Anesthetic Issues Research Articles

Pro-Con Debate: Anesthesiologists Should Be Responsible for Treating Preoperative Anemia.

In this Pro-Con commentary article, we discuss whether anesthesiologists should be responsible for treating preoperative anemia. This debate was proposed based on the article published in this issue of Anesthesia & Analgesia by Warner et al, which is an advisory on managing preoperative anemia endorsed by both the Society of Cardiovascular Anesthesiologists and the Society for Advancement of Patient Blood Management. All evidence suggests that anemia is not just an innocent "bystander" which can be solved by transfusion. In fact, both anemia and transfusion are independently associated with adverse outcomes, so why not avoid both? It just makes sense that patients show up for surgery with enough red blood cells to avoid needing transfusion with someone else's. Even if we agree that preoperative anemia is worth treating before surgery, the question remains who should be responsible for doing so, and therein lies the reason for this Pro-Con debate. Should it be the responsibility of the anesthesiologist, or not? Let the readers decide.

Peri-operative care of transgender and gender-diverse individuals: guidance for clinicians and departments.

The objective of this document is to guide best practice to ensure the safety and dignity of transgender and gender-diverse people in the peri-operative period. While transgender and gender-diverse people may have specific health needs in relation to gender dysphoria, their health requirements go beyond their gender identity. Most doctors will provide care to someone who is transgender or gender-diverse at some stage in their career. It is therefore important that all anaesthetists are educated on specific considerations when caring for these patients. A working party was assembled consisting of individuals with experience in direct clinical care of the relevant patient group, those who have expertise in endocrinology and gender-affirming hormones, educators on the topic of transgender and gender-diverse healthcare, and authors of both cisgender and transgender identities. After discussion among the working party, targeted searches of literature were undertaken. The authors initially came up with a list of over 25 recommendations which was subsequently revised to a list of 15 recommendations after further review by the working party. These included airway assessment and management; management of hormonal therapy; relevant issues in obstetric anaesthesia; and hospital infrastructure and processes. This document provides the first guidance produced to advise on best practice to ensure the safety and dignity of trans and gender-diverse individuals in the peri-operative period.

International Alliance of Urolithiasis (IAU) guideline on retrograde intrarenal surgery (Russian adaptation)

Introduction. The emergence of new scientific and clinical evidence on the use of retrograde intrarenal surgery (RIRS) for the management of kidney stones has prompted periodic systematisation, analysis, and evaluation of outcomes to standardise its application and determine future directions for research and development.Objective. To present the Russian adaptation of a guideline on retrograde intrarenal surgery from the International Urolithiasis Alliance guideline series to provide a theoretical basis for urologists performing RIRS.Materials & Methods. A systematic review was conducted on the RIRS-associated publications available in the PubMed database to prepare a set of recommendations during the period from 1 January 1964 until 1 October 2021. The recommendations were evaluated using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system, which classifies, evaluates, develops, and examines recommendations. The modified Oxford Centre for Evidence-Based Medicine's (OCEBM) system for categorising the level of evidence and relevant comments have been applied to assess the strength of the conclusions.Results. The research team conducted a comprehensive analysis of 36 published clinical guidelines on the following topics: 1. Indications and Contraindications 2. Preoperative Imaging 3. Preoperative Ureteral Stenting 4. Preoperative Medications 5. Perioperative Use of Antibiotics 6. Use of Antithrombotic Therapy 7. Anesthesia Issues 8. Intraoperative Positioning 9. Equipment 10. Complications.Conclusion. A series of recommendations for RIRS, offered here should help provide safe and effective performance of RIRS.

Debatable issues of anesthesiological provision of fetal surgery

The article presents an analysis of literature data on the issues of anesthesia in fetal surgery for various interventions on the fetus. Publications containing detailed information on maternal and fetal anesthesia, published in the EMBASE, MedLine, PubMed, Google Scholar, Web of Science, Scopus databases for the period 2012–2022 were analyzed. Meta-analyses, systematic reviews, clinical guidelines, observational studies, and case series were reviewed, supplemented by a review of the literature lists in relevant publications. Our review of scientific publications showed the lack of standardized approaches when choosing anesthesia for each type of fetal intervention.

