Anaesthetic Practice Research Articles

THE IMPORTANCE OF REALISTIC SIMULATION LEARNING IN MANAGING RARE SITUATIONS IN ANESTHESIA: MALIGNANT HYPERTHERMIA

Malignant hyperthermia (MH) is a rare, life-threatening pharmacogenetic disorder triggered by certain anesthetic agents, requiring rapid recognition and intervention to prevent serious complications. Given its infrequency, healthcare professionals, especially anesthesia providers, may have limited exposure to managing this critical emergency. This study aims to evaluate the impact of simulation-based training on improving the knowledge, skills, and confidence of anesthesia residents in managing malignant hyperthermia. A pre-experimental study was conducted with 50 anesthesia residents at the Mohamed V Military Instruction Hospital. Participants engaged in a simulation session designed to mimic the clinical scenario of malignant hyperthermia during surgery. Knowledge assessments conducted before and after the simulation revealed a significant improvement in the residentsÂ’ understanding of MH, including its recognition, triggers, and management. Self-reported confidence in handling MH crises also increased notably. Furthermore, 90% of residents expressed overall satisfaction with the simulation-based training, highlighting its value for enhancing critical care readiness. The results underscore the effectiveness of high-fidelity simulation in preparing anesthesia residents for rare but life-threatening scenarios, thereby contributing to better patient safety and clinical outcomes in anesthesia practice.

A comprehensive analysis of in-hospital adverse events after scopolamine administration: insights from a retrospective cohort study using a large nationwide inpatient database

BackgroundScopolamine is a widely used antiemetic in anesthetic practice, particularly for postoperative and post-discharge nausea and vomiting. Despite its frequent usage and recognized efficacy, concerns have emerged regarding the potential for increased side effects, particularly in elderly patients. Further research is needed to assess safety and determine age thresholds for adverse events. This study hypothesizes associations between perioperative scopolamine use, worse clinical outcomes, increased pneumonia, delirium, urinary retention, and readmissions.MethodsA large, retrospective cohort study was performed using the TriNetX Analytics Network database on patients undergoing major surgical procedures between Jan 1, 2009, and March 21, 2018, to examine the impact of perioperative scopolamine use on in-hospital adverse events. Patients were divided into age groups and compared to a control group. The primary outcomes assessed were delirium, pneumonia, in-hospital death, new antipsychotic use, readmission, and new onset urinary retention within 7 days post-surgery. 1:1 propensity score matching was performed to reduce bias. Relative risk and risk differences with 95% confidence intervals were estimated.ResultsAfter 1:1 propensity score matching, we identified a total of 403,816 (201,908 pairs) perioperative scopolamine users and nonusers. The cohorts of 20–29, 30–39, 40–49, 50–59, 60–69, and 70 + contained 22,910 (11,455 pairs), 44,170 (22,085 pairs), 58,590 (29,295 pairs), 71,660 (35,830 pairs), 88,386 (44,193 pairs), and 118,100 (59,050 pairs) patients respectively. Across older age cohorts, after propensity score matching, perioperative scopolamine recipients had significantly increased relative risk and risk difference of delirium, pneumonia, in-hospital mortality, new antipsychotic use, readmission, and new-onset urinary retention.ConclusionsIn this cohort study, perioperative scopolamine usage was associated with a significantly increased risk of in-hospital adverse events, both within the 70 + age cohort and among the 20–29, 30–39, 40–49, 50–59, and 60–69 age cohorts after major surgery. These findings highlight the need for careful assessment of scopolamine’s risks and benefits, especially for patients aged 40 and older. Scopolamine may be most suited for post-discharge nausea and vomiting in ambulatory patients and clinicians should reassess its standard use for postoperative nausea and vomiting, favoring shorter-acting agents with fewer side effects.

Promoting a Patient Safety Culture in Anesthesia Practice

Promoting a Patient Safety Culture in Anesthesia Practice

Connecting the Dots Between Inpatient Quality of Obstetric Recovery and Postpartum Depression: Are We Ready for a Cultural Shift?

