Anesthesia Specialists Research Articles

Acute cholecystitis in pregnancy

Acute cholecystitis is the most common non-obstetric abdominal emergency in pregnant patients. It is a consequence of increased formation of cholelithiasis, and occurs due to inflammation of the gallbladder, usually caused by the blockage of the cystic duct. There is also described the appearance of cholecystitis without the presence of gallstones, and this is named as acalculous cholecystitis. Elevated levels of estrogen and progesterone are thought to be a cause of women’s increased predisposition to this condition. In pregnancy, literature describe the appearance of gallstones in 1% to almost 3% pregnancies, and it is known that pregnancy by itself affects the contractility of gallbladder. For sludge and gallstones, even if there is a large range of symptoms, almost up to 50% of patients are asymptomatic. Acute cholecystitis is suspected in a patient with continuous pain in the right upper quadrant, alongside anorexia, vomiting, and fever. Laboratory findings in acute cholecystitis show leukocytosis, an elevated level of bilirubin, up to 4 mg/dl and elevated liver tests. The most useful imaging tool in diagnosing gallstones and further acute cholecystitis is an abdominal ultrasound. Any pregnant women with upper right quadrant pain should be hospitalized to exclude other differential diagnoses and for pain management, usually done with acetaminophen. Supportive care treatment includes administration of intravenous fluids and when necessary antibiotic therapy. Recent studies have showed that interventional surgery by itself brings some associated risks during pregnancy, but with an experienced team of surgeon, anesthesia specialist, and obstetrician, outcomes are better, no matter the trimester of pregnancy.

Perioperative Use of Anticoagulant and Antiaggregant Drugs; Approaches of Anesthesiology and Reanimation Physicians in Türkiye: A survey study

Abstract Objective: We aimed to assess the approach of Turkish Anesthesiology and Reanimation Specialists in patients receiving preoperative anticoagulant/antiaggregant therapy. A survey was designed to evaluate perioperative management of anticoagulant/antiaggregant drugs. Methods: We surveyed Anesthesiology and Reanimation specialists and residents in various hospitals in Türkiye through e-mail and smartphone messenger application. We asked them to complete questionnaire form regarding anticoagulant use on a voluntary basis between February 15 and March 15 in 2022. Results: The survey was responded by 296 anesthesiology specialists and residents. The majority of the participants (73.3%) were anesthesiology specialist physicians and work in 3rd level (academic, teaching, or university) hospital. The mostly used antithrombotic drugs were warfarin (75.9%) and acetylsalicylic acid (100%). Most of the participants (61%) use international guidelines regarding the timing of drug discontinuation. Participants commonly (82%) refer to the consultant specialist of the patient for deciding to discontinue or restarting the patient’s antithrombotic drug. The major perioperative concern about the antithrombotic drugs was bleeding complications of central neuraxial procedures (44.8%). Conclusion: The anesthesia and reanimation specialists in Türkiye manage antithrombotic drugs in accordance with international guidelines. The distribution ranges are wide in times of preoperative discontinuation and postoperative restarting times of the medications; thus, the awareness needs to be increased to clear up this controversy.

