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1.  Regional block versus general anaesthesia for caesarean section and neonatal outcomes: a population-based study 
BMC Medicine  2009;7:20.
Background
Anaesthesia guidelines recommend regional anaesthesia for most caesarean sections due to the risk of failed intubation and aspiration with general anaesthesia. However, general anaesthesia is considered to be safe for the foetus, based on limited evidence, and is still used for caesarean sections.
Methods
Cohorts of caesarean sections by indication (that is, planned repeat caesarean section, failure to progress, foetal distress) were selected from the period 1998 to 2004 (N = 50,806). Deliveries performed under general anaesthesia were compared with those performed under spinal or epidural, for the outcomes of neonatal intubation and 5-minute Apgar (Apgar5) <7.
Results
The risk of adverse outcomes was increased for caesarean sections under general anaesthesia for all three indications and across all levels of hospital. The relative risks were largest for low-risk planned repeat caesarean deliveries: resuscitation with intubation relative risk was 12.8 (95% confidence interval 7.6, 21.7), and Apgar5 <7 relative risk was 13.4 (95% confidence interval 9.2, 19.4). The largest absolute increase in risk was for unplanned caesareans due to foetal distress: there were five extra intubations per 100 deliveries and six extra Apgar5 <7 per 100 deliveries.
Conclusion
The infants most affected by general anaesthesia were those already compromised in utero, as evidenced by foetal distress. The increased rate of adverse neonatal outcomes should be weighed up when general anaesthesia is under consideration.
doi:10.1186/1741-7015-7-20
PMCID: PMC2683867  PMID: 19402884
2.  Type of anaesthesia and the safety and efficacy of thromboprophylaxis with enoxaparin or dabigatran etexilate in major orthopaedic surgery: pooled analysis of three randomized controlled trials 
Thrombosis Journal  2012;10:9.
Background
There has been a shift towards greater use of neuraxial over general anaesthesia for patients undergoing total hip or knee arthroplasty. Furthermore, suggestions that peripheral nerve block may reduce adverse effects have recently been put forward. Although older studies showed a reduction in venous thromboembolism (VTE) with neuraxial compared with general anaesthesia, this difference has not been confirmed in studies using effective current thromboprophylaxis. We used a large data set to investigate the pattern of anaesthesia usage, and whether anaesthesia type affects efficacy and bleeding outcomes of thromboprophylaxis overall, within each treatment group, or for the novel oral anticoagulant dabigatran etexilate versus enoxaparin.
Methods
Three previously reported trials compared 220 mg and 150 mg dabigatran etexilate once daily with enoxaparin after knee or hip arthroplasty. A pooled analysis was performed in patients receiving general or neuraxial anaesthesia, or the combination of either with peripheral nerve block (n = 8062). Outcome measures were major VTE plus VTE-related mortality, major bleeding and major plus clinically relevant bleeding events.
Results
General, neuraxial and combination anaesthesia were used in 29%, 52% and 19% of patients, respectively. Differences in efficacy and safety between anaesthesia subgroups were small and not significant, except for a slightly higher rate of major VTE and VTE-related mortality with general versus neuraxial anaesthesia (odds ratio: 1.40; 95% confidence interval: 1.03–1.90; p = 0.035) in the overall population. There were no significant effects of anaesthesia type on efficacy or safety of dabigatran etexilate versus enoxaparin.
Conclusions
Anaesthesia type did not greatly affect efficacy and safety outcomes in the pooled population of all three treatment groups. The efficacy and safety of dabigatran etexilate was comparable with enoxaparin, regardless of type of anaesthesia.
Trial registration
ClinicalTrials.gov identifiers: NCT00168805, NCT00168818, NCT00152971.
doi:10.1186/1477-9560-10-9
PMCID: PMC3444414  PMID: 22709460
Thromboprophylaxis; Type of anaesthesia; Venous thromboembolism; Bleeding; Dabigatran etexilate
3.  The role of the post-anaesthesia care unit in the management of high-risk obstetric patients 
Introduction
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.
Results
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.
Conclusions
The PACU can offer an intermediate intensive care facility for high-risk obstetric patients, thus reducing unnecessary admissions to the intensive care unit.
doi:10.5114/aoms.2011.20616
PMCID: PMC3258694  PMID: 22291744
maternal morbidity and mortality; complications of pregnancy
4.  Epidural anaesthesia and low back pain after delivery: a prospective cohort study. 
BMJ : British Medical Journal  1995;311(7016):1336-1339.
