Anaesthetic Practice Research Articles

State of the Art of Anesthetic Practice for Endouterine Evacuation in the South-East of DR Congo

Objective: Evaluate the different anesthetic practices in the management of incomplete abortions. Materials and Methods: Our study is descriptive in a retrospective approach on; in six hospitals in South Kivu in DR Congo and data were collected then entered then encoded in Microsoft Excel software (preliminary analysis of the data or statistical description of the variables) then they were analyzed in Epi Info software. Results: The age group between 26 to 35 years was the most represented with an average of 30±7.5 years, the weight for the majority of them varied in the group from 60 to 69 or 60.4%, the majority came from the health zone and represented 94.6%, they were a priori housewives and Catholics and represented 55.4%. We noted narcosis or hyponosis (propofol + Fentanyl followed by Ketamine + Diazepam + Atropine) with a very high frequency at 97.5%. Many patients did not have any complications during their interventions and this would be estimated at a rate of 92.5%; all remaining complications represented 7.5%, i.e. respectively: Desaturation, hypotension and Vomiting. The factors correlated with morbidity and mortality were ASA class and complications with a significant difference because their P value is < 0.001. Conclusion: The current recommendations in terms of ECP for incomplete abortions are respected in the hospital structures of South Kivu but as elsewhere, there is no predominant anesthetic technique hence the need to think about a more effective and more effective anesthetic technique. comfortable for patients and practitioners in terms of management of incomplete abortions than the techniques currently practiced.

Identifying Relevant Topics for Inclusion in an Ethics Curriculum for Anesthesiology Trainees: A Survey of Practitioners in the Field.

Anesthesiology training programs are tasked with equipping trainees with the skills to become medically and ethically competent in the practice of anesthesia and to be prepared to obtain board certification, yet there is currently no standardized ethics curriculum within anesthesia training programs in the United States. To bridge this gap, and to provide a validated ethics curriculum to meet the aforementioned needs, in July 2021, a survey was sent to anesthesia scholars in the field of biomedical ethics to identify key areas that should be included in such an ethics curriculum. The responses were rated on a Likert scale and ranked. This paper identifies the top ten topics identified as high priority for inclusion in an anesthesiology training program and consequently deemed most relevant to meet the educational needs of graduates of an anesthesiology residency: (1) capacity to consent; (2) capacity to refuse elective versus lifesaving treatment; (3) application of surrogate decisionmaking; (4) approach to do not resuscitate (DNR) status in the operating room; (5) patient autonomy and advance directives; (6) navigating patient beliefs that may impair care; (7) "futility" in end-of-life care: when to withdraw life support; (8) disclosure of medical errors; (9) clinical criteria for "brain death" and consequences of this definition; and (10) the impaired anesthesiologist.

Advances in pediatric anesthesia services over the past 10 years in French-speaking sub-Saharan Africa.

To improve and maintain quality and safety in anesthesia, standards have been proposed regarding human resources, facilities and equipment, medications and intravenous fluids, monitoring, and the conduct of anesthesia. Compliance with these standards remains a challenge in French-speaking sub-Saharan Africa (SSA) and results in high morbidity and mortality particularly in children. This aim of this study was to assess the progress made in improving the pediatric anesthesia infrastructures, human resources, education, medications, and equipment in French-speaking SSA over the past 10 years (2013-2022). This is a descriptive, multicenter, cross-sectional study with retrospective data collection, conducted from September 1 to November 5, 2023. Comparative data from 2012 to 2022 were collected through an online survey. Descriptive statistics were used to summarize data. Data were obtained from 12 countries out of 14. The number of hospitals providing pediatric surgery and anesthesia rose from 94 in 2012 to 142 in 2022 (+51%). The total number of physician anesthesiologists rose from 293 (0.1 physician anesthesiologists/100 000 inhabitants) in 2012 to 597 (0.2 physician anesthesiologists/100 000 inhabitants) in 2022 (+103.7%). Five (0.006 physician anesthesiologists/100 000 children) had completed a fellowship in pediatric anesthesia and intensive care in 2012, and 15 (0.01 physician anesthesiologists/100 000 children) in 2022 (+200%). Five physician anesthesiologists had an exclusive pediatric anesthesia practice in 2012, whereas they were 32 in 2022 (+540%). There is no specialized training in pediatric anesthesia and intensive care in any of these countries. Halothane was always available in 81.5% of the hospitals in 2012, and in 50.4% of the hospitals in 2022. Sevoflurane was always available in 5% of the hospitals in 2012, and in 36.2% in 2022. Morphine was always available in 32.2% in 2012, whereas it was available in 52.9% of them in 2022. Pediatric pulse oximeter sensors were available in 36% of the hospitals in 2012, and in 63.4% in 2022. Capnography was available in 5.3% of the hospitals in 2012, and in 48% in 2022. Progress have been made over the last 10 years in French-speaking SSA to improve infrastructures, human resources, education, medications, and equipment for pediatric anesthesia in French-speaking SSA. However, major efforts must be continued. Standards adapted to the local context should be formulated.

