The anaesthesia recovery toolbox: practical tips

Administration of general anesthesia requires continuous monitoring of vital parameters of the body including body temperature. However, temperature continues to be one of the least seriously monitored parameters perioperatively. Inadvertent perioperative hypothermia is a relatively common occurrence with both general and regional anesthesia and can have significant adverse impact on patients’ outcome. While guidelines for perioperative temperature management have been proposed, there are no specific guidelines regarding the best site or best modality of temperature monitoring and management intraoperatively. Various warming and cooling devices are available which help maintain perioperative normothermia. This article discusses the physiology of thermoregulation, effects of anesthesia on thermoregulation, various temperature monitoring sites and methods, perioperative warming devices, guidelines for perioperative temperature management and inadvertent temperature complications (hypothermia/hyperthermia) and measures to control it in the operating room.

Carotid endarterectomy (CEA) is a prophylactic operation that is used to mitigate the risk of stroke caused by embolism of atherosclerotic plaques in the carotid bifurcation. Previously, the large, multicentre, randomised, controlled GALA study found no significant differences in clinical outcomes between patients treated using general or local anaesthesia. While this study provided important insights into disease outcomes based on treatment modalities, it did not answer questions regarding the safety of CEA under local anaesthesia in patients at high risk for cardiovascular complications. Here, we examined the use of two different management plans in patients requiring both carotid endarterectomy and coronary artery bypass grafting (CABG), in terms of their effects on hospital mortality. Thirty-four patients consecutively operated on in our cardiovascular department were included in this analysis. The patients were divided into two groups based on the anaesthetic management plan. The first group consisted of patients who underwent CEA and CABG under general anaesthesia in the same session (GA group); the second group consisted of patients who initially underwent CEA under cervical block anaesthesia followed by CABG under general anaesthesia in a separate session (CB-GA group). These two groups were compared in terms of postoperative complications and hospital mortality. The incidence of postoperative myocardial infarction was higher in the CB-GA group, with four patients experiencing postoperative myocardial infarction, compared to no patients in the GA group. For patients requiring CEA and CABG, performing both operations under general anaesthesia in the same session was safer than initially performing CEA under cervical block anaesthesia followed by CABG under general anaesthesia.

Inadvertent perioperative hypothermia causes serious morbidity in surgical patients. However, recent reports suggest that patients might still be hypothermic after elective surgery. We thus surveyed intraoperative temperature monitoring and management practices in Europe. Postal survey of 801 representative hospitals from 17 European countries on the same day. The questions addressed the number of surgical procedures and type of anaesthesia performed, mode and site of temperature monitoring and method of patient warming. Mean and standard error of the mean or count and percentage were calculated. The t-test or contingency table analysis with the Fisher's exact test were used. Eight thousand and eighty-three surgical procedures were assessed from 316 responding hospitals (39.4%). Overall, patient temperature monitored in 19.4% and 38.5% of the patients were actively warmed. Under general anaesthesia, body temperature was monitored in 25% and during regional anaesthesia in 6%, P = 0.0005. Nasopharyngeal temperature was most often taken under general anaesthesia, while tympanic temperature was preferred during regional anaesthesia. Under general anaesthesia, 43% of patients were actively warmed as compared to 28% with regional anaesthesia, P = 0.0005. Forced-air warming was the method of choice for both general and regional anaesthesia. Intraoperative temperature monitoring is still uncommon and hence active patient warming is not a standard of care in Europe. Awareness of perioperative hypothermia is critical to its prevention, and thus temperature monitoring is a pre-requisite. The objective is to maintain normothermia in patients throughout surgery. A European practice guideline for perioperative patient temperature management is warranted.