Is Industry- Versus Government-Sponsored Research a Zero-Sum Game?

Is Industry- Versus Government-Sponsored Research a Zero-Sum Game?

Global issues in obstetric anaesthesia: perspectives from South Africa, Japan, China, Latin America and North America

South Africa is classified as a low- and middle-income country, with a complex mixture of resource-rich and resource-limited settings. In the major referral hospitals, the necessary skill level exists for the management of complex challenges. However, this contrasts with the frequently-inadequate skill levels of anaesthesia practitioners in resource-limited environments.In Japan, obstetricians administer anaesthesia for 40% of caesarean deliveries and 80% of labour analgesia. Centralisation of delivery facilities is now occurring and it is expected that obstetric anaesthesiologists will be available 24 h a day in centralised facilities in the future.In China, improvements in women’s reproductive, maternal, neonatal, child, and adolescent health are critical government policies. Obstetric anaesthesia, especially labour analgesia, has received unprecedented attention. Chinese obstetric anaesthesiologists are passionate about clinical research, focusing on efficacy, safety, and topical issues.The Latin-American region has different landscapes, people, languages, and cultures, and is one of the world’s regions with the most inequality. There are large gaps in research, knowledge, and health services, and the World Federation of Societies of Anaesthesiologists is committed to working with governmental and non-governmental organisations to improve patient care and access to safe anaesthesia.Anaesthesia workforce challenges, exacerbated by coronavirus disease 2019, beset North American healthcare. Pre-existing struggles by governments and decision-makers to improve health care access remain, partly due to unfamiliarity with the role of the anaesthesiologist. In addition to weaknesses in work environments and dated standards of work culture, the work-life balance demanded by new generations of anaesthesiologists must be acknowledged.

Gender Gap: A Call for Women Leaders.

An original clinical research report and accompanying editorial in this issue of Anesthesia & Analgesia directly address a reality that deserves our undivided attention: a stark disparity continues to exist between men and women in leadership roles in academic anesthesiology. Basile et al identified 26 women in our field who have successfully achieved leadership positions. These leaders participated in structured interviews to ascertain whether there were specific factors common to women in leadership in anesthesiology, and how they obtained these positions. Four themes related to career development for these women were identified. Personality traits such as perseverance and adaptability were common among these women. Many of these individuals completed leadership courses and received early mentorship. As well, a major obstacle for these women was overcoming workplace bias and competing family obligations. Finally, leadership acquisition required self-promotion and sponsorship. The attributes of the interviewees are illustrated above. The reader is strongly encouraged to review the cited article and editorial for an in-depth understanding of the concepts summarized in this infographic.

How Did They Get There? What Perspectives From the Top Tell Us About Developing Women Leaders in Academic Anesthesiology.

How Did They Get There? What Perspectives From the Top Tell Us About Developing Women Leaders in Academic Anesthesiology.

Optimal anesthesia protocols for successful intraoperative neuromonitoring during thyroid surgery

There are several factors related to anesthesia that are required for successful intraoperative neuromonitoring (IONM) during thyroid and parathyroid surgery, including proper placement of endotracheal tube, adequate neuromuscular blockade, use of appropriate neuromuscular blockade reversal agent, and pain management. In this review, we summarize the anesthesia issues related to IONM during thyroid and parathyroid surgery.

A Growing Transparency in Medicine.

The provision of health services has been transforming from a largely top-down, paternalistic model into a construct in which patients play a substantive role in decision making over their care. Two articles in this month's issue of Anesthesia & Analgesia and an accompanying editorial address the growing momentum behind transparency in health care. Firstly, Quinonez et al consider the increasing expectation of family presence during surgical procedures and resuscitation of loved ones. They entertain the valid merits of family presence, such as the anxiolytic effect it may have as well as increased understanding of procedural goals and enhanced staff professionalism. Conversely, family members may not be psychologically prepared to bear witness to more invasive clinical environments and may serve as a source of distraction to providers. The impact of family presence on medical litigation is unclear. There have been long standing precedents set by way of obstetric and pediatric populations as seen in this infographic. In conjunction with the increased desire for physical presence of loved ones during clinical procedures, so too is there a demand for complete access to all medical records, including even the arcane hieroglyphics of an anesthesia record as detailed by Ramaswamy et al. As federal law now mandates such access, questions naturally arise as to their utility and medicolegal implications. The reader is strongly encouraged to review the concepts elaborated in these articles for in depth appreciation of their considerations.