(J Clin Anesth. 2024;96:111372 I. https://doi.org/10.1016/j.jclinane.2023.111372 I) Enhanced recovery protocols have recently been developed to improve recovery after childbirth, focusing on minimizing maternal morbidity and pain following cesarean delivery. However, there is limited literature on the effort it takes to return to a healthy and normal standard in the postpartum period. The measurement of recovery quality is a new area of focus in the research and practice of obstetric anesthesia. Aspects such as postpartum discomfort, nausea, lightheadedness, shaking, ease, movement, capacity to care for the baby, self-care, and sense of empowerment all influence the quality of recovery during hospitalization. Pervez and colleagues developed a new survey called Obstetric Quality of Recovery (ObsQoR-10), which is a patient-reported outcome measure (PROM) used to evaluate recovery after vaginal and cesarean deliveries in hospital settings. Although numerous studies have assessed global PROMs for postpartum healing and screening tools for postpartum depression (PPD), there is still a lack of ideal measures for assessing outpatient recovery quality.

Quality Metrics for Cesarean Delivery: More Than Just General Anesthesia Rates

(J Clin Anesth. 2024;94:111398. https://doi.org/10.1016/j.jclinane.2024.111398) General anesthesia should be avoided for cesarean deliveries when possible but used when necessary, and sometimes it may be the preferred option. The shift in obstetric anesthesia practices to minimize general anesthesia for cesarean deliveries for maternal safety began in 1997. Hawkins and colleagues reported a 17-fold increase in mortality for patients undergoing general anesthesia for cesarean delivery compared with those receiving regional anesthesia. From 2011 to 2013, maternal mortality in the United States was 17 per 100,000 births, and the proportion of anesthesia-related maternal deaths decreased from 1.6% (1990 to 1997) to 0.2% (2011 to 2013). This reduction is partly attributed to decreased general anesthesia rates for cesarean deliveries.

Comparative evaluation of first-attempt intubation success rate using direct laryngoscope with Macintosh blade and video laryngoscope during rapid sequence induction in patients undergoing emergency surgery: A prospective randomised controlled trial.

Airway management skills form the cornerstone of routine anaesthesia practice. Its role becomes more significant in emergency areas where time is of the essence. Patients presenting for emergency surgery require definitive airway management with endotracheal intubation. Rapid sequence induction with direct laryngoscopy using a Macintosh blade has been used consistently with varying success. With the advent of video laryngoscopes, their utility is being explored in emergency areas. We aimed to assess the role of a video laryngoscope (Medizintechnik, Sulz, Germany) in rapid sequence induction and intubation during emergency surgeries. We hypothesised that video laryngoscope would improve the first-attempt intubation success rate in patients undergoing emergency surgery. In total, 76 patients presenting for emergency surgery were enrolled and randomly assigned into two groups (38 each), who were intubated with either a video laryngoscope or Macintosh blade during rapid sequence induction. This study aimed to compare and evaluate direct laryngoscopy using a Macintosh blade and a video laryngoscope during rapid sequence induction. The two groups were similar in the type and indication for surgery. Airway characteristics were also compared, and there were no significant differences in all airway parameters, including mouth opening, thyromental distance, Mallampati grading and neck circumference. The first-attempt intubation success rate was significantly higher in the video laryngoscope group (p = 0.017, χ2 = 5.684). The Cormack-Lehane grade distribution was compared in both groups, with better glottis visualisation in group video laryngoscope (p = 0.028, χ2 = 9.123). This prospective, randomised, controlled study aimed to compare the first-attempt intubation success rate using direct laryngoscopy with a Macintosh blade and a video laryngoscope during rapid sequence induction in patients undergoing emergency surgeries and observed that first-attempt intubation success rate was significantly higher in group video laryngoscope (86.8%) than in group direct laryngoscopy (63.2%). Therefore, video laryngoscopy offers an attractive alternative to conventional laryngoscopy while securing the airway in patients presenting for emergency surgery.

Management of the Expected Difficult Airway with Planned One-Lung Ventilation: A Retrospective Analysis of 44 Cases.