OBJECTIVE--To determine whether epidural anaesthesia during labour and delivery is a risk factor for postpartum back pain. DESIGN--Prospective cohort study with follow up at one day, seven days, and six weeks after delivery. SETTING--Teaching hospital in Montreal. SUBJECTS--329 women who delivered a live infant(s) during the study period. Exclusion criteria were back pain before pregnancy and delivery by elective caesarean section. INTERVENTION--Epidural anaesthesia during labour and delivery. MAIN OUTCOME MEASURES AND RESULTS--The primary outcome variable was development of postpartum low back pain. Back pain was quantified with self reports (yes/no), a pain score (numeric rating scale), and degree of interference with daily activities. Of the 329 women, 164 received epidural anaesthesia during labour and 165 did not. The incidence of low back pain in epidural v non-epidural group was 53% v 43% on day one; 21% on day seven; and 14% v 7% at six weeks. The relative risk for low back pain (epidural v non-epidural) adjusted for parity, delivery, ethnicity, and weight was 1.76 (95% confidence interval 1.06 to 2.92) on day one; 1.00 (0.54 to 1.86) on day seven; and 2.22 (0.89 to 5.53) at six weeks. There were no differences between the two groups in pain scores or the frequency of interference with daily activities. Similar results were obtained in the subgroup of women with low back pain of new onset--that is, those women with no back pain during their pregnancy. CONCLUSIONS--Postpartum low back pain was common but decreased considerably over the short term. The association between epidural anaesthesia and postpartum low back pain was inconsistent over time with a significantly increased risk of low back pain (epidural v non-epidural) noted only on the first day after delivery.
PMCID: PMC2551244  PMID: 7496283
5.  Complications And Controversies Of Regional Anaesthesia: A Review 
Indian Journal of Anaesthesia  2009;53(5):543-553.
Summary
Complications of regional anaesthesia has been recognised from very long time. Fortunately serious complication are rare. Safe, effective practice of neuraxial anaesthesia requires a detailed knowledge of potential complications, their incidence and risk factors associated with their occurrence. The incidence of complication were higher for spinal than for epidural anaesthesia. These complications being rare, so existing studies are mainly retrospective, providing information about incidence and their associations but not necessarily demonstrate causality.
There are many areas of controversies regarding the usage of regional anaesthesia i.e. in outpatient surgical procedures, epidural test dose, its safety in infected / febrile / immuno compromised patients, / in patients with neurological disorder and in patients receiving anti-coagulants. Recommendations proposed may be acceptable based on the judgment of the responsible anaesthesiologist. The consensus statements are designed to encourage safe and quality patient care but cannot guarantee a specific outcome.
PMCID: PMC2900086  PMID: 20640104
Regional anaesthesia; Complications; Controversies
6.  Closed loop anaesthesia at high altitude (3505 m above sea level): Performance characteristics of an indigenously developed closed loop anaesthesia delivery system 
Indian Journal of Anaesthesia  2012;56(3):238-242.
Background:
Closed loop anaesthesia delivery systems (CLADSs) are a recent advancement in accurate titration of anaesthetic drugs. They have been shown to be superior in maintaining adequate depth of anaesthesia with few fluctuations as compared with target-controlled infusion or manual titration of drug delivery.
Methods:
Twenty patients scheduled to undergo general abdominal or orthopaedic procedures under general anaesthesia at Leh (3505 m above sea level) were recruited as subjects. Anaesthesia was delivered by a patented closed loop system that uses the Bispectral Index (BIS™) as a feedback parameter to titrate the rate of propofol infusion. All vital parameters, drug infusion rate and the BIS™ values were continuously recorded and stored online by the system. The data generated was analysed for the adequacy of anaesthetic depth, haemodynamic stability and post-operative recovery parameters.
Results:
The CLADS was able to maintain a BIS™ within ±10 of the target of 50 for 85.0±7.8% of the time. Haemodynamics were appropriately maintained (heart rate and mean arterial blood pressure were within 25% of baseline values for 91.2±2.2% and 94.1±3% of the total anaesthesia time, respectively). Subjects were awake within a median of 3 min from cessation of drug infusion and achieved fitness to recovery room discharge within a median of 15 min. There were no adverse events or report of awareness under anaesthesia.
Conclusions:
The study demonstrates the safety of our CLADS at high altitude. It seeks to extend the use of our system in challenging anaesthesia environments. The system performance was also adequate and no adverse events were recorded.
doi:10.4103/0019-5049.98765
PMCID: PMC3425282  PMID: 22923821
Bispectral index; closed loop anaesthesia; high altitude; propofol
7.  Comparison between the complications of cataract surgery following local anaesthesia with short stay and general anaesthesia with a five-day hospitalisation. 
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.
PMCID: PMC1040602  PMID: 3994952
8.  Ambulatory Laparoscopic Tubal Ligation: A Comparison of General Anaesthesia with Local Anaesthesia and Sedation 
Background:
To compare the anaesthetic techniques for laparoscopic tubal ligation using either general anaesthesia with LMA or a combination of local anaesthetic and intravenous sedation, this study was conducted on 60 ASA-1/2 patients in the age group of 20-40 years.