Background and Aims:Unintended hypothermia (UIH) during surgery under general anaesthesia has adverse implications. A retrospective analysis of the perioperative temperature records of healthy voluntary liver donors was done to evaluate the efficacy of a multimodal protocol for temperature management.Methods:Records of 50 American Society of Anesthesiologists physical status Class 1 patients operated for Donor Hepatectomy lasting >2 h under combined general and epidural anaesthesia were analysed. Ambient temperature was maintained 24°C–27°C before induction of GA and during insertion of epidural catheter. Active warming was done using warming mattress set to temperature 38°C, hot air blanket with temperature set to 38°C and fluid warming device (Hotline™) with preset temperature of 41°C. Nasopharyngeal temperature was continuously monitored. After induction of GA and draping of the patient, ambient temperature was decreased and maintained at 21°C–24°C and was again increased to 24°C–27°C at the conclusion of surgery. During surgery, for every 0.1°C above 37°C, one heating device was switched off such that at 37.3°C all the 3 devices were switched off. Irrigation fluid was pre-warmed to 39°C.Results:Baseline temperature was 35.9°C ± 0.4°C. Minimum temperature recorded was 35.7°C ± 0.4°C. Mean decrease in temperature below the baseline temperature was 0.2°C ± 0.2°C. Temperature at the end of surgery was 37.4°C ± 0.5°C.Conclusion:Protocol-based temperature management with simultaneous use of resistive heating mattress, forced-air warming blanket, and fluid warmer along with ambient temperature management is an effective method to prevent unintended perioperative variation in body temperature.

ObjectiveMeasure wait times, characterise current information flow and define requirements for a technological information system that supports the patient's journey.DesignFirst, patients were observed during eight random weekdays and the durations...

11th International Dental Congress on Modern Pain Control The Essential Role of Dental Anesthesiology in the 21st Century Safe and Comfortable Dentistry 4th–7th October, 2006

Simple SummaryRecovery is the most dangerous phase of general anaesthesia in horses. Numerous publications have reported about this phase, but structured reviews that try to reduce the risk of bias of narrative reviews/expert opinions, focussing on the topic are missing. Therefore, the aim of the present article was to publish the first structured review as a summary of the literature focussing on the recovery phase after general anaesthesia in horses. The objective was to summarise the available literature, taking into account the scientific evidence of the individual studies. A structured approach was followed with two experts in the field independently deciding on article inclusion and its level of scientific evidence. A total number of 444 articles, sorted by topics and classified based on their levels of evidence, were finally included into the present summary. The most important findings were summarised and discussed. The present structured review can be used as a compilation of the publications that, to date, focus on the recovery phase after general anaesthesia in adult horses. This type of review tries to minimise the risk of bias inherent to narrative reviews/expert opinions.Recovery remains the most dangerous phase of general anaesthesia in horses. The objective of this publication was to perform a structured literature review including levels of evidence (LoE) of each study with the keywords “recovery anaesthesia horse”, entered at once, in the search browsers PubMed and Web of Science. The two authors independently evaluated each candidate article. A final list with 444 articles was obtained on 5 April 2021, classified as: 41 “narrative reviews/expert opinions”, 16 “retrospective outcome studies”, 5 “surveys”, 59 “premedication/sedation and induction drugs”, 27 “maintenance with inhalant agents”, 55 “maintenance with total intravenous anaesthesia (TIVA)”, 3 “TIVA versus inhalants”, 56 “maintenance with partial intravenous anaesthesia (PIVA)”, 27 “other drugs used during maintenance”, 18 “drugs before/during recovery”, 18 “recovery systems”, 21 “respiratory system in recovery”, 41 “other factors”, 51 “case series/reports” and 6 “systems to score recoveries”. Of them, 167 were LoE 1, 36 LoE 2, 33 LoE 3, 110 LoE 4, 90 LoE 5 and 8 could not be classified based on the available abstract. This review can be used as an up-to-date compilation of the literature about recovery after general anaesthesia in adult horses that tried to minimise the bias inherent to narrative reviews.