Difficult airway management is essential in anesthesia practice. Particular challenges are posed to patients who require intraoperative one-lung ventilation. Specific guidelines for these scenarios have been lacking. The recent update of German guidelines incorporates recommendations for securing the airway in anticipated difficult airway scenarios in patients requiring one-lung ventilation. However, scientific data on this specific topic is rare. A retrospective analysis was conducted on adult patients undergoing thoracic surgery with one-lung ventilation from 2016 to 2021. During these years, the standard of practice has been in line with the now published guidelines. Patients with anticipated difficult airways were identified, and airway management strategies were analyzed. Among 3,197 anesthetic procedures, 44 cases involved anticipated difficult airways, primarily due to prior head and neck tumor treatment. Nasal bronchoscopic awake intubation followed by oral reintubation under videolaryngoscopic inspection and the use of bronchial blockers was the standard procedure. No severe complications were recorded, and one-lung ventilation was maintained successfully in all cases. The study highlights the challenges of managing difficult airways during thoracic surgery. Recommendations align with recent guidelines, emphasizing the importance of tailored approaches. The use of single-lumen tubes with bronchial blockers appears favorable over double-lumen tubes, offering comparable ventilation quality with reduced risks. Despite limitations, the study underscores the safety and efficacy of tailored airway management strategies during one-lung ventilation in patients with anticipated difficult airways. The presented approach offers patient safety and practicability. Further multicenter studies are warranted to validate these findings and refine clinical approaches.

Safe Anesthesia Practices for Minimally Invasive, Image-guided Procedures: CT, MRI, and Ultrasound

Background: The demand for minimally invasive, image-guided procedures, such as CT, MRI, and ultrasound, is increasing. Understanding the role of anesthesia in enhancing patient safety, comfort, and procedural success is essential. Methods: This study was conducted at Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, over two years, involving 150 patients. Anesthesia techniques were categorized as general anesthesia, sedation, and local anesthesia. Patient outcomes, complications, and satisfaction scores were recorded and analyzed. Results: In this study, general anesthesia was administered to 65 patients (43.3% of cases), sedation was used for 56 patients (37.3%), and local anesthesia was applied to 29 patients (19.3%). The overall procedural success rate was high, at 141 successful completions (94%), with minor complications occurring in 7 patients (4.7%) and major complications in 2 patients (1.3%). Patient satisfaction scores indicated that 96 participants (64%) reported being very satisfied with their anesthesia experience, while 45 patients (30%) indicated they were satisfied. These findings highlight the effectiveness and safety of the selected anesthesia practices in minimally invasive, image-guided procedures, demonstrating a strong correlation between appropriate anesthesia techniques and positive patient outcomes. The data underscore the importance of tailored anesthesia protocols to enhance procedural success and patient satisfaction in this clinical setting. Conclusion: The study demonstrates that tailored anesthesia practices can achieve high success rates and patient satisfaction in minimally invasive, image-guided procedures. Despite the low incidence of complications, ongoing research is needed to refine anesthesia protocols and explore advanced, image-guided techniques to further enhance patient safety and comfort.

Protocol development and feasibility of the PEACH in Asia study: A pilot study on PEri-anesthetic morbidity in CHildren in Asia.

Comprehensive data on pediatric anesthesia outcomes, particularly severe critical events (SCEs), are scarce in Asia. This highlights the need for standardized research to assess anesthesia safety and quality in the diverse settings. The PEACH in Asia pilot study aimed to test the feasibility of a standardized protocol for investigating SCEs in anesthesia practices across Asia, evaluate the data acquisition processes, and determine the sample size for a main study. This multicenter pilot study involved ten institutions across nine Asian countries, including children from birth to 15 years undergoing diagnostic or surgical procedures. Data on SCEs were collected using standardized definitions. The study assessed the feasibility and estimated the sample size needed for the main study. The pilot study enrolled 330 patients, with a SCE incidence of 12.4% (95% CI: 9.2-16.4%). Respiratory events were observed in 7.0% of cases, cardiovascular instability in 4.9%, and drug errors in 0.6%. Based on the SCE incidence observed in the pilot study, the estimated sample size required for the main study is at least 10 958 patients. The pilot study demonstrated the feasibility of the study protocol but identified several challenges, particularly in resource-limited settings. These challenges included a significant burden associated with data collection, technical issues with electronic case report forms (e-CRFs), variability in patient enrollment across institutions (ranging from 4 to 86 patients per site), and incomplete data acquisition (24.8% of height data and 9.7% of disposition data were missing). The PEACH in Asia pilot study successfully validated a protocol for investigating SCEs in pediatric anesthesia across Asia. Addressing the challenges identified in the pilot study will be crucial for generating robust data to improve pediatric anesthesia safety in the region. Key issues to address include improving data collection methods, resolving e-CRF technical difficulties, and ensuring consistent institutional support.

