Anaesthetic Practice Research Articles

Anesthesia Practice Finances, 2030

Article| October 2021 Anesthesia Practice Finances, 2030 Gordon Morewood, MD, MBA, FASE, FASA; Gordon Morewood, MD, MBA, FASE, FASA Search for other works by this author on: This Site PubMed Google Scholar Neal H. Cohen, MD, MPH, MS; Neal H. Cohen, MD, MPH, MS Search for other works by this author on: This Site PubMed Google Scholar Sharon K. Merrick, MS, CCS-P Sharon K. Merrick, MS, CCS-P Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor October 2021, Vol. 85, 24–26. https://doi.org/10.1097/01.ASM.0000795164.24106.b8 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Cite Icon Cite Get Permissions Search Site Citation Gordon Morewood, Neal H. Cohen, Sharon K. Merrick; Anesthesia Practice Finances, 2030. ASA Monitor 2021; 85:24–26 doi: https://doi.org/10.1097/01.ASM.0000795164.24106.b8 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu nav search search input Search input auto suggest search filter All ContentAll PublicationsASA Monitor Search Advanced Search Topics: finance, health care systems, medicare The finances of an anesthesia practice are dictated primarily by the payment rates and policies of both government and private payors. In recent years, both government and private insurers have focused on reducing the costs of individual episodes of care as well as the rate of growth in overall health care spending. As a result, the past decade has undoubtedly seemed quite turbulent to many physicians, particularly in comparison to the relative stability of the health care payment system during the two decades prior. Despite a variety of approaches to managing these costs, the containment strategies to date have not been successful. New approaches designed to value health care differently are being implemented. Most of these changes are based primarily on quality and safety rather than cost alone. Many of the alternative payment models require providers and health systems to assume new financial risks. These approaches represent more sophisticated attempts... You do not currently have access to this content.

Job Satisfaction and Associated Factors Among Anesthetists at Government Hospitals of Addis Ababa, Ethiopia

Background : Anesthetic practice is always at high risk in medical profession. Job satisfaction level of Anesthetist can be affected by different factors. An investigation to retain anesthetists in the profession to meet the increasing demands of the healthcare system has a great importance. This study was aimed to determine the level of job satisfaction and associated factors among anesthetists working in government hospitals of Addis Ababa. Methods: A cross-sectional study conducted on sampled 101 anesthetists. Simple random sampling method was used to obtain the study participants. Data were collected using a structured questionnaire, comprised two main parts; demography and job satisfaction. Respondent rated 18 factors related to job satisfaction using six point Likert scale. A descriptive analysis using Proportion and frequency were used . A‘chi square’ test were used to assess statistical significance of association and P- values less than 0.05 were considered as statistically significant. Results: Among 101 anesthetists respondent, 57% were male, the majority of respondents were below the age of 30 years 58.4% and 59.4% of the respondents were single. A 53% of the respondents were satisfied and the highest dissatisfaction rate was in the age group of below thirty. Satisfaction in helping others, responsibilities and freedom to choose method of working were significantly associated with job satisfaction. The major reasons reported for their dissatisfaction were inadequate salary, lack of public awareness about the role of anesthetists and professional hazard. Conclusion: There is a low level of job satisfaction among anesthetists who are working in government hospitals of Addis Ababa. Therefore, improving satisfaction level of anesthetist by solving major reasons of dissatisfaction is strongly recommended. Keywords: Anesthetists , satisfaction , dissatisfaction , government hospitals DOI: 10.7176/JHMN/94-05 Publication date: October 31 st 2021

Use of high flow oxygen (HFO) for difficult airway management in Jael syndrome: a case report