Professor Emeritus in Pediatrics and Anesthesiology. Received from the Department of Pediatrics and Anesthesiology, The George Washington University Medical Center, Washington, District of Columbia.I am honored to have been selected to deliver the 40th Annual Emery A. Rovenstine Memorial Lecture. At previous Rovenstine lectures, I learned about his pioneering efforts as the Director of the Anesthesia Service at Bellevue Hospital (New York City, New York) where he served from 1935 to 1960; his Presidency of the American Society of Anesthesiologists (ASA), 1943–1944; and as the recipient of the ASA's Distinguished Service Award in 1957. In the past year, however, two outstanding articles have been written that present material I was unaware of.Lucien Morris, M.D. (Professor Emeritus, Medical College of Ohio, Toledo, Ohio) authored the fascinating article “Ralph M. Waters’ Legacy: The Establishment of Academic Anesthesia Centers by the ‘Aqualumni’.”1The ’aqualumni,’ is defined as Waters’ own trainees. The article was written to commemorate the 75th Anniversary of Waters accepting an academic appointment to the medical faculty of the University of Wisconsin (Madison, Wisconsin).I found particularly interesting the section describing Professor Waters’ concern that when Dr. Rovenstine, one of his aqualumni, went to Bellevue Hospital, New York University (NYU, New York City, New York), he might not have sufficient staff to establish a new academic training center for anesthesia. As a result, Waters split his Wisconsin group, sending both staff and residents to New York City to ensure the success of Dr. Rovenstine at NYU. Waters had enough confidence in Dr. Rovenstine to predict that he would succeed. He would not disappoint Dr. Waters.David Waisel, M.D. (Department of Anesthesia, Children's Hospital, Boston, Massachusetts) provided a comprehensive review of “The Role of World War II and The European Theater of Operations in the Development of Anesthesiology as a Physician Specialty in the USA.”2In 1942, Waters and Rovenstine and others teamed up to train “90-day wonders” in 12-week courses “to prepare medical officers to take charge of the anesthesia sections of the various types of hospitals of the U.S. Army.” Courses were given at several institutions, including Bellevue, and were developed by the Subcommittee on Anesthesia of the National Research Council. The latter was chaired by Dr. Waters. Dr. Rovenstine was the Secretary. Many future anesthesiologists were attracted to the specialty as a result of their initial exposure to the field in World War II and the influence of role models such as Dr. Rovenstine.Although I did not know Dr. Rovenstine personally, I was trained by another aqualumnus of Dr. Waters, Robert D. Dripps, M.D. (Professor and Chair, Department of Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania). Dr. Dripps was interested in attracting medical students into the field of Anesthesiology. One of his efforts led to the establishment of the ASA Preceptorship Program and the Committee on which I first served the ASA.In the 36 yr in which I have been involved in the activities of the ASA, 20 yr have been spent on developing guidelines for sedation for nonanesthesiologists. It has been the most challenging, frustrating, and contentious issue I have had to address.Even though ASA's efforts have been exemplary, the results have been misunderstood by not only the groups we have attempted to educate but also by our own members. I have decided to set the record straight by discussing the history of “ASA's Efforts in Developing Guidelines for Sedation and Analgesia for Nonanesthesiologists.” Some of the comments that follow are my own thoughts and interpretations; however, most of the statements are documented in the literature or are part of my own collection of documents. The latter will be donated to the Wood Library Museum (Park Ridge, Illinois) together with the script of this lecture.The formal process of ASA's evidence-based guideline development for members did not begin until 1990, and for nonanesthesiologists, in 1993. Other specialty groups began setting guidelines earlier and their efforts must be acknowledged before proceeding with ASA's efforts. It is not intended to provide a comprehensive or complete review of these accomplishments but rather to attempt to chronicle the background from which ASA developed some of its interest.Driscoll 3describes one of the anesthetic eras, “conscious and unconscious sedation,” as beginning in 1970. He notes that, previously, the use of diazepam along with local analgesia was relatively uncomplicated. However, soon meperidine, atropine, fentanyl, methohexital, and a host of other drugs were also added. Polypharmacy posed a potential problem.In 1972, “Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry” were published. 4These guidelines established a standard for training all dental personnel in this area of patient management. 5Apparently the dental profession continued to strive for a balance between minimizing fear and anxiety and maximizing safety. To resolve some of the issues, The National Institutes of Health (NIH), The Food and Drug Administration, and The NIH Office of Medical Applications of Research (Bethesda, Maryland) convened a Consensus Development Conference on Anesthesia and Sedation in the Dental Office. 6A host of experts, including anesthesiologists, agreed on developing answers to frequently asked questions. Although the principles and definitions described in the document are not necessarily original (but undoubtedly originated in the dental literature), they do represent important features, which continue to be emphasized, and must not be ignored. Several of these are as follows:From time to time, other Dental groups, such as The American Dental Association (Chicago, Illinois) and American Association of Oral and Maxillofacial Surgeons (Rosemont, Illinois), have issued comprehensive guidelines for sedation and anesthesia; however their design and content are beyond the scope of this discussion.My involvement with the formulation of guidelines related to sedation began in 1983 as a member of the Committee of the Section on Anesthesiology, American Academy of Pediatrics (AAP) (Elk Grove Village, Illinois). Sedation guidelines were developed by the AAP primarily because of the reporting of a number of deaths in dental offices. 