A Paradigm for Shared Decision-Making in Pediatric Anesthesia Practice for Children with Autism for the Generalist Clinician.

A Paradigm for Shared Decision-Making in Pediatric Anesthesia Practice for Children with Autism for the Generalist Clinician.

A deep dive into neonatal well-being and anesthesia in cesarean sections: From procedure to outcome.

This observational study analyzed data from 502 participants undergoing cesarean section (CS) procedures at an obstetrics and gynecology department, aiming to explore anesthesia practices, neonatal outcomes, and demographic characteristics within the cohort. Participants, aged 17 to 59 years with a mean age of 32.23 years, were enrolled based on the clinical necessity for cesarean delivery during the study period. Informed consent was obtained from each participant or their guardians before data collection, which included detailed demographic information, medical histories, specifics of the cesarean section procedure, and APGAR scores of neonates immediately postbirth (at 0 and 5 minutes). Primary outcomes focused on APGAR scores, critical indicators of neonatal health, while secondary outcomes included the distribution of patient ages, reasons for cesarean sections, and the administration of Bupivacaine during anesthesia. Data were rigorously analyzed using descriptive and inferential statistics to summarize participant demographics, anesthesia practices, and neonatal outcomes. Statistical methods included measures of central tendency and dispersion, correlation analyzes to explore associations between variables, and regression models to identify predictors of neonatal APGAR scores. The study identified a range of indications for cesarean sections, with common reasons including fetal distress and maternal health complications. Findings indicated an average APGAR score of 7.02 at 0 minutes and 7.84 at 5 minutes, reflecting generally favorable immediate neonatal outcomes. Anesthesia protocols predominantly involved Bupivacaine, with doses ranging from 1.8 to 2.2 mL, administered based on clinical requirements. In conclusion, this study underscores the importance of comprehensive data collection and rigorous statistical analysis in evaluating cesarean section procedures. Future research could further explore long-term neonatal outcomes and refine anesthesia protocols to optimize maternal and neonatal health during cesarean deliveries.

A Randomized Controlled Trial to Compare the Analgesic Efficacy of Ultrasound-Guided Fascia Iliaca Compartment Block and Femoral Nerve Block in Patients with Neck of Femur Fracture

ABSTRACT Background and Aims: Regional nerve blocks under ultrasound guidance have heralded the era toward safer anesthetic practices. They provide adequate analgesia during positioning for subarachnoid block in patients posted for hip. We aimed to compare the analgesic efficacy of fascia iliaca compartment block and femoral nerve block for pain during sitting position for subarachnoid block, duration of post-op analgesia, and document any complications. Material and Methods: A randomized double-blind study was conducted in 60 patients undergoing isolated neck of femur fracture surgery under subarachnoid block. They were randomized by a computer-generated randomization table into two groups – group A received a fascia iliaca compartment block and group B received a femoral nerve block. Numeric rating score (NRS) was noted before block, during positioning, and postoperatively for 24 hours. An independent sample t-test and a paired t-test were used for intergroup and intra-group comparisons. Results: The mean NRS before block in group A (7.57 ± 0.50) and group B (7.40 ± 0.49) (P-value = 0.203) was not significant. NRS during positioning in group A (2.10 ± 0.88) was significantly lower than group B (3.33 ± 0.71) (P-value = 0.001*). The mean NRS from the sixth till 20th hour postoperatively was significantly higher in group B compared to group A (P-value <0.05 for all). The mean time to first rescue analgesia was significantly longer in group A (23.57 ± 2.22 hours) compared to group B (11.97 ± 1.73 hours) (P-value = 0.001*). No complications were noted during the study. Conclusion: Fascia iliaca compartment block gives significantly better pain relief during positioning for subarachnoid block and prolonged postoperative analgesia as compared to femoral nerve block.

Regional anaesthetic techniques in 14 Slovenian obstetric units between 2013 and 2021: where are we and where are we going?

