Anaesthetic Assessment Research Articles

Comparision of airway assessment by Mallampati classification and cormack and lehane grading in Indian population

Introduction: This prospective cross-sectional observational study was undertaken to compare preanaesthetic predictive value of Modified Mallampati classification in relation to Cormac Lehane grades in Indian population. Materials and Methods: One hundred patients of either sex, who have underwent general anaesthesia were includes in the study. Inclusion criteria were aged between 18 to 60 years, ASA grades I and II, weighing between 45- 80 kg. The parameters observed were, Mallampati class (MMT) during pre anaesthetic assessment and their percentages, Cormack and Lehane grades (CL) at intubation and their percentages and correlation of Cormack and Lehane grading and Mallampati classification. Results: Out of 100 patients, men women ratio was 1: 2.1(32: 68), mean age of the patients were 43.15± 12.96yrs, mean BMI of the patients were 23.34 ± 1.34 kg/m?2;. The corrected chi square test showed a value of 76.8 with a P value of Conclusion: To increase predictive value of preassessment of difficult airway, Mallampati test should be supplemented by other airway assessment tools. Keywords: Mallampati test, Predictive value, Difficult intubation.

A comparative study of caudal epidural bupivacaine with bupivacaine plus fentanyl and bupivacaine plus neostigmine for anaesthesia and postoperative analgesia in children undergoing sub-umbilical surgeries

Background: Single-shot caudal anaesthesia with local anaesthetic has a limited duration of action.Therefore, many children undergoing sub-umbilical surgery with caudal analgesia require furtheranalgesia during the postoperative period. This study compared the effect of single-dose caudal epiduralbupivacaine, bupivacaine plus fentanyl and bupivacaine plus neostigmine for anaesthesia andpostoperative analgesia in children. Objective: To evaluate effectiveness of bupivacaine with the addition of fentanyl or neostigmine forcaudal anaesthesia and analgesia in children undergoing sub-umbilical surgeries. Methods: Total ninety (90) paediatric patients, aged 2-8 years with ASA(American society ofanesthesiologist) grades I & II who were scheduled for surgery in Sher-E-Bangla Medical college Hospital,Barisal were included in this study. Data were collected by using a pre-designed questionnaire. Thepatients were randomly allocated to one of the three groups. Group A was received caudal 1 ml/kg ofbupivacaine 0.25%, Group B 1 ml/kg of bupivacaine 0.25% with fentanyl 1 μg/kg and Group C 1 ml/kgof bupivacaine 0.25% with neostigmine 2 μg/kg. Heart rate (HR), Blood pressure (BP), oxygen saturation(SpO2), Respiratory rate (RR) were recorded during operation and every five minutes thereafter. Theduration of analgesia was defined as the time from caudal injection to first dose of rescue analgesia.Rescue analgesia was given for an objective pain scale (greater than or equal to) 4 in the form of oralparacetamol (15mg/kg). Results: Assessment of anaesthesia was significantly longer in the two groups of children who receivedadditives compared with local anaesthetics group alone (p<0.01). Mean time to first postoperativeanalgesic administration was 167.37±17.30 min, 280.57±14.40min, and 357.77±19.08 min in groupA, Group B, and group C respectively. The difference was statistically significant (p<0.01) between thethree groups. In these cases duration of analgesia was considered from the placement of caudal to firstanalgesia. Conclusion: Addition of fentanyl or neostigmine to bupivacaine prolonged the duration of surgicalanaesthesia and postoperative analgesia after a single shot caudal injection with minimal incidence ofside effects in children undergoing sub-umbilical surgeries. This could be a safe and cheap alternative toextradural catheter placement for surgical procedures of intermediate duration. JBSA 2019; 32(1): 3-9

‘Golden Patient’: A quality improvement project aiming to improve trauma theatre efficiency in the Royal Gwent Hospital

The efficiency of trauma lists when compared with elective orthopaedic lists is a frustration of many orthopaedic departments. At the Royal Gwent Hospital, late start times affecting total operating capacity...