Patients & Methods:
60 ASA grade I & II female patients undergoing laparoscopic tubal ligation on a day care basis were randomly divided in two groups- group I (GA using LMA, n=30), group II (Local anaesthesia, n=30). Both groups received similar premedication. General anaesthesia in group I was induced with propofol 2-3 mg kg-1 and following LMA insertion, the anaesthesia was maintained with 0.5-1.5% halothane. In group II the incision site was infiltrated with 10 ml of 1.5% lidocaine with adrenaline and patients were sedated with intravenous midazolam 0.07mg kg-1 and ketamine 0.5 mg kg-1. A rescue dose of 0.15 mg kg-1 of ketamine was given in group II if the patient complained of pain or discomfort during the procedure. Diclofenac sodium 1 mg kg-1 was used for postoperative analgesia in both the groups. All patients were observed in the PACU until they met the discharge criteria.
Results:
The demographic profile was similar in both the groups. The induction to skin incision time was significantly more in group I (5.13 ±0.93 min vs 3.01 ±1.86 min in group II). The decrease in pulse rate and blood pressure (systolic and diastolic) was also significant in group I. The incidence of intraoperative bradycardia was 16.7% and 10% in group I & group II respectively. The changes in SpO2 during the procedure, recovery time and time to meet discharge criteria were comparable in both the groups. The incidence of PONV was 20% & 3.3% in group I and 10% & 6.6% in group II respectively. All patients in both the groups required postoperative analgesics.
Conclusions:
Both the techniques were found to be comparable for laparoscopic sterilization, however a longer induction to skin incision time and higher incidence of PONV and shivering in GA group makes LA with sedation a better choice.
PMCID: PMC3146168  PMID: 21804716
Laparoscopy; Tubal ligation; Propofol; Ketamine; Local anesthesia
9.  Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials 
BMJ : British Medical Journal  2000;321(7275):1493.
Objectives
To obtain reliable estimates of the effects of neuraxial blockade with epidural or spinal anaesthesia on postoperative morbidity and mortality.
Design
Systematic review of all trials with randomisation to intraoperative neuraxial blockade or not.
Studies
141 trials including 9559 patients for which data were available before 1 January 1997. Trials were eligible irrespective of their primary aims, concomitant use of general anaesthesia, publication status, or language. Trials were identified by extensive search methods, and substantial amounts of data were obtained or confirmed by correspondence with trialists.
Main outcome measures
All cause mortality, deep vein thrombosis, pulmonary embolism, myocardial infarction, transfusion requirements, pneumonia, other infections, respiratory depression, and renal failure.
Results
Overall mortality was reduced by about a third in patients allocated to neuraxial blockade (103 deaths/4871 patients versus 144/4688 patients, odds ratio=0.70, 95% confidence interval 0.54 to 0.90, P=0.006). Neuraxial blockade reduced the odds of deep vein thrombosis by 44%, pulmonary embolism by 55%, transfusion requirements by 50%, pneumonia by 39%, and respiratory depression by 59% (all P<0.001). There were also reductions in myocardial infarction and renal failure. Although there was limited power to assess subgroup effects, the proportional reductions in mortality did not clearly differ by surgical group, type of blockade (epidural or spinal), or in those trials in which neuraxial blockade was combined with general anaesthesia compared with trials in which neuraxial blockade was used alone.
Conclusions
Neuraxial blockade reduces postoperative mortality and other serious complications. The size of some of these benefits remains uncertain, and further research is required to determine whether these effects are due solely to benefits of neuraxial blockade or partly to avoidance of general anaesthesia. Nevertheless, these findings support more widespread use of neuraxial blockade.
PMCID: PMC27550  PMID: 11118174
10.  Improving surveillance system and surgical site infection rates through a network: A pilot study from Thailand 
Clinical epidemiology  2009;1:67-74.
Background:
Surveillance of surgical site infections (SSI) provides data upon which interventions to improve patient safety can be based. In Thailand, however, SSI surveillance has not yet been standardized.
Objectives:
To develop a standardized SSI surveillance system and to monitor SSI rates after introduction of such a system.
Methods:
We conducted a prospective study among 17,752 patients who underwent surgery in ten hospitals in Thailand from April 2004 to May 2005. The SSI rates were computed and benchmarked with the US rates, reported in terms of standardized infection ratio (SIR). We estimated the incidence rate ratio of surgical site infections by comparing the incidence in the last study period with the incidence in the first study period.
Results:
The study included 17,869 operations and identified 248 SSIs, yielding an SSI rate of 1.4 infections/100 operations and a corresponding SIR of 0.6 (95% confidence interval [CI] = 0.5–0.7). During the study period the overall SSI rate decreased from 1.8 infections/100 operations to 1.2 infections/100 operations, yielding an incidence rate ratio of 0.65 (95% CI = 0.47–0.89).
Conclusion:
Our study highlighted that a standardized SSI surveillance in a developing country can be initiated through a network and may be followed by a decrease in SSI rates.
PMCID: PMC2943169  PMID: 20865088
surgical site infection; surveillance; network; Thailand
11.  Anaesthesia for lower-segment caesarean section: Changing perspectives 
Indian Journal of Anaesthesia  2010;54(5):409-414.
