General Anesthetic Research Articles

Timely diagnostics and safe procedures in children with anterior mediastinal masses (AMMs): a qualitative review of the AMM protocol at BC Children’s Hospital in Vancouver BC

The presence of an anterior mediastinal mass should prompt rapid triage, workup and treatment to effectively manage and prevent emergent complications. Implementation of an AMM protocol can ensure the response is standardized and coordinated. Importantly, such a protocol can encourage prompt multi-disciplinary communication to mitigate risks associated with procedures required for timely diagnosis. The aim of this review is to evaluate the BC Children’s Hospital’s Pediatric New/Suspected Anterior Mediastinal Mass (AMM) Protocol. Retrospective chart review was conducted for 18 patients admitted from February 2016 to May 2020 with AMM for whom the protocol was enacted. Primary parameters assessed presence of high-risk feature at time of presentation, time from admission and/or protocol activation to specific time points, including imaging, first diagnostic procedure, and diagnosis. Data regarding perioperative management, including anesthetic considerations and peri-operative complications, was also collected. Mean time from protocol activation to first diagnostic procedure and diagnosis were 1.88 days (range 0–7) and 2.24 days (range 0–7), respectively. The majority of procedures were conducted under sedation (n = 77, 64%), followed by general anesthetic (GA; n = 34, 28%) and local anesthetic (n = 10, 8%). Despite 15 cases having more than one high risk feature, pre-operative steroids were only administered for four of the total 158 procedures (3%) and extracorporeal life support (ECLS) and otolaryngology (ENT) were only required for immediate availability for seven procedures (4%). Furthermore, only 10 procedures (8%) had associated complications and none of these complications resulted in patient death. Our data demonstrate that implementation of a streamlined multi-disciplinary protocol can expedite time to diagnosis without impacting patient safety.

Design and Development of Site Specific Null Allosteric Ligands for γ‐Aminobutyric Acid Type A Receptor as Reversal Agents for General Anesthesia

The γ‐aminobutyric acid type A receptors (GABA(A)Rs) are the main inhibitory neurotransmitter receptors in the CNS. They control the synaptic and extrasynaptic GABA‐mediated inhibitory signals in the brain. They are the target of general anesthetics, sedatives and anticonvulsants. Our overall goal is to design and develop site specific Null Allosteric Ligands (NALs) for GABA(A)Rs as reversal agents of these actions. For example, faster recovery from general anesthesia is associated with less postoperative anesthesia‐related complications such as memory loss and confusion. Whereas flumazenil is a NAL that binds to the benzodiazepine site in the extracellular domain’s (ECD) α+/γ‐ interface, there are no known NALs that bind to the transmembrane domain (TMD) sites. We adopted a strategy based on the structures of etomidate, flavanols and barbiturates as starting points, while utilizing computational docking, SAR studies and radioligand binding assays to assist in the design and development of the new agents. Here, we report the first NAL that binds to the TMD of GABA(A)Rs and that antagonizes the action of R‐mTFD‐MPAB (it binds to the TMD at the α+/β− and γ+/β− interfaces), while having a marginal effect on the binding of the agonist, [3H]muscimol. The development of the first NAL(s) targeting the TMD of GABA(A)Rs will aid in understanding GABAergic actions in the CNS, support the mechanistic studies on GABA(A)Rs and potentially lead to reversal agents for general anesthesia and sedation.

Potentiometric quantitation of general local anesthetics with a new highly sensitive membrane sensor.

