Acupuncture and Anesthesia: The Role of Perioperative Medical Acupuncture in Modern Surgical Care.

Perioperative Medicine: What the Future Can Hold for Anesthesiology.

Why is the surgical high-risk patient still at risk?

English language proficiency has been reported to correlate with disparities in health outcomes. Therefore, it is important to identify and describe the association of language barriers with perioperative care and surgical outcomes to inform efforts aimed at reducing health care disparities. To examine whether limited English proficiency compared with English proficiency in adult patients is associated with differences in perioperative care and surgical outcomes. A systematic review was conducted in MEDLINE, Embase, Web of Science, Sociological Abstracts, and CINAHL of all English-language publications from database inception to December 7, 2022. Searches included Medical Subject Headings terms related to language barriers, perioperative or surgical care, and perioperative outcomes. Studies that investigated adults in perioperative settings and involved quantitative data comparing cohorts with limited English proficiency and English proficiency were included. The quality of studies was evaluated using the Newcastle-Ottawa Scale. Because of heterogeneity in analysis and reported outcomes, data were not pooled for quantitative analysis. Results are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guideline. Of 2230 unique records identified, 29 were eligible for inclusion (281 266 total patients; mean [SD] age, 57.2 [10.0] years; 121 772 [43.3%] male and 159 240 [56.6%] female). Included studies were observational cohort studies, except for a single cross-sectional study. Median cohort size was 1763 (IQR, 266-7402), with a median limited English proficiency cohort size of 179 (IQR, 51-671). Six studies explored access to surgery, 4 assessed delays in surgical care, 14 assessed surgical admission length of stay, 4 assessed discharge disposition, 10 assessed mortality, 5 assessed postoperative complications, 9 assessed unplanned readmissions, 2 assessed pain management, and 3 assessed functional outcomes. Surgical patients with limited English proficiency were more likely to experience reduced access in 4 of 6 studies, delays in obtaining care in 3 of 4 studies, longer surgical admission length of stay in 6 of 14 studies, and more likely discharge to a skilled facility than patients with English proficiency in 3 of 4 studies. Some additional differences in associations were found between patients with limited English proficiency who spoke Spanish vs other languages. Mortality, postoperative complications, and unplanned readmissions had fewer significant associations with English proficiency status. In this systematic review, most of the included studies found associations between English proficiency and multiple perioperative process-of-care outcomes, but fewer associations were seen between English proficiency and clinical outcomes. Because of limitations of the existing research, including study heterogeneity and residual confounding, mediators of the observed associations remain unclear. Standardized reporting and higher-quality studies are needed to understand the impact of language barriers on perioperative health disparities and identify opportunities to reduce related perioperative health care disparities.

Nearly all patients receiving treatment in a peri-operative or intensive care setting receive supplemental oxygen therapy. It is biologically plausible that the dose of oxygen used might affect important patient outcomes. Most peri-operative research has focussed on oxygen regimens that target higher than normal blood oxygen levels. Whereas, intensive care research has mostly focussed on conservative oxygen regimens which assiduously avoid exposure to higher than normal blood oxygen levels. While such conservative oxygen therapy is preferred for spontaneously breathing patients with chronic obstructive pulmonary disease, the optimal oxygen regimen in other patient groups is not clear. Some data suggest that conservative oxygen therapy might be preferred for patients with hypoxic ischaemic encephalopathy. However, unless oxygen supplies are constrained, routinely aggressively down-titrating oxygen in either the peri-operative or intensive care setting is not necessary based on available data. Targeting higher than normal levels of oxygen might reduce surgical site infections in the perioperative setting and/or improve outcomes for intensive care patients with sepsis but further research is required and available data are not sufficiently strong to warrant routine implementation of such oxygen strategies.