Core Topics in Preoperative Anaesthetic Assessment and Management

Core Topics in Preoperative Anaesthetic Assessment and Management

Sciatic nerve block or not for outpatient total knee arthroplasty? Study protocol for a randomized controlled trial

BackgroundThe number of patients operated on for total knee arthroplasty (TKA) is growing worldwide. Outpatient surgery is defined by a length of stay (LOS) in the hospital of less than 12 h. This can be limited for TKA, with the efficient management of pain and perioperative complications, such as blood loss, affecting a safe hospital discharge. Outpatient TKA with a suitable protocol, including multimodal measures, could improve the success rate of this procedure. Among the main measures, single-shot sciatic nerve block in association with continuous femoral nerve block for pain control needs to be evaluated in outpatient TKA. Furthermore, to promote the safety of the postoperative period and to accelerate rehabilitation, patients who undergo ambulatory TKA could be discharged to a rehabilitation center on the day of surgery to screen adverse events and to optimize the rehabilitation process. This study is designed to assess the benefits of sciatic nerve block in postoperative pain relief for outpatient TKA.Methods/designThis randomized prospective controlled study will be conducted in the knee unit of the teaching hospital of the Nice university and will include 40 patients undergoing primary unilateral outpatient TKA, discharged the day of surgery to a private rehabilitation center for enhanced recovery after surgery, after a hospital stay of less than 12 h. Before surgery, all patients will receive a continuous femoral nerve block with 2 mg/ml ropivacaine 20 ml, and then patients will be randomly assigned to receive or not receive a single-shot sciatic nerve block with 2 mg/ml ropivacaine, 20 ml. The primary outcome measure is the success rate of outpatient TKA. This rate is defined by patients discharged from the hospital to a rehabilitation center the day of surgery with no re-hospitalization due to insufficient pain control before the fifth postoperative day. Secondary outcomes include the incidence of major and minor adverse events during the first five postoperative days and measurement of the quality of recovery using the Knee injury and Osteoarthritis Outcome Score and the new International Knee Society scores plus the Quality of Recovery-40 questionnaire.DiscussionThe assessment of anesthesia and rehabilitation protocols enabling major orthopedic surgery, such as TKA, is necessary. This randomized controlled study will address the hypothesis that a suitable multimodal protocol including sciatic nerve block could improve pain control and thus improve the success rate of outpatient TKA.Trial registrationEudraCT, 2016-000226-19. Registered on 15 April 2016.

Too much or too frail: a review of decision making in colorectal cancer

Aim: Of approximately 30,000 patients diagnosed with colorectal cancer between April 2014 and March 2015, 37% did not undergo major resection. In 11.8%, there was too much cancer and in 4.7% the patients were too frail with a large variation across trusts (0-32%). 2 year survival in those not undergoing major resection is only 30%. This study is designed to review the decision making process for those patients who are deemed to be too frail. How are patients being assessed for surgery? Is the decision process robust? Patients: All patients diagnosed with colorectal cancer through their first discussed at the MDT would be identified and included. Intervention: As a prospective multicentre observational study, there would be no intervention, however, patients will be divided into groups; those undergoing major resection (R) and those not undergoing major resection (NR), the second group being subdivided by reason; too much (TM) cancer, or too frail (TF). Primary Outcomes: 1 & 2 year survival Secondary outcomes: Mode of presentation (Emergency vs elective), Rockwood Frailty Score, anaesthetic assessment (performed or not, and type (i.e.CPEX)), review by geriatrician, patient decision, comorbidities, length of stay, Quality of life score , chemotherapy, colonic stenting, repeated blood transfusions, readmission with cancer complications. All eligible patients identified at MDT will be included and have prospective data collected. Frailty scores, if not routinely used for MDT decision, will be collected posthoc and remain blind to the original MDT decision.