An Investigation Into Quality of Recovery After General Anesthesia With Isoflurane and Propofol in Patients Undergoing Abdominal Hysterectomy.

The quality of postanesthesia recovery is among the important issues of general anesthesia that affect the patient's ability to perform daily activities. This study hence aimed to investigate the effects of general anesthesia with isoflurane and propofol on the quality of recovery (QoR) in patients undergoing an abdominal hysterectomy. This clinical trial was conducted on 80 women aged 30-65 years who visited Ayatollah Rouhani Hospital of Babol for an elective abdominal hysterectomy in 2020. Based on a randomized block design (4 blocks of 20), the participants were equally assigned to two groups of propofol (P) and isoflurane (I). The QoR-15 scale was employed to measure the QoR in terms of physical and mental dimensions, as primary outcomes, and duration of anesthesia, duration of surgery, response time, quality of extubation, changes in blood pressure and heart rate, length of stay in the recovery unit, Aldrete score, pain score, and prevalence of postoperative nausea and vomiting (PONV), as secondary outcomes. The results showed that there was no significant difference between the two groups in terms of postoperative physical and mental changes (P = 0.142), except for the second night after surgery (P = 0.001). The QoR, both physically and mentally, significantly changed in both groups over time (P ＜ 0.05). The results also indicated that response time (P ＜ 0.001), quality of extubation (P = 0.01), prevalence of PONV (P = 0.001), and increase in blood pressure (P = 0.02) were significantly lower in the propofol group (P) than in the isoflurane group (I). There was no significant difference between the two groups in the length of stay in the recovery unit (P = 0.44), pre-discharge Aldrete score (P = 0.31), pain score (P = 0.18), duration of anesthesia (P = 0.30), duration of surgery (P = 0.64), and heart rate (P = 0.30). Propofol outperformed isoflurane in terms of response time, quality of extubation, prevalence of PONV, and increase in blood pressure. In addition, the physical and mental QoR on the second night after surgery was higher in patients anesthetized with propofol compared to those anesthetized with isoflurane.

An Investigation Into Quality of Recovery After General Anesthesia With Isoflurane and Propofol in Patients Undergoing Abdominal Hysterectomy.

The quality of postanesthesia recovery is among the important issues of general anesthesia that affect the patient's ability to perform daily activities. This study hence aimed to investigate the effects of general anesthesia with isoflurane and propofol on the quality of recovery (QoR) in patients undergoing an abdominal hysterectomy. This clinical trial was conducted on 80 women aged 30-65 years who visited Ayatollah Rouhani Hospital of Babol for an elective abdominal hysterectomy in 2020. Based on a randomized block design (4 blocks of 20), the participants were equally assigned to two groups of propofol (P) and isoflurane (I). The QoR-15 scale was employed to measure the QoR in terms of physical and mental dimensions, as primary outcomes, and duration of anesthesia, duration of surgery, response time, quality of extubation, changes in blood pressure and heart rate, length of stay in the recovery unit, Aldrete score, pain score, and prevalence of postoperative nausea and vomiting (PONV), as secondary outcomes. The results showed that there was no significant difference between the two groups in terms of postoperative physical and mental changes (P = 0.142), except for the second night after surgery (P = 0.001). The QoR, both physically and mentally, significantly changed in both groups over time (P ＜ 0.05). The results also indicated that response time (P ＜ 0.001), quality of extubation (P = 0.01), prevalence of PONV (P = 0.001), and increase in blood pressure (P = 0.02) were significantly lower in the propofol group (P) than in the isoflurane group (I). There was no significant difference between the two groups in the length of stay in the recovery unit (P = 0.44), pre-discharge Aldrete score (P = 0.31), pain score (P = 0.18), duration of anesthesia (P = 0.30), duration of surgery (P = 0.64), and heart rate (P = 0.30). Propofol outperformed isoflurane in terms of response time, quality of extubation, prevalence of PONV, and increase in blood pressure. In addition, the physical and mental QoR on the second night after surgery was higher in patients anesthetized with propofol compared to those anesthetized with isoflurane.