7In 1985, The Committee on Drugs, Section on Anesthesiology, AAP, in conjunction with The American Academy of Pediatric Dentistry (Chicago, Illinois), published Guidelines for the Elective Use of Conscious Sedation, Deep Sedation, and General Anesthesia in Pediatric Patients. 8In this document, the three states were defined as were the requirements for selection of patients, personnel, monitoring procedures, facility, equipment, and recovery care. The definition of conscious sedation included the patient's ability to maintain a patent airway and that this be retained independently and “continuously.” It also noted that “the drugs and techniques used should carry a margin of safety wide enough to render unintended loss of consciousness unlikely.”Although a number of anesthesiologists, including myself, were members of one of the committees drafting the Guidelines, the ASA was not officially involved. As a matter of fact, in its 1985 Annual Report, the ASA Committee on Pediatric Anesthesia stated “members of the committee, as well as others within the ASA, were interested and concerned with (these) guidelines …”*As a result, the 1985 ASA House of Delegates instructed the ASA Committee on Standards of Care to review the Guidelines and report back to the March Board of Directors. At the time of the referral, I was the Chair of this Committee. An official reply was drafted and specifically addressed items of concern, such as the requirement for the use of intravenous (IV) injections in patients undergoing Deep Sedation and General Anesthesia. †This was subsequently “clarified” by the AAP making it permissible for personnel expert in securing IV access in infants and children to be immediately available. Both the Committee on Pediatric Anesthesia and Standards of Care agreed that many portions of the AAP Guidelines were well designed but believed that it was “essential—that future undertakings of this type and importance have official input from the ASA.”In 1992, the AAP published a revision of the 1985 Guidelines. 9In this document, it was noted that “regardless of the intended level of sedation or route of administration, the sedation of a patient represents a continuum—and a patient may move easily from a light level of sedation to obtundation.” It also added that “the practitioner should be prepared to increase the level of vigilance corresponding to that necessary—” if the patient becomes more deeply sedated. Use of pulse oximetry was required for both conscious and deep sedation. (Note: I have not attempted to describe this important document in its entirety.) The 1992 Guidelines were reviewed and suggestions made by the ASA's Committees on Pediatric Anesthesia and Standards of Care before the document was published. Their contributions were acknowledged by the AAP.Several articles have been written that describe the evolution of the development of the AAP's Guidelines. 10,11Of particular interest to me are several references to the reason that ASA “renewed” its interest in the revised (1992) Guidelines. Striker and Coté11state, “at the time of revision, the Committee on Drugs felt it important to once again work with the ASA, since during the intervening years from the original guidelines, The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (Oakbrook Terrace, Illinois) took the torch of responsibility.” Further, “with renewed interest (in part because of the JCAHO), the ASA Committee on Standards reviewed each iteration of the revised pediatric guidelines.”These statements clearly imply that ASA was complacent until JCAHO provided the impetus for ASA to get moving. Nothing could be further from the truth. To the contrary, ASA had taken a different path in generating guidelines for sedation and, as early as 1985 through our liaison activities with JCAHO, we were able to convince them to incorporate the concept of sedation into their accreditation standards. ASA's initial concern and involvement related to deaths outside the operating room when nonanesthesiologists sedated adult patients with a new drug, midazolam (VERSED®, Hoffman–La Roche Laboratories, Nutley, NJ).In 1985, the Food and Drug Administration approved the use of midazolam, and in 1986, it was marketed in the United States. Midazolam was reported to be twice as potent as diazepam. 12There were warnings from abroad that the comparative potency with diazepam was underestimated. 13Midazolam had certain advantages over diazepam—water solubility, less venous irritation, potent amnesia, and “short” duration of action. As a result, its use was embraced by a variety of types of practitioners who administered sedation.Bailey et al. 14demonstrated in human volunteers that the combination of midazolam with fentanyl in reasonable doses produced hypoxemia. Subsequently, they cited data from the Department of Health and Human Services, Office of Epidemiology and Biostatistics, Center for Drug Evaluation and Research, Data Retrieval Unit, in which 86 deaths were collected in the United States after the use of midazolam. 