Ethical issues in anesthesia: the need for a more practical and contextual approach in teaching

Teaching ethics to medical students is one of the current topics of major interest. Issues of ethics pertaining to anesthesia are unique. This article reviews these issues with respect to the preoperative, intraoperative, and postoperative periods. The author shares the experience of incorporating ethical issues into every clinical scenario in the problem-based learning sessions of both undergraduate and postgraduate students. In addition to separate modules in didactic and clinical formats, incorporating the ethical aspects into every clinical problem has many advantages. This approach will stimulate students to ponder over the ethical dimension of every clinical scenario, and the reinforcement of this approach during teaching in the clinical setting may help in inculcating these qualities in the students. Additionally, this approach contextualizes these issues to the local and regional perspective, instead of lecturing on the ethical codes developed elsewhere.

Evaluation of the utilization of the preanaesthetic clinics in a University teaching hospital

BACKGROUND: Dedicated out-patient preanaesthetic clinics are relatively recent phenomenon and information is sparse from developing world. This study attempted to evaluate the utilization of adult and paediatric preanaesthetic clinics and its impact on the cancellations of surgery in Trinidad. METHODS: All patients scheduled to have elective surgery during the period of twelve weeks were enrolled for prospective collection of data including demographics, the admitting diagnoses, surgical procedure, category of surgery and specialty, and the patients' attendance to preanaesthetic clinics. Cancellations on the day of surgery along with reasons were recorded. The difference between patients who attended and did not attend the clinic was analysed. RESULTS: Of 424 patients scheduled for procedures during the study period, 213 were adults and 211 were children. Overall 39 percent of adults and 46 percent of the children scheduled for surgery had previously attended the preanaesthetic clinic. Among adults, general surgery patients were the largest majority to attend the preanaesthetic clinic. The paediatric preanaesthetic clinic was mostly utilized by paediatric general surgery. Overall 30 percent of procedures in adults and 26 percent of those in children were cancelled. There was a statistically significant difference in cancellations between patients who attended and did not attend the preanaesthetic clinic (p = 0.004). There was a 52 percent more chance of the procedure getting cancelled if the patient did not attend the clinic. CONCLUSION: The study highlights the inadequate use of the preanaesthetic clinics and the impactof the clinics on last-minute cancellations.

Performance of a pediatric ambulatory anesthesia program – a developing country experience

BACKGROUND:  The aim of this study was to evaluate the performance of a pediatric ambulatory anesthesia program in a tertiary care teaching hospital in a developing country. METHODS:  Data on all pediatric patients (<16 years of age) scheduled to have elective day-care surgery during a 1 year period from January 1999 to December 1999 were collected retrospectively. An audit form was used to determine the specialty of the procedures, anesthesia techniques, postoperative analgesia, perioperative complications, unplanned admissions and outcomes with respect to morbidity and mortality. RESULTS:  A total of 763 pediatric ambulatory surgical procedures were performed during the year of 1999. The procedures included general surgery, ENT, orthopedic and plastic surgery. The most common procedure was inguinal hernia repair followed by umbilical hernia repair, adenotonsillectomy and circumcision and 96% of the patients had general anesthesia. There were only three unplanned admissions (0.4%); one for a surgical reason and two for anesthetic reasons. There was no serious morbidity or mortality in any patient. CONCLUSIONS:  Performance of pediatric day-care anesthesia has been good in our day-care unit and we have a successful ambulatory surgery program, despite the limitations of a developing country.

Topical anaesthesia without sedation in Phaco-Emulsification [abstract]

Before my transition to Phaco-Emulsification with topical anaesthesia, I believed that this method should be called "general sedation with topical anaesthesia". Today I perform all my Phaco-Emulsification with topical anaesthesia and no sedation. The most important is the pre-operative explanation and preparation of the patient. PROTOCOL: Marcaine 0.75 percent every 5 minutes, 1 drop before surgery and repeating this 3 times after having obtained dilation. After draping the patient and before the incision a shower of 0.3cc Marcaine 0.75 percent is given. Together with a good coaching of the patient and with knowledge and confidence of the procedure, it is possible to perform Phaco-Emulsification even in the most difficult or complicated cases. (AU)

Knowledge and fears of anaesthesia and surgery: the Jamaican perspective

This study was undertaken to assess patients' knowledge and perceptions, fears and concern regarding perioperative management. 300 patients were interviewed consecutively and a questionnaire was completed for each patient. 25 percent admitted to having anxiety about their upcomming operation. The prevalence of preoperative fear was significantly higher in younger patients (age <40 years, p<0.05) and in more educated patients (secondary and tertiary levels, p<0.001). The commonest fears were those of a morbid nature (eg. death on the operating table). 34 percent of the patients did not realize than anaesthetists were qualified doctors, and only 10 percent recognized the central role played by anaesthetists in the monitoring of vital signs throughout an operation. There is continuing need for public education on the role of the anaesthetists in health care, and anaesthetists must ensure that preoperative concerns of their patients are adequately addressed.(AU)

Trial of three methods of introperative bupivacaine analgesia for pain after paediatric groin surgery