THE ROLE OF HIGH FIDELITY CARDIOVASCULAR SIMULATION IN ANESTHESIA TRAINING

Introduction Simulation has become an essential element in the learning and assessment of anesthesia trainees [1]. It offers a controlled environment to explore various clinical entities and their impact on anesthesia management without the risk of harming an actual patient. Cardiac anesthesia seems to be an excellent field for simulation due to the complexity of cardiac pathophysiology. A systematic review with meta-analysis on simulation-based anesthesia training demonstrated that simulation training in anesthesia is at least as good as non-simulator training, and is much better than no intervention. [1] Our aim was to evaluate the role of a high-fidelity cardiovascular simulation software on the anesthesia trainees' education and professional evolution. Methods We used a high-fidelity cardiovascular simulator, present at the University Hospitals Leuven, reproducing the main hemodynamic changes of the cardiovascular system [2]. For this purpose, the simulator was uploaded to a server so users could access it remotely. The simulator was used in 4 consecutive simulation sessions, awarded only for the senior (4th- and 5th-year) anesthesia specialist trainees at the University Hospitals Leuven. Each session focused on a specific topic, namely cardiac tamponade, aortic valve, and mitral valve pathologies. The sessions were given online via zoom video communication due to Covid-19 social restrictions. The trainees initially received a short PowerPoint presentation regarding the topic, followed by hands-on training using the cardiovascular software accessible online. A short quiz was implemented at the beginning and end of the training session to assess the trainee's knowledge and progress. Furthermore, the trainees completed a satisfaction questionnaire at the end of the simulation course. Results In total, 47 anesthesia trainees attended the online simulation sessions. The trainees were markedly pleased with the format of the simulation, combining the short theoretical overview with the hands-on simulation training. Besides, they reacted positively to the simulation cases and the explanations given by the instructors. Yet, there is still room for improvement to make the simulator better accessible from remote locations. All the trainees agreed that the simulator is a valuable tool in anesthesia training, and 78,7% of them stated that the simulator promotes a better understanding of cardiovascular pathophysiology and helps develop clinical reasoning. Discussion The simulator has proven to improve knowledge of pathophysiology of the cardiac patient. The majority of trainees evaluated the simulation as a useful experience, a valuable tool for understanding the complex cardiac pathophysiology, with a good format and clear explanations by the instructors. The study has some limitation concerning sample size. To thoroughly study the effect of the use of the simulation on the trainees’ progress, the sample size should be larger and a comparison should be made between a simulation group and a control group.

High-flow nasal oxygen, procedural sedation, and clinical governance.

Procedural sedation for therapeutic and diagnostic procedures can now be achieved through deep sedation techniques that guarantee procedural success. Deep sedation techniques are delivered in a variety of non-theatre environments where the usual levels of anesthetic equipment are not practical or economical. Hypoxic events are particularly frequent, and challenge sedation providers. Traditional low flow nasal or facial oxygen therapy techniques are often insufficient to maintain acceptable oxygen levels and prevent peri-procedural hypoxia. High flow nasal oxygen delivers warm humidified oxygen up to 70 L/min, at oxygen concentrations between 21-100%, and reduces the incidence of hypoxic events. The provision of deep sedation is a complex process, fraught with risk, which can challenge even the skilled anesthetist. Therefore, regulatory authorities previously stipulated that anesthesia personnel be present during deep sedation. Changing attitudes by regulatory authorities and practical challenges providing anesthesia specialists have led to the acknowledgement that appropriately trained non-anesthetic staff can safely provide deep sedation. Deep sedation services are increasingly applied to subjects with complex co-morbidities, sometimes excluded for safety reasons from surgery under general anesthesia. The development of deep sedation services, delivered by non-anesthesia personnel, to patients with complex co-morbidities requires that services implement appropriate clinical governance tools to prevent deep sedation being the wild west of anesthesia services. Therefore, whilst high flow nasal oxygen may reduce the incidence of peri-procedural hypoxia, the introduction of clinical governance tools and the systematic introduction of initiatives to improve quality, will maintain the safety of deep sedation services.

Converting an Under-Construction Healthcare Facility into a COVID-19 Screening and Emergency Response Centre During Complete Lockdown in India.

In view of the COVID-19 surge, the construction of the Burns and Plastic Surgery Block at AIIMS, New Delhi was expedited at war footing level and converted into a COVID-19 Emergency response Centre (ERC). Engineering works were completed in a speedy manner and various patient care areas were equipped as deemed necessary for providing tertiary care to COVID-19 patients. A highly spirited team comprising of Emergency Medicine Specialists, Anesthesia and Critical Care specialist, Hospital Administrators and Nursing Officers was formed. Effective segregation of patient care areas into clean, contaminated, and intermediate zones was done using physical barriers and air conditioning modifications. The screening area for patients suspected of having COVID-19 was created in addition to a 2-step process i.e., Triage 1 and Triage 2, thereafter, patients requiring admission would be referred to the emergency area. An in-house designed and fabricated sampling booth was created to bring down the use of PPEs and for better infection control. The ERC has a general ward and state of the art intensive care units. Mobilizing resources (machinery, manpower, consumables etc.) during the lockdown required commitment from top leadership, motivated teams, expeditious procurement, coordination with multiple agencies working on site, expediting statutory clearances, coordination with police services, transportation of labor etc.