THE AUTHORITY OF ANESTHESIA TECHNICIANS IN CONDUCTING ANESTHESIA PRACTICES REVIEWED IN LIGHT OF MINISTER OF HEALTH REGULATION NUMBER 18 OF 2016 REGARDING THE LICENSING AND IMPLEMENTATION OF ANESTHESIA TECHNICIAN PRACTICES (A STUDY AT MELAWI DISTRICT GENERAL HOSPITAL, WEST KALIMANTAN)

This study aims to evaluate the clinical authority of anesthesia providers in relation to Health Regulation No. 18/2016 and its implementation at Melawi Regional General Hospital. Anesthesia services in Indonesia are performed by anesthesiologists and anesthetists. The government issued Minister of Health Regulation Number 18 Year 2016 on Anesthesia Practice Permits and Implementation to clarify the responsibilities of anesthesiologists in performing such medical actions. In addition, nowadays, it is highly recommended that all hospitals be accredited to measure public safety and service quality. As part of the accreditation process, all medical professionals will be required to provide evidence of proficiency by demonstrating their credentials. Therefore, the purpose of this study is to determine the clinical authority of anesthesia providers in relation to Health Regulation Number 18 Year 2016 and its implementation. Examining Health Regulation No. 18/2016 on the License to Practice and Implementation of Anesthesia, this research uses a normative juridical analytical approach. The legal review was conducted by referring to several legal materials and expert opinions. The results showed that the authority of the anesthesiologist at Melawi Regional General Hospital is in accordance with Permenkes No. 18 of 2016. The research also noted that the procedure for delegation of authority from anesthesiologist to anesthesiologist is carried out with Standard Operating Procedures that have been determined by the Melawi Regional General Hospital. Keywords: Anesthesiologist; Authority; Implementation.

Clinical Knowledge and Reasoning Abilities of AI Large Language Models in Anesthesiology: A Comparative Study on the American Board of Anesthesiology Examination.

Over the past decade, artificial intelligence (AI) has expanded significantly with increased adoption across various industries, including medicine. Recently, AI-based large language models such as Generative Pretrained Transformer-3 (GPT-3), Bard, and Generative Pretrained Transformer-3 (GPT-4) have demonstrated remarkable language capabilities. While previous studies have explored their potential in general medical knowledge tasks, here we assess their clinical knowledge and reasoning abilities in a specialized medical context. We studied and compared the performance of all 3 models on both the written and oral portions of the comprehensive and challenging American Board of Anesthesiology (ABA) examination, which evaluates candidates' knowledge and competence in anesthesia practice. Our results reveal that only GPT-4 successfully passed the written examination, achieving an accuracy of 78% on the basic section and 80% on the advanced section. In comparison, the less recent or smaller GPT-3 and Bard models scored 58% and 47% on the basic examination, and 50% and 46% on the advanced examination, respectively. Consequently, only GPT-4 was evaluated in the oral examination, with examiners concluding that it had a reasonable possibility of passing the structured oral examination. Additionally, we observe that these models exhibit varying degrees of proficiency across distinct topics, which could serve as an indicator of the relative quality of information contained in the corresponding training datasets. This may also act as a predictor for determining which anesthesiology subspecialty is most likely to witness the earliest integration with AI. GPT-4 outperformed GPT-3 and Bard on both basic and advanced sections of the written ABA examination, and actual board examiners considered GPT-4 to have a reasonable possibility of passing the real oral examination; these models also exhibit varying degrees of proficiency across distinct topics.