Background: The use of regional anaesthetic techniques for caesarean section and labour analgesia is necessary for quality-driven obstetric anaesthesia as required by European minimum standards for obstetric analgesia and anaesthesia departments, which were issued by the European Society of Anaesthesiology and Intensive Therapy in 2020. The aim of this article is to evaluate the rate of caesarean sections performed using regional anaesthetic techniques and the rates of epidural, remifentanil-PCA, and meperidine analgesia for managing labour pain across the 14 Slovenian obstetric units, respectively. Methods: Data from the Slovenian National Perinatal Information System (NPIS) from 2013 to 2021 were analysed. Results: Spinal anaesthesia was used as a primary anaesthetic method (> 50% of elective caesarean sections) in a half of Slovenian obstetric units. For emergency caesarean sections, regional anaesthetic methods (spinal and epidural) were used in > 50% parturients in 3 obstetric units. Eight obstetric units had an epidural rate of >10%. The use of epidural analgesia has progressively increased in 9 of 14 obstetric units. Remifentanil has been routinely used in 6 obstetric units. Accordingly, the consumption of meperidine has dropped in all but one obstetric unit in Slovenia. Conclusion: In the past decade, considerable progress has been observed in obstetric anaesthesia practice in Slovenia. This is evident from the increased use of regional anaesthesia for caesarean section and labour analgesia. However, there are considerable discrepancies in anaesthetic practices between different obstetric units in Slovenia, a situation the parturients should be informed of well in advance to be able to choose the obstetric unit according to their labour and delivery preferences. In order to avoid the differences in the quality and accessibility of anaesthetic practice between units, it is necessary to increase the number of anaesthesiologists involved in obstetric anaesthesia to ensure 24/7 service of labour analgesia to be able to fulfill minimum European standards for obstetric analgesia and anaesthesia departments.

Sugammadex for our little ones: a brief narrative review.

Sugammadex, the first noncompetitive antagonist developed for the reversal of neuromuscular blockade (NMB), is one of the few drugs that has revolutionized anesthetic practice. However, the use of sugammadex for children between the ages of 2 and 17 years has only recently been approved and is currently not approved for children under the age of 2 years. Although the precision and reliability of reversal of NMB with sugammadex are of great benefit in pediatric anesthesia, several important questions remain regarding its use in our youngest patients. In this brief narrative review, we aim to provide an overview of the key considerations and potential challenges that anesthesiologists often face when using sugammadex in pediatric patients.

Extubation and removal of supraglottic airway devices in pediatric anesthesia.

In pediatric anesthesia, respiratory adverse events often occur during emergence from anesthesia and at the time of endotracheal tube or supraglottic device removal. The removal of airway devices and extubation are conducted either while patients are deeply anesthetized or when patients awaken from anesthesia and have regained consciousness. The airways of children are easily irritated by external stimuli and are structurally prone to collapse, and the timing of both methods of airway device removal is similarly associated with various airway complications, including upper airway obstruction, coughing, or serious adverse events such as laryngospasm and desaturation. In current pediatric anesthesia practice, the choice of the timing and method of extubation is made by anesthesiologists. To achieve a smooth and safe recovery from anesthesia, understanding the unique characteristics of pediatric airways and the factors likely to contribute to an increased risk of perioperative complications remains essential. These factors include patient age, comorbidities, and physical conditions. The level of anesthesia and readiness for removal of airway devices should be evaluated carefully for each patient, and quick identification of airway problems and intervention is required if patients fail to maintain the airway and sufficient ventilation after removal of airway devices.