15All but 3 occurred outside the operating room “in clinical situations where patients are typically unattended by anesthesia personnel.” Seventy-eight percent of these deaths were associated with oxygenation or ventilation difficulties, and in 57% of these respiratory deaths, various opioids were used.Bailey et al. 15also noted that endoscopists were beginning to document the risk of hypoxemia in their environment. Further, most of these midazolam-associated adverse drug reaction reports involved care outside the operating room, where standards for the assessment of ventilation and oxygenation had not been defined and therefore were variable.In 1986, the ASA published its first standards for its members—Standards for Basic Intraoperative Monitoring. These applied not only to the states of general and regional anesthesia but also to “Monitored Anesthesia Care” or “MAC.” The latter term was also introduced in 1986 and applies to the service provided by the anesthesia care team in which the same level of care is provided with sedation/analgesia as with general or regional anesthesia. In the 1986 Standards, the use of pulse oximetry was encouraged.In 1988, the package insert for midazolam HCl (VERSED®) was modified to state the “clinical experience has shown VERSED® to be 3–4 times as potent per mg. as diazepam. Because serious and life-threatening cardiorespiratory adverse events have been reported, provision for monitoring, detection, and correction of these reactions must be made for every patient to whom VERSED® injection is administered, regardless of age or health status” (injection, package insert, Hoffmann–La Roche, Nutley, NJ).In the early 1980s, the section in the JCAH manual titled “Anesthesia Services” focused primarily on organization; staffing; safety (electrical and explosion hazards); delivery of care (e.g. , written guidelines for use of all general anesthetics); and quality and appropriateness of care. In 1982, the ASA developed a liaison with the JCAH (no “O” at that time). Representation was established in the Hospital Professional and Technical Advisory Committee (HPTAC), and in the Ambulatory Health Care Professional and Technical Advisory Committee (AHCPTAC). 16ASA's representatives, Eli Brown, M.D. (then, Professor and Chair, Department of Anesthesiology, Wayne State University, Detroit, Michigan) and Harry Wong, M.D. (then, Medical Director and President of the Medical Staff, Salt Lake Surgical Center, Salt Lake City, Utah) brought to the JCAH their concerns with the deaths occurring outside the operating room when potent sedatives with or without narcotics were administered by the “operating practitioner” to patients who were not adequately monitored. Largely due to their influential efforts, in 1985 the JCAH drafted proposed Standards for Surgery and Anesthesia services that addressed the surgical and anesthesia care of patients wherever they receive care in a hospital and to reflect current practices in the delivery of surgery and anesthesia care.In 1986, a draft was sent for “field review” to 1951 organizations and individuals. This led to the landmark language of the 1988 Standards for Surgical and Anesthesia Services (SA).“The standards in this chapter apply to services for all patients who (1) receive general, spinal, or other major regional anesthesia or (2) undergo surgery or other invasive procedures when receiving general, spinal, or other major regional anesthesia and/or intravenous, intramuscular, or inhalation sedation/analgesia that, in the manner used in the hospital, may result in the loss of the patient's protective reflexes. Invasive procedures include, but are not necessarily limited to, percutaneous aspirations and biopsies, cardiac and vascular catheterizations, and endoscopies.”‡The Director of Anesthesia's clinical and administrative responsibilities included “assuring” the effective monitoring and evaluation of the quality of appropriateness of anesthesia care provided by individuals in any department/service of the hospital, including—dental, emergency, etc. Requirements for assuring the availability of continuing medical education programs, monitoring the quality and appropriateness of anesthesia services, and other key items were included. The Standards required that “patients with the same health status and condition receive a comparable level of quality of surgery and anesthesia care throughout the hospital.” Obviously, the standard applied to adults and children and was promulgated by an accrediting organization that required conformance or else “deemed status” might not be attained.The endoscopists, in particular, were very alarmed by this development and considered the whole issue to be a turf battle between them and the anesthesiologists. They objected to being placed under the category of “surgical and anesthesia services.” In 1988, I replaced Eli Brown, M.D. (then, Professor and Chair, Department of Anesthesiology, Wayne State University, Detroit, Michigan) as ASA's liaison with the JCAH HPTAC. At the request of Jim Roberts, M.D. (Vice President, JCAH), I met with him and a representative of the endoscopy community, David Fleisher, M.D. (Division of Gastroenterology, Georgetown University Hospital, Washington, DC). After a lengthy discussion, Dr. Roberts confirmed that the language in the JCAH Standards for Surgery and Anesthesia Services was intended to promote safety and uniformity in the quality of care and that, indeed, the requirements applied to endoscopists using sedation that “in the manner used—may result in the loss of protective reflexes.”One of the results of this meeting was the establishment of a dialogue between the endoscopists and anesthesiologists at a national level. In 1989 and 1992, I was invited to address the conventions of the American Society of Gastrointestinal Endoscopists (ASGE) (May, 1989, Washington, DC, and May, 1992, San Francisco, California). In 1989, The Society of Ambulatory Anesthesiologists (SAMBA invited the Chair of the Standard's Committee, ASGE, to SAMBA's annual meeting; April, 1989, San Antonio, Texas). Anesthesiologists and endoscopists began a dialogue but disagreed on several key issues: (1) the level of sedation for which the JCAH Standards applied, and (2) the use of the pulse “the role of pulse oximetry and monitoring during procedures is and The was that the of monitoring should be to the patient's risk of and the type and duration of the 1990, the