Objective assessment of mental nerve local anesthesia

To study the reaction of the mental nerve to selective stimulation of thin nerve fibers by thermal stimuli during conduction anesthesia. The pilot study involved 24 healthy volunteers: 13 subjects were injected with a 4% solution of articaine-containing anesthetic with a vasoconstrictor in a ratio of 1:200 000 (pH 4.8-5.4) and 11 subjects - a 3% solution of mepivacaine-containing local anesthetic without a vasoconstrictor (pH value 5.8-6.4). The registration of evoked potentials was performed twice: before local anesthesia and 5 minutes after anesthesia. With the help of disposable carpal dental injectors, local anesthesia was performed near the mental foramen in order to anesthetize the innervation region of the mental nerve through a conductive type. The evoked potentials (VP) were recorded on a Nicolet instrument (USA) with Bravo evoked potentials software. The study of thermal EPs was performed using a Contact heat evoked potential stimulator (CHEPS) device ('Medoc Ltd, Ramat Yishai', Israel). The base and peak temperature were set at 33 and 54 °C, correspondingly. The evoked potentials for thermal stimulation demonstrated a significant decrease in the amplitude of all components and the elongation of the LP of the main negative-positive N2-P2 complex after anesthesia compared with the initial thermal EP. The complete disappearance of thermal responses was observed in 14 (58%) of 24 study participants, minor changes were seen in 3 (12.5%) cases only. The total response disappearance was observed in 10 (77%) of 13 participants after articaine and in 3 (27%) of 11 - after mepivacaine (p<0.05), weak changes were registered in 2 (15%) cases in the articaine group and in 1 (9%) case in the mepivacaine group. A 4% solution of articaine is somewhat more effective for pain relief of teeth and bone since it often causes deeper anesthesia, and a 3% solution of mepivacaine without a vasoconstrictor is physiologically more suitable for working with soft tissues.

A Summary of Preclinical Poster Presentations at the Sixth Biennial Pediatric Anesthesia Neurodevelopment Assessment (PANDA) Symposium.

The potential for long-term neurotoxic effects of anesthetics on the developing human brain has led to intensified research in this area. To date, the human evidence has been inconclusive, but a large body of animal evidence continues to demonstrate cause for concern. On April 14 and 15, 2018 the sixth biennial Pediatric Anesthesia and Neurodevelopmental Assessment (PANDA) study symposium was held at Morgan Stanley Children's Hospital of New York. This symposium brought together clinicians and researchers and served as a platform to review preclinical and clinical data related to anesthesia and neurotoxicity in developing brains. The program participants included many active investigators in the field of anesthesia neurotoxicity as well as stakeholders from different backgrounds with the common interest of potential anesthetic neurotoxicity in children. The moderated poster session included presentations of preclinical animal research studies. These studies focused on defining the anesthetic-induced neurotoxicity phenotype, understanding the mechanism of injury and discovering potential inhibitors of neurotoxic effects.

Outcomes Research in Vulnerable Pediatric Populations.

The Pediatric Anesthesia and Neurodevelopment Assessment (PANDA) study team held its biennial symposium in April 2018 to discuss issues on anesthetic neurotoxicity in the developing brain. One of the sessions invited speakers with different areas of expertise to discuss "Outcomes Research in Vulnerable Pediatric Populations." The vulnerable populations included neonates, children with congenital heart disease, children from low socioeconomic status, and children with incarcerated parents. Each speaker presented some of the ongoing research efforts in these groups as well as the challenges encountered in studying them.

Bilateral Loss of Vision after Spinal Anaesthesia on a Dwarf Patient

Achondroplasia is the most common form of dwarfism. Achondroplasia poses multiple anaesthetic challenges ranging from securing intravenous line, monitoring and drug dose calculations and airway management among others. Spinal anaesthesia is a very common method of anaesthesia in Botswana. The only type of anaesthetic drug that is in use for spinal anaesthesia in Botswana is hyper baric bupivacaine 0.5%. We report a case of a 33-year-old achondroplastic dwarf patient who developed bilateral visual loss for three days after he had received spinal anaesthesia for appendectomy. Postoperatively the patient was found to have increased intracranial pressure on magnetic resonance imaging scan. Subsequently decompressive ventriculo-peritoneal shunt operation was done and he gradually regained his vision. Meticulous and detailed pre anaesthetic assessment, well planned mode of anaesthesia and post-operative care of dwarf patients is essential to minimize complications and its severity. Post-operative signs and symptoms that may indicate any neurological effect of high intracranial pressure on dwarf patients have to be promptly identified and treated urgently to reduce further damage.