Strategies to Limit Benzodiazepine Use in Anesthesia for Older Adults

Despite guidelines recommending avoidance of benzodiazepine administration to older patients, many of them now receive benzodiazepines as a part of anesthesia care. The effectiveness of clinician- and patient-facing interventions to discourage such use remains insufficiently characterized. To evaluate the effect of clinician peer comparison, patient informational mail, or a combination of these interventions compared with usual care on the rate of perioperative benzodiazepine administration to older patients. This 2 × 2 factorial, stepped-wedge, cluster randomized clinical trial of a corporate quality improvement initiative was conducted between August 8, 2022, and May 28, 2023, across 415 hospitals, surgery centers, and physician offices in 8 US states served by anesthesia clinicians from a national anesthesia practice. Participants were adults aged 65 years or older who underwent an elective surgical or endoscopic procedure with general anesthesia. Data analyses followed the intention-to-treat principle. Patients were randomly assigned to 1 of 4 groups-clinician peer comparison (wherein clinicians received feedback regarding their performance compared with other clinicians in the practice), patient informational mail (wherein patients received an informational letter encouraging them to have a discussion regarding medication selection with their clinician on the day of surgery), both interventions, or usual care (no intervention). Rate of benzodiazepine administration during anesthesia care and patient satisfaction with anesthesia care (measured by the Anesthesia Patient Satisfaction Questionnaire, version 2). Among the 509 269 enrolled participants (255 871 females [50.2%]; mean [SD] age, 74 [7] years), 81 363 (16.0%) were assigned to clinician peer comparison, 98 520 (19.3%) to patient informational mail, 169 712 (33.3%) to both interventions, and 159 674 (31.4%) to usual care. Among patients who received benzodiazepine during anesthesia care, 24.5% were in the usual care group compared with 19.7% in the clinician peer comparison group, 20.0% in the patient informational mail group, and 19.7% in the combination group. After adjustment for time, none of the study interventions were associated with lower odds of benzodiazepine administration compared with usual care (odds ratio [OR], 1.02 [95% CI, 0.98-1.07]; P = .35 for clinician peer comparison; OR, 1.01 [95% CI, 0.96-1.05]; P = .81 for patient informational mail; and OR, 1.11 [95% CI, 1.05-1.16]; P < .001 for combined interventions). Satisfaction scores were high in all groups and did not vary by treatment assignment. This randomized clinical trial found that clinician peer comparison, patient informational mail, or a combination of both interventions did not reduce benzodiazepine administration to older patients compared with usual care; patient satisfaction remained high throughout the study. Overall, the findings suggest a need to explore other patient-targeted interventions to improve anesthesia care. Clinicaltrials.gov Identifier: NCT05436392.

Management and monitoring of anesthesia during the perioperative period in a Tertiary Hospital in Bangladesh

Background: Anesthesia management is crucial for ensuring patient safety and optimal surgical outcomes during the perioperative period. In Bangladesh, the challenges faced in managing and monitoring anesthesia in tertiary care hospitals necessitate a comprehensive evaluation of current practices. This study aims to assess the anesthetic management protocols and monitoring strategies employed in a tertiary hospital in Bangladesh. Methods: This observational study was conducted in Islami Bank Medical College Hospital, Rajshahi, Bangladesh from July to December 2023. Data were collected from patients undergoing various surgical procedures requiring anesthesia. The anesthetic techniques used, intraoperative monitoring parameters, and any complications encountered were recorded. The study included a review of anesthesia charts, patient records, and interviews with anesthesia providers. Statistical analysis was performed to identify trends and correlations. Results: A total of 200 patients were included in the study. The most commonly used anesthetic technique was general anesthesia (65%), followed by regional anesthesia (30%) and local anesthesia (5%). Intraoperative monitoring parameters included heart rate, blood pressure, oxygen saturation, and end-tidal carbon dioxide levels, which were consistently documented in 95% of cases. Complications occurred in 10% of patients, primarily involving respiratory issues and cardiovascular instability. Proper adherence to monitoring protocols significantly reduced the incidence of complications. Conclusion: Effective management and monitoring of anesthesia during the perioperative period are vital for patient safety in a tertiary hospital setting. The study highlights the importance of standardized protocols and continuous monitoring to minimize complications. Recommendations for improving anesthetic practices include regular training for anesthesia providers and enhancing monitoring infrastructure to ensure optimal patient care.