The effects of anesthesia on cancer progression and anti-tumor immunity. A review

Introduction: Breast cancer is one of the most common malignancies, treated with primary surgery, or surgery after neoadjuvant chemotherapy. Many studies indicate that the peri-operative period is critical as interference with the immune system may affect prognosis. Whether certain anesthetic agents can affect the immune response and cancer progression is still unresolved. Evidence acquisition: In the current study, we review the existing clinical and experimental studies, in an attempt to extract useful information for clinical application in the anesthesia practice for patients treated with surgery for breast cancer. A bibliographic search in PubMed and ScienceDirect related to the effects of anesthesia on cancer progression and anti-tumor immunity, published from January 2000 till today was performed. Evidence synthesis: All included studies were gathered in a list and they were analysed. A total of 34 studies were found relevant to the subject in PubMed and ScienceDirect. Conclusion: The overall experience suggests that the peri-operative management of cancer patients should focus on the reduction of surgical stress, the minimization of the use of opioids, and the adoption of regional anesthetics. This could have an impact on anti-tumour immunity and the outcome of cancer patients.

Bridging the gap: understanding Belgian anesthesiologists’ proficiency and training demands in gastric point-of-care ultrasound, a case-based survey

BackgroundPulmonary aspiration syndrome remains a significant complication of general anesthesia, particularly in unfasted patients. Gastric point-of-care ultrasound (POCUS) allows for both qualitative and quantitative assessment of gastric content, providing a safe and reliable method to assess gastric emptying and reduce the risk of aspiration during general anesthesia.MethodsThe survey was distributed to Belgian certified anesthesiologists and trainees between April 2020 and June 2021. Participants received a simulated clinical case of a patient at risk of gastric aspiration, created and approved by two certified anesthesiologists trained to perform gastric POCUS. The objectives of this study were to assess recognition of high-risk clinical situations for gastric aspiration, awareness of the gastric POCUS and its indications, and knowledge of the technical and practical conditions of the procedure among respondents trained in the technique. Furthermore, the study assessed the state of training in gastric POCUS, the desire for education, and the practical availability of ultrasound equipment. The survey used conditional branching to ensure unbiased responses to POCUS-related questions. It included multiple-choice questions, quantitative variables, and 5-point Likert scales. The margin of error was calculated using Daniel’s formula, corrected for a finite population.ResultsThe survey was conducted among 323 anesthesiologists. Only 20.8% (27) recognized the risk of a full stomach based on the patient’s history. Anesthesiologists who recognized the indication for gastric POCUS and were trained in the procedure demonstrated good recall of the practical conditions for performing the procedure and interpreting the results. Only 13.08% (31) of all respondents had received training in gastric POCUS, while 72.57% (172) expressed interest in future training. Furthermore, 80.17% (190) of participants had access to adequate ultrasound equipment and 78.90% (187) supported teaching gastric POCUS to anesthesia trainees.ConclusionsThis survey offers insight into the epidemiology, clinical recognition, knowledge, and utilization of gastric POCUS among Belgian anesthesia professionals. The results emphasize the significance of proper equipment and training to ensure the safe and effective implementation of gastric POCUS in anesthesia practice. Additional efforts should focus on improving training and promoting the integration of gastric POCUS into daily clinical practice.

The New Reform of the National Health System in Morocco: An Opportunity to Meet the Challenges and Improve the Practice of Anesthesiology.