Outpatient Total Hip Arthroplasty: A Meta-Analysis

Introduction: Outpatient total hip arthroplasty (THA) is increasingly popular. This meta-analysis investigated the potential advantages of outpatient regimes for THA. Methods: This study followed the PRISMA guidelines. PubMed, Web of Science, Google Scholar, Embase, and Scopus databases were accessed in June 2021. All clinical studies investigating outpatient THA were considered. The outcomes of interest were pain, infection, mortality, revision, dislocation, readmission rates, and deep vein thrombosis (DVT). Results: Data from 102,839 patients were included. A total of 52% (153,168 of 102,839 patients) were women. The mean age of patients was 62.6 ± 4.6 years, the mean BMI was 29.1 ± 1.8 kg/m2. Good comparability was found in age, BMI, and gender (p > 0.1). No difference was found in pain (p = 0.4), infections (p = 0.9), mortality (p = 0.9), rate of revision (p = 0.1), dislocation (p = 0.9), and readmission (p = 0.8). The outpatient group demonstrated a greater rate of DVT (OR 3.57; 95% CI 2.47 to 5.18; p < 0.0001). Conclusions: In selected patients, outpatient THA can be performed safely with optimal outcomes comparable with inpatient THA. Clear and comprehensive pre-operative planning should involve a multi-disciplinary group composed of orthopaedic surgeons, anaesthesia and rehabilitation specialists, and physiotherapists. Each centre performing outpatient THA should implement continuous homecoming welfare activity, to supervise physiotherapy and monitor anticoagulant therapy.

Massive transfusion experience, current practice and decision support: A survey of Australian and New Zealand anaesthetists.

Massive transfusions guided by massive transfusion protocols are commonly used to manage critical bleeding, when the patient is at significant risk of morbidity and mortality, and multiple timely decisions must be made by clinicians. Clinical decision support systems are increasingly used to provide patient-specific recommendations by comparing patient information to a knowledge base, and have been shown to improve patient outcomes. To investigate current massive transfusion practice and the experiences and attitudes of anaesthetists towards massive transfusion and clinical decision support systems, we anonymously surveyed 1000 anaesthetists and anaesthesia trainees across Australia and New Zealand. A total of 228 surveys (23.6%) were successfully completed and 227 were analysed for a 23.3% response rate. Most respondents were involved in massive transfusions infrequently (88.1% managed five or fewer massive transfusion protocols per year) and worked at hospitals which have massive transfusion protocols (89.4%). Massive transfusion management was predominantly limited by timely access to point-of-care coagulation assessment and by competition with other tasks, with trainees reporting more significant limitations compared to specialists. The majority of respondents reported that they were likely, or very likely, both to use (73.1%) and to trust (85%) a clinical decision support system for massive transfusions, with no significant difference between anaesthesia trainees and specialists (P = 0.375 and P = 0.73, respectively). While the response rate to our survey was poor, there was still a wide range of massive transfusion experience among respondents, with multiple subjective factors identified limiting massive transfusion practice. We identified several potential design features and barriers to implementation to assist with the future development of a clinical decision support system for massive transfusion, and overall wide support for a clinical decision support system for massive transfusion among respondents.