The detection of local anesthetic drugs is of great importance in the analysis of pharmaceutical, clinical and forensic samples. This paper reports a simple and sensitive potentiometric assay suitable for detecting general local anesthetics (LAs) of two types, namely: amino ester-anesthetics (procaine) and amino amide-anesthetics (lidocaine, articaine). As a detector, a new highly sensitive sensor based on a poly(vinyl chloride)-matrix membrane incorporating ion-pair complexes of protonated procaine with 2-[bis-octadecyl-sulfonic)-closo-decaborate is used. To improve the analytical characteristics of the sensor, the tetradodecylammonium - 2-[bis-octadecyl-sulfonic)-closo-decaborate associate as a lipophilic additive is proposed. The procedures for the synthesis of both electroactive membrane components are described. The dependence of potential response characteristics of the potentiometric system on the membrane composition, local anesthetic properties, and pH of the sample solutions is discussed. The difference in sensitivity and selectivity of the sensor was found to be responsible for the lipophilic property and pKa values of local anesthetic molecules. The developed sensor exhibited a near Nernstian response to cationic forms of procaine and some other anesthetics of higher lipophility, in particular lidocaine and articaine, over a wide linear concentration range. The limit of detection was varied from 2×10-8 to 5×10-7μM, and it is the lowest value among the early published potentiometric analogs. The proposed method was successfully applied to the analysis of pharmaceutical formulations and spiked enzyme-free urine samples containing LAs at low concentration levels (0.5-100μgmL-1). The recovery range (n=5) was 98.0-101.5%, and the relative standard deviation was no more than 5.0%.

AB185. SOH22ABS018. Alleged recurrent traumatic shoulder dislocation in a young male patient—diagnostic and management considerations

: Asher’s original description of Munchausen’s syndrome was characterised by pathological lying, feigning illness and wandering from hospital to hospital. Munchausen’s syndrome—orthopaedic variant has been rarely reported in the literature. A young male presented to a nearby hospital with a left shoulder dislocation after an alleged kickboxing injury. The patient reported worrying clinical findings including excruciating pain and absent sensation distally. Reduction was successful but his shoulder re-dislocated shortly after. His reported symptoms worsened and he was transferred to our institution. Imaging findings were not immediately concerning and he went to theatre the next day for an examination under anaesthetic. His shoulder was re-located easily and an immobiliser applied. Less than an hour later, the patient managed to re-dislocate his shoulder in recovery. He was subjected to another general anaesthetic and successful reduction. He absconded the following day after being declined multiple and increasing doses of opioid analgesia. He re-presented three weeks later with similar clinical findings but a different mechanism of injury. Further exploration of his collateral history revealed that he had been using a false identity. He had presented to all hospitals in our city within the previous 6 months. Once confronted, he did not return to these hospitals. He was also capable of self-relocating his shoulder. This case bore a striking resemblance to a case described by Warren in 2000 of a young lady with an apparently dislocated shoulder presenting to multiple city hospitals looking for analgesia and general anaesthetics. We wished to highlight the diagnostic and ethical challenges associated with these patients. They are vulnerable and so a high index of clinical suspicion is needed on the part of the surgeon to avoid unnecessary interventions. Effective communication between orthopaedic departments is a key recommendation from this case to mitigate risk of harm to these patients.

Comparison the Efficacy of Ketamine on the Patients Undergoing Elective Surgery for Prevention of Postoperative Shivering

Introduction: Patients frequently suffer from shivering following surgery. The shivering experienced by the patients may be a natural, thermal regulatory response to central hypothermia or as a result of the release of cytokines during the surgical process. This is unpleasant and occurs following surgery in 30-65% of patients who have received general anesthetics. Shivering increases the muscular activity, O2 consumption, CO2 production and may result in hypoxaemia, hypercarbia and lactic acidosis. It is not only uncomfortable but also cold sensation which is even worse feeling than pain sensation. Objective: To assess the Comparison the efficacy of ketamine on the patients undergoing elective surgery for prevention of postoperative shivering. Material & Methods: In this prospective study was conduct at the dept. of Anaesthesia, Shaheed Tajuddin Ahmad Medical College Hospital, Gazipur, Bangladesh from January to June-2021. Fifty (50) patients included in our study. The inclusion criteria were women aged between 30-65 years and ASA-PS classes I and II. Patients preoperative period were fasted at least 6 hrs and on arrival at OT I/V line was inserted; pulse, BP respiratory rate and SpO2 were recorded. Results: In our study fifty two (52) patients demographic data concerning the patient age, weight as well as duration of anaesthesia and type of surgery were comparable in two groups which are fairly matched. In preoperative situation in Group A mean pulse rate was 79 ±2.4, in Group B 82 ±1.5, mean anterial pressure 92.71±1.05 (Group A), 94.01±1.14 (Group B), SpO2 99±0.56 Group A, 98 ±0.26 (Group B) which showed no significant difference between the groups. In the postoperative period, incidences of shivering were 80.07% & 50% in Group-A and Group-B which are highly significant between the groups P<.001 Cardiovascular parameters SAP, DAP, MAP and SpO2 between the groups were not significant P>.05. The study showed that patients of Group-B were less shivering with good recovery. Conclusion: In concluded that the post-operative shivering are the most common complaints. The aetiology of postoperative shivering is multifactorial including anesthetic, patients and surgical factors. Antishivering prophylaxis may be justified in patients who are at great risk of developing post-operative shivering after general anaesthesia. The incidence of major side effects is not significant in ketamine group and contributes to some extent to post-operative analgesia.

