Peri-operative management of the obese surgical patient 2015: Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia.

Guidelines are presented for the organisational and clinical peri-operative management of anaesthesia and surgery for patients who are obese, along with a summary of the problems that obesity may cause peri-operatively. The advice presented is based on previously published advice, clinical studies and expert opinion.

The effect of a mandibular advancement splint in subjects with sleep-related breathing disorders.

OBJECTIVE: This study assessed the effectiveness of a mandibular advancement splint (MAS) in subjects with sleep-related breathing disorders using both objective and subjective outcome measures. DESIGN: The study was carried out as a retrospective analysis. SETTING: The study was conducted within the Sleep Studies Unit at the Queen Victoria Hospital, East Grinstead, between May 1997 and March 2000. SUBJECTS AND METHODS: Twenty subjects with obstructive sleep apnoea (OSA) and six with non-apnoeic snoring, diagnosed by overnight polysomnography, were fitted with a monobloc appliance between May 1997 and March 2000. MAIN OUTCOME MEASURES: The subjects were analysed for changes in the respiratory disturbance index (RDI) and Epworth Sleepiness Scale (ESS) scores. In addition each subject completed an outcome questionnaire following fitting of the appliance. RESULTS: Variability in response measured by the change in the respiratory disturbance index was found with no correlation to the baseline recording. Although median RDI values improved in both groups, significantly so in the obstructive sleep apnoea group (p<0.05), seven subjects exhibited an increased RDI score following mandibular advancement splint therapy. The median Epworth Sleepiness Scale scores decreased in both the OSA group and the non-apnoeic snorers although not significantly. Twenty-one of the 26 subjects completed the outcome questionnaire revealing an 81% reduction in snoring. Side-effects were generally transient and minor. Eighty-six per cent of the subjects' partners reported better quality of sleep as a result of MAS therapy. CONCLUSIONS: The monobloc appliance significantly improved the Respiratory Disturbance Index in the obstructive sleep apnoea group. Some subjects had increased RDI scores following splint therapy. This supports the need for an objective assessment in the follow-up of patients treated with mandibular advancement splints.

Detection of extrinsic bronchial compression during foreign body removal by pulse oximetry.

A case of stridor is described which was due to the presence of a foreign body in the larynx of an infant. Following partial removal, compression of the right main bronchus was detected because of continuing low arterial oxygen saturation. The use of pulse oximetry allowed this complication to be identified, and the advantages of this method of monitoring are discussed.

Combined radial forearm and pharyngeal flap for soft palate reconstruction.

The use of a free vascularised fascio-cutaneous radial forearm flap in combination with a cranially based pharyngeal flap for soft palate reconstruction has not been previously reported. We present the technique and illustrate its use in two cases of total and one case of subtotal soft palate reconstruction. The functional outcome is discussed with particular reference to nasal airway patency, speech and swallowing.

Evaluation of the Ambu CPAP system.

We have assessed a Venturi driven device for delivering continuous positive airway pressure (CPAP) using a reservoir bag and expiratory valve under conditions of continuous flow and simulated spontaneous breathing. The system performed well and was economical, consuming only 3.5 litre min-1 of fresh gas. One Venturi was partially blocked and performed inadequately, but the function of a second one was close to the manufacturer's specification (inspired oxygen 33%, flow 20 litre min-1 against end-expiratory pressures of 0-1.8 kPa). Compliance curves for two reservoir bags (new and old) were defined; these showed that compliance increased as the pressure in the circuit increased. The characteristics of the expiratory valve approached those of a threshold resistor. Small fluctuations in airway pressure occurred at all settings of CPAP and decreased with the increasing compliance of the circuit at higher values of CPAP. The method provided to monitor the airway pressure was inaccurate and overestimated the true pressure by 20% at pressures greater than 1 kPa.

Fibreoptic intubation through a laryngeal mask airway in an infant with Robin sequence.

Airway management is a major concern in Robin sequence, where micrognathia, glossoptosis and a cleft of the soft palate exist. The management of an infant with a potentially difficult airway is discussed where tracheal intubation was aided by the use of a 2.2-mm fibrescope mounted with a 3-mm endotracheal tube passed through a size 1 laryngeal mask airway.

The influence of timing and route of administration of intravenous ketorolac on analgesia after hand surgery.

A double-blind clinical trial was conducted on 47 patients scheduled for hand surgery under general anaesthesia to determine whether ketorolac given as part of an intravenous regional anaesthesia technique could provide better postoperative analgesia than ketorolac given intravenously either before or after surgery. Patients were randomly allocated to one of three groups to receive ketorolac 20 mg: intravenously in the non-operative arm before surgery (systemic presurgery group); intravenously to the operative arm after tourniquet inflation (regional presurgery group); intravenously in the non-operative arm after surgery (systemic postsurgery group). Postoperative pain scores were similar in the systemic presurgery and regional presurgery groups. The mean visual analogue summary pain score during the 24 h after surgery was 12.2 mm higher in the systemic postsurgery group than in the systemic presurgery group (95% CI: 0.8-23.7 mm, p = 0.037). There were no clinically important differences in mean postoperative visual analogue pain scores between the three study groups. There were no statistical differences in the mean postoperative morphine requirements between the three study groups. There is no benefit, in terms of improved postoperative analgesia, in giving ketorolac as an intravenous regional anaesthetic compared with systemic administration before surgery. The administration of ketorolac after surgery, rather then before, is not supported.

Effect of fluid preloading on cardiovascular variables after spinal anaesthesia with glucose-free 0.75% bupivacaine.

We studied the effect on systemic arterial pressure of fluid preloading with 1 litre of crystalloid fluid before spinal anaesthesia in 40 patients undergoing minor lower abdominal or lower limb surgery. Fluid was given at a rate of either 1 ml min-1 (no preload group), or 1000 ml in the 15 min (preload group) immediately before induction of spinal anaesthesia with 3 ml of 0.75% glucose-free bupivacaine. There was no difference between the groups in the character of anaesthesia or motor block in the lower limbs. The cephalad spread of analgesia ranged from L1 to C8. Analgesia was insufficient for surgery without supplementary analgesia in three patients in each group. The group not given a fluid preload had significantly lower arterial pressures (P less than 0.05) when anaesthesia extended above the T5 dermatome. The mean time before the lowest arterial pressure was recorded was twice as long in the preloaded group as in the non-preloaded group. Glucose-free 0.75% bupivacaine did not give a reliable extent of anaesthesia for lower abdominal surgery.

Management of Jehovah's Witness patients undergoing major head and neck surgery.

BACKGROUND: Several diverse strategies have been recommended to manage Jehovah's Witness patients undergoing surgery when significant blood loss is expected. However, many of the proposed management strategies cannot be used when the urgent nature of the disease precludes adequate preoperative preparation of the patient. We present our experience of the management of two Jehovah's Witnesses with oral carcinoma requiring extensive resection, neck dissection, and reconstruction with free tissue transfer. METHODS: Hypervolemic hemodilution, hypotensive anesthesia, meticulous surgical hemostasis, and antifibrinolytic therapy were used as an alternative to blood products or transfusion. RESULTS: Radical surgical ablation and state-of-the-art reconstruction were possible, as a single-stage procedure, even though blood transfusion or blood product replacement therapy was refused. CONCLUSION: Radical surgical ablation of oral carcinoma, with free tissue transfer reconstruction, is possible in this group of patients without the use of blood products or transfusion. There would have been no advantage in raising the red cell mass preoperatively, as the packed cell volume was ideal for free tissue transfer.