Safety in Dermatologic Procedures: Hypertensive Crises and Potentially Fatal Arrhythmias

As dermatologic surgeons often have to perform long surgeries with local anesthetic only, they should be familiar with the fundamentals of how to manage 2 potentially serious complications: Hypertensive crises and intraoperative arrhythmias.Hypertensive crises can be classified as 1) hypertensive urgencies, characterized by a significant spike in blood pressure (>180/110 mmHg) without target-organ dysfunction or 2) hypertensive emergencies, characterized by a blood pressure above 180/110 mmHg with progressive target-organ damage. In emergencies, the blood pressure needs to be reduced immediately whereas in urgencies the goal is to reduce it over several days. Care must still be taken not to reduce the blood pressure excessively rapidly in emergencies, however, to avoid ischemic injury to vascular beds that have adapted to a high blood pressure.We recommend that dermatologic surgeons use captopril in hypertensive emergencies because of its safety profile and ease of use. Asymptomatic intraoperative bradycardia does not require treatment, but patients should always be checked to ensure they are alert and responsive. The first step in clinically stable patients with tachycardia is to measure the width of the QRS complex and notify the anesthetist when this is wide.Dermatologic surgeons should also be familiar with the drugs available in the operating room, ensure that they are easily accessible, and identify the most essential ones so they can familiarize themselves with indications and dosage. Patients should be monitored throughout the operation, and material to secure a peripheral intravenous line should be prepared in case of need. Finally, the dermatologic surgeon should know all the staff working in the operating room and be able to locate the specialist in anesthesia and resuscitation.

Seguridad en procedimientos dermatológicos: crisis hipertensiva y arritmias potencialmente malignas

As dermatologic surgeons often have to perform long surgeries with local anesthetic only, they should be familiar with the fundamentals of how to manage 2 potentially serious complications: Hypertensive crises and intraoperative arrhythmias.Hypertensive crises can be classified as 1) hypertensive urgencies, characterized by a significant spike in blood pressure (>180/110mmHg) without target-organ dysfunction or 2) hypertensive emergencies, characterized by a blood pressure above 180/110mmHg with progressive target-organ damage. In emergencies, the blood pressure needs to be reduced immediately whereas in urgencies the goal is to reduce it over several days. Care must still be taken not to reduce the blood pressure excessively rapidly in emergencies, however, to avoid ischemic injury to vascular beds that have adapted to a high blood pressure.We recommend that dermatologic surgeons use captopril in hypertensive emergencies because of its safety profile and ease of use. Asymptomatic intraoperative bradycardia does not require treatment, but patients should always be checked to ensure they are alert and responsive. The first step in clinically stable patients with tachycardia is to measure the width of the QRS complex and notify the anesthetist when this is wide.Dermatologic surgeons should also be familiar with the drugs available in the operating room, ensure that they are easily accessible, and identify the most essential ones so they can familiarize themselves with indications and dosage. Patients should be monitored throughout the operation, and material to secure a peripheral intravenous line should be prepared in case of need. Finally, the dermatologic surgeon should know all the staff working in the operating room and be able to locate the specialist in anesthesia and resuscitation.

Ketamine and Calcium Signaling-A Crosstalk for Neuronal Physiology and Pathology.

Ketamine is a non-competitive antagonist of NMDA (N-methyl-D-aspartate) receptor, which has been in clinical practice for over a half century. Despite recent data suggesting its harmful side effects, such as neuronal loss, synapse dysfunction or disturbed neural network formation, the drug is still applied in veterinary medicine and specialist anesthesia. Several lines of evidence indicate that structural and functional abnormalities in the nervous system caused by ketamine are crosslinked with the imbalanced activity of multiple Ca2+-regulated signaling pathways. Due to its ubiquitous nature, Ca2+ is also frequently located in the center of ketamine action, although the precise mechanisms underlying drug’s negative or therapeutic properties remain mysterious for the large part. This review seeks to delineate the relationship between ketamine-triggered imbalance in Ca2+ homeostasis and functional consequences for downstream processes regulating key aspects of neuronal function.

Validation of the Scale of Psychological Evaluation Specific to Intensive Therapy (IPAT) on a Population of Patients in Romania Admitted to Intensive Care Units.