JCAHO added to the for Anesthesia the requirement for the Director of Anesthesia Services to or through a with of other that provide anesthesia services in the formulation of and material that to provide quality of anesthesia services throughout the hospital.” language including to and the quality and appropriateness of anesthesia care in any department/service in the hospital requirement to was by many anesthesiologists as an to and procedures and to be for the activities of practitioners who outside their without the to their To to the of of Anesthesia were also to official ASA to incorporate into their and procedures for sedation. In an attempt to this issue and to our I authored an article for the ASA Anesthesia Services in other Hospital this I that the JCAHO standards only required that the Director of Anesthesia be for the of the members of to practitioners not with the ASA that could be used as the for and procedures such as Standards for Basic Intraoperative were many other events occurred in the of the language of the JCAHO Standards between and it to that and within ASA and between our organization and other In one by JCAHO of the definition of anesthesia care was and It the under which the sedation standards applied including or without for which is a reasonable that in the manner the sedation/analgesia will result in the loss of protective for a of a of In other if the and techniques used were not to a loss of consciousness for a of a of patients, sedation as used in the manner would not the with the Standards for Anesthesia endoscopists were The Board that during IV conscious sedation by most endoscopists, protective are not in a of JCAHO to the continued to , that in most procedures are and that cardiorespiratory are to this JCAHO revision, an ASA member to the President of the ASA is the of by the I am and to be a member of a which did not the role of patient's The ASA was I in on Accreditation for new language was by the of the JCAHO, the Board of without the or of the and without the field to JCAHO from ASA and The Society for Ambulatory Anesthesia were This that, if had been from our at the their might have been or modified by the two , Standards and Committee and The Board of 1985 and we learned many from Guidelines and Standards by other organizations and input from our members about they to their and related to the development of and procedures for the of nonanesthesiologists who provided sedation outside the operating began ASA's efforts to establish its own Guidelines for this The of 1989, The for Health Care and In 1990, President of the ASA, was by the Office of the for and in Health for Health Care and Research Department of Health and Human Services of new to and clinical The were to be from of the expert and of health care In ASA established the Committee on under the of M.D. (then, President for University of Medical the process that ASA for guideline development is the are beyond the scope of this it to the original members of the Committee and the of the two initial and of the were on the in The who the was Office of the for Department of Health and Human The Guidelines were to be 1992, was in of the development of an ASA to be titled or for nonanesthesiologists. President, Anesthesia (Park Ridge, Illinois), that the development of Standards, Guidelines, and/or should be the of the not He also noted in anesthesia it will be considered by the other specialty involved. by the is to have it at the level of the for Health Care and President, to President, ASA, took and to that they the they ASA would was not In ASA selected members of a and as its Chair, M.D. (Professor of Anesthesiology and University of of Dr. and I described the of the process in an article on Analgesia and Sedation by this article are several to its the on the guidelines from selected in the field of and from other in which sedation and analgesia is The draft was also to anesthesiologists and invited of specialty groups of nonanesthesiologists at several In the included as a M.D. (Department of Gastroenterology, an who was officially by The Guidelines for Sedation and Analgesia by was approved by the ASA House of Delegates and in was published in the Anesthesiology. Guidelines were also by the with the to the document to our for their in their President, to ASA, After yr of dialogue and on the to the sedated ASA and had Guidelines were by the ASA material was by Roche and and the was by in this material was a which was part of the ASA under the of the Committee on and the it that ASA had produced an evidence-based which would be embraced by all this was not the ASA's initial did not address the state of In its of it is stated that “patients is from a are sedated to a by The was on the state patients to procedures cardiorespiratory and the ability to to and/or pediatric anesthesiologists that most pediatric patients, a level of deep the new AAP (1992) sedation guidelines will the ASA and that less personnel and less monitoring and recovery are associated with the state of “conscious in current all sedation is conscious regardless of the of sedation procedures or procedures complete (e.g. , or be in a who is the is The of the of a state of conscious sedation in which pediatric patients are to in the of is were that the ASA was developing guidelines for nonanesthesiologists in to their turf and that, in the the to be a of by the without the of specialty groups was also JCAHO was of adverse events associated with the use of sedation by nonanesthesiologists outside the operating room environment. of the related to practitioners the of sedation provided and not the monitoring and efforts liaison to the JCAHO are members of the ASA Committee on and Administration the Chair, M.D. Memorial Healthcare of In to JCAHO staff in the Standards, Dr. a to address a report of the ASA Committee on Standards of Care to monitoring the of the House of Delegates of the definition of to a of the President