Impact of a geriatric assessment and optimisation-based preoperative clinic on the management of older patients receiving dental treatment under general anaesthetic or conscious sedation: A service evaluation.

The main objectives of the study were to review patient characteristics, recommendations made and treatment outcomes of frail/older patients referred to a specialist multidisciplinary geriatric assessment and optimisation-based preoperative clinic (PROKARE), prior to patients receiving dental treatment under general anaesthesia (GA) or conscious sedation (CS). Although the use of preoperative comprehensive geriatric assessment to improve pre/peri and postoperative mortality has been reported for many surgical domains, its use prior to dental surgery has not been reported previously. The data were collected retrospectively from the dental notes of 52 patients referred from the Special Care Dental (SCD) Department to the PROKARE service for optimisation prior to dental treatment under GA/CS using a case note study approach. The data extracted included patient demographic characteristics, medical history, clinical management and the treatment outcomes for each patient. The data extracted was analysed with descriptive statistics. Key reasons for referral were caries management, retained roots and poor co-operation. Multiple co-morbidities were noted among the patients referred, with 14 (27%) having four or more co-morbidities. The PROKARE assessment identified issues such as treatment could be carried out under CS instead of GA; consent; and the need for medication change and/or further medical investigations. As per recommendations from PROKARE, 39 patients (75%) received dental treatment while five (10%) did not receive treatment, and a further eight (15%) died prior to treatment. Geriatric assessment and optimisation-based preoperative clinics in the dental management of frail, elderly patients having treatment under GA or CS techniques is valuable, but further research and assessment of current service provision are needed to increase the evidence base.

General anesthesia globally synchronizes activity selectively in layer 5 cortical pyramidal neurons

SummaryGeneral anesthetics induce loss of consciousness, a global change in behavior. However, a corresponding global change in activity in the context of defined cortical cell types has not been identified. Here, we show that spontaneous activity of mouse layer 5 pyramidal neurons, but of no other cortical cell type, becomes consistently synchronized in vivo by different general anesthetics. This heightened neuronal synchrony is aperiodic, present across large distances, and absent in cortical neurons presynaptic to layer 5 pyramidal neurons. During the transition to and from anesthesia, changes in synchrony in layer 5 coincide with the loss and recovery of consciousness. Activity within both apical and basal dendrites is synchronous, but only basal dendrites’ activity is temporally locked to somatic activity. Given that layer 5 is a major cortical output, our results suggest that brain-wide synchrony in layer 5 pyramidal neurons may contribute to the loss of consciousness during general anesthesia.