ObjectiveThrough this study, we want to see to what extent the stress is present among the patients admitted in the intensive care units of the Fundeni Clinical Institute of Bucharest, outlining intervention strategies both individually and collectively and validating the psychological evaluation tool (IPAT) specific to the anesthesia and intensive care units in our population.MethodIntensive Psychological Assessment Tool (IPAT) with 10 items was used for stress assessment in the intensive care unit and Hospital Anxiety Depression Scale (HADS) with 14 items and two subscales, one for anxiety (7 items) and one for depression (7 items).ConclusionThe study demonstrates the validity of IPAT scale for the patients participating in the study; the results of the study provide the specialists in anesthesia and intensive care units directions to identify elements of stress, anxiety and depression – directions that can improve their daily work, communication with patients and possibly a better quality of life for all involved in the care of a patient.ResultsThe results of the study provide the specialists in anesthesia and intensive care units the directions to improve their daily work and possibly a better quality of life for all involved in the care of a patient.

Major perioperative critical incidents: Prospective review in 3 years’ period at a university hospital

BackgroundLittle is known about perioperative critical incidents in our hospital since it became part of quality control system. The aim was to identify, rate, type and analyse factors leading to severe critical incidences in patients undergoing surgery under anaesthesia. Patients and methodsWe conducted a prospective three-year perioperative critical incidents reporting at a tertiary university hospital in Jordan from January 2016 till December 2018. Reports included date, location, patients, demographics, ASA score, type of surgery and anaesthesia, the events led to critical incidents and outcome. Severe critical incidence was defined as a complication requiring immediate action and did lead (or could have led) to major disability or death. Results59136 patients underwent 78346 surgical procedures under anaesthesia during the study period. Severe critical events were reported in 80 (0.14%) patients. 51 patients recovered, 29 (0.05%) patients died. 27 patients were above 60 years. 55 patients ASA III and IV, 43 males, 13 occurred in each of orthopaedics and general surgery. 66 were during or after general anaesthesia. 27 critical incidents involved cardiovascular, and 24 respiratory systems. 62 occurred in operating room, 23 were avoidable and 53 were elective. Anaesthesia and surgery related and contributing factors were found in 31 and 13 of them died. ConclusionCritical incidents reporting should be part of quality control system in any teaching hospital, where it identifies weak area for the purpose of improvement in patient safety and education of trainees and specialists in anaesthesia.