: Jael Syndrome is defined as an intentional craniofacial stab injury. There are few cases in the medical literature describing such facial impalements with the presence of the instrument in the face. Such cases present a complex challenge, involving many specialities, and in particular requires cautious considerations in the immediate preoperative management and intubation of such patients. The use of High Flow Oxygen (HFO) has an increasingly popular role in anaesthetic and intensive care practices, with numerous studies supporting its efficacy in preoxygenation and increasing the safe apnoea time prior to intubation. We report the case of a 20 years old man who presented with facial impalement with a kitchen knife following an altercation. Imaging confirmed that the knife passed through the nasopharynx and was embedded in his right occipital condyle. He was transferred to theatre, where prior to the removal of the implement and haemostasis control, he was preoxygenated using (HFO) and his airway secured with video laryngoscopy. Post operatively, he was kept sedated and ventilation in the Intensive Care Unit (ICU) prior to being successfully extubated and transferred to the ward. He was subsequently discharged form hospital with only mild sensory loss secondary to the injury. This case highlights the technical difficulties associated with the preoxygenation and intubation in patients presenting with facial impalement, and in particular use of HFO in providing for an extended safe apnoea time prior to securing a difficult airway in the context of maxillofacial trauma.

Способ минимизации типичных осложнений при спинальной анестезии

Целью работы было исследовать влияние низкодозовой спинальной монолатеральной анестезии с использованием гипербарических растворов бупивакаина на кардиогемодинамику, респираторную депрессию, мышечную дрожь, постпункционную головную боль, транзиторный ишемический синдром и потребность в дополнительной внутривенной седации. Низкодозовая спинальная анестезия выявила больший протективный эффект в отношении кардиогемодинамики: стабильное состояние гемодинамики на этапах оперативного лечения при выполнении низкодозовой спинальной монолатеральной анестезии наблюдали в среднем в 3 раза чаще, чем при стандартной спинномозговой анестезии. Использование монолатеральной техники предотвращало опасные изменения респираторной функции на основном этапе в среднем в 2 раза больше, а по окончании операции — в 4 раза. Озноб и дрожь после монолатеральной спинномозговой анестезии наблюдали на основном этапе в 1,5 раза реже, а по окончании оперативного лечения — в 2,4 раза реже, чем при ортодоксальной спинномозговой анестезии.

Telemedicine for preanesthesia evaluation: review of current literature and recommendations for future implementation.

The in-person preanesthesia visit serves multiple purposes including identification and optimization of comorbid conditions as well as patient education. However, it imposes a significant burden on patients and healthcare providers. In this review, we define the scope of telemedicine and present the most up-to-date literature supporting its role for the preanesthesia evaluation. The opportunities and challenges are discussed and approaches to implementation of telemedicine in preanesthesia care are offered. Finally, the future of telemedicine as it pertains to preanesthesia care is examined. Although telemedicine for preanesthesia practice was proposed almost two decades ago, the COVID-19 pandemic has accelerated its implementation. The potential benefits of telemedicine include improved patient satisfaction as well as the ability to provide cost-effective specialty services while reducing the burden on healthcare providers. Limitations to telemedicine include lack of technology, training, regulatory barriers, and an inability to perform a physical exam. Telemedicine will continue to expand and its application to the preanesthesia evaluation is a clear example of how technology will revolutionize anesthesia practice. In order for telemedicine to continue to expand in the postpandemic period, steps must be taken to ensure that healthcare facilities and providers keep up with the times.

A Review of Current Literature of Interest to the Office-Based Anesthesiologist.

A Review of Current Literature of Interest to the Office-Based Anesthesiologist.

S980 Point of Care Gastric Ultrasound for Predicting Residual Gastric Content and Risk of Aspiration in Ambulatory Patients for Advanced Endoscopy Procedures