Developed by the Task Force on Pain Management, Acute Pain Section: L. Brian Ready, M.D. (Chair), Seattle, Washington; Michael Ashburn, M.D., Salt Lake City, Utah; Robert A. Caplan, M.D., Seattle, Washington; Daniel B. Carr, M.D., Boston, Massachusetts; Richard T. Connis, Ph.D., Woodinville, Washington; Cheryl L. Dixon M.D., Jacksonville, Florida; Lex Hubbard, M.D., Shreveport, Louisiana; and Linda Jo Rice, M.D., Hartford, Connecticut.Submitted for publication December 27, 1994. Accepted for publication December 27, 1994. Supported by the American Society of Anesthesiologists, under the direction of James F. Arens, M.D. Chairman of the Ad-Hoc Committee on Practice Parameters. Approved by the House of Delegates, October 19, 1994. A list of the articles used to develop these guidelines is available by writing to the American Society of Anesthesiologists.Address reprint requests to the American Society of Anesthesiologists: 520 North Northwest Highway, Park Ridge, Illinois 60068-2573.Click on the links below to access all the ArticlePlus for this article.Please note that ArticlePlus files may launch a viewer application outside of your web browser.Key words: Pain: acute; perioperative. Practice guidelines: acute pain management.Practice guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints.Practice guidelines are not intended as standards or absolute requirements. The use of practice guidelines cannot guarantee any specific outcome. Practice guidelines are subject to revision from time to time, as warranted by the evolution of medical knowledge, technology, and practice. The guidelines provide basic recommendations that are supported by analysis of the current literature and by a synthesis of expert opinion, open forum commentary, and clinical feasibility data (Appendix).Acute pain in the perioperative setting has not been specifically defined in the available literature. The Task Force has not given preference to literature based on any particular system of definition or classification. For these guidelines, acute pain in the perioperative setting is defined as pain that is present in a surgical patient because of preexisting disease, the surgical procedure (e.g., associated drains, chest or nasogastric tubes, complications), or a combination of disease-related and procedure-related sources.The purpose of these guidelines is to facilitate the efficacy and safety of acute pain management in the perioperative setting and to reduce the risk of adverse outcomes. A number of adverse outcomes can result from undertreatment of postoperative pain. These include (but are not limited to) thromboembolic and pulmonary complications, extension of time spent in an intensive care unit and/or in a hospital, and reduced patient satisfaction. The principal adverse outcomes associated with management of perioperative pain include (but are not limited to) respiratory depression, brain injury, other neurologic injury, sedation, circulatory depression, nausea and/or vomiting, impairment of bowel function, pruritus, and urinary retention.These guidelines focus on modalities of perioperative pain management that require a higher level of expertise and organizational structure than "as needed" intramuscular or intravenous injections of opioids and that generally provide more effective relief of pain. Examples include (but are not limited to) epidural (and intrathecal) analgesia (EA), intravenous patient-controlled analgesia (PCA), and a number of regional analgesic (RA) techniques. The guidelines are not intended as an exhaustive or detailed consideration of specific techniques or all possible approaches.The specialty of anesthesiology brings an exceptional level of interest and expertise to the area of perioperative pain management. As a consequence, the anesthesiologist is in a unique position to provide leadership in integrating pain management into other aspects of perioperative care and thus improve this area of practice. In this leadership role, the anesthesiologist can contribute further to quality of care by developing and directing institution-wide perioperative analgesia programs that include collaboration with and participation by others, when appropriate.The role of anesthesiologists in managing acute pain extends beyond the perioperative setting. Patients with severe or concurrent medical illness such as sickle cell crisis, pancreatitis, or acute pain related to cancer or cancer treatment also benefit from aggressive pain control. Labor pain is another condition of interest to anesthesiologists. However, the complex interactions of concurrent medical therapies and physiologic alterations make it impractical to address pain management for these populations within the context of this document.These guidelines focus on management of acute pain in the perioperative setting for adult (including geriatric) and pediatric patients. The guidelines apply to inpatient and outpatient surgery. These guidelines are intended for use by anesthesiologists or by individuals who deliver care under the supervision of anesthesiologists.Evidence to support each guideline was carefully sought. The search included a comprehensive review of the published literature, surveys of the opinions of a large panel of consultants with expertise in acute pain management, and the opinions of the members of the Task Force. An indication of the strength of the evidence supporting each guideline is provided.The Task Force defines proactive planning as a process of integrating pain management into the perioperative care of patients. The literature, the panel of consultants, and the Task Force members strongly support the use of proactive planning for postoperative pain management. This support is based on recognized associations between preoperative and intraoperative analgesic techniques for the reduction of pain in the postoperative period.Recommendations: An individualized proactive plan (e.g., a predetermined strategy for postoperative analgesia) should be considered for all surgical patients. Factors that may influence the formulation of a proactive plan include (but are not limited to) type of surgery and expected severity of postoperative pain, underlying medical conditions (e.g., presence of respiratory or cardiac disease, allergies), the risk-benefit ratio of the techniques available, and patients' preferences and/or previous experience with pain. Proactive planning of perioperative pain should be part of the preoperative evaluation by the anesthesiologist and, in collaboration with others (e.g., nurses, surgeons, pharmacists), should be part of an institution's general plan for patient