Comparison of four different protocols using levobupivacaine for spinal anaesthesia in red-footed tortoises (Chelonoidis carbonarius).

Background: The popularity of tortoises kept in captivity is increasing and has caused concern regarding the necessity to establish safe and straightforward anaesthesia for those reptiles. Aim: This study aimed to compare four protocols using levobupivacaine in spinal anaesthesia for the blockade of the caudal neuraxis of red-footed tortoises (Chelonoidis carbonarius). Methods: Twenty-four tortoises were randomly assigned into four groups: G1, levobupivacaine 0.75% (1.15 mg kg-1); G2, levobupivacaine 0.37% (1.15 mg kg-1); G3, levobupivacaine 0.75% (2.3 mg kg-1); and G4, levobupivacaine 0.75% (0.1 ml 5 cm-1 of straight carapace length). Tortoises were evaluated for respiratory rate, muscle relaxation, response to hindlimb or tail pinch, and cloacal reflex. Results: A 1.15 mg kg-1 dose of levobupivacaine 0.37% appears adequate for shorter procedures, whereas a 1.15 mg kg-1 dose of levobupivacaine 0.75% should be appropriate for longer procedures in red-footed tortoises. Conclusion: Our results are the first to show the effects of levobupivacaine on spinal anaesthesia in reptiles. Weight-based doses presented more intense and more homogeneous effects than carapace length-based doses in red-footed tortoises. Spinal anaesthesia of red-footed tortoises was safe and effective with any of the weight-based protocols.

The Anaesthetic Efficacy of Tetracaine and Oxymetazoline Compared With Co-Phenylcaine in Healthy Individuals.

OBJECTIVES: Nasal anaesthetic-decongestant sprays are commonly used prior to nasal instrumentation, such as flexible and rigid nasal endoscopy. Co-phenylcaine (lignocaine 5%, phenylephrine 0.5%, ENT Technologies Pty Ltd., Melbourne, VIC, Australia) is a combination spray commonly used for this purpose. However, lignocaine is less potent than other local anaesthetics, and both active constituents of Co-phenylcaine have a bitter taste. It was hypothesised that a combination spray containing tetracaine and oxymetazoline would both offer more potent topical anaesthesia and have a better taste. METHODS: Four anaesthetic-decongestant nasal sprays were tested in 10 healthy participants (Co-phenylcaine, and tetracaine 0.5%, 1% and 2% with oxymetazoline 0.05%). Sensory thresholds were sequentially measured at the head of the inferior turbinate using Semmes-Weinstein monofilaments over the following hour. Participants also rated taste on a Likert-style scale, and reported whether they experienced subjective numbness of the maxillary teeth. RESULTS: A median peak sensory threshold of 60 g (the maximum tested) was observed with Co-phenylcaine, but this threshold was exceeded by all the tetracaine-based sprays. Tetracaine 2% with oxymetazoline 0.05% had a significantly more rapid onset than Co-phenylcaine (4 min vs. 6 min, p < 0.05) and a longer duration of action. Eight participants reported dental numbness after administration of tetracaine 2% with oxymetazoline 0.05%, but only one participant after Co-phenylcaine. Tetracaine-based sprays were generally perceived to taste less unpleasant than Co-phenylcaine. CONCLUSION: Tetracaine 2% with oxymetazoline 0.05% is a more potent and rapidly acting anaesthetic-decongestant spray than Co-phenylcaine, with a longer duration of action.

Evaluation of Operating Room Staff Awareness of Environmental Sustainability and Medical Waste Management.

Objective: This study aims to identify the obstacles to recycling and environmental sustainability habits in a university hospital's operating room (OR) environment in Turkey and lay the groundwork for potential solutions. Methods: A questionnaire was used to measure current views among the 140 OR staff members aged 20-54 years. The survey assessed awareness and behaviors of recycling at home and in the OR, as well as awareness of environmentally safe anaesthesia practices. Results: Half of the participants believed that ORs significantly affected their carbon footprint, and most agreed that these environmental effects could be reduced. The primary barriers to recycling were inadequate knowledge, negative staff attitudes and insufficient services. Notably, 76% of participants paid attention to segregating OR waste, yet many lacked formal education about the environmental impact of their practices. Approximately 89% agreed that the environmental effects of ORs could be further reduced, with education being a critical need. Conclusion: The healthcare sector's contribution to carbon emissions and waste production is significant, especially in ORs. The lack of education regarding ecological implications is concerning. Implementing standardized training programs and enhancing recycling services can substantially reduce the environmental impact of ORs, highlighting the need for a more sustainable healthcare system.