To evaluate the relative effectiveness of three techniques of regional anaesthesia in the provision of postoperative analgesia in children. Methods: Random assignment of 183 children scheduled for groin surgery to one of three groups. Bupivacaine 0.5 percent plain (2 mg.kgˉ) was injected by the surgeon after skin incision. Group A received wound infiltration. Group B had regional nerve blockade. Group C had a combination of both methods. Post-operatively, pain was assessed using the CHEOPS behavioral scale at half-hourly intervals until discharge home. Satisfactory pain control was arbitrarily defined as CHEOPS score of ≤ six. Potential differences among the groups were sought using graphical presentation of mean pain scores, the frequencies of pain scores, and the incidence of postoperative vomiting and oral analgesic consumption. Results: Fifteen patients had to be excluded from analysis. This left 61 patients in Group A, 55 in Group B and 52 in Group C. There were no demographic differences among the groups. No differences were demonstrated among the groups either in CHEOPS pain scores at any observation point (P = >0.8), or in the incidence of vomiting or need for postoperative analgesia. (P = 0.52 and P = 0.41 respectively). Overall, 80 percent of the observations made (1135/1425) met our definition of satisfactory pain control. A post hoc calculation of the power of the study confirmed sufficient power to detect a 5 percent difference among groups. Conclusion: All three methods achieved analgesia with 80 percent of the pain scores meeting our definition of satisfactory pain control. None of the techniques enjoyed any apparent advantage (AU)

A survey of pre-anaesthetic information needs in Jamaican patients

The study was designed to primarily assess the desire for information in patients awaiting elective surgery at the University Hospital of the West Indies and to see what factors affected this desire. Secondarily, the patients' knowledge of anaesthesia, and the impact of an audiovisual presentation about anaesthesia was assessed. Three hundred and eighty-nine patients were interviewed on the day prior to surgery and a questionnaire completed for each patient. The results showed that the Jamaican patients had an overall positive desire for information concerning anaesthesia and surgery. Priority was given by patients to the more practical aspects of anaesthesia and surgery such as moving around and eating and drinking. Younger patients (< 40 years), female patients and patients with no previous operative experience had a greater wish to receive more information. Meeting the anaesthetist was high in the list of priorities and from the reasons advanced, many patients sought to derive some reasurrance from this meeting. Most patients (63 percent) had a simple understanding of what the anaesthetic was, approximately half of the study population thought that a patient always had to be put to sleep in order to have surgery. If a patient was female, tertiary-level educated, had had a previous operation or had been visited by an anaesthetist prior to the interview, he/she was more likely to have relevant information on the anaesthetic. The vast majority of patients (94 percent) thought that it was a patients' right to have all information, if they wished to do so. Only a small percentage of the population recalled seeing the audiovisual programme but of that number, approximately half thought it was very good. The further use of this medium for presentation of information was recommended. (AU)

Anaesthesia: the medical students' perspective - abstract

Traditionally the number of doctors specialising in anaesthesia is low, an occurrence even more marked in the Caribbean. This study presents an analysis of the attitude of 219 medical students to anaesthesia at the University Hospital of the West Indies. Three groups of medical students - the preclinical group, the first clinical year group and the final year group were surveyed, using a questionnaire containing 10 knowledge and 15 attitude questions. The mean knowledge scores (out of ten) were 7.29 ñ 1.56 for the preclinical group, 8.52 ñ 1.33 for the first clinical year group and 9.28 ñ 0.86 for the final year group. The score of the final year group was significantly higher (p<0.001) than that of both other groups, this group having completed a five-week mandatory rotation in anaesthesia. Significant differences were found between the responses of the different groups in 3 of the attitude questions, but the overall response in all groups generally indicated a positive attitude to anaesthesia; 25.5 percent of the preclinical group, 32 percent of the first clinical year group and 40.5 percent of the final year group indicated an interest in anaesthesia as a post-graduate speciality (p = 0.13). However, the number of residents entering the anaesthetic postgraduate programme does not reflect such a high level of interest. This may indicate a change in attitude during the internship period resulting in a decreasing level of interest in the specialty. Measures need to be instituted so that this level of interest may be sustained throughout internship and encourage admission into the specialty (AU)

Non-cardiogenic pulmonary oedema: a complication of larynagospasm - abstract

Four cases are presented in which pulmonary oedema followed general anaesthesia in fit, male patients. All patients developed laryngospasm on extubation, which promptly resolved on treatment but which was followed by acute pulmonary oedema. Oxygenation defects and X-ray changes diagnostic of pulmonary oedema were documented in all cases. Management consisted of endotracheal intubation with intermittent positive ventilation and the administration of furosemide. Independent cardiology evaluation, including a 12-lead electrocardiogram, was done post-operatively and was completely normal in each case. All patients recovered completely. The risk of laryngospasm is reduced if extubation is done at a deep plane of anaesthesia. In emergencies when this is not possible, extubation is best delayed until the protective reflexes have returned. If pulmonary oedema occurs, it should be treated with intermittent positive pressure ventilation and diuretics (AU)