In Response

We welcome and wish to endorse the points made by Sund1 in his commentary on our article “Anesthesia Capacity of District-Level Hospitals in Malawi, Tanzania, and Zambia: A Mixed-Methods Study.”2 The importance of our article lies to a great extent in the size of the evidence gap and the paucity of research on anesthesia capacity at district hospitals, which are best placed to address the bulk of unmet population need. Sund1 has highlighted some of the obstacles, including lack of funding and capacity to conduct such research. We wish to commend Anesthesia & Analgesia for publishing our article, despite its shortcomings, not least being the lack of anesthesiologists among the authors. We are not the first—and sadly, we may not be the last—to come to the realization that lack of anesthesia capacity is often the rate-limiting step to delivering essential and life-saving surgery to rural populations in much of Sub-Saharan Africa. The positive development is that our study has produced hard evidence from 76 district-level hospitals across 3 such countries, which the anesthesia and public health communities can use in advocating for resources from global and national policy makers and funding bodies. We suggest that those in the anesthesia community, who are committed to building on this modest platform of population-level research on anesthesia capacity, need to work with a broader coalition of stakeholders who share their commitment. At the global level, this will include global public health and global surgery communities, so as to build synergies of effort. Even more important, we believe, is the national commitment in countries with the greatest need, which is essential to the future sustainability of the interventions we are currently testing, where anesthesia as well as surgical and nursing specialists are working together in building capacity at district level.3 This national-level commitment needs to translate into the availability of local and international funding to improve surgical services. There is also an important need to extend the focus beyond national surgery, anesthesia, and obstetric specialists, who are leading the development of national plans in several Sub-Saharan African countries, to include frontline district health care providers—doctors, nonphysician clinicians, nurses, managers, and support staff. District level health care, although of crucial importance, has not been the main focus for most researchers, academics, and implementers working in global surgery. Its importance is also not adequately reflected at the policy level. The prioritization of district-level surgery is currently missing in 4 of 5 published national surgery, obstetric, and anesthesia plans. Therefore, an inclusive approach is needed in both research and interventions to ensure the perspectives of all members of the surgical team (surgical providers, anesthesia providers, and nursing) are taken into account to best serve patients where the need is the greatest. In our current study, our focus is on the teams and teamwork needed to deliver these essential services. This requires moving out of the professional silos that can otherwise impede the collective effort that is needed. Our research has contributed a further brick to build evidence that the availability of quality-assured safe anesthesia is the critical and common underlying determinant of countries’ abilities to deliver essential surgery and emergency obstetric care. Hence, we wish to join in Sund’s1 impassioned call to—and we look forward to working with—the global anesthesia research community in building on this platform. Global access to safe surgical and anesthesia care in the developing world will not be possible to achieve if not attempted cross-disciplinary. Surgical and anesthesia providers, together with public health researchers, economists, and health planners, need to work collaboratively and maximize the impact each discipline brings to the field of global surgery. ACKNOWLEDGMENTS The authors acknowledge the contribution of the whole Scaling up Safe Surgery for District and Rural Populations in Africa (SURG-Africa) research consortium. Jakub Gajewski, PhDInstitute of Global SurgeryRoyal College of Surgeons in IrelandDublin, Ireland[email protected]Chiara Pittalis, MSRuairi Brugha, MDDepartment of Epidemiology and Public Health MedicineRoyal College of Surgeons in IrelandDublin, Ireland

Understanding hand hygiene behaviour in the intensive care unit to inform interventions: an interview study

BackgroundImproving hand hygiene (HH) compliance is one of the most important, but elusive, goals of infection control. The purpose of this study was to use the capability (C), opportunity (O), motivation (M), and behaviour (B; COM-B) model and the theoretical domains framework (TDF) to gain an understanding of the barriers and enablers of HH behaviours in an intensive care unit (ICU) in order to identify specific interventions to improve HH compliance.MethodsA semi-structured interview schedule was developed based upon the COM-B model. This schedule was used to interview a total of 26 ICU staff: 12 ICU nurses, 11 anaesthetic specialist registrars, and three anaesthetic senior house officers.ResultsParticipants were confident in their capabilities to carry out appropriate HH behaviours. The vast majority of participants reported having the necessary knowledge and skills, and believed they were capable of carrying out appropriate HH behaviours. Social influence was regarded as being important in encouraging HH compliance by the interviewees- particularly by nurses. The participants were motivated to carry out HH behaviours, and it was recognised that HH was an important part of their job and is important in preventing infection. It is recommended that staff are provided with targeted HH training, in which individuals receive direct and individualised feedback on actual performance and are provided guidance on how to address deficiencies in HH compliance at the bedside at the time at which the HH behaviour is performed. Modelling of appropriate HH behaviours by senior leaders is also suggested, particularly by senior doctors. Finally, appropriate levels of staffing are a factor that must be considered if HH compliance is to be improved.ConclusionsThis study has demonstrated that short interviews with ICU staff, founded on appropriate behavioural change frameworks, can provide an understanding of HH behaviour. This understanding can then be applied to design interventions appropriately tailored to the needs of a specific unit, which will have an increased likelihood of improving HH compliance.

Retention and Migration of Rwandan Anesthesiologists: A Qualitative Study.