Introduction: The risk of aspiration of gastric contents during endoscopy can be associated with significant morbidity and mortality. Even with complete fasting status, the gastric emptying times and residual gastric volumes other than basal secretions vary and depend on many patient factors. Bedside ultrasound imaging can be helpful in determining these gastric contents and volumes while enabling safe anesthesia practices. Our goals were to determine the gastric volume and compare the ultrasound guided gastric volumes in real time with endoscopist measured volumes. Methods: Patients presenting to the UAB endoscopy suite were taken written informed consent to participate in this study. The anesthesiologists experienced in performing gastric ultrasound performed the preoperative gastric ultrasound. The gastric cross-sectional area (CSA) is measured in supine and right lateral decubitus positions and gastric volumes calculated both using the nomograms and the formula. The anesthesia plan intraoperatively is based on the risk profile pattern of these gastric ultrasound estimates. The endoscopist blinded to these gastric ultrasound estimates performed endoscopy to suction the gastric volumes. These direct measured gastric volumes were then compared to calculated gastric volumes (CGV) to assess the degree of correlation and threshold values. Results: 81 patients were included in the study (Mean age 57.78 years, Male 49.38%, Mean BMI 29.83 patients). 2 patients were excluded as there was missing information or technical issues with documentation. Majority of patients underwent EUS (38.27%) followed by EGD ± therapy (30.86 %) ERCP (22.22%) and DBE (6.17 %). Mean CGV by nomogram is 33.84 ml, mean CGV by formula is 30.79 ml. Mean measures gastric volume by endoscopist is 28.64 ml. The gastric ultrasound was able to predict correlation significantly comparing measured gastric volume by endoscopy (ml) to CGV measured by nomogram (0.794, 95% CI for Pearson correlation (0.697-0.863) (Figure A) and measured gastric volume by endoscopy (ml) to CGV by formula (r=0.834 95% CI for Pearson correlation (0.753-0.890) (Figure B). There were no intra or post procedural adverse events noted in particular for aspiration. Conclusion: Gastric ultrasound acts as a reliable tool in predicting residual gastric volume and contents prior to undergoing anesthesia for advanced endoscopy procedures. This can potentially offer and guide preventive measures to prioritize on airway protection.Figure 1.: Measured gastric vol by

Future Challenges in Health Care: Health Policy, Health Care Financing, Access, and Clinical Care Delivery

Article| October 2021 Future Challenges in Health Care: Health Policy, Health Care Financing, Access, and Clinical Care Delivery Lee A. Fleisher, MD Lee A. Fleisher, MD Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor October 2021, Vol. 85, 5–7. https://doi.org/10.1097/01.ASM.0000795140.87972.ba Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Cite Icon Cite Get Permissions Search Site Citation Lee A. Fleisher; Future Challenges in Health Care: Health Policy, Health Care Financing, Access, and Clinical Care Delivery. ASA Monitor 2021; 85:5–7 doi: https://doi.org/10.1097/01.ASM.0000795140.87972.ba Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu nav search search input Search input auto suggest search filter All ContentAll PublicationsASA Monitor Search Advanced Search Topics: delivery of health care, health care financing, health policy, pandemics Since assuming my role at Centers for Medicare and Medicaid Services (CMS), I have learned how important it is for every specialty to engage with the organization to advance the “value-based” approach to care, improve quality and safety, and ensure equitable access. Based on this perspective, let me identify some key issues related to the future of health care, health policy, financing, and quality that will impact anesthesia practices over the next decade. A number of recent events, including the COVID pandemic and Black Lives Matter movement have raised awareness of health inequities for marginalized populations in this country and, as a result, have altered the course of health care delivery and health care policy. There is now clear direction from the federal government that ensuring high-quality health care for all is a priority. While the focus has increased considerably, the passage of the Patient Protection and Affordable Care Act... You do not currently have access to this content.

BLOOD CORTISOL CONCENTRATION, HEMODYNAMICS AND METABOLISM OF PATIENTS WITH SECONDARY HYPERPARATHYROIDISM, POSSIBILITIES OF PERIOPERATIVE CORRECTION