The number of caesarean sections has increased over the last two decades, especially in the developed countries. Hence, it has increasingly become a greater challenge to provide care for the parturient, but this has given obstetric anaesthetists a greater opportunity to contribute to obstetric services. While caesarean deliveries were historically performed using general anaesthesia, there is a recent significant move towards regional anaesthesia. Unique problems that patients with obesity and pre-eclampsia present will be discussed in the present article. New medications and devices now used in obstetric anaesthesia will change the practice and perspectives of our clinical practice.
doi:10.4103/0019-5049.71037
PMCID: PMC2991650  PMID: 21189878
Caesarean section; obstetrics; regional anaesthesia
12.  Empiric evidence for a genetic contribution to predisposition to surgical site infection 
The genetics of microbial pathogens have been extensively studied, but there has been little work on human genetic susceptibility to surgical site infection (SSI). We analyzed a large genealogical population database to study the familial contribution to SSI.
We analyzed 651 individuals with ICD-9 codes indicating presence of SSI. Matched hospital controls were randomly selected from the database based on birth year, sex and birthplace. The average relatedness of all possible pairs of cases, and separately of controls (x1000 sets) was compared empirically. The relative risk for SSI was estimated by comparing the number of observed affected individuals among the relatives of cases to the number of affected individuals observed among relatives of matched hospital controls. The Genealogical Index of Familiality test for patients with SSI showed significant excess relatedness (p< 0.010); this excess was still observed when close relationships were ignored (p=0.019). The RR for third-degree relatives of cases was significantly elevated (1.62, p = 0.029). The significant excess relatedness and the significantly elevated RR to distant relatives support a genetic predisposition to acquiring SSI.
doi:10.1111/wrr.12024
PMCID: PMC3594658  PMID: 23438157
surgical site infection; genetics; familiality; population database
13.  Epidural anaesthesia and urinary dysfunction: the risks in total hip replacement. 
Epidural anaesthesia in total hip replacement is an established and safe practice. It may be used alone or in combination with general anaesthesia for analgesia. Urethral catheterization in the perioperative period is known to greatly increase the complication of deep sepsis following total hip replacement. We assessed the effect on the incidence of urinary catheterization of using bupivocaine epidural anaesthesia in addition to general anaesthesia in total hip replacement. A prospective study was made of 113 total hip replacements. The incidence of catheterization in male patients who received an epidural was 67% compared to only 12% who had no epidural [P = 0.001]. In women the corresponding rates were 30% and 23%. We conclude that in men the use of supplementary epidural anaesthesia with bupivocaine is associated with a worrying increased need for urinary catheterization. This must be balanced against the claimed benefits of this form of anaesthesia.
PMCID: PMC1295420  PMID: 8786593
14.  General Anaesthesia With Multimodal Principles Versus Intrathecal Analgesia With Conventional Principles in Total Knee Arthroplasty: A Consecutive, Randomized Study 
Background
Postoperative outcomes following major surgery are influenced by surgical and anaesthesiological factors. While techniques of minimal invasive surgery have been associated with improved outcome, the techniques of minimal invasive, multimodal anaesthesia have not been adequately investigated. The aim of this study was to compare intrathecally based anaesthesia (ITA) including standardized, traditional intraoperative and postoperative care, with, general anaesthesia (GA) combined with intraoperative glucocorticoids, exclusion of intraoperative tourniquet and indwelling urethral catheter, and, an accelerated postoperative care regime. Outcome variables in the study were pain, requirement of analgesics, global satisfaction score and length-of-hospital stay.
Methods
Sixty patients were included and randomized to the ITA or the GA group. The ITA group received intrathecal bupivacaine (12.5 - 15.0 mg)/morphine (0.1 mg)/clonidine (0.03 mg), a standard surgical procedure, local infiltration analgesia (LIA) with ropivacaine (110 mg) /epinephrine (0.5 mg)/morphine (10 mg), an indwelling urethral catheter and mobilization with start Day 1 after the surgery. The GA group received a target-controlled infusion of propofol/remifentanil, betamethasone 4 mg i.v. intraoperatively, surgery was performed without a tourniquet, an indwelling urethral catheter was not used, LIA was with ropivacaine (250 mg)/epinephrine (0.3 mg) and mobilization was planned with start ≤ 2 hrs. after end of surgery. Outcomes were followed daily for the first 96 hrs. and at visits 3 months and 12 months postoperatively.
Results
Requirement of analgesics was decreased in the ITA group in the immediate postoperative period (P < 0.05). Pain scores were significantly lower in the ITA group (P < 0.01) between 0 - 12 hrs and in the GA group (P < 0.05) between 12 - 24 hrs after surgery. Fifteen of the patients in the GA group had to be intermittent catheterized due to bladder volumes > 400 mL. The LOS in the ITA group was significantly longer compared to the GA group (P < 0.01). There was no difference in global satisfaction score.