Health care professional migration continues to challenge countries where the lack of surgical and anesthesia specialists results in being unable to address the global burden of surgical disease in their populations. Medical migration is particularly damaging to health care systems that are just beginning to scale up capacity building of human resources for health. Anesthesiologists are scarce in low-resource settings. Defining reasons why anesthesiologists leave their country of training through in-depth interviews may provide guidance to policy makers and academic organizations on how to retain valuable health professionals. There were 24 anesthesiologists eligible to participate in this qualitative interview study, 15 of whom are currently practicing in Rwanda and 9 had left the country. From the eligible group, interviews were conducted with 13 currently practicing in Rwanda and 2 who had left to practice elsewhere. In-depth interviews of approximately 60 minutes were used to define themes influencing retention and migration among anesthesiologists in Rwanda. Interviews were conducted using a semistructured guide and continued until theoretical sufficiency was reached. Thematic analysis was done by 4 members of the research team using open coding to inductively identify themes. Interpretation of results used the framework categorizing themes into push, pull, stick, and stay to describe factors that influence migration, or the potential for migration, of anesthesiologists in Rwanda. While adequate salary is essential to retention of anesthesiologists in Rwanda, other factors such as lack of equipment and medication for safe anesthesia, isolation, and demoralization are strong push factors. Conversely, a rich academic life and optimism for the future encourage anesthesiologists to stay. Our study suggests that better clinical resources and equipment, a more supportive community of practice, and advocacy by mentors and academic partners could encourage more staff anesthesiologists to stay and work in Rwanda.

An analysis of citations of publications in anaesthesia journals.

Which journals cite work published in anaesthetic journals is of potential interest to authors, editors and publishers. We analysed citations made in 2017-2018 for articles, reviews, editorials and letters published by 12 anaesthetic journals in 2016, using the Web of Science™ citation index platform. We analysed 12,544 citations made for 3518 items. Citations were most often made by specialist anaesthesia journals and critical care journals, and occurred most commonly in articles, followed by reviews, editorials and letters. The median (IQR [range]) number of citations made per item was 3.3 (2.6-4.1 [1.6-5.1]). The median (IQR [range]) number of journals that cited the 12 source journals was 302 (236-449 [139-671]). The median (IQR [range]) proportion of citations made by the same journal that published the items (i.e. 'self-citations') was 15% (11-17% [5-32%]). There were 1305/1932 (68%) citations made by North American journals for items published in North American journals and 1712/2063 (83%) citations made by European journals for items published in European journals, p<0.0001. Our analysis may inform authors, editors and publishers where to submit work, what editorial policy to pursue and what journal strategy to follow, respectively.

Development and validation of an instrument for procedure-related death notification.

Anaesthesia-related mortality is an important, potentially avoidable cause of perioperative mortality. A procedure-related death notification (PRDN) instrument is completed by relevant medical practitioners after a procedure-related death and is used to audit practice and identify areas of care that require improvement. It is also used in medicolegal investigations when establishing cause of death, and in the case of litigation. The current South African (SA) PRDN instrument, designated the GW7/24 form, contains both surgical and anaesthetic sections and is considered to be outdated, inadequate and in need of revision. To develop and validate a revised anaesthetic section of the SA PRDN instrument that can be used for procedure-related deaths in future and be used to update the GW7/24 form for epidemiological, forensic or academic use. Lynn's two-stage model was utilised. After an extensive literature review, a provisional PRDN instrument was developed. This provisional instrument was debated and reviewed at a peer group discussion in which 6 local experts took part. These experts were anaesthetic and forensic pathology specialists who specifically have expert knowledge on procedure-related deaths. A revised PRDN instrument was developed, which was then rated by 8 national experts using a Likert scale. The content validity index (CVI) for each item and for the instrument as a whole was then established. Items with a CVI &lt;0.88 were removed to formulate the final PRDN instrument. The provisional PRDN instrument consisted of 14 domains and 66 items. The revised PRDN instrument consisted of 13 domains and 65 items, of which 3 items with a CVI &lt;0.88 were removed. The final PRDN instrument, after minor revisions based on suggestions from the 8 national experts, consisted of 18 domains and 79 items. Every item on the form was declared relevant and important by the national experts, with the final instrument scoring an overall CVI of 1. A comprehensive, updated and validated anaesthetic section of the SA PRDN instrument was developed. This could be used as a government and anaesthesiology society-endorsed template when updating the current GW7/24 form.