care.Activities that are commonly encompassed by proactive planning include (but are not limited to) (1) obtaining a pain history based on patients' experiences, (2) preoperative pain therapy when appropriate and feasible, (3) intraoperative procedures (e.g., wound infiltration) when appropriate and feasible, and (4) intraoperative or postincisional preparation of patients for postoperative pain management (e.g., initiating EA administration before the completion of surgery). Any treatment plan requires regular assessment and refinement based on the changing responses of individual patients.The available literature suggests that training and experience of hospital personnel (e.g. nurses, house-officers, pharmacists, psychologists) may be helpful in reduction of risk. There is strong agreement among the panel of consultants and the Task Force members that such education, training, and experience also contribute to improved quality of care.Recommendations: Anesthesiologists offering perioperative analgesia services should provide, in collaboration with others as appropriate, ongoing education and training to ensure that hospital personnel are knowledgeable and skilled with regard to the effective and safe use of the available treatment options within the institution. The scope of education should include topics ranging from basic bedside skills for evaluation of acute pain to an understanding of sophisticated pharmacologic techniques (e.g., PCA, EA, and various RA techniques) and nonpharmacologic techniques (e.g., relaxation, imagery, hypnotic methods). The need for education and training is ongoing as new personnel enter an institution and as modifications in therapeutic approaches are made.The panel of consultants and the Task Force members regard the concept of education of patients and families in planning and participation in perioperative pain control as being important to their comfort and well-being.Recommendations: Anesthesiologists offering perioperative analgesia services should provide, in collaboration with others as appropriate, education to patients and families regarding their roles in achieving comfort, reporting pain, and using the recommended analgesic methods to optimal benefit. Common misconceptions about the risk of side effects and addiction should be dispelled. Educational methods that facilitate optimal care of patients using PCA and other sophisticated methods might include (but are not limited to) discussion of analgesic methods at the time of the pre-anesthetic evaluation, brochures and video tapes to educate patients about therapeutic options, and discussion at the bedside during postoperative visits.The panel of consultants and the Task Force members strongly support the concept of assessment and documentation of response to perioperative pain therapy as important to effective care. Unless the response to pain therapy is regularly evaluated, there is no basis for rational, individualized therapy.Recommendations: Anesthesiologists offering perioperative analgesia services should use, in collaboration with others as appropriate, pain assessment instruments to facilitate the regular evaluation and documentation of pain, the effects of pain therapy, and side effects caused by the therapy (Table 1and Table 6templates 1 and 6).The panel of consultants and the Task Force members support the concept of 24-hour availability of anesthesiologists providing perioperative pain management as being important for maximizing patient comfort and safety. The condition of patients after surgery is frequently dynamic, and analgesic needs may change at any time.Recommendations: Most analgesic techniques place patients at some risk for side effects of complications that require prompt medical evaluation. Anesthesiologists responsible for perioperative analgesia, in collaboration with others as appropriate, should be available at all times to consult with ward nurses, surgeons, or other involved physicians and assist in evaluating patients who are experiencing problems with any aspect of postoperative pain relief.The available literature suggests that institutional protocols and procedures for ordering, administering, discontinuing, and transferring responsibility for pain management are helpful in providing effective and continuous pain control. The Task Force regards the use of institutional policies and procedures as a logical part of interdisciplinary management of perioperative pain, and there is strong agreement from the panel of consultants that this approach is beneficial. The development of hospital-wide policies and procedures helps standardize clinical practice using techniques such as PCA, EA, and various RA techniques (Table 2and Table 3templates 2 and 3). Standardization promotes safety and creates a framework for customization of care. Routine use of bedside documentation encourages caregivers to continually reevaluate pain treatment and respond to inadequate therapy in a timely manner. Daily evaluation, planning, and written documentation by those who are medically responsible for pain relief help establish the importance of a formal and structured approach to pain management (Table 4, Table 5, Table 6, Table 7templates 4-7).Recommendations: Anesthesiologists offering perioperative analgesia services should participate in developing, in collaboration with others as appropriate (especially nurses), standardized institutional policies and procedures for ordering, administering, discontinuing, and transferring responsibility for postoperative pain management. Policies (the foundation or "ground rules" for practice) and procedures (outlining the "how to" aspects of applying policies to patient care) should be readily available on each patient care unit. The polices and procedures also serve as ongoing educational and informational references.The literature strongly supports the efficacy and safety of three techniques used by anesthesiologists for the control of pain in the perioperative setting: (1) PCA with systemic opioids, (2) EA with opioids or opioid/local anesthetic mixtures (or intrathecal opioids), and (3) RA techniques, including (but not limited to) intercostal blocks, plexus infusions, and local anesthetic infiltration of incisions. The literature indicates that these three techniques used by anesthesiologists have no higher incidence of side effects than less effective techniques for perioperative pain management. The panel of consultants and the Task Force members strongly support the use of PCA, EA, and RA by anesthesiologists when appropriate and feasible.Recommendations: To meet the diverse needs of individual