Adjustable Transobturator Male System® (ATOMS) as a novel treatment for men with stress urinary incontinence in the United Kingdom

Objectives: To investigate the first experience in the United Kingdom of using the Adjustable Transobturator Male System® (ATOMS) in treating men with stress urinary incontinence (SUI). Methods: Between 2015 and 2021, 71 men (average age: 70.3, range: 50–81 years) were recruited and followed up. Of these, 67 (94%) had SUI secondary to a radical prostatectomy and 16 (23%) had previous radiotherapy post-prostatectomy. Seventy men underwent an insertion of ATOMS® under general anaesthetic. In one patient, due to his underlying morbid obesity, it was not possible to insert ATOMS and thus he was excluded from the study. Follow-up was up to 6 years (mean: 4 years, range: 2–6 years). Results: Out of 70 men, 53 (76%) were dry after ATOMS insertion (defined as using a maximum of one pad per day for reassurance only). Dryness was achieved within 6 months for 34/53 patients (range: 1–24 months). The average pad use was 3.4 pre-operatively and 0.7 post-operatively. Of the men who did not achieve dryness, 7/17 (41%) had previously undergone radiotherapy. There were 11 (16%) complications: two cases of infected device requiring removal, one case of balloon mechanism erosion requiring re-implantation, one case of balloon mechanism require repositioning, four cases of persistent perineal or scrotal pain, two cases of urinary retention and one case of a superficial wound infection treated medically. Overall, five devices were removed. Conclusions: The ATOMS appears to be a safe and efficacious treatment for men with SUI. Previous radiotherapy decreased the efficacy of ATOMS. Further studies on ATOMS with larger numbers of patients and longer follow-ups are required. In particular, establishing randomised control trials to confirm these positive outcomes as well as ascertain its long-term safety profile. Level of evidence: 4

Analysis of outcomes and complications of 187 coronectomies

IntroductionThis is a retrospective audit of 187 cases of coronectomies of mandibular third molars (M3M) carried out at a two large teaching hospitals in London. MethodsWe collected data from the electronic patient records on all mandibular third molar coronectomy procedures performed between April 2017 and November 2020. Data was collected on complications including dry socket, infection, re-operation and nerve injuries to the inferior dental and lingual nerves. Results187 coronectomies were performed on 153 patients during the study period. This represents approximately 3% of the total number of third molars managed surgically. Almost 80% of these cases had cone beam computed tomography imaging prior to surgery. The majority (64%) of cases performed under general anaesthetic. Seven consultants and their teams managed the patients. Over half of the patients were prescribed antibiotics post-operatively. Complications were as follows: dry socket 2.1%; infection 4%; re-operation 1.6%; lingual nerve injury 0.5%, inferior alveolar nerve injury 1%. Of these nerve injuries, only one (0.5%) was considered to be permanent after two years of follow up. One patient (0.5%) had roots removed 12 months after coronectomy. ConclusionWe found that coronectomy is a safe and effective modality for treating high risk mandibular third molars. Complication rates are similar to those seen from surgical removal of such teeth with a lower than expected incidence of nerve injuries.

Bouveret syndrome: A challenging case of impacted gallstone within the fourth part of the duodenum.

Introduction and importanceBouveret syndrome is a rare condition characterised by gastric outlet obstruction secondary to a gallstone fistulating into the proximal duodenum or pylorus. Although rare, this condition carries a high mortality rate and no current standardised guidelines for management.Case presentationWe present a case of a patient in their 60s with recurrent small bowel obstruction secondary to a cholecysto-duodenal fistula and large gallstone which became impacted in the fourth part of the duodenum. The patient had a P-POSSUM Score of 14% mortality and 60% morbidity risk, had multiple co-morbidities, was bedbound, BMI 59 and had been deemed high risk for general anaesthetic at oncology centre for a 10 × 10 cm likely gynaecological malignancy a month prior to this admission.Clinical discussionIn contrast to existing literature, endoscopic lithotripsy was considered but not attempted due to unavailability of this service locally. Surgical intervention was decided based on radiological features of impending duodenal perforation on CT imaging and multiple disciplinary team discussion. The patient was managed with open enterolithotomy at the duodeno-jejunal (DJ) flexure and discharged 3 weeks post-operatively at her pre-operative baseline.ConclusionThis is the first report to our knowledge to describe successful surgical management of a gallstone impacted in the fourth part of the duodenum. In cases where anatomical location of impaction precludes retrieval via simple gastrostomy, we suggest using high pressure flush to mobilise the stone to more favourable location distally. We emphasise that stone size should be considered when planning surgical management.