Caring for Patients With Ventricular Assist Devices: A Mini-Review of the Literature

Heart transplantation, one of the treatment options for end-stage heart failure, is still regarded as the gold standard treatment to improve quality and length of life. However, the rapid increase in the number of patients waiting for heart transplantation and the inadequate number of donors makes heart transplantation a less feasible option and increases the need for ventricular assist devices as an alternative. The success of ventricular assist device implantation requires the collaboration of a multidisciplinary team consisting of cardiac surgeons, nurses, ventricular assist device coordinators, cardiologist, cardiac anesthesia specialists, perfusionists, and physiotherapists. Nurses working in different fields such as intensive care units, operating rooms, outpatient clinics, and ventricular assist device coordination units have important responsibilities in multidisciplinary teams. In this study, national and international studies on the responsibilities of nurses for the management and care of ventricular assist devices were reviewed. Nurses undertake many tasks, especially in the postoperative care of patients and in preparing them for discharge. Important responsibilities of nurses in the care of patients with ventricular assist devices include monitoring complications, managing equipment and emergency situations, establishing dressing change protocols, organizing daily life activities, determining rehabilitation needs, ensuring use of medicines, and providing comprehensive discharge education. Organizational and communication skills of nurses working with multidisciplinary teams are very important for the success of the ventricular assist device implantation process.

Ketamine applications beyond anesthesia – A literature review

Ketamine's clinical use began in the 1970s. Physicians benefited from its safety and ability to induce short-term anesthesia and analgesia. The psychodysleptic effects caused by the drug called its further clinical use into question. Despite these unpleasant effects, ketamine is still applied in veterinary medicine, field medicine, and specialist anesthesia. Recent intensive research brought into light new possible applications of this drug. It began to be used in acute, chronic and cancer pain management. Most interesting reports come from research on the antidepressive and antisuicidal properties of ketamine giving hope for the creation of an effective treatment for major depressive disorder. Other reports highlight the possible use of ketamine in treating addiction, asthma and preventing cancer growth. Besides clinical use, the drug is also applied to in animal model of schizophrenia. It seems that nowadays, with numerous possible applications, the use of ketamine has returned; to its former glory. Nevertheless, the drug must be used with caution because still the mechanisms by which it executes its functions and long-term effects of its use are not fully known. This review aims to discuss the well-known and new promising applications of ketamine.

National Survey of Attitudes and Practices of Endotracheal Tube Management in Infants and Small Children in Japan

Background: Surveys of pediatric endotracheal tube (ETT) management previously reported that specialists in pediatric anesthesia and intensive care medicine preferred to use uncuffed ETTs for children younger than 8 to 10 years of age. The aim of this study was to reveal the most recent attitudes and clinical practices of pediatric ETT management in Japan. Methods: The attitudes and clinical practices of pediatric ETT management were investigated using the data sheets of each institution and each patient. The data sheets contained information on patient characteristics and type of hospital, surgical procedures, devices used for intubation, and ETT information including types, size, depth, intracuff pressure (ICP), interval of ICP measurement, laryngeal packing, ETT exchange, airway complications, and reintubations. Results: The response rate of this survey was 66.7%. More than half of children older than 2 years of age were intubated with cuffed ETTs; 83.5% of cuffed ETTs were used with the cuffs inflated, and ICP was measured in 80.7% of cuffed ETTs. More than half of ICP measurements were only taken at the time of intubation. Post-extubation stridor was rarely observed in cuffed (0.4%) or uncuffed ETTs (1.2%). The pediatric ETT management questionnaire revealed age-based size selection, differences in pressure of air leakage between cuffed (15 - 20 cmH2O) and uncuffed ETTs (20 - 30 cmH2O) of different sizes, the depthmarking method of insertion length. Continuous measurement of ICP was not common. Conclusion: This study revealed widespread use of cuffed ETTs in children older than 2 years of age, rarely occurrence of post-extubation stridor, inflation of cuffs, and practice of ICP measurement.