Conclusion
General anaesthesia combined with intraoperative glucocorticoids and accelerated postoperative care, compared with, intrathecal blockade and traditional postoperative care, seems to generate the same overall pain ratings and a decrease in length-of-hospital stay, in patients undergoing elective total knee arthroplasty.
doi:10.4021/jocmr1210e
PMCID: PMC3564567  PMID: 23390475
General anaesthesia; Glucocorticoids; Intrathecal analgesia; Length of hospital stay; Postoperative recovery; Total knee arthroplasty; Urinary catheter
15.  A Comparative Study of Induction, Maintenance and Recovery Characteristics of Sevoflurane and Halothane Anaesthesia in Pediatric Patients (6 months to 6 years) 
Patients & Methods:
In a randomized , double blind clinical study, we studied 30 children, aged 6 months to 6 years, to compare halothane and sevoflurane anaesthesia in patients undergoing short surgical procedures under general anaesthesia. All the patients were premedicated with atropine 0.02mg kg-1and midazolam 0.1mg kg-1body weight intravenously and received inhalation induction using nitrous oxide in oxygen supplemented with either halothane (maximum inspired concentration of 5%) or sevoflurane (maximum inspired concentration of 8%). Induction was by inhalation of increasing concentrations of sevoflurane (1%) or halothane (0.5%) in the vaporizing setting after every three breaths of the patient.
Results:
Time to loss of eyelash reflex and tracheal intubation was more rapid using sevoflurane. Cardiac arrhythmias were significantly more frequent during halothane than sevoflurane anaesthesia. Psychomotor recovery was more rapid after sevoflurane anaesthesia. Children who received sevoflurane had comparatively less nausea and vomiting and the incidence of clinically important side effects was significantly less with sevoflurane anaesthesia.
Conclusion:
We conclude that induction with sevoflurane in nitrous oxide and oxygen leads to fast loss of consciousness and provides ideal conditions for managing the airway without supplemental opioids or muscle relaxants with haemodynamic stability and is therefore a reasonable alternative to halothane for paediatric patients.
PMCID: PMC3087258  PMID: 21547175
Halothane; Sevoflurane; paediatric; children
16.  Rapid emergence of day-care anaesthesia: A review 
Indian Journal of Anaesthesia  2012;56(4):336-341.
The number of day-care surgeries is increasing every day. The boundaries of day-care surgeries are being redefined on a continual basis. Multi-dimensional benefits to the patient, hospital and national economy are the driving forces behind the changing scenario on the horizon of day surgery. The literature search included Google, medlinx, pubmed and medline. We have attempted to look at the controversies in patient selection with comorbidities, pre-operative assessment and an acceptable ASA grade of patients. An attempt is also made to look at suitable surgical procedures, a pathway of introducing procedures, which are still complex and specialist procedures in challenging environment. The techniques of general anaesthesia, central neuraxial blocks, regional nerve blocks with indwelling catheters and monitoring techniques are deliberated upon. Finally the most important post-operative issues of discharge criteria, including recovery after spinal anaesthetic, oral fluid intake, voiding and travel after day surgery, are considered.
doi:10.4103/0019-5049.100813
PMCID: PMC3469910  PMID: 23087454
Ambulatory surgery; anaesthetic techniques; controversies; day surgery; discharge; patient selection; surgical procedures
17.  A randomised, controlled crossover comparison of the C-MAC videolaryngoscope with direct laryngoscopy in 150 patients during routine induction of anaesthesia 
BMC Anesthesiology  2011;11:6.
Background
The C-MAC® (Karl Storz, Tuttlingen, Germany) has recently been introduced as a new device for videolaryngoscopy guided intubation. The purpose of the present study was to compare for the first time the C-MAC with conventional direct laryngoscopy in 150 patients during routine induction of anaesthesia.
Methods
After approval of the institutional review board and written informed consent, 150 patients (ASA I-III) with general anaesthesia were enrolled. Computer-based open crossover randomisation was used to determine the sequence of the three laryngoscopies: Conventional direct laryngoscopy (HEINE Macintosh classic, Herrsching, Germany; blade sizes 3 or 4; DL group), C-MAC size 3 (C-MAC3 group) and C-MAC size 4 (C-MAC4 group) videolaryngoscopy, respectively. After 50 patients, laryngoscopy technique in the C-MAC4 group was changed to the straight blade technique described by Miller (C-MAC4/SBT).
Results
Including all 150 patients (70 male, aged (median [range]) 53 [20-82] years, 80 [48-179] kg), there was no difference of glottic view between DL, C-MAC3, C-MAC4, and C-MAC4/SBT groups; however, worst glottic view (C/L 4) was only seen with DL, but not with C-MAC videolaryngoscopy. In the subgroup of patients that had suboptimal glottic view with DL (C/L≥2a; n = 24), glottic view was improved in the C-MAC4/SBT group; C/L class improved by three classes in 5 patients, by two classes in 2 patients, by one class in 8 patients, remained unchanged in 8 patients, or decreased by two classes in 1 patient. The median (range) time taken for tracheal intubation in the DL, C-MAC3, C-MAC4 and C-MAC4/SBT groups was 8 sec (2-91 sec; n = 44), 10 sec (2-60 sec; n = 37), 8 sec (5-80 sec; n = 18) and 12 sec (2-70 sec; n = 51), respectively.