Anesthetic management of a repeatedly operated patient with extrahepatic portal hypertension: Сase report

BACKGROUND: The use of high doses of opioids and general anesthetics can cause unwanted side effects that directly affect the patient's recovery and his psycho-emotional and social well-being. In this regard, the general anesthesia method enables the dose reduction of general anesthetics and opioid analgesics. This is relevant, especially in children with concomitant thrombocytopenia, in whom epidural blockade is contraindicated.
 CASE REPORT: This article describes using the alpha-2-adrenergic agonist, dexmedetomidine, for anesthesia in a 16-year-old girl during corrective surgery for extrahepatic portal hypertension after several previous operations. Using the selective alpha-2-adrenergic agonist, dexmedetomidine, for general anesthesia produced effective and stable pain relief intraoperatively and rapid recovery of spontaneous breathing and consciousness after anesthesia. The total dose of intraoperative consumption of fentanyl compared with previously performed anesthesia was less than two times, and sevoflurane by 30%, while maintaining adequate anesthetic protection.
 CONCLUSION: During surgical interventions, it is impossible to perform epidural anesthesia in patients with thrombocytopenia with extrahepatic portal hypertension. The centrally acting alpha-2-agonist, dexmedetomidine, may be used to reduce the doses of anesthetics and opioid analgesics used.

Kidney biopsy adequacy and complications in children — does technique matter?

Kidney biopsy is part of the diagnostic workup of many children with renal disease. Traditionally, a perpendicular approach to the biopsy has been used, but more recently, some proceduralists have favoured a tangential approach. It is not clear if one technique is superior with regards to tissue adequacy or complication rates. In our centre, interventional radiologists (IR) use general anaesthetic and a tangential approach, whereas paediatric nephrologists (PN) use sedation and a perpendicular approach. We examined consecutive native kidney biopsies performed between January 2008 and December 2017 for adequacy (sufficient tissue for light and electron microscopy and immunofluorescence) and examined the electronic medical records for data regarding technique and complications. IR performed 72 (29%) of the 245 native kidney biopsies, obtaining more total glomeruli (median 39 vs 16, p < 0.001) and more glomeruli per tissue core (median 13 vs 8, p < 0.001) than PN. No differences in specimen adequacy were observed between the two groups (79% IR vs 81% PN, p = 0.75) and a diagnosis could be made in 99% and 94% respectively (p = 0.1). A statistically lower rate of peri-nephric haematoma (28% vs 42%, p = 0.04) was detected in the IR group, but there were no significant differences in other complications. One patient required a blood transfusion (PN) and another required surgical intervention for a perinephric haematoma (IR).Conclusion: IR obtained larger samples and number of glomeruli, but the overall adequacy for native kidney biopsies was good using both perpendicular and tangential techniques, with low rates of significant complications.What is Known:• Kidney biopsy is integral to the diagnostic work-up of many children with kidney disease.• Kidney biopsy is a safe procedure with well-established complications in a minority of children.What is New:• Interventional radiologists had higher biopsy yield than paediatric nephrologists, possibly due to the tangential approach.• Biopsy adequacy rates are high using both techniques and provided a diagnosis in over 95% of cases.

Deflux® (NASHATM/Dx) urethral bulking injections: Outcomes over a decade in women with stress urinary incontinence