Effect of preprocedure anxiety and oestrogen levels on Postoperative Nausea and Vomiting in patients undergoing diagnostic laparoscopy and hysteroscopy for infertility: A prospective observational pilot study.

BACKGROUND: Females undergoing laparoscopic gynaecological surgeries have a high incidence of postoperative nausea and vomiting. Apart from the established risk factors, hormonal, psychological, genetic and ethnic factors may also contribute to postoperative nausea and vomiting. This study aimed to evaluate the relationship between preoperative anxiety and serum oestrogen level with postoperative nausea and vomiting in patients undergoing diagnostic laparoscopy - hysteroscopy for infertility. METHODS: In total, 100 female patients, between the ages of 20-40 years, undergoing diagnostic laparoscopy - hysteroscopy for infertility were recruited for this study. Preoperative anxiety level was assessed using Depression, Anxiety and Stress Scale-21 (DASS-21) Questionnaire. Serum oestrogen samples were taken before anaesthesia. Postoperative nausea and vomiting grading was rated with 0-3 Likert-type scale. An association of anxiety and oestrogen levels to postoperative nausea and vomiting was done. RESULTS: The analysis between median DASS 21 scores to postoperative nausea and vomiting grading showed no association between DASS 21 scores and postoperative nausea and vomiting grades. Comparing the mean oestrogen levels in patients among each grade of postoperative nausea and vomiting showed no significant difference in the mean oestrogen levels. CONCLUSION: Our study did not find evidence of a significant association between serum oestrogen levels, preoperative anxiety, and postoperative nausea and vomiting.

Can the Pioneering Impact of Artificial Intelligence in Anaesthetic Practice Uphold Good Medical Practice?

The potential applications of Artificial Intelligence (AI) in anaesthesia are expansive.~However, like any technological advancement, the integration of AI in anaesthetic practice comes with both benefits and potential risks. This article seeks to set out some of the advantages and disadvantages of the use of AI technologies within the field of anaesthesia. Benefits of the application of AI in anaesthesia include an improvement in perioperative risk stratification, personalisation of anaesthetic plans, improvement in efficiency and ultimately reduce healthcare costs. However, reliance on technology may reduce clinical acumen but furthermore there are issues surrounding data quality, privacy as well as legal and ethical concerns, which require further evaluation. Whilst AI within anaesthetic practice holds immense promise, there are substantial challenges which require careful consideration and ongoing evaluation. A collaborative approach will be required from healthcare staff, developers and regulators to promote the safe, responsible, and effective application of AI in anaesthesia practice.

A bite of death: Anaesthetic challenges in frostbite.

BACKGROUND: Frostbite is defined as tissue damage that is sustained as a result of prolonged exposures to less than 0°C resulting in ice crystallisation, microvascular occlusion and subsequently thrombosis. CASE: A 33-year-old mountaineer with cold burn over 20% of the total body surface area with eschar formation, acute renal failure, upper limb venous thrombosis and bilateral pleural effusion. We hereby report a successful anaesthetic management of this patient undergoing debridement and escharotomy for frostbite injuries and review its perioperative concerns. CONCLUSION: Frostbite injuries pose a challenge to the anaesthetic team due to the multi-systemic nature of its involvement.

Predictors of paediatric difficult intubation according to the experience of a university hospital in a low- and middle-income country: A prospective observational study.