Conclusions
Combining the benefits of conventional direct laryngoscopy and videolaryngoscopy in one device, the C-MAC may serve as a standard intubation device for both routine airway management and educational purposes. However, in patients with suboptimal glottic view (C/L≥2a), the C-MAC size 4 with straight blade technique may reduce the number of C/L 3 or C/L 4 views, and therefore facilitate intubation. Further studies on patients with difficult airway should be performed to confirm these findings.
doi:10.1186/1471-2253-11-6
PMCID: PMC3060123  PMID: 21362173
18.  Evaluation of Spinal and Epidural Anaesthesia for Day Care Surgery in Lower Limb and Inguinoscrotal Region 
Background:
Day care surgery is still in its infancy in India. Both regional and general anaesthesia can be used for this. Central neuraxial blocks are simple cheap and easy to perform. This study was done to evaluate usefulness of spinal and epidural anaesthesia for day care surgery.
Patients & Method:
100 patients were randomized to either spinal (n=50) or epidural (n=50) group anaesthetized with either 0.5% hyperbaric 2ml bupivacaine or 0.5% 20ml bupivacaine respectively. In spinal group 27 gauze quincke needle and in epidural group 18 gazue tuohy needle was used. Both the groups were compared for haemodynamic stability, side effects, complications, postanaesthesia discharge score (PADS), time taken to micturate, total duration of stay in hospital and patient satisfaction score for technique.
Results:
We observed that spinal anaesthesia had significantly early onset of anaesthesia and better muscle relaxation (p<0.05) as compared to epidural block otherwise both groups were comparable for haemodynamic stability, side effects or complications. Although more patients in spinal group (64% vs 48%) achieved PADS earlier (in 4-8 hours) but statistically it was insignificant. Time to micturition (6.02 0.55 v/s 6.03 0.47 hours) and total duration of stay (7.49 1.36 v/s 8.03 1.33 hours) were comparable in both the groups.
Conclusion:
Both spinal and epidural anaesthesia can be used for day care surgery. Spinal anaesthesia with 27 gauze quincke needle and 2ml 0.5% hyperbaric bupivacaine provides added advantage of early onset and complete relaxation.
PMCID: PMC3130356  PMID: 21804709
Day Care; Spinal; Epidural; Bupivacaine
19.  Surgical site infections in Italian Hospitals: a prospective multicenter study 
Background
Surgical site infections (SSI) remain a major clinical problem in terms of morbidity, mortality, and hospital costs. Nearly 60% of SSI diagnosis occur in the postdischarge period. However, literature provides little information on risk factors associated to in-hospital and postdischarge SSI occurrence. A national prospective multicenter study was conducted with the aim of assessing the incidence of both in-hospital and postdisharge SSI, and the associated risk factors.
Methods
In 2002, a one-month, prospective national multicenter surveillance study was conducted in General and Gynecological units of 48 Italian hospitals. Case ascertainment of SSI was carried out using standardized surveillance methodology. To assess potential risk factors for SSI we used a conditional logistic regression model. We also reported the odds ratios of in-hospital and postdischarge SSI.
Results
SSI occurred in 241 (5.2%) of 4,665 patients, of which 148 (61.4%) during in-hospital, and 93 (38.6%) during postdischarge period. Of 93 postdischarge SSI, sixty-two (66.7%) and 31 (33.3%) were detected through telephone interview and questionnaire survey, respectively. Higher SSI incidence rates were observed in colon surgery (18.9%), gastric surgery (13.6%), and appendectomy (8.6%). If considering risk factors for SSI, at multivariate analysis we found that emergency interventions, NNIS risk score, pre-operative hospital stay, and use of drains were significantly associated with SSI occurrence. Moreover, risk factors for total SSI were also associated to in-hospital SSI. Additionally, only NNIS, pre-operative hospital stay, use of drains, and antibiotic prophylaxis were associated with postdischarge SSI.
Conclusion
Our study provided information on risk factors for SSI in a large population in general surgery setting in Italy. Standardized postdischarge surveillance detected 38.6% of all SSI. We also compared risk factors for in-hospital and postdischarge SSI, thus providing additional information to that of the current available literature. Finally, a large amount of postdischarge SSI were detected through telephone interview. The evaluation of the cost-effectiveness of the telephone interview as a postdischarge surveillance method could be an issue for further research.
doi:10.1186/1471-2334-8-34
PMCID: PMC2311314  PMID: 18328101
20.  Survey on Maternal Satisfaction in Receiving Spinal Anaesthesia for Caesarean Section 
Background:
This study was undertaken to evaluate patient satisfaction after spinal anaesthesia, which is the most frequently administered anaesthesia in obstetric patients.