Objectives: Urethral bulking injections are thought to be a low risk minimally invasive but temporary treatment option for women with stress urinary incontinence (SUI) with increasing prominence especially in the current era of the mesh controversy. However, little is known about their long-term effects. This study aims to evaluate the efficacy and long-term outcomes of Deflux®, a non-animal stabilised hyaluronic acid/dextranomer (NASHATM/Dx) gel, when used as a urethral bulking agent in the treatment of SUI in women. Methods: All women with SUI treated with Deflux® from 2001 to 2007 were analysed. The success rates, duration of efficacy and short- and long-term complications of the treatment were recorded. Results: A total of 142 women with a follow-up of up to 13 years (mean 8.8 years) were included. Subjective treatment success was achieved in 92/142 (65%) patients. In those who achieved continence, the mean efficacy was 4.7 years. Side effects were uncommon with 12 (6%) of 209 experiencing transient urinary retention and 11 (5%) of 209 experiencing pseudocyst formation. All pseudocysts were treated successfully with an incision and drainage under either general or local anaesthetic. Sixty (42%) of 142 patients went on to have subsequent definitive incontinence surgery, and Deflux® treatment was found not to have negatively impacted the operation. Conclusion: Deflux® urethral bulking injections appear to be efficacious and safe when used as a treatment for SUI in women with a longer duration of efficacy than previously thought and a low side effect profile. This study provides a valuable timeline to help manage the expectations of patients considering urethral bulking treatment. Level of evidence: 4

Dental Extractions under General Anesthesia: New Insights from Process Mining.

Tooth extraction under general anesthetic (GA) is a global health problem. It is expensive, high risk, and resource intensive, and its prevalence and burden should be reduced where possible. Recent innovation in data analysis techniques now makes it possible to assess the impact of GA policy decisions on public health outcomes. This article describes results from one such technique called process mining, which was applied to dental electronic health record (EHR) data. Treatment pathways preceding extractions under general anesthetic were mined to yield useful insights into waiting times, number of dental visits, treatments, and prescribing behaviors associated with this undesirable outcome. Anonymized data were extracted from a dental EHR covering a population of 231,760 patients aged 0 to 16 y, treated in the Irish public health care system between 2000 and 2014. The data were profiled, assessed for quality, and preprocessed in preparation for analysis. Existing process mining methods were adapted to execute process mining in the context of assessing dental EHR data. Process models of dental treatment preceding extractions under general anesthetic were generated from the EHR data using process mining tools. A total of 5,563 patients who had 26,115 GA were identified. Of these, 9% received a tooth dressing before extraction with an average lag time of 6 mo between dressing and extraction. In total, 11,867 emergency appointments were attended by the cohort with 2,668 X-rays, 4,370 prescriptions, and over 800 restorations and other treatments carried out prior to tooth extraction. Process models generated useful insights, identifying metrics and issues around extractions under general anesthetic and revealing the complexity of dental treatment pathways. The pathways showed high levels of emergency appointments, prescriptions, and additional tooth restorations ultimately unsuccessful in preventing extractions. Supporting earlier publications, the study suggested earlier screening, preventive initiatives, guideline development, and alternative treatments deserve consideration. This study generates insights into tooth extractions under general anesthetic using process mining technologies and methods, revealing levels of extraction and associated high levels of prescriptions, emergency appointments, and restorative treatments. These insights can inform dental planners assessing policy decisions for tooth extractions under general anesthetic. The methods used can be combined with costs and patient outcomes to contribute to more effective decision-making.

Sevoflurane-Induced Apoptosis in the Mouse Cerebral Cortex Follows Similar Characteristics of Physiological Apoptosis.