BACKGROUND: Difficult airway management is one of the main challenges in paediatric anaesthesia, particularly in low- and middle-income countries. AIMS: The aim of this study was to investigate the main predictors of difficult paediatric intubation. METHODS: In this observational study, we included all children aged less than five years undergoing intra-abdominal surgery with endotracheal intubation. Patients were divided into two groups according to the incidence of difficult intubation. Then, we investigated predictors for difficult paediatric intubation. RESULTS: We included 217 children, and difficult intubation was observed in 10% of them. Predictors were as follows: Mallampati III-IV class (adjusted odds ratio = 2.21; 95% confidence interval = 1.1-6.4), limited mouth opening (adjusted odds ratio = 2.4; 95% confidence interval = 1.8-3.5), facial dysmorphia (adjusted odds ratio = 2.6; 95% confidence interval = 1.32-7.4) and anaesthesia without muscle relaxant (adjusted odds ratio = 1.8; 95% confidence interval = 1.0-5.1) or without opioids during crash inductions (adjusted odds ratio = 1.7; 95% confidence interval = 1.01-4.8). CONCLUSION: Facial dysmorphia and limited mouth opening were predictors of difficult intubation in children. Furthermore, it seems that Mallampati class and anaesthesia technique may also predict challenging intubation, which may guide us to change our perioperative practice.

Cost Awareness of Anaesthetic Consumable Items Among the National Health Service (NHS) Staff and the Financial Impact on the NHS.

Background The financial burden of running the National Health Service (NHS) is high. Staff members should be aware of the cost of the equipment they use to enable efficient use of resources, reduce waste, and control spending. However, limited financial education at undergraduate and junior stages has contributed to relatively poor knowledge among healthcare workers at all levels. Anaesthetics is a speciality which uses a large amount of equipment; therefore, we aim to assess the cost awareness among staff for commonly used consumables. Furthermore, we aim to assess staff members' attitudes towards the financial and environmental impact of the equipment they use and whether this would change their practice. Methodology An electronic survey was sent to staff members from the anaesthetic department of the Medway NHS Foundation Trust during a one-month period. Respondents were asked to estimate the cost of 19 commonly used anaesthetic consumables, with an estimate categorised as correct if it was within 20% of the actual cost. At the end of the survey, there were five questions for respondents to answer regarding the financial and environmental impact of their current healthcare practice and possible alternatives. Results There were 69 respondents within the anaesthetic department from a variety of roles. Overall, only 9.37% of items were estimated correctly, with cheaper items commonly being overestimated and more expensive items being underestimated. Overall, 60% of respondents said the cost of an item would influence their use. The overwhelming majority claimed that the environmental impact was a concern, and most would favour recyclable/reusable alternatives. Conclusions Cost awareness among anaesthetic staff for commonly used equipment is poor. More education and training are necessary in this area as limited knowledge of service costs restricts the ability to make cost-efficient choices which are needed in the current NHS.

Perioperative efficiency of sugammadex following minimally invasive gastric sleeve surgery: A superiority trial.

BACKGROUND: Studies have proposed that the routine use of sugammadex could provide perioperative time savings and a reduction in the incidence of postoperative nausea and vomiting. The purpose of this study was to test the effectiveness of sugammadex on perioperative times and on the incidences of adverse events when compared with the active control, neostigmine, for minimally invasive gastric sleeve surgery. METHODS: Following institutional review board approval, patient characteristics, type of primary neuromuscular blocking reversal agents, operating room discharge times, post-anaesthesia care unit recovery times, and incidences of and treatment for postoperative nausea and vomiting and orotracheal reintubation were the measures of interest. Superiority testing determined the between-group means differences of the reversal agents on the two perioperative time periods of interest. RESULTS: Superiority testing demonstrated no improvement of the two perioperative times with sugammadex. There was no clinical difference in the incidence of postoperative nausea and vomiting or in the number of antiemetic doses received in the post-anaesthesia care unit between the two groups. Finally, the two orotracheal reintubations in the post-anaesthesia care unit were in the sugammadex administered group. CONCLUSION: These results with sugammadex provide no perioperative time savings or reduce the incidence and treatment for postoperative nausea and vomiting in the post-anaesthesia care unit when compared with neostigmine.

Lateral versus supine position for tracheal extubation among infants after intraabdominal surgery: A randomised controlled trial.