patients, anesthesiologists who manage perioperative pain should make available as appropriate a variety of effective therapeutic options such as PCA, EA, and RA.During the administration of anesthetics for surgery, the needs of many patients may best be met by taking advantage of the combined effects of a number of agents. Similarly, there is growing conviction that a multimodality approach (i.e., two or more analgesic agents or techniques used in combination) to providing postoperative analgesia has advantages over the use of a single modality.The literature supports the efficacy of two or more analgesic techniques (including nonpharmacologic methods) used in combination for the control of perioperative pain, especially when different sites and/or mechanisms of action are involved and/or when synergy of effect is achieved. In addition, the literature indicates that multimodality approaches are associated with side effects no greater than those resulting from single analgesic techniques for perioperative pain management. The panel of consultants and the Task Force members support the use of multimodality techniques when appropriate and feasible.Recommendations: Anesthesiologists managing perioperative pain should make available as appropriate a variety of analgesic techniques and should consider their use in combination under appropriate circumstances.Although dedicated individuals can improve perioperative pain control for the individual patients they treat, comprehensive programs provide optimal analgesia throughout an institution. Such programs have been advocated by national and international pain specialty societies [1,2]and the Federal government.* The Task Force strongly believes that, based on training, knowledge, skills, interest, and historical innovation, anesthesiologists are uniquely qualified to provide leadership within their institutions in developing and managing perioperative pain management programs.The panel of consultants and the Task Force members regard organized interdisciplinary activities (e.g., anesthesiologists in collaboration with nurses, surgeons, and pharmacists) as important and optimal in providing effective, safe, and continuous perioperative pain control (Table 8template 8). An essential feature of such an approach should be an ongoing strong working relationship between anesthesiologists and nurses.Recommendations: Anesthesiologists who manage perioperative pain should develop (in collaboration with nurses, surgeons, pharmacists, and others) an organized, interdisciplinary approach to perioperative pain management within their institutions.Pediatric patients (infants and children) present unique problems regarding perioperative pain management for reasons that include differences in the perception of care-givers regarding the need for analgesia, differences in the pharmacology of analgesic medications when used in this group, and the strong emotional components of pain in children. In the past, safe methods for providing analgesia have been underused in pediatric patients because of fear of opioid-induced respiratory depression.The emotional component of pain is very strong in children. Absence of parents, security objects, and familiar surroundings may be perceived by the child to be as painful as the surgical incision. When clear evidence of physical pain is not seen, the tendency of health-care providers is to assume pain is not present and therefore defer treatment. In addition, young childrens' fear of injections makes intramuscular opioids or other methods, which themselves cause discomfort, less acceptable to this group than to adults. Many children will choose to suffer in silence knowing that an expression of pain will result in a dreaded injection.Pain assessment is more difficult in children because, as they grow and develop, cognitive and emotional responses are different from adults and are constantly changing. Special instruments are available to assist young children in self-reporting of pain, and behavioral and physiologic parameters can be employed to assess preverbal children or in those who cannot self-report.The literature strongly supports the effectiveness of a variety of techniques in providing analgesia in pediatric patients. Many of these are the same techniques used in adults, although some techniques (e.g., caudal analgesia) are more commonly used in children. There is strong agreement among the panel of consultants and the Task Force members that it is important to recognize that pediatric patients represent a unique population with special features when planning and providing perioperative analgesia.Recommendations: Anesthesiologists who treat perioperative pain in pediatric patients should be familiar with the special features of this group. Based on that knowledge, pharmacologic and nonpharmacologic strategies for perioperative analgesia appropriate for the age of the child should be offered in a manner that promotes efficacy and safety.Elderly patients are a unique population facing surgery. They may experience physical and mental limitation and may have different attitudes than younger patients with regard to expressing pain and appropriate therapy for it. Altered physiology with aging changes the way analgesic drugs and local anesthetics are distributed and metabolized, frequently necessitating alterations in dosing. There is strong agreement from the panel of consultants and the Task Force members on the importance of recognizing the unique features of geriatric patients in planning and providing perioperative analgesia.The literature indicates that single and multimodality techniques that have been shown to be effective in younger adult patients are also effective (often with reduced drug dose requirements) in geriatric patients without increasing side effects.Recommendations: Anesthesiologists who treat perioperative pain in geriatric patients should be familiar with the special features of this group. In particular, dose reduction for drugs that may cause central nervous system depression should be considered.The increasing trend toward ambulatory surgery poses special problems in perioperative pain management. One of the most common reasons for unanticipated hospital admission in this population is inadequate pain control. Analgesic techniques must provide safe, adequate pain relief for patients who quickly leave the supervised hospital environment. Techniques such as EA and intravenous PCA, which require special nursing and monitoring, are not suitable for such patients, but others such as local anesthetic wound infiltration and oral nonsteroidal antiinflammatory drugs may be very