The health sector in Morocco has undergone major changes in recent years, thanks to the reform of the national health system. This reform aims to improve accessibility and the equitable distribution of care throughout the country and enhance the quality and safety of health services. Anesthesia plays an important role in improving patients' quality of life and reducing the risks associated with surgical procedures. However, anesthetic practice in Morocco faces several challenges, including territorial disparities, unequal access to anesthetic services, financial constraints, a shortage of qualified staff, insufficient continuing education, and the need for appropriate administrative and legal frameworks regarding current anesthesiology practice. The reform of the Moroccan national health system has the potential to significantly advance the practice of anesthesia in Morocco. Indeed, this reform includes a number of measures that could help to improve access to anesthesia services, enhance the quality of care, ensure patient safety, and promote research in this field. Its success will depend on the effective implementation of planned measures and the ability to overcome potential obstacles.

A survey of practice in the anesthetic management of adolescent idiopathic scoliosis spine fusion by the North American Pediatric Spine Anesthesiologists Collaborative.

Adolescent Idiopathic Scoliosis (AIS) affects 2%-4% of the general pediatric population. While surgical correction remains one of the most common orthopedic procedures performed in pediatrics, limited consensus exists on the perioperative anesthetic management. To examine the current state of anesthetic management of typical AIS spine fusions at institutions which have a dedicated pediatric orthopedic spine surgeon. A web-based survey was sent to all members of the North American Pediatric Spine Anesthesiologists (NAPSA) Collaborative. This group included 34 anesthesiologists at 19 different institutions, each of whom has a Harms Study Group surgeon performing spine fusions at their hospital. Thirty-one of 34 (91.2%) anesthesiologists completed the survey, with a missing response rate from 0% to 16.1% depending on the question. Most anesthesia practices (77.4%; 95% confidence interval [CI], 67.7-93.4) do not have patients come for a preoperative visit prior to the day of surgery. Intravenous induction was the preferred method (74.2%; 95% CI 61.3-89.9), with the majority utilizing two peripheral IVs (93.5%; 95% CI 90.3-100) and an arterial line (100%; 95% CI 88.8-100). Paralytic administration for intubation and/or exposure was divided (51.6% rocuronium/vecuronium, 45.2% no paralytic, and 3.2% succinylcholine) amongst respondents. While tranexamic acid was consistently utilized for reducing blood loss, dosing regimens varied. When faced with neuromonitoring signal issues, 67.7% employ a formal protocol. Most anesthesiologists (93.5%; 95% CI 78.6-99.2) extubate immediately postoperatively with patients admitted to an inpatient floor bed (77.4%; 95% CI 67.7-93.3). Most anesthesiologists (87.1%; 95% CI 80.6-99.9) report the use of some form of an anesthesia-based protocol for AIS fusions, but our survey results show there is considerable variation in all aspects of perioperative care. Areas of agreement on management comprise the typical vascular access required, utilization of tranexamic acid, immediate extubation, and disposition to a floor bed. By recognizing the diversity of anesthetic care, we can develop areas of research and improve the perioperative management of AIS.

The Prevalence of Difficult Airway and Associated Risk Factors in Pediatric Patients: A Cross-sessional Observational Study.

Difficult airway remains a great challenge in pediatric anesthesia practice. Previously published data show the prevalence of difficult airways in pediatric population varies in a wide range. However, there is a lack of studies in the Asian region. This cross-sectional single-center study was conducted in a tertiary pediatric hospital in China from October 2022 to October 2023. The patients who underwent elective surgery under general anesthesia with tracheal intubation were recruited consecutively. Data on patient characteristics, airway assessment, and airway management information were collected. Multivariable logistic regression analysis was performed to detect the independent variables of difficult airway in pediatric patients. A total of 18,491 pediatric patients were included in this study. The overall incidence of difficult airways was 0.22%, 39% of whom were unanticipated. Very few previous airway management information was available in the patients presented with a known difficult airway. Patients with younger age, higher American Society of Anesthesiologists (ASA) physical status classification grade, and presented for craniofacial and thoracic surgery were associated with higher incidence of difficult airway. Further multivariable logistic regression analysis revealed that age ≤28 days (OR=50.48), age between 28days and 1 year (OR=6.053), craniofacial surgery (OR=1.81), and thoracic surgery (OR=0.2465) were independent risk factors of increased incidence of difficult airway. Our study showed the prevalence of difficult airways in pediatric surgical patients. Patient characteristics, age, and type of surgery were identified as the independent factors associated with increased occurrence of difficult airways. Unanticipated difficult airway was not unusual in our study population, even for the patients with previous surgical history.