Secondary hyperparathyroidism (SHPT) affects a majority of patients with chronic kidney disease (CKD) of stage 3 or worse with manifestations of chronic renal failure (CRF) who undergo hemodialysis. Most of them have severe metabolic disorders, metabolic acidosis and a range of disorders associated with hyperparathyroidism and require parathyroid surgery (PTS). Aim of research. To assess the possibilities of metabolic correction in patients with SHPT with PTS, depending on the level of blood cortisol. Materials and methods. The study was carried out in the clinic of SIS «RPC PCM» SAD, Kyiv, Ukraine, was prospective, not randomized. The study group (n=133) included patients with severe SHPT manifestations due to end-stage chronic renal failure due to CKD, who underwent PTS. Patient age: 21-75 years old. Men – 69 (51,9%), women – 64 (48,1%). The degree of preoperative risk of ASA III-IV. Surgical interventions were performed under general anesthesia using the inhalation anesthetic sevoflurane and the narcotic analgesic fentanyl under conditions of low-flow artificial ventilation. The patients underwent a personalized energy monitoring developed and implemented in our clinic, using indirect calorimetry, by determining the index of current metabolism (Metabolic Rate Index, MRI, cal min-1 m2 ), basal metabolism (Basal Metabolic Rate Index, BMRI, cal min-1 m2), target metabolism (Target Metabolic Rate Index) and severity of metabolic disorders (Metabolic Disordes, MD,% = ). The patients were divided into two groups. The first group (I,72) consisted of patients who had reference values of the morning blood cortisol level before the operation – 171,03 and higher (173-374) nmol/L. The second group (II, 61) consisted of patients who had cortisol levels below this limit (91,5-168 nmol/L). In group I, intensive perioperative therapy was standard and aimed at supporting and correcting vital signs, according International Standards for a Safe Practice of Anesthesia 2010, WFSA. In group II, patients additionally received intravenous drip of 125-250 mg of prednisolone and further situationally hydrocortisone under the control of energy monitoring indicators. Results. In 45.9% of patients with SHPT and end-stage CKD, glucocorticoid insufficiency and low metabolic rate were diagnosed, which can lead to irreversible changes in organs or the life support system and increase the risks of perioperative complications and death in PTS. Preventive and perioperative administration of glucocorticoids under the control of energy monitoring, restores homeostasis indicators. Patients with normal blood cortisol levels did not have significant metabolic disorders. It was enough for them to follow the standard protocol of perioperative intensive care. Conclusions. Mandatory preoperative monitoring of blood cortisol levels in patients with SHPT against the background of end-stage CKD, who are on programmed hemodialysis, who are planned for PTS, is required in order to achieve a differential approach to treatment: to determine the need and dose of intravenous glucocorticoids.

Management of veterinary anaesthesia and analgesia in small animals: A survey of English-speaking practitioners in Canada.

To describe how small animal anaesthesia and analgesia is performed in English-speaking Canada, document any variation among practices especially in relation to practice type and veterinarian's experience and compare results to published guidelines. Observational study, electronic survey. 126 respondents. A questionnaire was designed to assess current small animal anaesthesia and analgesia practices in English-speaking Canadian provinces, mainly in Ontario, Alberta and British Columbia. The questionnaire was available through SurveyMonkey® and included four parts: demographic information about the veterinarians surveyed, evaluation and management of anaesthetic risk, anaesthesia procedure, monitoring and safety. Year of graduation and type of practice were evaluated as potential risk factors. Exact chi-square tests were used to study the association between risk factors and the association between risk factors and survey responses. For ordinal data, the Mantel-Haenszel test was used instead. Response rate over a period of 3 months was 12.4% (126 respondents out of 1 016 invitations). Current anaesthesia and analgesia management failed to meet international guidelines for a sizable number of participants, notably regarding patient evaluation and preparation, safety and monitoring. Nearly one third of the participants still consider analgesia as optional for routine surgeries. Referral centres tend to follow guidelines more accurately and are better equipped than general practices. A proportion of surveyed Canadian English-speaking general practitioners do not follow current small animal anaesthesia and analgesia guidelines, but practitioners working in referral centres are closer to meet these recommendations.

Is simulation-based team training performed by personnel in accordance with the INACSL Standards of Best Practice: SimulationSM?\u2014a qualitative interview study

BackgroundAnesthesia personnel was among the first to implement simulation and team training including non-technical skills (NTS) in the field of healthcare. Within anesthesia practice, NTS are critically important in preventing harmful undesirable events. To our best knowledge, there has been little documentation of the extent to which anesthesia personnel uses recommended frameworks like the Standards of Best Practice: SimulationSM to guide simulation and thereby optimize learning. The aim of our study was to explore how anesthesia personnel in Norway conduct simulation-based team training (SBTT) with respect to outcomes and objectives, facilitation, debriefing, and participant evaluation.MethodsIndividual qualitative interviews with healthcare professionals, with experience and responsible for SBTT in anesthesia, from 51 Norwegian public hospitals were conducted from August 2016 to October 2017. A qualitative deductive content analysis was performed.ResultsThe use of objectives and educated facilitators was common. All participants participated in debriefings, and almost all conducted evaluations, mainly formative. Preparedness, structure, and time available were pointed out as issues affecting SBTT.ConclusionsAnesthesia personnel’s SBTT in this study met the International Nursing Association for Clinical Simulation and Learning (INACSL) Standard of Best Practice: SimulationSM framework to a certain extent with regard to objectives, facilitators’ education and skills, debriefing, and participant evaluation.

