients preoperatively. This study shows that either this trend should be reversed or the role of reassurer should be assumed by someone else, possibly the anaesthetic nurse. For optimal effect, the visits should be combined with use of the booklet. Unless such measures are taken, up to three million people each year may be being denied any form of reassurance before surgical treatment.
BACKGROUND/AIMS—Visual awareness during phacoemulsification cataract surgery is an important determinant of patient satisfaction with any anaesthetic technique. Topical anaesthesia could be associated with significant visual awareness because it does not affect optic nerve function.
METHODS—The visual experience during phacoemulsification cataract surgery under topical anaesthesia (without sedation) was assessed for 106 consecutive unselected patients. Patients were interviewed immediately after surgery using a standardised questionnaire that explored specific aspects of their visual experience.
RESULTS—Four patients were excluded because they had poor recollection of their visual experience. The visual awareness of the remaining 102 patients comprised operating microscope light (99), colours (73), flashes of light (7), vague movements (19), surgical instruments or other objects (12), change in light brightness during surgery (49), change in colours during surgery (30), and transient visual alteration during corneal irrigation (25). No patient found their visual experience during surgery unpleasant, though the operating microscope light was uncomfortably bright for two patients. Six patients lost light perception for a short interval during surgery. There was no association between the various visual phenomena reported and patients' age, sex, preoperative visual acuity, cataract morphology, coexisting ocular pathology, or previous experience of cataract surgery under local anaesthesia (p>0.05).
CONCLUSIONS—Patients experience a wide variety of visual sensations during phacoemulsification cataract surgery under topical anaesthesia. Topical anaesthesia does not, however, appear to result in greater visual awareness than regional anaesthesia. Preoperative patient counselling should include information about the visual experience during surgery.
AIMS—To determine the relation between pH of anaesthetic solutions and patient perception of pain with peribulbar injection of local anaesthesia.
METHODS—This prospective randomised controlled double blind pilot study involved 60 consecutive patients who received a peribulbar block with either a standard acidic local anaesthetic of 5 ml 2% lignocaine and 5 ml of 0.5% bupivacaine (solution A), or an alkalinised solution composed of the same anaesthetic agents but with a pH of 7.44 (solution B). Before surgery patients were asked to grade the pain of both the preoperative dilating drops and the peribulbar injection using a visual analogue scale.
RESULTS—The mean pain scores were similar in the two treatment groups—slightly higher (4.97) in group B who received the buffered solution, compared with group A (4.84) who received the plain solution. The small difference (−0.13, 95% confidence limits −1.6 and +1.3) was not significant. There was, however, a highly significant association between pain threshold ("drop pain") and injection pain levels (p<0.0001).
CONCLUSION—This study showed no difference in the reduction in the pain experienced by patients undergoing peribulbar anaesthesia with pH buffered local anaesthetic. The study suggests the importance of "pain threshold" as a confounder and also showed the considerable pain felt by some patients on instillation of the preoperative dilating drops.
The effect of the local anaesthetic agent, etidocaine, on the optic nerve function was examined at regional ophthalmic anaesthesia. Visual evoked potential (VEP) was recorded before and 15 minutes after injection of the anaesthetic agent in 19 patients scheduled for elective cataract surgery (seven retrobulbar and 12 periocular). Both the anaesthetised--that is, the eye to be operated on--and the fellow eye were examined. In the retrobulbar group, two patients displayed non-recordable VEPs while one had virtually non-detectable waves following the anaesthesia. In two retrobulbarly anaesthetised eyes, later peaks were unidentifiable while two other eyes had decreased amplitudes. In the periocular group, in nine patients, there was no clearcut effect on VEP resulting from the anaesthetic. In three patients of this group mild changes in the anaesthetised eyes were found. The differences in the effect of retrobulbarly or periocularly injected anaesthetics on VEP are probably due to the different concentration of the anaesthetic agent around the optic nerve.