Local anaesthesia training for undergraduate students \u2013 how big is the step from model to man?

BackgroundLocal anesthesia is an important skill and a prerequisite for most dental treatments. However, the step from theory to application on the patient is huge for the novice. Hence, a mannequin training model course was developed and implemented into the existing local anesthesia curriculum in undergraduate dental students. It was the aim of this study to evaluate the relation between training-model and real-life anesthesia performance and to measure whether a gain in skill on the model translates to the actual patient situation.MethodsThirty-six third-year students (14 males, 22 females, age 24 years±2.98) attended the four-day course comprising each 4 h of lectures and practical training. The student cohort gave subjective ratings about the didactical components of the course after attendance by using the TRIL questionnaire (TRIL-mod; University of Trier). At the end of the course the performance of each student in administering an inferior alveolar nerve (IAN) block on the training model as well as on a fellow dental student was investigated using a standardized checklist. To evaluate the successful performance, the in vivo IAN-block was assessed using subjective patient-feeling, the sharp-blunt test and an objective pain- and thermal sensitivity tester (PATH).ResultsThe course was rated with an average score of 5.25 ± 0.44 (range 1–6; 6 = best). On the training model, 69.4% of the students successfully performed an IAN-block. The in vivo assessment, objectified by the PATH test, showed a successful anesthesia in 36.9% of the cases. The assessment of local anesthesia by using the sharp blunt test and the subjective patient feeling significantly correlated with these findings (k = 0.453–0.751, p < 0.05). The model performance did not correlate with the performance on the patient (k = 0.137, p = 0.198).ConclusionsAlthough subjective ratings of the course were high, the anesthesia success rate on mannequin models did not imply an equal performance on the in vivo setting. As local anesthesia training models are a valuable didactic complement, the focus of the training should be on to the actual real life situation. Chair side feedback should be offered to the students using one of the presented evaluation methods.

Advance electronic screening of patients with cancer leveraging a new EHR to increase efficiency of care delivery, driving clinical care pathways in a perioperative anesthesia assessment center (PAAC), at a comprehensive cancer center.

308 Background: Most cancer institutions are using electronic health records (EHRs). With MACRA and MIPS, this number will continue to grow. EHR’s can be frustrating as some are seen as more cumbersome than useful to patient care delivery. In 2017, the MD Anderson cancer center (MDACC) PAAC assessed over 20,000 patients. We wanted to demonstrate positive utility of our EHR. We hypothesized that advanced electronic screening of our cancer patients, leveraging a questionnaire embedded in the EHR, could increase efficiency by driving patient specific perioperative care pathways leading to positive patient experience while not negatively affecting our low same day surgery cancellation rate of 2.07%. Methods: In March of 2016, MDACC launched a new EHR and the PAAC commenced an online medical and anesthesia screening questionnaire to be completed via a secure online portal by our cancer patients in advance of the surgery date. The questionnaire was developed and vetted by specialists from many areas including anesthesia, cardiology, internal medicine, and surgery. The answers to these questions were validated by a healthcare provider, and the patient was directed to one of two care pathways. Complex patients were scheduled for an in person clinic assessment prior to surgery and all other patients were scheduled for a phone call assessment. We used reports created within our EHR to track baseline and 2017 data for numbers of patients directed to the 2 different pathways and same day surgery cancellation data throughout this time frame. Results: Using the online patient entered questionnaire, we were able to improve clinic efficiency by implementing two patient care delivery pathways. Using our new EHR we saw an increase of 18.4% in our phone assessment pathway for patients. Patient experience improved as we were able to offer patients more options in the delivery of care saving them time. Conclusions: Use of our new EHR and IT analytics helped drive patient-specific care pathways, improve efficiency and the patient experience. MDACC same day surgery cancellation rate remained 2.07%.