Methods:
A cross-sectional study of patients who underwent caesarean section under spinal anaesthesia in the operating rooms of Hospital Teluk Intan was conducted. Post-operative survey of patients on the day after surgery was conducted by collecting pre-operative and intra-operative data on a constructed questionnaire. Post-operative data, including satisfaction and understanding the anaesthetist’s explanation regarding anaesthesia, satisfaction in receiving spinal anaesthesia and adverse effects, and willingness to accept or refuse spinal anaesthesia for a similar surgery again, were inquired by trained anaesthesia personnel.
Results:
A total of 200 pregnant patients, with age ranging from 17 to 45 years, were surveyed: 64.5% Malay, 17% Indian, 14% Chinese and 4.5% others. All (100%) the patients were satisfied with the explanation provided regarding the choices of anaesthesia, but 2% could not concentrate on the explanation because of labour pain. Overall, the average satisfaction with spinal anaesthesia administration was divided into 194 (97%) satisfied patients and 6 (3%) dissatisfied patients. Factors associated with dissatisfaction were inadequate analgesia during surgery and failed spinal anaesthesia. Post-operative complications included spinal headache 5 (2.5%), post-operative nausea and vomiting (PONV) 1 (0.5%), pain at the surgical site 2 (1%) and backache 2 (1%). Furthermore, 177 (88.5%) patients would opt for spinal anaesthesia in future for similar surgery, if required; 16 (8%) would not; and 7 (3.5%) were not sure. The reasons for refusal to receive spinal anaesthesia were as follows: awareness and failed regional anaesthesia.
Conclusion:
The patients receiving spinal anaesthesia demonstrated a high rate of patient satisfaction. Ensuring the quality of spinal anaesthesia, improving clinical skill of the anaesthesiologists, and prevention of side effects might improve patient satisfaction.
PMCID: PMC3743982  PMID: 23966825
spinal; anaesthesia; patient satisfaction; caesarean section
21.  Evaluation of Staphylococcus aureus Nasal Carriage Screening before Vascular Surgery 
PLoS ONE  2012;7(6):e38127.
Introduction
Staphylococcus aureus is the most important pathogen in the development of surgical site infections (SSI). Patients who carry S. aureus in the nose are at increased risk for the development of SSI in cardiothoracic and orthopedic surgery. In these populations it has been shown that the risk for SSI can be substantially reduced by eradicating S. aureus carriage. For vascular surgery the relation between nasal carriage and surgical site infections has not been clearly investigated. For this reason we performed this study to analyze the relation between S. aureus nasal carriage and SSI in our vascular surgery population.
Methods
A prospective cohort study was undertaken, including all patients undergoing vascular surgery between January first 2010 and December 31th 2010. Before surgery patients were screened for S. aureus nasal carriage using a PCR technique. The presence of SSI was recorded based on criteria of the CDC.
Results
Screening was performed in 224. Of those, 55 (24.5%) were positive, 159 (71.0%) were negative and 10 (4.5%) were inconclusive. In the screened vascular population 4 S. aureus SSI occurred in the 55 carriers compared with 6 in 159 non-carriers (p = 0.24). A stratified analysis revealed a 10-fold increased risk in nasal carriers undergoing central reconstruction surgery (3 S. aureus SSI in 20 procedures versus 1 in 65 procedures in non-carriers, p = 0.039).
Discussion
In patients undergoing central reconstruction surgery nasals carriers are at increased risk for the development of S. aureus SSI. These patients will probably benefit from perioperative treatment to eradicate nasal carriage.
doi:10.1371/journal.pone.0038127
PMCID: PMC3369867  PMID: 22685553
22.  The breast feeding mother and xenon anaesthesia: four case reports. Breast feeding and xenon anaesthesia 
BMC Anesthesiology  2010;10:1.
Background
Four nursing mothers consented to anaesthesia for urgent surgery only on condition that their ability to breast feed would not be impaired.
Methods
Following induction of general anaesthesia with propofol and remifentanil, 65-69% xenon supplemented with remifentanil was used as an inhalational anaesthetic for maintenance.
Results
After finishing surgery the women could be extubated between 2:52 and 7:22 minutes. The women were fully alert just minutes after extubation and spent about 45 minutes in the recovery room before discharge to a regular ward. They resumed regular breast feeding some time later. The propofol concentration in the blood was measured after 0, 30, 90, and 300 minutes and in the milk after 90 and 300 minutes. Just 90 minutes after extubation, the concentration of propofol in the milk was limited (> 3 mg/l) so that pharmacological effects on the babies were excluded after oral intake. Also, no traces of xenon gas were found in the maternal milk at any time. After propofol induction and maintenance of anaesthesia with xenon in combination with a water-soluble short-acting drug like remifentanil, the concentration of propofol in maternal milk is low (> 3 mg/l 90 min after anesthesia) and harmless after oral intake.