effective.The panel of consultants and the Task Force members strongly agree that the provision of effective analgesia to ambulatory surgery patients is important and beneficial. A limited search of this evolving literature suggests that planning of perioperative analgesia for ambulatory patients including the use of certain procedures (e.g., local anesthetic wound infiltration and certain RA techniques) may improve analgesia without increasing the risk of side effects.Recommendations: Anesthesiologists who care for ambulatory surgery patients should proactively plan therapeutic strategies appropriate for them, recognizing that they are expected to leave the surgical facility within a few hours after the completion of surgery.The Task Force thanks those who responded to surveys on acute pain in the perioperative setting, reviewed guideline drafts, contributed oral and written testimony to the Open Forum, and participated in tests of clinical feasibility.The development of these guidelines included methods recommended in the following publications: (1) Clinical Practice Guidelines--Directions for a New Program, Committee to Advise the Public Health Service on Clinical Practice Guidelines, Division of Health Care Services, Institute of Medicine. Edited by Field MJ, Lohr KN, Washington, D.C., National Academy Press, original document 1990, summary document 1992; and (2) Woolf SH: Manual for Clinical Practice Guideline Development, Washington, D.C., U.S. Department of Health and Human Services. Agency for Health Care Policy and Research, publication number 91-0007, March 1991.The scientific assessment was based on the following statements or evidence linkages. These linkages represent directional hypotheses about relationships between perioperative pain management and clinical outcomes.1. Proactive planning for perioperative pain management improves pain control and reduces adverse outcomes.2. Education and training of hospital personnel improve pain control and reduce adverse outcomes.3. Education and participation of patients and families improve pain control and reduce adverse outcomes.4. Monitoring and documentation activities improve pain control and reduce adverse outcomes.5. Availability of anesthesiologists providing perioperative pain management improves pain control and reduces adverse outcomes.6. Standardized institutional policies and procedures for perioperative pain management improve pain control and reduce adverse outcomes.7. Use of PCA, EA, or RA techniques improves pain control and reduces adverse outcomes.8. Use of multimodality techniques improves pain control and reduces adverse outcomes.9. Organizational characteristics related to perioperative pain management improve pain control and reduce adverse outcomes.10. Pediatric perioperative pain management techniques improve pain control and reduce adverse outcomes.11. Geriatric perioperative management techniques improve pain control and reduce adverse outcomes.12. Ambulatory surgery acute pain management techniques improve pain control and reduce adverse outcomes.Scientific evidence was derived from aggregated research findings, including metaanalyses, and from surveys, open forum presentations, and other consensus-oriented activities. For purposes of literature aggregation, potentially relevant clinical studies were identified via electronic and manual searches of the literature. The search covered a 27-yr period from 1966 through 1993. More than 4,000 articles were identified initially, yielding 465 nonoverlapping articles that addressed the 12 evidence linkages. Studies that could not be analyzed statistically were reviewed and eliminated, yielding 233 articles used in the formal metaanalyses.A directional result for each study was determined initially by classifying the outcome as (1) supporting a linkage, (2) a linkage, or (3) The were to a directional assessment of support for each The literature to linkages EA, and RA as and studies with defined and for formal tests were to continuous and an procedure was to study combined tests were employed as (1) the combined based on of the from the and (2) the combined providing of the studies by each of the by the A procedure based on the for study using 2 2 was used when outcome was An acceptable level was at and were agreement was through assessment of for of the were to ensure among the study To control for a was for each combined search for studies was and no tests for research were from the combined tests for pain reduction were as 1 EA and RA and effect from to effect for all outcomes were (i.e., not for of tests and of effect were in all that the various studies common of the population effect for the linkages. among the Task Force members and two was by using a for agreement were as (1) type of study (2) type of (3) evidence and (4) literature for agreement (1) (2) and (3) linkage, These represent to of of the literature were by of opinions from a panel of anesthesiologists with expertise in acute pain in the perioperative setting and from the opinions of the Task Force were of the linkages (i.e., that they in in pain reduced adverse side and were important for the guidelines to The of consultants supporting each based on these were 1 2 and 12 was to the guidelines after completion of the feasibility of these guidelines into clinical practice was using a of opinions from a panel of anesthesiologists with expertise in acute pain in the perioperative setting. of the responses that these guidelines can be in a large of institutions with of the anesthesiologists that of the guidelines not result in the need to new or of guideline for all was to the who that be the was new of PCA epidural and anesthesiologists were to of the evidence linkages change their clinical the guidelines were The of consultants no change associated with each were as proactive planning education and training education and participation of patients and families and documentation availability of anesthesiologist institutional policies and procedures use of PCA, EA, and RA techniques use of multimodality techniques organizational characteristics pediatric techniques geriatric techniques and ambulatory surgery techniques of the that the guidelines have no effect on the of time spent on a that the guidelines reduce the of time spent For all the in the of time spent on a was the of who an in time spent on a the was Practice Pain or and Agency for Health Care Policy and Washington, D.C., U.S. Department of Health and Human Services, by with special interest in the used in these guidelines can further by writing L. Brian Ready, M.D., Department of Acute Pain of of Seattle,