Congenital complete heart block could be absolutely asymptomatic. Increased awareness of suspecting an atrioventricular heart block in patients with slow heart rate and electrocardiograph examination will ensure recognition of this problem. The possibility of sudden cardiac death in these patients should not be forgotten. The goal in the peri-operative anaesthetic management is to preserve the heart rate and maintain haemodynamic stability. Herein, we present a case of congenital complete heart block posted for elective caesarean section for an obstetric indication. We would like to highlight the advantage of bupivacaine–fentanyl combination in maintaining haemodynamic stability and peri-operative heart rate control with temporary pacemaker.
Complete heart block; fentanyl; pregnancy; spinal anaesthesia
Pre-anaesthetic evaluation is a basic component of safe anaesthetic practice and ends with the establishment of an anaesthetic plan of action for individual patients.
The aim of the present study was to assess the difficulties encountered by the anaesthetist during such visits and suggest ways they can be overcome
Subjects and Methods:
The ‘activity book’ of anaesthetic resident doctors in the hospital was reviewed retrospectively for documented problems they encountered during the pre-operative visit. The problems listed were then subjected to analysis using the SPSS 17.
The commonest problem was the unavailability of the patient for review 73.1% followed by very busy schedule (7.4%) and unfit patients (6.9%)
Anaesthetists still do encounter problems during the pre-operative visit. Exposing such problems creates the necessary awareness for improvement of patient care.
Anaesthetist; pre-operative visit; problems
OBJECTIVE--To determine the influence of general or regional anaesthesia on long term mental function in elderly patients. DESIGN--Prospective study of patients randomly allocated to receive general or regional anaesthesia. SETTING--The patients' homes and a large teaching hospital in Cardiff. SUBJECTS--146 Patients aged 60 and over scheduled for elective hip or knee replacement. MAIN OUTCOME MEASURES--Scores achieved in tests of cognitive function and functional competence. RESULTS--72 Patients were allocated to receive general anaesthesia and 74 regional anaesthesia. Anaesthetic technique did not influence the duration of the operation, time to mobilisation postoperatively, requirements for analgesia after the operation, or duration of stay in hospital. Three months after the operation there was an improvement in the score for the recognition component (76 ms, 95% confidence interval 9 to 144) and the response component (82 ms, 5 to 158) of the choice reaction time in the group receiving general anaesthesia compared with the group receiving regional anaesthesia. This was the only significant difference between the two groups in the assessments of cognitive and functional competence. Eleven patients receiving regional anaesthesia and 12 receiving general anaesthesia reported that their memory and concentration were worse than before the operation, but this was not confirmed by testing. CONCLUSION--Cognitive and functional competence in elderly patients was not detectably impaired after either general or regional anaesthesia when attention was paid to the known perioperative influences on mental function.
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.
A total of 300 consecutive anaesthetic axillary blocks was performed over a period of 18 months in 291 patients. These blocks were carried out for emergency and elective hand surgery. Patients did not require any preparation or starving; 20-30 ml of 1% prilocaine according to the size of the patient is used for the block. A minimum induction time of 45 min is needed and patients are able to leave the hospital 20 min-2 h after operation, depending on the nature of the operation. No operation had to be abandoned due to failure of the block. Eleven patients required further injection of local anaesthetic during the operation. The duration of operations ranged from 10 to 130 min. Only 20% needed postoperative analgesia. The technique is easy to perform, it is safe and has long-lasting analgesic effect. It is an efficient, economical method of treatment, well tolerated and often preferred by patients. We think axillary block anaesthesia should be more generally used in hand and orthopaedic units.
We report a case of a 40-year-old man affected by the Kearns-Sayre syndrome who underwent an elective laparoscopic cholecystectomy under general anaesthesia. We describe the management of general anaesthesia in this rare myopathy, with emphasis on the use of rocuronium as muscle blocking agent. Induction was achieved with propofol and fentanyl, and general anaesthesia was maintained with fentanyl and sevoflurane/N2O/O2 mixture. The anaesthetic plan proved to be safe and effective, and extubation was achieved in the operating theatre. The postoperative recovery of the patient was satisfactory and uneventful.