Patient Safety During Anesthesia: 100 Years of Progress Documented in Anesthesia & Analgesia.

Anesthesiology has evolved to be a leader in addressing patient safety. Our specialty has overcome serious morbidities including explosions, fires, organ toxicity, fatal arrhythmias, and hypoxic brain damage. Anesthesia safety has been significantly improved due to modern drug development, technical advances, and a strong leadership willing to apply human factors and systems' research strategies, but patient safety concerns remain at the forefront as we strive to improve patient care even further. This year marks the centennial year since the publication of the first issue of Anesthesia & Analgesia. Today, the International Anesthesia Research Society (IARS) and Anesthesia & Analgesia continue to advance the boundaries of patient safety by disseminating practice standards, serving as a forum for novel ideas, and supporting research advancements. This review will discuss several topics published in Anesthesia & Analgesia that exemplify steady changes leading to the safe practices that we rely on currently as well as other IARS activities that have advocated and elevated patient safety within the specialty.

Looking Ahead to the Frontier of Anesthesiology Education.

In this issue of Anesthesia & Analgesia, a series of articles focus on the elemental changes to anesthesia training and education. Kealey and Naik review the status of competency-based medical training, a method through which learners are deliberately observed for progression to mastery in clinical management. This is contrast to the assumption that trainees will presumably reach the same intended endpoint merely by spending a pre-specified amount of time in post-graduate residency training. The advantages and disadvantages of the competency-based approach are reviewed. Alam and Matava describe how education has also changed to incorporate digital technology by way of immersive simulation. They detail the use of virtual and augmented reality to offer trainees the opportunity to engage in clinical exercises that are infrequently encountered in real practice, increase the exposure to challenging scenarios and foster real-time collaborations on a global scale. An accompanying editorial offers further perspective on the future of training in our specialty. The reader is strongly encouraged to review the cited articles for an in-depth appreciation of the concepts discussed.

Management of a case of parathyroid adenoma- An anaesthetic challenge

Calcium plays a major role in a number of physiological actions. Primary hyperparathyroidism is the most common cause of hypercalcaemia. Many patients with primary hyperparathyroidism are asymptomatic. Parathyroidectomy is the definitive treatment for primary hyperparathyroidism. We present the successful anaesthetic management of a patient with primary hyperparathyroidism and discuss the anaesthetic issues involved.

New devices for blood transfusion, local anesthesia and other medical and technical purposes

Every year there is a growing interest in the issue of blood transfusion and local anesthesia. Thanks to the colossal advances achieved by medicine in these areas, we are able to use these methods in surgical practice. However, a big hindrance to the widespread use of these methods is still the complexity of techniques that require special knowledge. The equipment currently used for blood transfusion and local anesthesia does not fully meet the required tasks, complicates the technique of producing blood transfusion and local anesthesia, and also lengthens the production time.

Perioperative management of a rare case of severe polycythemia vera with gout coming for an emergency minor surgery – A concern for the anesthesiologists

Polycythaemia Vera is a chronic myeloproliferative neoplasm with an unknown etiology and is a rare occurrence. The erythrocytosis and thrombocytosis along with the hypercoagulable state as a direct result of surgery predispose these patients to thrombosis and hence haemorrhage. Here, we report the anaesthetic issues concerning an elderly male patient presenting with complaints of difficulty in passing stools, fever, and cough with mucoid sputum and diagnosed to be having low anal fistula and perianal abscess with presence of haemorrhoids along with polycythaemia and gout, who was not on any treatment, and posted for an emergency perianal abscess drainage and fistulectomy. With a hematocrit of 63.3% and normal arterial oxygen saturation, the anesthetic management included a thorough preoperative evaluation of associated comorbidities, proper positioning, conducting regional anesthesia meticulously and prevention of acute thrombotic or hemorrhagic episodes. The uneventful perioperative period resulted in the smooth recovery of the patient.