Translation, adaptation and psychometric validation of the Good Perioperative Nursing Care Scale (GPNCS) with surgical patients in perioperative care

Sir, In India, around 555,000 people died of cancer in 2010, representing 8% of estimated cancer deaths globally and 6% of deaths in India.[1] Physical and psychological effects of chronic pain affect the progression of the disease.[2] Opioids are considered as a key component for treatment of moderate to severe pain in cancer patients. Despite the abundant opium availability in India, opioid consumption, as estimated by World Health Organisation Collaborating Centre in 2012, is only 0.24 mg/person [Table 1].[3]Table 1: Opioid consumption 2010 (Pain and Policy Studies Group, UWCCC/WHO Collaborating Center, 2012)In India, only 0.4% of the total population have access to the opioids. Complicated rules and regulations along with problems related to attitude and knowledge regarding pain relief and opioids among the medical professionals and the public are major hindrances for poor access to opioids.[4] According to Narcotic Drugs and Psychotropic Substances (NDPS) Act (1985), to procure opioids, all the medical institutes should possess a license; they should specify the drug, the required quantity and also the formulation of the drug. The procedure to procure the license includes filing an application to the Drug Controller in the capital city; the drug inspector then institutes an inspection. Inspector inspects for adequate storage facilities, security setup, facilities to discard drugs, etc. Approval by the Drug Inspector is transmitted to the Drug Controller. Then the health authority confirms the approval to Drug Controller and License is issued. Frequently, the validity of one licence expires by the time another licence is obtained. Thus, it becomes a tedious job for doctors and hospitals to get all the licences to procure morphine.[5] Narcotic Drugs and Psychotropic Substances Amendment Bill, 2014 has been passed in 2014 with path-breaking changes for access to narcotics by medical specialty, breaking the various barriers which were included in the 1985 act. Parliament has adopted a new category of essential narcotic drugs in which central government can notify on the basis of expediency in medical practice. Drugs considered as essential will be subjected to central rules and will apply uniformly throughout the country. With the relaxation of rules, chances of misuse may be more and also due to the possibility of pilferage, chances of addiction increase. Physicians are scared to prescribe narcotic drugs due to unfounded fear of addiction and respiratory depression in patients. Patients who want pain relief are seen as drug addicts and doctors fear prosecution under NDPS Act.[6] Many laws and government policies so far were restrictive, and availability was difficult, without realising their rational medical use in pain management.[78] Next is fear of dependence; for a patient in pain, dependence rarely results and this is not the reason for not prescribing opioids to ailing patients.[9] Studies in palliative care showed that increased use of morphine did not lead to misuse.[10] Our aim is to update the readers on improved access and awareness of opioids to patients and identify regulatory barriers in the availability of opioids. Physicians and nurses should be educated about the principles of palliative care. Sustained and persistent efforts should be made by the palliative care leaders so that regulatory barriers can be overcome. Awareness can be created by conducting more and more workshops on the proper use of narcotics. Administration also plays a great role as it monitors the administration of narcotics and ensures the accountability of these drugs. It also guides and helps in maintaining the records. License should be issued to the institution or to the panel of physicians rather than on the individual basis and punishment should be harsher. New ampoules are expected to be exchanged for the discarded ones. According to the the Drug Inspector, the provisions of the NDPS Act, 2014 will allow medical institutes to have uninterrupted supply of narcotics for the patient care and process of getting the different licences is expected to be less tedious. It is better to remember that by simplifying the narcotic regulation, opioid availability cannot be improved to the cancer patients as it needs education of health care professionals in pain management and palliative care along with the integration of the palliative care programmes into the health care system.[4]