Concept Analysis: The Scope of Practice of a Nurse Anesthetist in South Africa

PurposeThe purpose of this article is to propose a definition for the concept “scope of practice” as it applies to a nurse anesthetist in South Africa. DesignConcept analysis. MethodsWalker and Avant's procedure of concept analysis was followed. The actions included “Select a concept”; “Determine the purpose of analysis”; “Identifying uses of the concept”; “Determining the defining attributes”; “Identifying antecedents and consequences”; “Define empirical referents”; “Identify model case”; and “Identifying additional cases.” FindingsThe concept ‘scope of practice’ as it applies to the nurse anesthetist in South Africa can be defined as the individual's competence, accountability, and responsibility as a health professional. The nurse anesthetist is (1) competent: ready to use skills and judgement in practice; (2) accountable: able to be registered as a nurse anesthetist and willing to abide by the regulations; and (3) responsible: upholding professionalism and demanding recognition from the public and peers. ConclusionsA definition (revealing the concept's structure) and it's uses (revealing the concept's function) for “scope of practice” of a South African nurse anesthetist is proposed for the consideration of introducing nurse anesthesia to provide safe and affordable anesthesia services in South Africa. This article forms part of a larger study titled “A Model for Nurse Anaesthesia Practice in South Africa.”

Dexmedetomidine-induced hemodynamic instability in patients undergoing orthopedic upper limb surgery under brachial plexus block: a retrospective study

BackgroundHemodynamic instability is a frequent adverse effect following administration of dexmedetomidine (DMED). In this study, we evaluated the incidence of DMED-induced hemodynamic instability and its predictive factors in clinical regional anesthesia practice.MethodsOne hundred sixteen patients who underwent orthopedic upper limb surgery under brachial plexus block with intravenous DMED administration were retrospectively identified. The primary outcome was the incidence of DMED-induced hemodynamic instability. The participants were allocated to a stable or unstable group by their hemodynamic instability status. Patients’ characteristics were compared between the groups. The relationship between the potential risk factors and development of DMED-induced hemodynamic instability was analyzed with a logistic regression model.ResultsDMED-induced hemodynamic instability was observed in 14.7% of patients (17/116). The unstable group had more women than the stable group (76.5% vs. 39.4%, P = 0.010). When patients were classified into four subgroup according to body mass index (underweight, normal weight, overweight, and obesity), there was significant difference in the composition of the subgroups in the two groups (P = 0.008). In univariate analysis, female sex, obesity, and pre-existing hypertension were significant predictors of DMED-induced hemodynamic instability. Multivariate analysis demonstrated that female sex (adjusted OR 3.86, CI 1.09; 13.59, P = 0.036) and obesity (adjusted OR 6.41, CI 1.22; 33.57, P = 0.028) were independent predictors of DMED-induced hemodynamic instability.ConclusionsFemale and obese patients are more likely to have hemodynamic instability following intravenous DMED administration in clinical regional anesthesia practice. This study suggests that DMED dose may be diminished to prevent hypotensive risk in these populations.Trial registrationThis article was retrospectively registered at WHO clinical trial registry platform (Trial number: KCT0005977).

December Is Coming: A Time Trend Analysis of Monthly Variation in Adult Elective Anesthesia Caseload across Florida and Texas Locations of a Large Multistate Practice.