This study was designed to compare the intra-operative and post-operative analgesic requirements and side effects of using fentanyl infusion versus remifentanil infusion during short-duration surgical procedures in children. The study comprised of 40 children randomly allocated into two equal groups: fentanyl (F-group) or remifentanil (R-group). Both were administered a continuous intravenous (i.v.) infusion. Anaesthetic recovery was assessed using the Brussels sedation scale every 5 min from the time of entry till discharge from recovery room. Post-operative analgesia was assessed throughout the first three post-operative (PO) hours using observational pain–discomfort scale (OPS) and adverse events were recorded. Haemodynamic variables showed a non-significant difference between both the groups. Patients who received remifentanil showed significantly shorter time to spontaneous respiration, eye opening, extubation and verbalization compared to those who received fentanyl. Discharge time was significantly shorter in R-group, and 18 patients fulfilled criteria for recovery-room discharge at ≤25 min with a significant difference in favour of remifentanil. Fentanyl provided significantly better PO analgesia than remifentanil and children in F-group showed a significantly lower mean cumulative OPS record than those in R-group; however, the number of patients requiring rescue analgesia did not show a significant difference between both the groups. Two cases in F-group and one in R-group had bradycardia, one case in R-group had mild hypotension and PO vomiting had occurred in three patients in the F-group and two patients in the R-group. In conclusion, remifentanil is appropriate for opioid-based anaesthesia for paediatric patients as it provides haemodynamic stability and rapid recovery with minimal post-operative side effects.
Opioid based; paediatric; remifentanil
All patients who presented to our Accident & Emergency Department over a 6-month period with an acute knee injury were randomly assigned to receive either immediate physiotherapy or not prior to further follow up at an out-patient clinic. Patients with trivial injuries not requiring follow up and patients with severe injuries requiring immediate admission were excluded from the study. Patients not immediately referred for physiotherapy could be referred if this was thought necessary at later follow up. There was no statistical difference in the number of outpatient follow up appointments or the length of time to discharge from the clinic between the groups. Those patients referred for physiotherapy immediately had a significantly greater number of total attendances at the physiotherapy department. However more patients in the 'no physiotherapy' group ultimately required arthroscopy for suspected meniscal injury. We conclude that a blanket referral of all acute knee injury patients is unjustified and wasteful of resources. However physiotherapy may be indicated in patients initially suspected of having meniscal injury.
The duration of impairment of mental functioning after anaesthesia was studied in 55 patients undergoing hernia repair who were divided into three groups in which the method of induction of anaesthesia (intravenous or inhalational) and ventilation (spontaneous or controlled) was varied. Performance in a five minute serial reaction time test and subjective estimates of coordination were assessed four times a day for two complete postoperative days and were compared with those in a control group of orthopaedic patients in hospital. After considerable impairment initially, reaction times in all groups gradually returned towards control values, but in patients breathing spontaneously during anaesthesia impairment recurred during the second postoperative day. These results suggest that such patients should be advised not to undertake hazardous tasks such as driving a car for at least 48 hours after a general anaesthetic. Discrepancies between subjective and objective assessments of impairment also suggest that patients should not rely on their own assessments of fitness to drive.
In December 1979 97 patients underwent intracapsular cataract extraction under local anaesthetic with planned discharge on the day after operation. Twenty-three of these patients had a prolonged stay in hospital, and five of these required early operative intervention following surgical complications. Sixteen patients did not attain a visual acuity better than 6/18. The visual outcome and postoperative course are compared with those of a similar group of patients who stayed in hospital for five days after intracapsular cataract extraction.
The effect of peribulbar anaesthesia on optic nerve function in 20 patients, before and after cataract surgery, was measured. All the patients had decreased visual acuity. Five (25%) had no perception of light. Seventeen (85%) developed a relative afferent pupil defect (RAPD). No patients saw the operating instruments. Seven (35%) had improved visual acuity immediately postoperatively. Patients should be warned that they may lose vision completely on being given a peribulbar anaesthetic; however their vision will improve, but not necessarily immediately, postoperatively. Examination for an RAPD is a good method of providing reassurance that the operating instruments will not be seen.