General anesthetics are capable of inducing neuronal apoptosis during the rapid synaptogenesis of immature mammalian brains. In this vulnerable time window, physiological apoptosis also occurs to eliminate excess and inappropriately integrated neurons. We previously showed that physiological and ketamine-induced apoptosis in mouse primary somatosensory cortex (S1) followed similar developmental patterns. However, since sevoflurane is more widely used in pediatric anesthesia, and targets mainly on different receptors, as compared with ketamine, it is important to determine whether sevoflurane-induced apoptosis also follows similar developmental patterns as physiological apoptosis or not. Mice at postnatal days 5 (P5) and P9 were anesthetized with 1.5% sevoflurane for 4 h, and the apoptotic neurons in S1 were quantitated by immunohistochemistry. The results showed that sevoflurane raised the levels of apoptosis in S1 without interfering with the developmental patterns of physiological apoptosis. The cells more vulnerable to both physiological and sevoflurane-induced apoptosis shifted from layer V pyramidal neurons at P5 to layers II–IV GABAergic neurons by P9. The magnitude of both sevoflurane-induced and physiological apoptosis was more attenuated at P9 than P5. To determine whether the Akt-FoxO1-PUMA pathway contributes to the developmental decrease in magnitude of both physiological and sevoflurane-induced apoptosis, Western blot was used to measure the levels of related proteins in S1 of P5 and P9 mice. We observed higher levels of antiapoptotic phosphorylated Akt (p-Akt) and phosphorylated FoxO1 (p-FoxO1), and lower levels of the downstream proapoptotic factor PUMA in control and anesthetized mice at P9 than P5. In addition, the Akt-FoxO1-PUMA pathway may also be responsible for sevoflurane-induced apoptosis. Together, these results suggest that magnitude, lamination pattern and cell-type specificity to sevoflurane-induced apoptosis are age-dependent and follow physiological apoptosis pattern. Moreover, The Akt-FoxO1-PUMA pathway may mediate the developmental decreases in magnitude of both physiological and sevoflurane-induced apoptosis in neonatal mouse S1.

Parental acceptability of pediatric forearm manipulations in a UK district hospital emergency department.

Purpose:Pediatric forearm fractures are a common presentation to Accident and Emergency departments. Standard treatment for the majority of these is manipulation under sedation within the department, followed by cast application. Concerns have been raised about the acceptability of such interventions, and reluctance to perform these procedures has led to increased admissions and manipulations performed under general anesthetic.Methods:A prospective case series of all pediatric patients with forearm fractures who underwent a manipulation under sedation in the Accident and Emergency department was collected over 12 months. All parents were invited to complete an acceptability questionnaire, adapted from the Swedish Pyramid Questionnaire for Treatment, based on their experiences.Results:A total of 77 patients were included and their parents were asked to complete a Swedish Pyramid Questionnaire of Treatment. Forty-four parents (55%) agreed to fill out the questionnaire. Patient demographics and fracture characteristics were compared between the group that responded and those that did not, with no significant differences. Average level of satisfaction was 9.4/10 (range = 7–10). 98% of respondents were satisfied with the level of analgesia provided, but only 86% with the timeliness of administration.Conclusion:This parent-focused evaluation of treatment confirms high levels of parental satisfaction with the management of pediatric forearm fractures in Accident and Emergency, with regard to care, analgesia, and information. It provides insights about parental concern relating to the injury and their anxiety as information useful to further improving care, a template for assessing quality improvement and should be considered as part of further studies in this field.Level of evidence:Level IV case series.

How London maxillofacial units faced the demands of COVID lockdown and lessons learnt

IntroductionIn the UK between the March 23, 2020 and May 10, 2020, the government enforced a lockdown. This, combined with COVID, caused OMFS hospitals across London to experience a change in staffing, resources and patient presentations. This study examines these changes, how patient care was adapted during this period and what can be learnt for the future. MethodData was collected from OMFS units attached to all 4 level 1 trauma centers in London. Prospective data was collected from March 23, 2020–May 10, 2020 (1st period). Retrospective data was collected from hospital coding records for 23rd of March - May 10, 2019 (2nd period). Data was collected on all referrals to the OMFS team including diagnosis, patient demographics and treatment received. ResultsThere was an 84% reduction in patients presenting with mandible fracture. 2 units with dental emergency services experienced no change in dental abscess presentations whilst the other 2 units saw a decrease of 70–75%.There was a trend towards reducing admission and general anaesthetic treatments. Most mandible fractures were treated in the outpatient setting with 1 unit discharging 100% of mandible fractures that presented to A&E. Only 13 of 72 paediatric lacerations were treated with general anaesthetic. ConclusionThe COVID lockdown period, like war time, posed great challenges to healthcare provision. This paper presents the changes experienced and how patients were managed. Aiming to allow reflection and learning to guide changes in management to be adopted for the future.

Cognitive Impairment Following Clinical or Recreational Use of Gammahydroxybutyric Acid (GHB): A Systematic Review.