Impact of anesttesia method on foetus condition

Topicality. Currently, intrapartum fetal health care is aimed at an adequate choice of anesthetic aid used during delivery to minimize the negative impact. Despite the wide range of currently existing anesthetics, the choice of anesthetic drug is limited by its negative effect not only on the fetus, but also on the contractile activity of the uterus, which significantly reduces the number of anesthetics used in obstetric practice.The purpose of this study is to analyze domestic and foreign literature in order to study the effect of anesthesia on the condition of the fetus. Material and methods. In the course of this study, an analysis of modern Russian and foreign literary sources, as well as the latest scientific works in the field of methods of general and regional anesthesia in the field of obstetrics and gynecology, was carried out.Results. Almost all drugs used for general anesthesia in obstetric practice can have a negative effect on the fetus. Neuroaxial pain relief methods are leading in obstetric practice, but their use is associated with complications that can lead to an adverse outcome not only from the mother, but also from the fetus. One such complication is the risk of arterial hypotension. It is interesting that comparative studies of general and regional anesthesia methods during operative delivery differ in the results obtained. Regarding the issue of anesthesia of natural births, the information of the Congress of the American Society of Anesthesiologists (lecture C.A. Wong (Chicago) “Neuroaxial Labor Analgesia and Prognancy Outcome: Factand Fiction”) remains relevant, according to which neuroaxial anesthesia methods do not affect the condition of the fetus, provided that the mother has stable hemodynamics.Conclusion. Due to the appearance and release of neuroaxial pain relief methods, completely unreasonably little attention is paid to the issues of general anesthesia of pregnant women, while according to the results of a study of scientific literary sources, it was revealed that this method of pain relief in obstetric practice is accompanied by the most direct and mediated effects on the fetus. Neuroaxial pain relief methods have practically no effect on the condition of the fetus, provided that the mother has stable hemodynamics.

Impact of Maternal Body Mass Index on Progress and Outcome of Labor in Nulliparous Females

Background; the body mass index (BMI) is frequently used to classify the severity of obesity and to inform weight-gain guidelines throughout pregnancy. Aim and objectives; to evaluate the impact of BMI of nulliparous females on progress of labour, incidence of peri-partum complications (1ry outcome) and neonatal outcome of these women (secondary outcome). Subjects and methods; This is a prospective cohort study, was carried out on 330nulliparous patients attending the labor ward of Al-Hussein and Sayed Galal hospitals, Al-Azhar University, Egypt, during active phase of labor, divided into 4 groups, from January 2021 until the end of the specified cases. Result; In terms of weight and BMI, there is a considerable disparity between the 4 groups. Conclusion; Labor development and labor time varied by BMI category, as evaluated by cervical dilatation rates. As per recent research, a higher BMI in nulliparous women is linked to a higher chance of caesarean birth during labor. This training should be available to first-time mothers prior to conception, and labor ward staff should be informed of this group of women before labour, with a concentration on the issues of analgesia and anesthesia in obese parturients.

Transfusion in Pediatric Cardiac Surgery: A Moving Target.

The relationship between hematocrit and postoperative mortality is complex. In the setting of pediatric cardiac surgery, the influences of hemodilution, thrombodilution, systemic inflammatory response, and intrinsic disease states superimpose themselves on this seemingly unanswerable question. This issue of Anesthesia & Analgesia offers a retrospective, cross-sectional analysis of >27,000 index operations in the pediatric cardiac surgery setting. The investigators were able to demonstrate that mortality and major complications increased as the postoperative hematocrit >38% and >42% in acyanotic and cyanotic patients, respectively. The accompanying editorial by Faraoni and DiNardo places their findings within a broader context of whether outcomes reflect hematocrit per se, or rather derive from the acuity and critical illness of patients for which transfusion is indicated. The reader is strongly encouraged to review both the primary investigation, as well as its attendant editorial for a comprehensive depth of understanding of this complex question.