Pain is an unpleasant sensory perception warning of actual or impending tissue damage. Pain serves a vital physiological role, however, severe and uncontrolled pain in the peri-operative setting can adversely affect outcome from surgery and lead to chronic pain. Multiple neurochemical and receptor processes are involved in pain perception but the role of pro-inflammatory cytokines and adrenergic pathways has only recently been recognised. Clonidine is an agonist at the alpha2-adrenergic receptor that has been in clinical use for over 40 years. Clonidine was recognised at an early stage as having analgesic properties however its systemic use was frequently limited by side-effects. Recent advances in anaesthetic practice, allowing more targeted drug delivery and a better understanding of the basic physiology of pain have led to a re-evaluation of the role of clonidine in pain management. Experimental and clinical studies have identified a diverse action of clonidine in modifying not only the adrenergic component to pain perception but also an important effect on modifying the neurohumoral response to tissue injury. This has implications for the management of a diverse range of pain problems and potentially offers a method of preventing the transition from acute to chronic pain. Clonidine is likely to play an increasing role in clinical practice in anaesthetics and pain management.

Healthcare provider perceptions of disparities in perioperative care

Chapter 12 - Clinical Outcomes and Measures in Perioperative Care

This pocket guide on perioperative echocardiography discusses various issues on echocardiography and Doppler imaging, a diagnostic and monitoring technique that is used increasingly in the perioperative and intensive care unit setting. The setup of the pocket guide is clear and straightforward. The sequence of the different topics is built up logically and step by step. Each chapter begins with learning objectives, informing the reader immediately what is to be found in that chapter. The first chapter deals with general views on how to use and implement echocardiography in a perioperative setting. The following two sections encompass the technology of the echocardiograph and probes. Quality of imaging and organization of echo-imaging is the topic of another chapter. The authors provide careful instruction to the reader on what different anatomical characteristics are, how they can be obtained and how these features should be viewed in terms of a three-dimensional construction from two-dimensional images. Transoesophageal imaging and transthoracic echocardiographic imaging are discussed in separate chapters, which also provide the official terminology. The chapter on Doppler imaging provides an overview of such basic issues as the Doppler effect and rapidly progresses to information on how to assess pressures with Doppler. This section forms the basis for the following chapter, on the assessment of haemodynamics. Various self-explanatory schemes guide the reader through decision making in this difficult issue. In addition, tables are well organized to illustrate decision making on hypovolaemia, assessment of fluid responsiveness and evaluation of ventricular function. Ventricular function is also covered later, encompassing both systolic and diastolic function of the left ventricle. Again, various diagrams provide illustrative information. Subsequent chapters discuss the most frequent problems of valvular pathology and provide information on problems with great vessels, and a further chapter discusses pericardial pathology from an echocardiographic point of view. In particular, the important issue of pericardial tamponade is elaborated extensively in clear diagrams. Regional anaesthesia and vascular access – two hot topics at the moment – are included in the book's later sections, and the information presented is important for general anaesthetists. Both issues are exemplified in several schemes. The final chapter discusses which items should be included when training and accreditation is organized. The booklet includes a small CD-Rom including several clips of most important issues, sorted by chapter. The pocket guide does not have the aim of including all facets of echocardiography. For example, tissue Doppler imaging is discussed only very briefly. In addition, other issues such as valvular pathology are summarized, although the most important problems are discussed. Some iconography could have been more specific and illustrative, as modern echographs often offer pretty visualizations. Real images could have replaced the presented schematic representations in the chapter on regional anaesthesia and vascular access. In summary, this booklet is a good pocket guide for anaesthetists or critical care physicians who deal with echocardiography and an echographic approach to haemodynamic follow-up and problem solving.

Introduction The incidence of dementia among patients in perioperative settings is on the rise, presenting significant challenges for healthcare professionals in delivering adequate and appropriate care to this patient population. In order to gain a deeper understanding of the perioperative care needs of patients with dementia, thirty healthcare professionals were interviewed. The focus was on their experiences and perspectives regarding the fulfilment of these needs. Key factors influencing perioperative care were identified and categorised into three main themes: patient-related factors, healthcare professional-related factors, and healthcare environment-related factors. Methods Thirty interviews were conducted with a diverse group of healthcare professionals, including anaesthetists, surgeons, nurses, and other perioperative staff. Thematic analysis was employed to process and interpret the data, identifying recurring themes and sub-themes that reflect the complexities of perioperative care for patients with dementia. Results The analysis revealed three primary themes: 1) Factors related to the patient with dementia: Cognitive impairment and comorbidities uniquely challenge perioperative care. The unfamiliar hospital environment often exacerbates cognitive symptoms, and adherence to postoperative protocols can be problematic. Family involvement is crucial in supporting these patients. 2) Healthcare Professional Factors: Perceptions of dementia, communication issues, pain assessment, and the need for personalised care were highlighted. Training and education deficits among healthcare professionals were evident, impacting the quality of care. 3) Institutional Factors: Organisational policies and resource allocation significantly affect the provision of dementia care. Support for healthcare professionals through ongoing education and the development of dementia-specific guidelines were identified as essential needs. Conclusion Effective perioperative care for patients with dementia requires addressing multifaceted challenges. Improving communication, enhancing education and training for healthcare professionals, involving family members, and ensuring institutional support are critical steps. A comprehensive, empathetic approach can lead to better outcomes and experiences for patients with dementia in the perioperative setting.