GHB (gamma-hydroxybutyric acid; sodium oxybate) is a general anaesthetic that is clinically used for the treatment of narcolepsy, cataplexy, alcohol withdrawal and alcohol relapse prevention. In addition, GHB is recreationally used. Most clinical and recreational users regard GHB as an innocent drug devoid of adverse effects, despite its high dependence potential and possible neurotoxic effects. At high doses, GHB may lead to a comatose state. This paper systematically reviews possible cognitive impairments due to clinical and recreational GHB use. PubMed and PsychINFO were searched for literature data about the acute and residual cognitive deficits following GHB use. This review is conducted using the PRISMA protocol. A total of 43 reports covering human and animal data on GHB-induced cognitive impairments were eligible and reviewed. This systematic review found no indication for cognitive impairments after clinical GHB use. However, it supports the view that moderate GHB use may result in acute short-term cognitive impairments, whereas regular high-dose GHB use and/or multiple GHB-induced comas are probably neurotoxic resulting in long-term residual cognitive impairments. These results emphasize the need for awareness among clinicians and recreational users to minimize negative health consequences of recreational GHB use, particularly when high doses are used and GHB-induced comas occur.

Cross-sectional Study of PONV Risk Factors for Oral Surgery After Intubated General Anesthesia With Total Intravenous Anesthesia.

The incidence of postoperative nausea and vomiting (PONV) after general anesthesia with total intravenous anesthesia (TIVA) was reported to be significantly lower than with volatile inhalational agents (13.3% vs 25%). However, no investigation of PONV risk factors associated with TIVA has ever been reported. This cross-sectional retrospective study aimed to investigate whether known risk factors influenced PONV in intubated general anesthetics utilizing TIVA for dental or oral and maxillofacial surgery. Subjects were 761 patients who underwent dental or oral and maxillofacial surgery under TIVA with propofol, fentanyl, and remifentanil. Univariate and multivariable logistic regression analyses were performed using PONV (within 24 hours) as the dependent variable and previously reported risk factors as independent variables. Age (odds ratio [OR]: 1.020 per year decrease; 95% confidence interval [CI]: 1.0002-1.0418; P = .047) and female sex (OR: 2.73; 95% CI: 1.60-4.84; P < .001) were positively associated with PONV. Sagittal split ramus osteotomy (SSRO) (OR: 2.28; 95% CI: 1.21-4.33; P = .011) and bimaxillary osteotomy (OR: 5.69; 95% CI: 2.09-15.99; P < .001) were more likely to be associated with PONV than operations that were neither bimaxillary osteotomy nor SSRO. Late PONV (2-24 hours) had an ∼2.7 times higher incidence than early PONV (0-2 hours). These findings suggest further PONV countermeasures, aside from TIVA with propofol and prophylactic antiemetics for orthognathic surgeries especially bimaxillary osteotomy, are needed.

The effect of neuroactive steroids in sex differences in the developmental neurotoxicity of the anaesthetic

AbstractThe rapid growth of the number of surgical cases in the world has brought opportunities and challenges to the development of anaesthesia. Modern anaesthesia technology provides safe and effective anaesthesia for hundreds of millions of surgical procedures each year, but there is a lot of concern about the complications (mainly cognitive dysfunction) that occur after anaesthesia exposure. Preclinical studies have demonstrated cognitive dysfunction and behavioural abnormalities that persist into adulthood after exposure to anaesthesia in rodents, revealing the potential neurotoxicity of anaesthetic drugs. In a further study, Sprague–Dawley rats treated with sevoflurane in the first week of life were then subjected to behavioural tests, and female rats were significantly more negatively affected in spatial learning than male rats, suggesting that there may be gender differences in neurotoxicity of the anaesthetic, but the specific mechanisms are unclear. According to the available data, the main hypothesis that can explain the sex difference in the effect of anaesthesia on the central nervous system development remains the difference in hormone levels between males and females. Therefore, this review briefly describes the role of neuroactive steroids in the mechanism of sex differences in neurotoxicity during the development of general anaesthetics.