BACKGROUNDLiver resection surgery has advanced greatly in recent years, and the adoption of fasttrack programs has yielded good results. Combination anesthesia (general anesthesia associated to epidural analgesia) is an anesthetic-analgesic strategy commonly used for the perioperative management of patients undergoing surgery of this kind, though there is controversy regarding the coagulation alterations it may cause and which can favor the development of spinal hematomas.AIMTo study the postoperative course of liver resection surgery, an analysis was made of the outcomes of liver resection surgery due to colorectal cancer metastases in our centre in terms of morbiditymortality and hospital stay according to the anesthetic technique used (general vs combination anesthesia).METHODSA prospective study was made of 61 colorectal cancer patients undergoing surgery due to liver metastases under general and combination anesthesia between January 2014 and October 2015. The patient characteristics, intraoperative variables, postoperative complications, evolution of hemostatic parameters, and stay in intensive care and in hospital were analyzed.RESULTSA total of 61 patients were included in two homogeneous groups: general anesthesia (n = 30) and combination anesthesia (general anesthesia associated to epidural analgesia) (n = 31). All patients had normal coagulation values before surgery. The international normalized ratio (INR) in both the general and combination anesthesia groups reached maximum values at 2448 h (mean 1.37 and 1.45 vs 1.39 and 1.41, respectively), followed by a gradual decrease. There was less intraoperative bleeding in the combination anesthesia group (769 mL) than in the general anesthesia group (1200 mL) (P < 0.05). Of the 61 patients, 38.8% in the general anesthesia group experienced some respiratory complication vs 6.6% in the combination anesthesia group (P < 0.001). The time to gastrointestinal tolerance was significantly correlated to the type of anesthesia, though not so the stay in critical care or the time to hospital discharge.CONCLUSIONEpidural analgesia in liver resection surgery was seen to be safe, with good results in terms of pain control and respiratory complications, and with no associated increase in complications secondary to altered hemostasis.

