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.
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.
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.
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 describe the effect of local adaptation of national
guidelines combined with active feedback and organisational analysis on the
ordering of preoperative investigations for patients at low risk from
anaesthetics. DESIGN: Assessment of preoperative tests ordered over one
month, before and after local adaptation of guidelines and feedback of
results, combined with an organisational analysis. SETTING: Motivated
anaesthetists in 15 surgical wards of Bordeaux University Hospital, Region
Aquitain, France. SUBJECTS: 42 anaesthetists, 60 surgeons, and their teams.
MAIN OUTCOME MEASURES: Number and type of preoperative tests ordered in
June 1993 and 1994, and the estimated savings. RESULTS: Of 536 patients at
low risk from anaesthetics studied in 1993 before the intervention 80% had
at least one preoperative test. Most (70%) tests were ordered by
anaesthetists. Twice the number of preoperative tests were ordered than
recommended by national guidelines. Organisational analysis indicated lack
of organised consultations and communication within teams. Changes
implemented included scheduling of anaesthetic consultations; regular
formal multidisciplinary meetings for all staff; preoperative ordering
decision charts. Of 516 low risk patients studied in 1994 after the
intervention only 48% had one or more preoperative tests ordered (p <
0.05). Estimated mean (SD) saving for one year if changes were applied to
all patients at low risk from anaesthesia in the hospital 3.04 (1.23) mFF.
CONCLUSIONS: A sharp decrease in tests ordered in low risk patients was
found. The likely cause was the package of changes that included local
adaptation of national guidelines, feedback, and organisational change.
Removal of genital warts by thermocautery was performed in 108 patients (57 men and 51 women) under topical anaesthesia with a local anaesthetic cream, lidocaine and prilocaine (EMLA). Most men had warts in the preputial cavity, most women had warts situated on the mucous membranes of the vulva, and warts at multiple sites were common. About 1 ml of cream per lesion was applied to the warts for 20 to 105 minutes before the operation. Plastic film (Glad, Union Carbide) was applied over the cream when natural occlusion, such as under the prepuce or on the introitus, was not present. Local pallor was seen in 30% of the patients, redness in 53%, and oedema in 15%, but did not cause any discomfort and were clinically insignificant. Analgesia was sufficient in 96% of the men and in 40% of the women. Additional local infiltration was given to 60% of the women, but was not as painful as injections generally are in the genital area. The analgesic efficacy on women may be further improved by optimising the application time on the genital mucosa.
AIM: To investigate whether discharge scoring criteria are as safe as clinical criteria for discharge decision and allow for earlier discharge.
METHODS: About 220 consecutive outpatients undergoing colonoscopy under sedation with Meperidine plus Midazolam were enrolled and assigned to 2 groups: in Control-group (110 subjects) discharge decision was based on the clinical assessment; in PADSS-group (110 subjects) discharge decision was based on the modified Post-Anaesthetic Discharge Scoring System (PADSS). Measurements of the PADDS score were taken every 20 min after colonoscopy, and patients were discharged after two consecutive PADSS scores ≥ 9. The investigator called each patient 24-48 h after discharge to administer a standardized questionnaire, to detect any delayed complications. Patients in which cecal intubation was not performed and those who were not found at follow-up phone call were excluded from the study.
RESULTS: Thirteen patients (7 in Control-group and 6 in PADSS-group) were excluded from the study. Recovery from sedation was faster in PADSS-group than in Control-group (58.75 ± 18.67 min vs 95.14 ± 10.85 min, respectively; P < 0.001). Recovery time resulted shorter than 60 min in 39 patients of PADSS-group (37.5%), and in no patient of Control-group (P < 0.001). At follow-up phone call, no patient declared any hospital re-admission because of problems related to colonoscopy and/or sedation. Mild delayed post-discharge symptoms occurred in 57 patients in Control-group (55.3%) and in 32 in PADSS-group (30.7%). The most common symptoms were drowsiness, weakness, abdominal distension, and headache. Only 3 subjects needed to take some drugs because of post-discharge symptoms.
CONCLUSION: The Post-Anaesthetic Discharge Scoring System is as safe as the clinical assessment and allows for an earlier patient discharge after colonoscopy performed under sedation.
Colonoscopy; Conscious sedation; Patient discharge; Recovery room; Complications
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.
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.
A patient who had shown some evidence of immunological sensitivity underwent several operations under general anaesthesia for otitis media without ill effect. On his second exposure to Althesin, however, he suffered a severe reaction. Facial angioneurotic oedema was accompanied by peripheral vasodilatation and sweating, and C3 conversion was observed in his plasma. Subsequent anaesthetics produced no reactions until four years later, when thiopentone and suxamethonium were given. This reaction was much milder, but C3 conversion again occurred. Although the clinical signs indicated an anaphylactoid reaction, the laboratory findings suggested that this patient had an underlying immunopathological condition involving complement activation, which could be triggered by any intravenous agent that activated complement. The judgment that a reaction to a particular drug is anaphylactic cannot be made on the basis of clinical signs alone. Simple laboratory analysis will show whether the reaction is due to an underlying immunopathological condition that may be triggered by any of several drugs.
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.
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%.
A 39-year-old male, post nephrectomy and adrenalectomy (right), was planned for adrenalectomy (left) and radiofrequency ablation of left renal mass. Clinical evaluation indicated a possibility of phaeochromocytoma, whereas biochemical parameters were found to be within normal limits. Intraoperatively, massive fluctuations in haemodynamic parameters were noticed while the tumour was being handled. Patient was stabilised with inotropes, vasopressors, fluids and careful titration of anaesthetic agents. Preoperatively diagnosed coronary disease could have complicated anaesthetic care. Optimum and modern anaesthetic care leads to safe execution of surgery.