The Arab world consists of 22 countries, representing 5.5% of the world's population. Morphine consumption accounts for less than 1% of the world's consumption. This is the first study to identify barriers to opioid use in the Arab world. This study aimed to investigate the barriers to opioid use in pain management in the Arab world. Online survey was developed to investigate barriers to governance, prescribing, distributing, dispensing and administering, as well as educational barriers in the Arab world. The questionnaire was sent via email and a mobile app to one expert physician in pain management and one licensed pharmacist from each Arab country. With the exception of Tunisia, Djibouti and Comoros, 34(77%) participants from 19 Arab countries answered the survey. Most countries lack local opioid production, necessitate special licenses for physicians, and restrict opioid prescribing to medical specialists. Special prescription forms are mandated, and pharmacists lack the authority to correct prescription errors or accept refill or verbal orders on opioids. Storage requirements for empty ampoules and prescriptions are enforced. Nurses are not allowed to carry opioids during home visits, and only first degree relatives can collect opioids for patients. Furthermore, the integration of palliative care and pain management curricula into pharmacies and medical schools is lacking. There is a wide range of regulatory and other barriers to opioid use in the Arab world. There is a substantial need for regulatory review and reform, as well as for educational initiatives, in most Arab countries.

196 Background: Cancer-related pain negatively affects symptom burden, morbidity, and mortality. Evidence suggests the use of ACU to relieve cancer-related pain. We investigated ACU efficacy and patient-specific factors associated with pain improvement. Methods: Medical charts were reviewed from oncology pts receiving ACU and concurrent palliative medicine management. Pre- and post-ACU pain scores, as assessed by the Edmonton Symptom Assessment Scale (ESAS), were measured at each session. Univariate logistic regression models, including an over-dispersion parameter to account for multiple observations per pt, were used to investigate the association between patient-specific variables (Table) and significant pain improvement, defined as a ≥ 2-point reduction in ESAS pain score, at each session. Results: A total of 122 ACU sessions from 53 pts were included in the analysis. Significant pain improvement was observed in 47% of all sessions (mean reduction 1.8). Baseline non-neuropathic pain was significantly associated with a higher odds of achieving pain reduction (OR 2.351; P = 0.047). Conversely, an opposite association was identified for baseline neuropathic pain (OR 0.421; P = 0.048). Age, stage, number of sessions and tumor type were not significantly associated with pain improvement, although several trends were noted (Table 1). Conclusions: ACU is an appropriate adjunct therapy for cancer-related pain, particularly for non-neuropathic pain. Larger studies to confirm patient-specific variables and further investigation into therapy related side effects will assist in determining a personalized approach to ACU therapy in the oncology population. [Table: see text]

To explore and explain how nurses minimise risk in the perioperative setting. Perioperative nurses care for patients who are having surgery or other invasive explorative procedures. Perioperative care is increasingly focused on how to improve patient safety. Safety and risk management is a global priority for health services in reducing risk. Many studies have explored safety within the healthcare settings. However, little is known about how nurses minimise risk in the perioperative setting. Classic grounded theory. Ethical approval was granted for all aspects of the study. Thirty-seven nurses working in 11 different perioperative settings in Ireland were interviewed and 33hr of nonparticipant observation was undertaken. Concurrent data collection and analysis was undertaken using theoretical sampling. Constant comparative method, coding and memoing and were used to analyse the data. Participants' main concern was how to minimise risk. Participants resolved this through engaging in anticipatory vigilance (core category). This strategy consisted of orchestrating, routinising and momentary adapting. Understanding the strategies of anticipatory vigilance extends and provides an in-depth explanation of how nurses' behaviour ensures that risk is minimised in a complex high-risk perioperative setting. This is the first theory situated in the perioperative area for nurses. This theory provides a guide and understanding for nurses working in the perioperative setting on how to minimise risk. It makes perioperative nursing visible enabling positive patient outcomes. This research suggests the need for training and education in maintaining safety and minimising risk in the perioperative setting.