Anaesthesia without nitrous oxide

Nitrous oxide has a long history of successful use in inhalational anaesthesia. Nevertheless questions are being raised over possible deleterious effects which may complicate its routine use. As more potent volatile agents have become available, compressed air/oxygen mixtures are gradually replacing nitrous oxide as a carrier gas in inhalational anaesthesia. We recommend that compressed air be installed on all anaesthetic machines and that in future, machines be designed so as to make it impossible to administer both nitrous oxide and air simultaneously (AU)

Anaesthesia without nitrous oxide

Nitrous oxide has a long history of successful use in inhalational anaesthesia. Nevertheless questions are being raised over possible deleterious effects which may complicate its routine use. As more potent volatile agents have become available, compressed air/oxygen mixtures are gradually replacing nitrous oxide as a carrier gas in inhalational anaesthesia. We recommend that compressed air be installed on all anaesthetic machines and that in future, machines be designed so as to make it impossible to administer both nitrous oxide and air simultaneously. (Summary)

Deaths within 24 hours of surgical procedures at the Port-of-Spain General Hospital (January, 1976 to December, 1987)

Mortality, possibly related to anaesthesia, was reviewed prospectively over a 12-year period. There were 186 deaths in 129,107 anaesthetics. Mortality was predominantly confined to the 15 - 44, and 45 - 64 -year age groups. The overall mortality rate was 1:694. Sixteen deaths were directly related to regional and local anaesthesia and three were directly related to general anaesthetic management. In 66 deaths, general anaesthesia was considered to be contributory, and 101 deaths were considered to be unassociated with anaesthesia (AU)

A proposed protocol and case report of the anaesthetic management of an HIV-positive patient

This report describes the anaesthetic mangement of an HIV-positive patient and proposes a protocol for the management that is suitable for the present working conditions in Jamaica (AU)

Endotracheal intubation and the neonate

A postmortem study of the degree of displacement of the endotracheal tube was performed on 13 neonates of varying birthweights. There was significant movement of the tube on flexion and extension of the neck, and on opening the infant's mouth. My findings lend support to certain techniques of endotracheal tube placement, the ultimate aim being accurate positioning. Other aspects of endotracheal intubation including its historical evolution, endobronchial anaesthesia, complications and physiological effects are here related from a review of the literature (AU)

Hepatic glutathione S-transferase release after multiple halothane anaesthesia

Halothane is a commonly used anaethetic in paediatric practice. However, it is thought to be hepatotoxic. This study was designed to examine the effects of both single and multiple halothane anaesthesia on liver function. Heaptic glutathione S-transferase (GST) was also examined as a possible index of acute liver damage. The study group consisted of ten children who had consumed corrosive substances. This group was subdivided into two groups, depending on the number of halothane exposures, the single and the multiple halothane group. These children were compared with a surgical (n=5) and a ketamine control group (n=5). All children were studied prospectively over a 24hr. period, and the trend of liver enzyme release following anaesthesia measured. In addition, the children in the multiple halothane group were studied longitudinally. Four children from the study group, exhibited dramatic increases in the B1 subunit of liver specific GST, 24 hours after anaethesia. Twelve studies showed an early transient rise in total plasma GST, between the end of anaesthesia and 6 hrs. after. Six studies exhibited marked secondary rise at 24 hrs. after anaesthesia. These data indicate two possible phases of liver dysfunction following halothane anaesthesia. Significant changes in the level of aminotransferases were observed in the multiple halothane group, suggesting that measurement of these liver enzymes are still useful as indices of liver dysfunction following multiple halothane exposure. Cellular antioxidant systems were also measured to examine the relationship between halothane exposure and oxidative stress. A significant increase (p<0.05) in red cell GST was noted in the multiple halothane group, indicating that these children are in fact subjected to chronic oxidant stress. Collectively, these data indicate a transient impairment of hepatocellular integrity following multiple halothane exposures, despite lack of clinical evidence of hepatotoxicity. It is recommended that children undergoing repeated halothane anaesthesia be examined carefully for possible hepatic dysfunction (AU)

Aspects of awareness during elective and emergency operations in three Jamaican hospitals, including a review of the literature

The incidence of awareness of intraoperative events, in 506 anaesthetized adult patients at three hospitals in Jamaica, was investigated. Prospective and retrospective studies on the topic were also reviewed. The overall incidence of awareness for the total study population was found to be 3 percent. The incidence for the individual hospital was: Victoria Jubilee Hospital (VJH) - 4.3 percent; Spanish Town Hospital (STH) - 3.5 percent; University Hospital of the West Indies (UCH) - 2.4 percent The physical characteristics of the patients did not appear to influence the incidence of awareness. However, the patient's preoperative emotional state appeared to influence the occurrence of intraoperative awareness. A correlation between the incidence of awareness was observed in the shorter operative procedures. Also a higher incidence of awareness occurred in obstetrical emergency procedures when compared with other operative procedures. Recommendations to prevent and/or minimize the occurrence of intraoperative awareness were suggested (AU)

Anaesthetics and intensive care 1948-1988 - abstract

This paper will review the development of the Department of Anaesthetics and Intensive Care at the U.H.W.I. and the growth of the specialty of anaesthesia between 1948 and 1988 (AU)