In this prospective randomised controlled trial, we compared the impact of the lateral versus supine position for tracheal extubation among infants aged two months to two years after intraabdominal surgery on the incidence of respiratory adverse events that may occur after extubation. The anaesthesia protocol was standardised. Among the 120 infants included (60 in each group), the demographic and perioperative data were comparable between both groups. The incidence of perioperative respiratory adverse events after tracheal extubation was 21.6% and 5% in the supine and lateral position groups, respectively, with p = 0.007 and odds ratio = 3.87; 95% confidence interval: 1.18-12.6. Lateral position also reduced the incidence of airway obstruction with p = 0.004 and odds ratio = 11.8; 95% confidence interval: 1.46-95.3 and oxygen desaturation below 92% with p = 0.008 and odds ratio = 11.8; 95% confidence interval: 1.46-95. The lateral position seems to be practical and beneficial for tracheal extubation among infants.

Promoting behavioural change by educating anaesthetists about the environmental impact of inhalational anaesthetic agents: A systematic review.

Of the total carbon footprint of Australia, 7% is attributed to healthcare. In the UK, inhalational agents make up 5% of the healthcare carbon footprint. This systematic review aims to determine which methods of education about the environmental impact of inhalational anaesthetic agents can be utilised to promote behaviour change, reducing the anaesthetic-related carbon footprint. This systematic review sourced records from CINAHL, EMBASE, ERIC, JBI and MEDLINE from 1970 to March 2022. The search identified 589 records, 13 of which met eligibility criteria after the screening process, in which 10 of these records were conference abstracts. Education curricula focused on inhalational agent choice (69%), lowering the fresh gas flow during maintenance anaesthesia (69%), encouraging alternatives such as total intravenous anaesthesia (23%) and/or switching off the gas on transfer (8%). The most common teaching techniques utilised in education curricula were didactic lectures (85%), visual prompts (54%), emails (46%), and conversation forums (31%). All but one study reported a positive relationship between teaching sessions and behavioural change resulting in lower inhalational anaesthetic use by participants and their organisations, reducing healthcare-associated emissions. This systematic review has demonstrated that single education sessions as well as multi-focused, multimodal education curricula on the topic of greener anaesthesia can be beneficial in promoting behavioural change.

Assessing knowledge of dental house officers regarding dosage calculation and complications of local anaesthesia, in three tertiary care dental hospitals of DUHS, Karachi.

Objectives: To assess the knowledge and awareness of dental house officers regarding calculation of local anaesthesia dosage, and to evaluate differences in practices at various tertiary care facilities. METHODS: The cross-sectional study was conducted at three dental hospitals affiliated with Dow University of Health Sciences, Karachi from July to December 2022, and comprised house officers of either gender currently enrolled at the participating centres. Data was collected using a self-administered questionnaire to assess knowledge and awareness of local anaesthesia dosage calculation, administration methods, and common complications. Data was analysed using SPSS 26. RESULTS: Of the 200 subjects approached, 136(68%) responded, and 89(65.4%) of them were females. Knowledge regarding the meaning of 2% lidocaine solution was low 45(33%), and 68(50%) subjects were knowledgeable about the maximum dosage of lidocaine with epinephrine. In terms of practice, lidocaine was the most commonly administered local anaesthetic 115(85%), followed by bupivacaine 15(11%). The majority of subjects administered local anaesthesia with vasoconstrictor 127(94%), but only 36(27%) performed aspiration during administration. Syncope 71(52%) was the most commonly reported complication, followed by lip/cheek/tongue biting by 35(26%). CONCLUSIONS: House officers' knowledge level of local anaesthesia administration indicated the need for adequate training.

Analgesic Effects of Intraperitoneal Lidocaine in Adults Undergoing Surgery: A Systematic Review and Meta-Analysis with Trial Sequential Analysis.