DIFFICULTIES AND CONSIDERATIONS IN ANESTHESIA FOR PREGNANT WOMEN: A LITERATURE REVIEW

Introduction: The management of anesthesia in pregnant women presents unique challenges due to the physiological changes that occur during pregnancy. A comprehensive understanding of these changes is essential for ensuring maternal and fetal safety. Objective: This study aims to explore the complexities of anesthetic management in pregnant women, focusing on the necessary adaptations in techniques, potential complications, and the impact of racial and socioeconomic disparities in access to care. Methods: A multidisciplinary approach was employed, including a review of current literature on anesthetic practices, complications, and healthcare disparities. Collaborative strategies among healthcare providers were also examined. A total of 10 articles were selected for meeting the research criteria. Results: The findings indicate that approximately 70% of studies emphasize the importance of tailored anesthetic techniques to address physiological changes. Additionally, disparities in access to anesthetic care were identified, highlighting the need for equitable health policies. Conclusion: Continued research and innovation are vital for improving anesthetic practices and ensuring that all pregnant women receive safe and effective care. This work contributes to the overarching goals of prioritizing maternal and neonatal safety and addresses systemic challenges in anesthetic management.

The Role of GABA Receptors in Anesthesia and Sedation: An Updated Review.

GABA (γ-aminobutyric acid) receptors are constituents of many inhibitory synapses within the central nervous system. They are formed by 5 subunits out of 19 various subunits: α1-6, β1-3, γ1-3, δ, ε, θ, π, and ρ1-3. Two main subtypes of GABA receptors have been identified, namely GABAA and GABAB. The GABAA receptor (GABAAR) is formed by a variety of combinations of five subunits, although both α and β subunits must be included to produce a GABA-gated ion channel. Other subunits are γ, δ, ε, π, and ϴ. GABAAR has many isoforms, that dictate, among other properties, their differing affinities and conductance. Drugs acting on GABAAR form the cornerstone of anesthesia and sedation practice. Some such GABAAR agonists used in anesthesia practice are propofol, etomidate, methohexital, thiopental, isoflurane, sevoflurane, and desflurane. Ketamine, nitrous oxide, and xenon are not GABAR agonists and instead inhibit glutamate receptors-mainly NMDA receptors. Inspite of its many drawbacks such as pain in injection, quick and uncontrolled conversion from sedation to general anesthesia and dose-related cardiovascular depression, propofol remains the most popular GABAR agonist employed by anesthesia providers. In addition, being formulated in a lipid emulsion, contamination and bacterial growth is possible. Literature is rife with newer propofol formulations, aiming to address many of these drawbacks, and with some degree of success. A nonemulsion propofol formulation has been developed with cyclodextrins, which form inclusion complexes with drugs having lipophilic properties while maintaining aqueous solubility. Inhalational anesthetics are also GABA agonists. The binding sites are primarily located within α+/β- and β+/α- subunit interfaces, with residues in the α+/γ- interface. Isoflurane and sevoflurane might have slightly different binding sites providing unexpected degree of selectivity. Methoxyflurane has made a comeback in Europe for rapid provision of analgesia in the emergency departments. Penthrox (Galen, UK) is the special device designed for its administration. With better understanding of pharmacology of GABAAR agonists, newer sedative agents have been developed, which utilize "soft pharmacology," a term pertaining to agents that are rapidly metabolized into inactive metabolites after producing desired therapeutic effect(s). These newer "soft" GABAAR agonists have many properties of ideal sedative agents, as they can offer well-controlled, titratable activity and ultrashort action. Remimazolam, a modified midazolam and methoxycarbonyl-etomidate (MOC-etomidate), an ultrashort-acting etomidate analog are two such examples. Cyclopropyl methoxycarbonyl metomidate is another second-generation soft etomidate analog that has a greater potency and longer half-life than MOC-etomidate. Additionally, it might not cause adrenal axis suppression. Carboetomidate is another soft analog of etomidate with low affinity for 11β-hydroxylase and is, therefore, unlikely to have clinically significant adrenocortical suppressant effects. Alphaxalone, a GABAAR agonist, is recently formulated in combination with 7-sulfobutylether-β-cyclodextrin (SBECD), which has a low hypersensitivity profile.

Perioperative Point-of-Care Ultrasound (POCUS) for Anaesthetists: Is It Time to Introduce Formal Training?

This article reviews point-of-care ultrasound (POCUS) in the perioperative period. Ultrasound-guided techniques for regional anaesthesia and vascular access have been well-established in anaesthesia for many years. However, integration of whole-body POCUS into UK anaesthetic practice remains limited. There is a growing body of evidence highlighting the benefits of POCUS throughout the perioperative period. Widespread use may help to improve patient care in anaesthesia.