Clinical Profile, Complications and Trends of Ocular Anaesthesia in a Multi-tier Ophthalmology Network in India: An Eight-Year Experience.

To describe the clinical profile, complications and trends of ocular anaesthesia in a multi-tier ophthalmology network in India. This retrospective hospital-based study included 417,622 patients presenting between January 2013 and December 2020. Patients who were administered either topical, local or general anaesthesia for ocular surgery in at least one eye were included as cases. The data were collected using an electronic medical record system. Among the 417,622 patients, local anaesthesia was administered to 280,638, (67.2%) patients and was the most commonly administered type followed by topical anaesthesia in 84,117 (20.14%) patients. The most common complication encountered in administering local anaesthesia was retrobulbar haemorrhage in 103 (0.037%) patients followed by lid haematoma in 49 (0.017%) patients. Tooth damage occurred in 40 (0.076%) patients followed by delayed recovery in 30 (0.057%) patients during general anaesthesia. The trend of local anaesthesia decreased (83.48% vs 53.36%), whereas the trend of topical anaesthesia increased (8.61% vs 32.42%) over the study period. There is a notable trend towards the adoption of less invasive anaesthetic methods, particularly in common surgeries such as cataract, intravitreal injection, and vitreoretinal surgery. However, despite this trend, a significant proportion of oculoplastic/orbital surgeries, trauma, and strabismus surgeries continue to be performed under general anaesthesia. These observations underscore the ongoing evolution of ocular anaesthesia practices, reflecting advancements in surgical techniques and patient preferences.

Perioperative Considerations in Older Kidney and Liver Transplant Recipients: A Review.

With the growth of the older adult population, the number of older adults waitlisted for and undergoing kidney and liver transplantation has increased. Transplantation is an important and definitive treatment for this population. We present a contemporary review of the unique preoperative, intraoperative, and postoperative issues that patients older than 65 y face when they undergo kidney or liver transplantation. We focus on geriatric syndromes that are common in older patients listed for kidney or liver transplantation including frailty, sarcopenia, and cognitive dysfunction; discuss important considerations for older transplant recipients, which may impact preoperative risk stratification; and describe unique challenges in intraoperative and postoperative management for older patients. Intraoperative challenges in the older adult include using evidence-based best anesthetic practices, maintaining adequate perfusion pressure, and using minimally invasive surgical techniques. Postoperative concerns include controlling acute postoperative pain; preventing cardiovascular complications and delirium; optimizing immunosuppression; preventing perioperative kidney injury; and avoiding nephrotoxicity and rehabilitation. Future studies are needed throughout the perioperative period to identify interventions that will improve patients' preoperative physiologic status, prevent postoperative medical complications, and improve medical and patient-centered outcomes in this vulnerable patient population.