Adrenal incidentaloma; adrenalectomy; phaeochromocytoma; radiofrequency ablation
We present the first reported case of the prophylactic use of lipid emulsion therapy in the removal of an extensive, circumferential malignant melanoma in a morbidly obese patient, under local anaesthetic. The advantages of this technique allowed the patient to avoid intraoperative invasive monitoring and postoperative critical care admission and assisted during the operation by rotating her leg when needed. This is a useful technique that can be employed in urgent cases where there is a need to excise extensive skin malignancies in patients who are unsuitable for general or regional anaesthesia.
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.
Anaesthesia of structures innervated by the mandibular nerve is necessary to provide adequate pain control when performing dental and localised surgical procedures. To date, numerous techniques have been described and, although many of these methods are not used routinely, there are some situations where their application may be indicated. Patient factors as well as anatomical variability of the mandibular nerve and associated structures dictate that no one technique can be universally applied with a 100% success rate. This fact has led to a proliferation of alternative techniques that have appeared in the literature. This selective review of the literature provides a brief description of the different techniques available to the clinician as well as the underlying anatomy which is fundamental to successfully anaesthetising the mandibular nerve.
The management of high-operative-risk patients with a pneumothorax is complicated. The case of a 79-year old man with an intractable secondary pneumothorax, who had taken oral steroids to control asthma, is presented. Since the patient could not tolerate general anaesthesia because of poor cardiac function, thoracoscopic surgery was performed under local anaesthesia. A successful lung fistula closure was achieved and the continuous air leakage disappeared immediately after the surgery.
Pneumothorax; Thoracoscopy; Local anaesthesia
Multiple sclerosis (MS) is a rare autoimmune demyelinating disorder of the central nervous system clinically manifesting as periodic attacks of varied neurologic symptoms, eventually progressing to fixed neurologic deficits and disability. The treatment is symptomatic and directed towards prevention of future progression of the disease involving multiple agents. We present here a case report of a patient with MS who underwent an orthopaedic procedure under general anaesthesia (G.A.) uneventfully. Anaesthetic implications include assessment of neurological deficits with documentation pre- and postoperatively, awareness towards side-effects, potential drug interactions of medications, selection of suitable techniques/anaesthetic agents, neuromuscular monitoring-guided titration of non-depolarizing blocking agents with lowest necessary dose and avoidance of hyperthermia along with temperature, haemodynamic and respiratory monitoring. Lower concentrations of local anaesthetic (LA) should be used for regional blocks keeping in mind the susceptibility of demyelinated neurons, towards LA neurotoxicity. To the best of our knowledge, this is the first report of anaesthetic management of MS in India.
Anaesthetic; demyelination; multiple sclerosis
Throughout the world there is considerable variation in the techniques used to manage anxious dental patients requiring treatment. Traditionally anxious or phobic dental patients may have been sent for general anaesthesia to allow dental treatment be undertaken. While this is still the case for the more invasive oral surgical procedures, such as wisdom teeth extraction, sedation in general dentistry is becoming more popular.
Various sedation techniques using many different anaesthetic agents have gained considerable popularity over the past 30 years. While the practice of sedating patients for dental procedures is invaluable in the management of suitably assessed patients, patient safety must always be the primary concern. Medical, dental and psychosocial considerations must be taken into account when evaluating the patient need and the patient suitability for sedation or general anaesthesia.
The regulations that govern the practice of dental sedation vary throughout the world, in particular regarding the techniques used and the training necessary for dental practitioners to sedate patients. It is necessary for medical and dental practitioners to be up to date on current practice to ensure standards of practice, competence and safety throughout our profession.
This article, the first in a two-part series, will provide information to practitioners on the practice of sedation in dentistry, the circumstances where it may be appropriate instead of general anaesthesia and the risks involved with sedation. It will also discuss the specific training and qualifications required for dental practitioners to provide sedation. The second article in this series will outline the different techniques used to administer inhalation, oral and intravenous sedation in dentistry and will focus on specific methods that are practiced.
Conscious sedation; sedation; dentistry; anaesthetic agents; fear; dental phobia; anxiolysis; access to treatment
Goal-directed fluid therapy (GDFT) has been shown to reduce complications and hospital length of stay following major surgery. However, there has been no assessment regarding its use in clinical practice.
An electronic survey was administered to randomly selected anaesthetists from the United Kingdom (UK, n = 2000) and the United States of America (USA, n = 2000), and 500 anaesthetists from Australia/New Zealand (AUS/NZ). Preferences, clinical use and attitudes towards GDFT were investigated. Results were collated to examine regional differences.
The response rates from the UK (n = 708) and AUS/NZ (n = 180) were 35%, and 36% respectively. The response rate from the USA was very low (n = 178; 9%). GDFT use was significantly more common in the UK than in AUS/NZ (p < 0.01). The Oesophageal Doppler Monitor was the most preferred instrument in the UK (n = 362; h76%) with no clear preferences in other regions. GDFT was most commonly utilised in major abdominal surgery and for patients with significant comorbidities. The commonest reasons stated for not using GDFT were either lack of availability of monitoring tools (AUS/NZ: 57 (70%); UK: 94 (64%)) or a lack of experience with instruments (AUS/NZ: 43 (53%); UK: 51 (35%)). A subset of respondents (AUS/NZ: 22(27%); UK: 45 (30%)) felt GDFT provided no perceived benefit. Enthusiasm towards the use of GDFT in the absence of existing barriers was high.
Several hypotheses were generated regarding important differences in the use of GDFT between anaesthetists from the UK and AUS/NZ. There is significant interest in utilising GDFT in clinical practice and existing barriers should be addressed.
Intravenous fluid; Goal-directed fluid therapy; Perioperative care; Surgery