Anesthesia staffing models rely on predictable surgical case volumes. Previous studies have found no relationship between month of the year and surgical volume. However, seasonal events and greater use of high-deductible health insurance plans may cause U.S. patients to schedule elective surgery later in the calendar year. The hypothesis was that elective anesthesia caseloads would be higher in December than in other months. This review analyzed yearly adult case data in Florida and Texas locations of a multistate anesthesia practice from 2017 to 2019. To focus on elective caseload, the study excluded obstetric, weekend, and holiday cases. Time trend decomposition analysis was used with seasonal variation to assess differences between December and other months in daily caseload and their relationship to age and insurance subgroups. A total of 3,504,394 adult cases were included in the analyses. Overall, daily caseloads increased by 2.5 ± 0.1 cases per day across the 3-yr data set. After adjusting for time trends, the average daily December caseload in 2017 was 5,039 cases (95% CI, 4,900 to 5,177), a 20% increase over the January-to-November baseline (4,196 cases; 95% CI, 4,158 to 4,235; P < 0.0001). This increase was replicated in 2018: 5,567 cases in December (95% CI, 5,434 to 5,700) versus 4,589 cases at baseline (95% CI, 4,538 to 4,641), a 21.3% increase; and in 2019: 6,103 cases in December (95% CI, 5,871 to 6,334) versus 5,045 cases at baseline (95% CI, 4,984 to 5,107), a 21% increase (both P < 0.001). The proportion of commercially insured patients and those aged 18 to 64 yr was also higher in December than in other months. In this 3-yr retrospective analysis, it was observed that, after accounting for time trends, elective anesthesia caseloads were higher in December than in other months of the year. Proportions of commercially insured and younger patients were also higher in December. When compared to previous studies finding no increase, this pattern suggests a recent shift in elective surgical scheduling behavior.

Ultrasound Assisted Neuraxial Blockade in Obstetric Anesthesia

Central Neuraxial Blocks (CNBs) relevant to the practice of obstetric anesthesia and analgesia are spinal, epidural and combined spinal-epidural injections. These techniques are routinely used for cesarean deliveries and labor pain relief. Traditionally, CNBs are performed using surface anatomical landmarks. In the first instance the highest point of each iliac crest is identifies. The imaginary line connecting these points allegedly passes through the L4 vertebral body in non-pregnant women, and L3 vertebral body in pregnant women [1]. Based on this, the operator palpates and counts the spinous processes and decides on the needle entry point. Although this technique is widely accepted as relatively reliable, the correlation is inconsistent even in non-complicated cases. Obesity, tissue edema, pelvic rotation, limited ability to bend forward, hyperlordosis, labor pain, underlying spinal deformity or previous back surgery and instrumentation pose additional difficulty for anesthesiologists to correctly locate the intervertebral levels.

The trends of obstetric anesthesia practice: In a tertiary care center in the Kingdom of Saudi Arabia.

Introduction:Obstetric anesthesia provides several methods for the analgesia of labor pain. The neuraxial technique is considered the standard of care for parturient women. The epidural block is widely used in vaginal delivery while the spinal block is the preferred method for cesarean section (C-section). We aim to know the practice of obstetric anesthesia in our center.Methods:A retrospective cross-sectional study was conducted at a tertiary center in Riyadh, Saudi Arabia. The data of all delivery cases from 1/7/2019 to 30/9/2019 were reviewed.Results:We identified a total of 2,140 cases during the 3 months, vaginal delivery was the most common with 72.4% (1550) while the C-section cases were 27.6% (590). Regarding the type of analgesia/anesthesia for vaginal deliveries, intramuscular analgesia was the commonest group with 34.8% (540), followed by the group of ladies who did not receive any analgesia/anesthesia with 31.9% (495), thirdly was epidural cases with 31.8% (493), and the fourth type was spinal 0.6% (10). Regarding C-section, the emergency cases were 65.4% (386). The types of anesthesia for all C-sections were as follows spinal 63.5% (375), GA 23.8% (141), and epidural 12% (74). Regarding anesthesia for elective cases, spinal was 85% (174), GA 14% (28), and epidural 1% (2). Regarding anesthesia for emergency cases, spinal was 52% (201), GA 29% (113), and epidural 19% (72).Conclusions:The use of epidural was low, and the spinal use was relatively on par if we compare with leading western countries. More focused studies and multicenter studies are needed in the country.