Randomized control study to evaluate the effect of adding Dexmedetomdine to levobupivacaine in femoral sciatic block in total knee replacement

Background In recent years there has been an increasing interest in the practice of regional anesthesia especially peripheral nerve blocks for surgical anesthesia and postoperative analgesia. Imaging guidance for nerve localization helps the promise of improving block success with fewer complications. Among the imaging modalities available nowadays, ultrasonography seems to be the most suitable for regional anesthesia. One the most significant advantage of ultrasound (US) technology is the availability to provide anatomic examination of the area of interest. Aim The aim of this study is to evaluate the additive effect of dexmedetomidine to levobupivacaine in femoral sciatic block in total knee replacement regarding the onset and duration of both sensory and motor blockade, postoperative analgesia requirements. Patients and methods After ethical approval, 60 patients aged 45–65 years old, with an American Society of Anesthesiologists (ASA) physical class I and II who underwent total knee replacement using combined femoral-sciatic nerve block, were included in this prospective, randomized, controlled, double-blinded study. Patients were randomly assigned to receive levobupivacaine alone (group B) or dexmedetomidine 100 µg added to levobupivacaine (group BD) [n=30 patients for each group] for combined femoral-sciatic nerve block. Results This study showed that the addition of dexmedetomidine 100 µg to levobupivacaine during ultrasound-guided combined femoral-sciatic nerve block for total knee replacement was associated with, −20% shorter onset times for sensory and motor block, −25% faster time for surgical readiness, and longer duration of sensory and motor block (+45% and +40%, respectively) and +50% longer duration of analgesia. Conclusion Addition of dexmedetomidine to levobupivacaine during combined femoral-sciatic nerve block for total knee replacement was associated with faster onset of sensory and motor block, decrease intraoperative and postoperative requirements of analgesia and longer duration of motor block than levobupvicaine alone.

Anesthesia Preferences and Outcomes in Saudi Arabian Healthcare: A Cross-Sectional Study.

Anesthesia choice is critical in ensuring optimal surgical outcomes and patient satisfaction. We aimed to investigate anesthesia preferences, trends, and outcomes in elective surgeries within Saudi Arabian healthcare settings. A cross-sectional survey-based study was conducted among anesthesia residents and attending anesthesiologists across Saudi Arabia. Participants provided demographic information and responded to questions regarding anesthesia preferences, trends, and outcomes. Descriptive statistics were used to summarize the data, and logistic regression analysis was employed to identify factors associated with anesthesia preference. The survey was completed by 572 healthcare professionals in Saudi Arabia. Among participants, 51.7% (n=296) preferred general anesthesia, while 48.3% (n=276) favored regional anesthesia for elective surgeries. Factors influencing anesthesia choice included patient preference, surgical complexity, and resource availability. Over half of the respondents reported an increase in regional anesthesia preference over the past five years, although some perceived inadequate training in this area. Common barriers to regional anesthesia adoption included equipment availability, patient reluctance, and limited training opportunities. Postoperative recovery was perceived as quicker with regional anesthesia by 52.3% (n=299) of participants, with postoperative nausea and vomiting being the most common complication associated with general anesthesia. Multivariable logistic regression analysis revealed that participants above 50 years had lower odds of preferring regional anesthesia, while those perceiving training adequacy in regional anesthesia as adequate had higher odds of preferring it (OR=0.64, 95% CI: 0.41-0.98, p=0.041; OR=1.58, 95% CI: 1.21-2.05, p=0.001, respectively). This study provides insights into anesthesia practice patterns in Saudi Arabian healthcare settings. Individualized anesthesia care, ongoing training in regional anesthesia, and evidence-based decision-making are essential to optimize perioperative outcomes and patient satisfaction.

A Cross-Sectional Study of Anesthesia Safety in Wad Medani, Sudan: A Pre-war Status Indicating a Post-war Crisis.