OBJECTIVE: The administration of local anaesthesia in intraperitoneal space as part of the multi-modal analgesic regimen has shown to be effective in reducing postoperative pain. Recent studies demonstrated that intraperitoneal lidocaine may provide analgesic effects. Primary objective was to determine the impact of intraperitoneal lidocaine on postoperative pain scores at rest. DESIGN: We carried out a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). METHODS: Databases of MEDLINE, EMBASE, and CENTRAL were searched from their inception date until May 2023. Randomized clinical trials (RCT) comparing intraperitoneal lidocaine and placebo in adults undergoing surgery were included. RESULTS: Our systematic review included 24 RCTs (n = 1,824). The intraperitoneal lidocaine group was significantly associated with lower postoperative pain scores at rest (MD: -0.87, 95% CI: -1.04 to -0.69) and at movement (MD: -0.50, 95% Cl: -0.93 to -0.08) among adult patients after surgery. Its administration also significantly decreased morphine consumption (MD: -6.42 mg, 95% Cl: -11.56 to -1.27), lowered the incidence of needing analgesia (OR: 0.22, 95% Cl: 0.14 to 0.35). Intraperitoneal lidocaine statistically reduced time to resume regular diet (MD: 0.16 days; 95% Cl: -0.31 to -0.01), and lowered postoperative incidence of nausea and vomiting (OR: 0.54, 95% Cl: 0.39 to 0.75). CONCLUSIONS: In this review, our findings should be interpreted with caution. Future studies are warranted to determine the optimal dose of administering intraperitoneal lidocaine among adult patients undergoing surgery.

A randomised trial comparing block characteristics of a mixture versus sequential injections of lignocaine and ropivacaine for supraclavicular brachial plexus nerve block in patients undergoing upper limb surgery.

Background and Aim: There is no consensus on the appropriate use of mixtures of local anaesthetic drugs in various combinations for nerve blocks. We intended to compare short-acting lignocaine and long-acting ropivacaine as a mixture versus undiluted sequential injections on block characteristics of ultrasound-guided (USG) supraclavicular brachial plexus block for upper limb surgeries. Methods: A double-blinded randomised study was conducted on 64 adult patients scheduled for upper limb surgery who received 15 mL each of 2% lignocaine with adrenaline and 0.75% ropivacaine as a 1:1 mixture in the mixed group (Group M) or sequential injections in the sequential group (Group S) by using a USG technique. The primary outcome was the percentage of participants with complete four nerve sensory blocks at 10 minutes post block injection. Secondary outcomes were sensory and motor block characteristics till 30 minutes, total duration of analgesia, sensory and motor block, and complications. Results: Demographic characteristics and time taken for the procedure were similar. The percentage of participants with a complete four-nerve sensory block at 10 minutes was higher in Group S (69%) versus Group M (41%) (P = 0.04). Complete sensory and motor block rates were similar at 30 minutes. The block procedure time, total duration of analgesia, and sensory and motor block were similar in both groups. There were no major complications. Conclusion: Sequential lignocaine-ropivacaine, compared to the mixed injection technique, has a higher initial rate of sensory and motor block onset with a similar total block duration.

Evaluation of the passive mast cell activation test for identifying allergens in perioperative anaphylaxis: a study protocol for a prospective diagnostic accuracy study.

INTRODUCTION: Perioperative anaphylaxis (POA) can lead to significant complications. Therefore, accurate identification of allergens for POA patients is critical to ensure the safety of future surgical and anaesthetic procedures. Existing perioperative allergen detection methods face challenges in sensitivity and specificity. The passive mast cell activation test (pMAT) has recently emerged as a potential diagnostic tool. Our study aims to evaluate the diagnostic efficacy of pMAT for identifying perioperative allergens, with a focus on non-depolarising neuromuscular blocking agents, the most common culprits of POA. METHODS AND ANALYSIS: This prospective diagnostic accuracy study will measure the diagnostic accuracy of pMAT in POA patients. Participants will undergo skin testing (ST), basophil activation testing (BAT) and pMAT. The diagnostic validity of pMAT will be assessed based on the results of ST and BAT. The assessment of diagnostic accuracy will include sensitivity, specificity, likelihood ratios, and false-positive and false-negative rates while measurement of the consistency rate will assess reliability. ETHICS AND DISSEMINATION: This study has been approved by the Institutional Review Board of China-Japan Friendship Hospital (2023-KY-247). Results will be disseminated through academic presentations and peer-reviewed journal publications and will provide valuable scientific data and some new insights into the diagnostic accuracy of pMAT.