Interdyscyplinarna współpraca w mikrochirurgii krtani z zastosowaniem lasera CO2 i znieczulenia ogólnego z użyciem wentylacji dyszowej

Background: Microsurgery of larynx requires free access to the operation field. It is possible under general anaesthesia with high frequency jet ventilation. Shared upper airway demands anaesthesiologist and surgeon cooperation. Methods: 40 patients scheduled for laser CO2 microsurgery were included in the study. 20 of patients presented malignant pathology and 20 benign lesions. Anaesthetic risk was assessed in ASA-scale. Patients under 18 and above 80 years old, with severe COPD and renal or hepatic failure were excluded. This article deals with preoperative assessment and management of general anaesthesia. Conditions for intubation were assessed using Krieg-score and conditions for surgery were assessed by surgeon using Likert-scale. Results: Presented method of anaesthesia enables efficient and safe surgical treatment. Conditions for surgery were highly scored by surgeon. Discussion: High risk of complications is associated with microsurgery of larynx under general anaesthesia with jet ventilation. Close cooperation between surgical and anaesthetic teams is essential for safety of this procedure.

Competency-based Assessment Tools for Regional Anaesthesia: A Narrative Review

(Br J Anaesth. 2018;120:264–273) Assessment tools play a critical role in the evaluation of trainee performance in competency-based postgraduate medical education programs. Consequently, the authors of the present narrative appraised published regional anesthesia assessment tools and addressed the type and purpose of current tools, relevant psychometric properties, implications for clinical adoption, and priorities in research.

Medical Evaluation of the Surgical Patient

Medical evaluation prior to surgery includes risk assessment and the institution of therapies to decrease perioperative morbidity and mortality to improve patient outcomes. The most effective medical consultation for surgical patients begins with an assessment of the individual patient and knowledge of the planned surgery and anesthesia followed by clear communication of a concise and specific recommended plan of perioperative care to the surgical team. This chapter describes anesthetic, cardiac, pulmonary, hepatic, nutritional, and endocrine risk assessment. Perioperative thrombotic management and postoperative care and complications, including fluid management; pulmonary, cardiac, renal complications; and delirium are discussed. Tables outline the American Society of Anesthesiologists class and perioperative mortality risk, a comparison of the Revised Cardiac Risk Index and National Surgery Quality Improvement Program, Duke Activity Status Index, high-risk stress test findings, markers for increased perioperative risk in pulmonary hypertension, aortic stenosis and nonemergent noncardiac surgery, risk factors for pulmonary complications in noncardiac surgery, the Model for End-Stage Liver Disease score to predict postoperative mortality, venous thromboembolism risk factors and options for pharmacologic prophylactic regimens, perioperative management of warfarin, and Brigham and Women’s Hospital guidelines for postoperative blood product replacement. Figures include a care algorithm for noncardiac surgery, an illustration of types of myocardial infarction, and an algorithm for the treatment of postoperative delirium. This review contains 3 highly rendered figures, 12 tables, and 68 references.

Chemical restraint of jaguars Panthera onca Linnaeus, 1758 with allometrically scaled doses of tiletamine, zolazepam, detomidine, and atropine

Chemical restraint of large felids is necessary for the handling, transportation, clinical assessment, and induction of anesthesia. The objective of this study was to evaluate the efficacy and safety of chemical restraint using a combination of tiletamine, zolazepam, detomidine, and atropine with interspecific allometric scaling doses in captive Panthera onca. There were ten males (two melanistic ones) and five females weighing between 35 and 80 kg. The evaluation of the chemical restraint protocol was carried out during routine management of the animals for physical examination, collection of blood and bone marrow samples, dental evaluation, and other procedures. During pre-established intervals, rectal temperature, heart rate, respiratory rate, nociception of thoracic and pelvic limbs, muscle relaxation and loss of the righting reflex were monitored. Loss of the righting reflex occurred at 8 ± 1.89 minutes post-injection (MPI). Respiratory rate returned at 77.6 ± 8.18 MPI; return of consciousness occurred at 112.6 ± 12.28 MPI, and complete recovery at 153 ± 12.47 MPI. There were no statistical differences between heart and respiratory rate means and oxyhemoglobin saturation. For rectal temperature, there was a significant reduction. The protocol analyzed was efficient for the chemical restraint of jaguars, enabling the manipulation, transportation, physical examination, dental evaluation, blood and bone marrow sample collection, and other minor invasive procedures of medium duration in these animals.