As the surgical burden grows, increasing patient safety during anesthesia and surgery becomes a major global public health priority. Anesthesia can be safely administered in higher-income countries, yet it is more challenging in third-world countries. This study focuses on Sudan, a third-world country, and its unmet anesthetic needs before the current war and how these needs might compromise the post-war status. The aim of this study is tocompare Sudan's outstanding anesthesia requirements to the World Health Organization's safe anesthesia practice standards in terms of workforce, medications, equipment, and anesthesia conduct. This study was carried out in four hospitals (Wad Medani Teaching Hospital, Wad Medani Maternity Hospital, Gezira Centre for Renal and Urological Surgeries, and the National Centre for Pediatric Surgeries) in Wad Medani, two of which were referral and two were state-run. Each hospital from every category was identified using a convenience sampling technique. The World Health Organization-World Federation of Societies of Anesthesiologists International Standard and earlier regional African publications were used to determine the minimum predicted safe anesthesia needs. The results of our study demonstrate that overall, the hospitals surveyed fulfilled the minimum standards set by the World Health Organization and the World Federation of Societies of Anesthesiologists (WHO-WFSA) for safe anesthesia practice by 73% with no significant difference in the safety of anesthesia practice between state and referral hospitals. The state of safe anesthesia care in Wad Medani hospitals surveyed fell well short of the expected minimal criteria due to important requirements such as patient monitoring indicators, the inaccessibility of life-saving facilities such as defibrillators, and difficult intubation instruments. More importantly, the conduct of anesthesia was far below the standard.

Advancing kidney xenotransplantation with anesthesia and surgery - bridging preclinical and clinical frontiers challenges and prospects.

Xenotransplantation is emerging as a vital solution to the critical shortage of organs available for transplantation, significantly propelled by advancements in genetic engineering and the development of sophisticated immunosuppressive treatments. Specifically, the transplantation of kidneys from genetically engineered pigs into human patients has made significant progress, offering a potential clinical solution to the shortage of human kidney supply. Recent trials involving the transplantation of these modified porcine kidneys into deceased human bodies have underscored the practicality of this approach, advancing the field towards potential clinical applications. However, numerous challenges remain, especially in the domains of identifying suitable donor-recipient matches and formulating effective immunosuppressive protocols crucial for transplant success. Critical to advancing xenotransplantation into clinical settings are the nuanced considerations of anesthesia and surgical practices required for these complex procedures. The precise genetic modification of porcine kidneys marks a significant leap in addressing the biological and immunological hurdles that have traditionally challenged xenotransplantation. Yet, the success of these transplants hinges on the process of meticulously matching these organs with human recipients, which demands thorough understanding of immunological compatibility, the risk of organ rejection, and the prevention of zoonotic disease transmission. In parallel, the development and optimization of immunosuppressive protocols are imperative to mitigate rejection risks while minimizing side effects, necessitating innovative approaches in both pharmacology and clinical practices. Furthermore, the post-operative care of recipients, encompassing vigilant monitoring for signs of organ rejection, infectious disease surveillance, and psychological support, is crucial for ensuring post-transplant life quality. This comprehensive care highlights the importance of a multidisciplinary approach involving transplant surgeons, anesthesiologists, immunologists, infectiologists and psychiatrists. The integration of anesthesia and surgical expertise is particularly vital, ensuring the best possible outcomes of those patients undergoing these novel transplants, through safe procedural practices. As xenotransplantation moving closer to clinical reality, establishing consensus guidelines on various aspects, including donor-recipient selection, immunosuppression, as well as surgical and anesthetic management of these transplants, is essential. Addressing these challenges through rigorous research and collective collaboration will be the key, not only to navigate the ethical, medical, and logistical complexities of introducing kidney xenotransplantation into mainstream clinical practice, but also itself marks a new era in organ transplantation.

Emerging significance of butyrylcholinesterase.

Butyrylcholinesterase (BChE; EC 3.1.1.8), an enzyme structurally related to acetylcholinesterase, is widely distributed in the human body. It plays a role in the detoxification of chemicals such as succinylcholine, a muscle relaxant used in anesthetic practice. BChE is well-known due to variant forms of the enzyme with little or no hydrolytic activity which exist in some endogamous communities and result in prolonged apnea following the administration of succinylcholine. Its other functions include the ability to hydrolyze acetylcholine, the cholinergic neurotransmitter in the brain, when its primary hydrolytic enzyme, acetylcholinesterase, is absent. To assess its potential roles, BChE was studied in relation to insulin resistance, type 2 diabetes mellitus, cognition, hepatic disorders, cardiovascular and cerebrovascular diseases, and inflammatory conditions. Individuals who lack the enzyme activity of BChE are otherwise healthy, until they are given drugs hydrolyzed by this enzyme. Therefore, BChE is a candidate for the study of loss-of-function mutations in humans. Studying individuals with variant forms of BChE can provide insights into whether they are protected against metabolic diseases. The potential utility of the enzyme as a biomarker for Alzheimer's disease and the response to its drug treatment can also be assessed.