Conclusions
These results, as well as the rapid elimination and absence of metabolism of xenon, are of great interest to nursing mothers. General anaesthesia with propofol for induction only, combined with remifentanil and xenon for maintenance, has not yet been described in breast feeding mothers.
doi:10.1186/1471-2253-10-1
PMCID: PMC2837001  PMID: 20167123
23.  Correlation between spinous process dimensions and ease of spinal anaesthesia 
Indian Journal of Anaesthesia  2012;56(3):250-254.
Background:
Neuraxial anaesthesia, despite being a common technique, may pose some technical challenges leading to complications such as post-dural puncture headache, trauma to neural structures and neuraxial haematoma. We hypothesised that the interspinous gap (ISG) and the spinous process width (SPW) could be used as objective measures to predict ease of access to the neuraxial space.
Methods:
Two hundred and two consecutive patients scheduled to have spinal anaesthesia for various surgical procedures were enrolled prospectively after institutional approval. Following proper positioning for the neuraxial blockade, the ISG and SPW at the intended level were measured with calipers. The number of attempts, and redirections at the selected spinal level, and the number of levels required for successful needle placement were also recorded.
Results:
Group-wise analysis of the data into patients requiring >1 attempt, >1 level and ≥3 redirections showed that the single independent predictor of a difficult neuraxial block was the ISG. Twenty-three percent of the patients required more than one attempt, with a mean gap of 6.35 (±1.2) mm, in contrast to 8.15 (±2.4) mm in those with a single attempt (P=0.000). In addition, 16% of the patients needed more than one level, with a mean gap of 6.03 (±2.01) mm in contrast to 8.07 (±2.37) mm for a single level (P=0.000).
Conclusions:
The single independent predictor of ease or difficulty during spinal anaesthesia was the ISG (P=0.000).
doi:10.4103/0019-5049.98769
PMCID: PMC3425284  PMID: 22923823
Difficulty; spinal anaesthesia; spinous process
24.  Effect of Intermittent Positive Pressure Ventilation on Depth of Anaesthesia during and after Isoflurane Anaesthesia in Sulphur-Crested Cockatoos (Cacatua galerita galerita) 
This study aimed to determine the effect of intermittent positive pressure ventilation (IPPV) on the depth of inhalation anaesthesia in parrots. Anaesthesia was induced with 3.0% isoflurane in six Sulphur-crested Cockatoos (Cacatua galerita galerita) and maintained using either 1.5% or 3.0% during spontaneous ventilation (SV) or IPPV at 6 (IPPV-6) or 12 (IPPV-12) breaths per minute. The time taken for the appearance of somatic reflexes and the return of SV after IPPV was recorded. During recovery, the body jerk, beak, eye, and shivering reflexes appeared after 126 ± 27 s, 133 ± 26 s, 165 ± 34 s, and 165 ± 44 s, respectively. All cockatoos developed apnoea after IPPV-12 and only some did after IPPV-6. Return of SV after IPPV-12 was delayed compared to IPPV-6. Recovery times after the SV runs were significantly different between 1.5% and 3.0% isoflurane anaesthesia. Similarly, after IPPV, the recovery times were significantly different between 1.5% and 3.0% isoflurane anaesthesia. Recovery times after 3.0% inhaled isoflurane were longer than those of 1.5% inhaled isoflurane. In conclusion, cockatoos recovering from isoflurane anaesthesia are likely to exhibit body jerk, beak, eye, and shivering reflexes in that order. IPPV increases the depth of anaesthesia in a rate and dose-related manner and prolongs recovery.
doi:10.1155/2014/250523
PMCID: PMC3920760  PMID: 24587938
25.  Crisis management during anaesthesia: awareness and anaesthesia 
Background: Patient awareness during general anaesthesia has considerable potential for severe emotional distress in the patient as well as professional, personal, and financial consequences for the anaesthetist.
Objectives: To examine the role of a previously described core algorithm "COVER ABCD–A SWIFT CHECK", supplemented by a specific sub-algorithm for awareness, in the detection and management of potential awareness in association with general anaesthesia.
Method: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved.
Results: Of the first 4000 reports received by AIMS, there were 21 incidents of patient awareness under general anaesthesia, and 20 of patients being paralysed while awake from "syringe swaps" before induction of anaesthesia. In 12 of the 21 reports there was an obvious cause, most commonly a low concentration of volatile agent (8 of 12 reports). The AIMS "core" crisis management algorithm would have detected the cause of awareness in all of these cases. In nine reports the course of anaesthesia appeared unremarkable, and in these the algorithm would not have been expected to detect or prevent awareness. Volatile agent monitoring would have prevented some cases of awareness, as would bispectral index electroencephalographic (BIS) monitoring. The role of BIS monitoring is still contentious, but it should be considered for high risk patients.
Conclusion: Awareness should be minimised by thorough checking of equipment, particularly vaporisers, and frequent application of a structured scanning routine. Awareness may occur during crisis management and aftermath protocols should include patient follow up to detect and manage awareness when it occurs.
doi:10.1136/qshc.2002.004358
PMCID: PMC1744013  PMID: 15933289

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