Research status and prospect on risk assessment of sedation and anesthesia in endoscopy

Research status and prospect on risk assessment of sedation and anesthesia in endoscopy

2192 The association of preoperative functional capacity and outcomes for head and neck cancer patients undergoing definitive surgical treatment

OBJECTIVES/SPECIFIC AIMS: To study the role functional capacity plays in surgical outcomes for head and neck cancers. METHODS/STUDY POPULATION: In this single-institution cohort study, we combined preoperative anesthesia assessment information with oncology registry data for newly-diagnosed patients with squamous cell carcinoma of the oral cavity, pharynx, and larynx (HNSCC) treated with definitive surgery at Siteman Cancer Center from 2012 to 2016. Patient-reported exercise capacity was assessed as metabolic equivalents. Metabolic equivalents&lt;4 was defined as poor functional capacity. The primary outcome measure was overall survival (OS). Kaplan-Meir survival analysis was used to compare the survival of patients with poor functional capacity (PFC) and patients with normal functional capacity (NFC). Cox proportional hazard regression was used to explore the independent prognostic role of functional capacity on overall survival after controlling for other factors. RESULTS/ANTICIPATED RESULTS: A total of 671 patients underwent surgical treatment for HNSCC. The average age was 62 years (range: 19–94 years). Majority of the patients were male (n=481; 72%), White race (n=589; 88%), and smokers (n=528; 79%). Of 671 patients, 22% (n=146) had PFC. Two-year OS rate in PFC patients was 70% compared with 85% in NFC patients (15% difference; 95% CI: 7%–23%). Unadjusted Cox proportional hazard analysis showed that PFC patients had 2.2 times higher risk of death (95% CI: 1.5–3.2) than NFC patients. After adjustment for age at surgery, BMI, preoperative weight loss, comorbidity score, tumor site, and TNM stage the magnitude of the association between functional capacity and OS decreased (aHR=1.3; 95% CI: 0.88–1.98). DISCUSSION/SIGNIFICANCE OF IMPACT: Poor functional capacity is associated with decreased overall survival, but the magnitude of the association, while clinically meaningful, decreases after controlling for other important patient and tumor factors. Nevertheless, we believe preoperative functional capacity status is an important patient factor to consider when discussing prognosis and attempting risk stratification. We also believe that functional capacity may be associated with 30-day unplanned readmissions and 90-day complications and are currently performing chart review to ascertain this information.

Airway Management for the Oral Surgery Patient.

This article discusses anesthesia assessment concepts related to airway evaluation and airway maintenance for safe and reliable selection of either open system (entrainment of room air) or closed system (no entrainment of room air) airway devices, which can be used during office-based oral surgical procedures, depending on the needs of a patient. Dental facial and oral structures are integral to an anesthetist's preoperative patient evaluation prior to surgery. The preoperative medical history and physical examination as well as the nature of the oral surgical procedure affect the selection of a proper and safe airway device.

Perioperative management of thyroid ambulatory surgery

The incidence rate of thyroid cancer and thyroid nodule in China are rising and surgical operation is the main treatment for thyroid nodule and thyroid carcinoma. It has been controversial whether thyroid surgery is suitable for day surgery. Perfect preoperative examination and anesthesia assessment, selection of an appropriate of patients and minimally invasive surgery , good postoperative analgesia and the prevention and treatment of postoperative nausea and vomiting, recognition and treatment of postoperative complications timely, postoperative follow-up, can ensure safety of patient with thyroid ambulatory surgery, and made the same medical quality as the surgery in hospital. Under certain criteria, thyroid ambulatory surgery is safety , high efficient, economy and time-efficient.It is a reasonable surgical management mode which can reduce days of hospitalization and hospitalization cost. But it still need further study on the inclusion and exclusion criteria of patients, anesthesia techniques and perioperative management. Key words: Thyroid diseases/SU; Ambulatory surgery; Anesthesia; Perioperative care