Anesthesia considerations in large-volume lipoplasty

Background and Objectives: Prostatectomy is a common surgical procedure for prostate cancer, the most frequently diagnosed cancer in the male population. The choice of anaesthetic technique has a significant impact on postoperative pain management. The changes in recommendations between 2015 and 2021 prompted this study to evaluate the impact of intrathecal morphine administration in combination with general anaesthesia compared to general anaesthesia alone on postoperative analgesic consumption and the associated side effects. Material and Methods: A single-centre retrospective cohort study was conducted, analysing data from 202 patients who underwent a prostatectomy between 2015 and 2021. Patients were divided into two groups: 147 patients received intrathecal morphine combined with general anaesthesia, while 49 patients received general anaesthesia alone. Key postoperative parameters, including numerical rating scale (NRS) scores, analgesic consumption, and side effects (e.g., nausea, pruritus, hypotension, and respiratory depression) were evaluated. Statistical analyses were performed using Mann-Whitney U-tests and multiple regression models. Results: The group receiving intrathecal morphine showed a significant decrease in NRS pain scores at rest and during movement in the recovery room (p < 0.001). The need for postoperative analgesics, especially opioids such as piritramide, was reduced in this group. No significant increase in serious side effects such as respiratory depression was observed. Conclusions: The present study investigates the potential of intrathecal morphine combined with general anaesthesia as a promising approach to improve pain management in prostatectomy patients. By reducing pain intensity, this method shows significant clinical benefits. In addition, the absence of a significant increase in serious adverse events reinforces the safety of this approach. However, further studies are warranted to assess the long-term outcomes and explore optimal dosing strategies. The reintroduction of this anaesthetic technique has great potential to improve patient recovery and satisfaction following major surgery.

Behavior and body temperature alterations in piglets anesthetized for castration during a four-hour recovery phase

Background: Sevoflurane is generally the preferred anesthetic agent for general anesthesia in pediatric patients, due to its rapid induction and recovery characteristics. However, it has been recognized that a major complication is emergence agitation when awakening from general anesthesia. The aim of this study was to evaluate the occurrence rate of emergence agitation in the operating room and postoperative recovery area following intraoperative administration of midazolam to pediatric patients under general anesthesia.Patients and methods: One hundred and twenty pediatric patients undergoing dental treatment under sevoflurane anesthesia were enrolled in this study. The patients were divided into three groups (n=40 each in the 0.1 mg/kg midazolam, 0.05 mg/kg midazolam, and control with saline groups). Midazolam or saline was injected intravenously approximately 30 minutes before the end of the dental treatment. We used the Richmond Agitation and Sedation Scale (RASS) to assess the level of sedation and drowsiness at emergence phase in the operating room. We also used the Pediatric Anesthesia Emergence Delirium Scale (PAED) to assess the level of agitation and delirium at the full recovery phase from anesthesia in the recovery area.Results: At the emergence phase, the incidence of emergence agitation in the 0.1 mg/kg midazolam group was significantly lower than in the other groups (p=0.0010). At the recovery phase, there was no significant difference among the three groups. The odds ratio between PAED score and RASS score was 4.0 using logistic regression analysis. The odds ratio between PAED score and Disability was 2.5.Conclusion: Administration of a single dose of 0.1 mg/kg midazolam dose significantly decreases the incidence of severe emergence agitation at the emergence after sevoflurane anesthesia, but not at the recovery phase. Furthermore, the evaluation of sedative and agitation condition using RASS score at emergence from anesthesia is useful to predict occurrence of agitation in the recovery phase.

The definitions of commonly used terms are given in Table 1 (1–8). Stroke has been simply defined as any form of cerebral infarction (2), which includes those attributable to hemorrhage. The latter group is more likely to occur as a complication of specific surgical procedures (e.g., carotid endarterectomy) or the use of anticoagulants and is otherwise rare in the perioperative period (3). Hence, much of the information in this review pertains to ischemic cerebral events.

AAGBI recommendations for standards of monitoring during anaesthesia and recovery 2015 - a further example of 'aggregation of marginal gains'.