Reinvestigation on Newer Facts to Anticipate, Avoid And Mitigate The Development of Post-Dural Puncture Headache-A Prospective Cohort Study

Purpose: Various researchers have described the size and the type of spinal needle used for neuraxial anesthesia as the most common risk factor for developing postdural puncture headache (PDPH). Even though the occurrence of the PDPH is rare in modern anesthesia practice, we come across many such patients despite following all guidelines or precautions. Patient-related factors for developing PDPH are relatively understudied. For that, clinical features commonly present in such patients may require a thorough investigation. Methods: This prospective cohort study included fifty patients admitted for lower extremities orthopedic surgeries and developed PDPH following the neuraxial blockade. We screened all patients in this study for the presence or absence of common manifestations suggestive of connective tissue disorders (CTD). The other outcomes, like the effect of spinal needle size/type to develop PDPH and time to develop PDPH, were also measured. Results: Almost all PDPH patients included in this study had common features suggestive of CTD: the ligamentous laxity (96%), high-arched palate (96%), the blue sclera (45%), joint hyperextensibility (82%), and ejection clicks (64%). PDPH occurred more frequently with the 25G spinal needle of Quincke type than 27G of Whitacre type (82% vs. 18%). The mean (SD) headache freedom time was 73.14 (24.74) hours. Conclusions: The CTD might also be a causative factor responsible for the development of PDPH in some individuals. It can be considered a risk factor to anticipate, avoid, and mitigate the development of PDPH.

Novel Regional Nerve Blocks in Clinical Practice: Evolving Techniques for Pain Management.

This review examines the use of novel US-guided nerve blocks in clinical practice. Erector spinae block is a regional anesthesia technique doing by injecting a local anesthetic among the erector spinae muscle group and transverse processes. The phrenic nerve is a branch of the cervical plexus, arising from the anterior rami of cervical nerves C3, C4, and C5. The quadratus lumborum muscle is located along the posterior abdominal wall. It originates from the transverse process of the L5 vertebral body, the iliolumbar ligament, and the iliac crest. US-guided peripheral nerve procedures have a considerable scope of use, including treating headaches and hiccups to abdominal surgical pain, cesarean sections, musculoskeletal pathologies. These nerve blocks have been an effective addition to clinical anesthesia practice. The use of peripheral nerve blocks has improved postoperative pain, lessened the use of opioids and their potential side effects, and decreased the incidence of sleep disturbance in patients. More research should be done to further delineate the potential benefits of these blocks.

Spinal Anesthesia-induced Hypotension: Is it More Than Just a Pesky Nuisance?

(Am J Obstet Gynecol. 2002;223:621–623) As early as the 1930s, maternal hypotension had been recognized as a significant problem when administering spinal anesthesia. Over the decades, the use of spinal anesthesia has peaked and waned as the practice of anesthesia has evolved. But since the 1990s, it has seen a resurgence as pencil-point needles reduced headache risk and the hemodynamic changes were better understood and management strategies were developed.

Raw and processed electroencephalography in modern anesthesia practice: a brief primer on select clinical applications.

The evidence supporting the intraoperative use of processed electroencephalography (pEEG) monitoring to guide anesthetic delivery is growing rapidly. This article reviews the key features of electroencephalography (EEG) waveforms and their clinical implications in select patient populations and anesthetic techniques. The first patient topic reviewed is the vulnerable brain. This term has emerged as a description of patients who may exhibit increased sensitivity to anesthetics and/or may develop adverse neurocognitive effects following anesthesia. pEEG monitoring of patients who are known to have or are suspected of having vulnerable brains, with focused attention on the suppression ratio, alpha band power, and pEEG indices, may prove useful. Second, pEEG monitoring along with vigilant attention to anesthetic delivery may minimize the risk of intraoperative awareness when administering a total intravenous anesthesia in combination with a neuromuscular blockade. Third, we suggest that processed EEG monitoring may play a role in anesthetic and resuscitative management when adverse changes in blood pressure occur. Fourth, pEEG monitoring can be used to better identify anesthesia requirements and guide anesthetic titration in patients with known or suspected substance use.