Barriers to safe anaesthesia care in South Asian countries: a virtual focus group discussion.

To identify barriers to safe anaesthesia practice across the South Asian region. The qualitative study was conducted from September 2020 to August 2021 at the Department of Anaesthesiology at a leading medical university after getting exemption from the ethics review committee of the Pakistan Society of Anaesthesiologists. The sample comprised anaesthetists from 6 countries of the South Asian Association for Regional Cooperation. Data was collected through a focus group discussion held virtually using the Zoom app on September 22, 2020. The proceedings were transcribed and the data was subjected to thematic analysis. Of the 12 anaesthetists, 4(33.3%) were from India, 3(25%) from Pakistan, 2(16.7%) from Bangladesh, and 1(8.3%) each from Sri Lanka, Nepal and Afghanistan. There were 2 main themes identified; Safe anaesthesia and barriers to safe anaesthesia. They had 4 and 6 subthemes, respectively. The participants agreed that fresh medical graduates were not choosing anaesthesia as a preferred career specialty. One major concern raised was that qualified anaesthetists were leaving their countries for better-paid jobs abroad. The lack of a definition describing qualified anaesthetists in South Asian countries was pointed out. Lack of basic monitoring and drugs, brain drain, lack of ownership, lack of training programmes, lack of accountability, weak leadership, and disconnect between professional societies and governments were identified as the main barriers to safe anaesthesia.

MULTIMODAL ANESTHESIA AS AN IMPORTANT COMPONENT OF ERAS

Introduction. The ideology of Fast Track-Surgery (FTS) and Enhanced Recovery After Surgery (ERAS) represents modern trends in global surgical practice. Anesthesiology aims to provide ideal and universal solutions for protecting patients from surgical aggression. A multimodal approach, which includes multilevel, multifaceted antinociception, is well-founded, where maximum effectiveness is combined with minimal side effects.
 The aim. To analyze the issue of multimodal pain management as an important component of ERAS (Enhanced Recovery After Surgery) from modern sources of literature for optimizing perioperative care in the minimally invasive surgery department.
 Materials and methods. Bibliosemantic, comparative, and systemic analysis methods were employed. The proposed recommendations were developed based on an analysis of modern literature, the results of randomized trials and meta-analyses, as well as our own studies dedicated to the study of perioperative pain issues.
 The results. It has been proven that the use of opioids in anesthesia practice is decreasing. New and modern methods of continuous monitoring of vital organs in patients are being introduced as supplements to classical monitoring protocols. These methods are used to avoid excessive or inadequate dosing of anesthetics, adjust the concentration of substances used, reduce post-anesthesia complications, and improve patient comfort. The method of perioperative energy monitoring significantly complements the "International Standards for Safe Anesthetic Practice", WFSA (2010), and enhances perioperative patient safety by detecting metabolic disturbances and implementing appropriate pathogenetic correction. The importance of regional anesthesia under ultrasound control, nociception-antinociception balance management, and the impact of these methods on opioid consumption, patient satisfaction, and postoperative recovery have been proven.
 Conclusions. The most commonly used combination of drugs for multimodal analgesia often includes acetaminophen and NSAIDs (strong recommendation). It has been proven that deep and prolonged sedation in intensive care unit (ICU) patients is associated with worse outcomes, longer mechanical ventilation duration, extended ICU and hospital stays, and higher rates of complications, including infections and sometimes even death.

Epidural register (record of epidural catheter placement) - Need of current anesthesia practice.

Epidural register (record of epidural catheter placement) - Need of current anesthesia practice.