Dental treatment need and dental general anesthetics among preschool-age children with cleft lip and palate in northern Finland.

Cleft lip and palate incidence is high in northern Finland. This study aimed to investigate the proportion of children in need of restorative dental treatment among cleft lip and palate patients in northern Finland, as well as their need for dental treatment under general anesthesia. The records of 183 cleft lip and palate patients, treated in Oulu University Hospital from 1997 to 2013, were reviewed. Data on dental caries were analyzed in association with cleft type, considering also the presence of syndromes. The frequency of dental general anesthetic (DGA) use, and of treatments, were also analyzed. Dental treatment need was most frequently observed, in this rather limited study population, in patients with the most severe deformities, namely bilateral cleft lip and palate, of whom 60% had caries. Among the study population, 11.5% (n = 21) had a syndrome. Of those, 57.1% had dental caries at the age of 3 or 6 yr, and only four could be treated without a DGA. Dental treatment under general anesthesia was performed in 14.8% of cleft patients without a syndrome, but in 38.1% of those with a syndrome. General anaesthesia is required for the provision of dental care more often in cleft (17.5%) than in non-cleft (0.2%) patients, and especially for those with a syndrome.

An audit into the reasons why treatment was not completed as planned under intravenous sedation in an adult oral surgery department, and the cost implications.

This audit aimed to identify the prevalence of, and reasons for failed intravenous conscious sedation in an adult oral surgery department, to develop recommendations to reduce such failures and to identify any cost implications. Data were collected prospectively for three months for all intravenous sedation appointments in the Oral Surgery department. Data were collected for 109 sedation appointments of which 83 were successful (76%). The failure rate (24%) was higher than the acceptable departmental failure rate (10%), and included reasons for failure that should have been avoided by a thorough patient assessment prior to treatment. Of the 26 failures, the most common reasons for failure were: cancellation: 8 patients (30.8%), failure to attend: 6 patients (23.1%), excessively late arrival of patient: 4 patients (15.4%) and failure to cannulate: 3 patients (11.6%). When sedation was unsuccessful, 13 of the 26 patients (50%) had their treatment successfully completed under local anaesthesia alone, 10 patients (38%) were rebooked for sedation and 3 patient. (12%) were rebooked for a general anaesthetic. Identifying and correcting the reasons for failure can result in vast savings in appointment time, clinical resources and cost. That 13 patients subsequently had their treatment completed under local anaesthesia alone opens the debate on how rigorous the patient assessment and allocation of sedation appointments was, and the potential to achieve savings.

[Incorrect programming of a target controlled infusion pump. Case SENSAR of the trimester]. / Programación errónea de una bomba de TCI. Caso SENSAR del trimestre.

We report the case of a patient who underwent surgical aortic valve replacement. During general anaesthesia maintenance, the patient received a remifentanyl infusion via a target controlled infusion (TCI) system. The infusion pump that was prepared to deliver the infusion showed malfunction at the beginning of the surgery, so it was quickly replaced with a second pump. After a few minutes into the surgery, the patient presented with hypotension refractory to treatment. The remifentanyl syringe also emptied faster than expected. On reviewing the TCI pump, it was found that it was erroneously programmed for propofol instead of remifentanyl, thus the patient had received a very high dose of remifentanyl that was probably the cause of the haemodynamic disturbances. The incident was an error in equipment use, facilitated by hurry, lack of checking of the equipment prior to its use, and the complex and unclear design of the devices' screens. After analysis of this incident, all TCI pumps were reviewed, and all the programs for infrequently used drugs were deleted. Furthermore, 2 pumps were selected for exclusive use in the cardiac surgery theatre, one with propofol-only programming, and the other with remifentanyl-only programming, both clearly marked and situated in fixed places in that theatre.

[Supraglottic airways in infants and children]. / Kinderanästhesie--Supraglottische Atemwege bei Säuglingen und Kleinkindern.

The development of the LMA-Classic™ revolutionized anaesthesia practice as its wide-spread use led to the establishment of a unique form of airway management, the "supraglottic airway management", besides the existing classical airway management with the face mask or endotracheal tube. Today, 25 years later, along with the original prototype of supraglottic airways quite a few numbers of different devices exist that can be used to secure the airway "above the glottis". After initially primarily marketing adult sizes many suppliers offer paediatric sizes nowadays. However, the scientific evidence in terms of superiority or at a least equality to the original LMA-Classic( of any of these airway devices must be considered insufficient except for the LMA-ProSeal™. Consequently, the routine use of these devices outside controlled clinical studies must be considered questionable. The following article aims at providing a critical appraisal of currently available supraglottic airway devices for neonates and infants.

[Clinical basics of supraglottic airway management in paediatric anaesthesia]. / Kinderanästhesie--Klinische Grundlagen des supraglottischen Atemwegsmanagements.

The low invasiveness and simplicity of use of the LMA-Classic™ contributed substantially to the supraglottic airway management acquiring a special role in the anaesthesia care of neonates and children. Due to the introduction of new supraglottic airway devices and the expansion of indications, this form of airway management has a predominant role in paediatric anaesthesia in many institutions nowadays. As securing the airway "above the glottis" differs substantially in some aspects from securing the airway using the endotracheal tube it is mandatory to acknowledge special aspects in routine clinical practice in order to avoid complications. The following article describes basic aspects of supraglottic airway management in paediatric anaesthesia and illustrates, where possible, the available scientific evidence in the use of different supraglottic airway devices in this regard.

Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study.

BACKGROUND: Perioperative respiratory adverse events in children are one of the major causes of morbidity and mortality during paediatric anaesthesia. We aimed to identify associations between family history, anaesthesia management, and occurrence of perioperative respiratory adverse events. METHODS: We prospectively included all children who had general anaesthesia for surgical or medical interventions, elective or urgent procedures at Princess Margaret Hospital for Children, Perth, Australia, from Feb 1, 2007, to Jan 31, 2008. On the day of surgery, anaesthetists in charge of paediatric patients completed an adapted version of the International Study Group for Asthma and Allergies in Childhood questionnaire. We collected data on family medical history of asthma, atopy, allergy, upper respiratory tract infection, and passive smoking. Anaesthesia management and all perioperative respiratory adverse events were recorded. FINDINGS: 9297 questionnaires were available for analysis. A positive respiratory history (nocturnal dry cough, wheezing during exercise, wheezing more than three times in the past 12 months, or a history of present or past eczema) was associated with an increased risk for bronchospasm (relative risk [RR] 8.46, 95% CI 6.18-11.59; p<0.0001), laryngospasm (4.13, 3.37-5.08; p<0.0001), and perioperative cough, desaturation, or airway obstruction (3.05, 2.76-3.37; p<0.0001). Upper respiratory tract infection was associated with an increased risk for perioperative respiratory adverse events only when symptoms were present (RR 2.05, 95% CI 1.82-2.31; p<0.0001) or less than 2 weeks before the procedure (2.34, 2.07-2.66; p<0.0001), whereas symptoms of upper respiratory tract infection 2-4 weeks before the procedure significantly lowered the incidence of perioperative respiratory adverse events (0.66, 0.53-0.81; p<0.0001). A history of at least two family members having asthma, atopy, or smoking increased the risk for perioperative respiratory adverse events (all p<0.0001). Risk was lower with intravenous induction compared with inhalational induction (all p<0.0001), inhalational compared with intravenous maintenance of anaesthesia (all p<0.0001), airway management by a specialist paediatric anaesthetist compared with a registrar (all p<0.0001), and use of face mask compared with tracheal intubation (all p<0.0001). INTERPRETATION: Children at high risk for perioperative respiratory adverse events could be systematically identified at the preanaesthetic assessment and thus can benefit from a specifically targeted anaesthesia management. FUNDING: Department of Anaesthesia, Princess Margaret Hospital for Children, Swiss Foundation for Grants in Biology and Medicine, and the Voluntary Academic Society Basel.

Sugammadex for the reversal of muscle relaxation in general anaesthesia: a systematic review and economic assessment.

BACKGROUND: Sugammadex (Bridion) is a newly developed agent for the reversal of neuromuscular blockade (NMB) induced by rocuronium or vecuronium. Sugammadex can reverse profound blockade and can be given for immediate reversal and its use would avoid the potentially serious adverse effects of the currently used agent, succinylcholine. Also, sugammadex can reverse NMB more quickly and predictably than existing agents. OBJECTIVES: To determine the clinical effectiveness and cost-effectiveness of sugammadex for the reversal of muscle relaxation after general anaesthesia in UK practice following routine or rapid induction of NMB. DATA SOURCES: Medical databases [including MEDLINE, EMBASE, CINAHL, Science Citation Index, BIOSIS and Cochrane Central Register of Controlled Trials (CENTRAL), conference proceedings, internet sites and clinical trials registers] were searched to identify published and unpublished studies. The main searches were carried out in May 2008 and supplemented by current awareness updates up until November 2008. REVIEW METHODS: For the clinical effectiveness review, randomised controlled trials of sugammadex against placebo or an active comparator (neostigmine + glycopyrrolate) for the reversal of moderate or profound NMB and for immediate reversal (spontaneous recovery from succinylcholine-induced blockade) were included. The primary effectiveness outcome was speed of recovery from NMB, as measured by objective monitoring of neuromuscular function. For the cost-effectiveness review, a de novo economic assessment considered the routine induction of NMB and the rapid induction and/or reversal of NMB, and threshold analyses were carried out on a series of pairwise comparisons to establish how effective sugammadex needs to be to justify its cost. RESULTS: The review of clinical effectiveness included four randomised active-control trials of sugammadex, nine randomised placebo-controlled trials and five studies in special populations. A total of 2132 titles and abstracts and 265 full-text publications were screened. The included trials indicated that sugammadex produces more rapid recovery from moderate or profound NMB than placebo or neostigmine. Median time to recovery from moderate blockade was 1.3-1.7 minutes for rocuronium + sugammadex, 21-86 minutes for rocuronium + placebo and 17.6 minutes for rocuronium + neostigmine. In profound blockade, median time to recovery was 2.7 minutes for rocuronium + sugammadex, 30 to > 90 minutes for rocuronium + placebo, and 49 minutes for rocuronium + neostigmine. Results for vecuronium were similar. In addition, recovery from NMB was faster with rocuronium reversed by sugammadex 16 mg/kg after 3 minutes (immediate reversal) than with succinylcholine followed by spontaneous recovery (median time to primary outcome 4.2 versus 7.1 minutes). The evidence base for modelling cost-effectiveness is very limited. However, assuming that the reductions in recovery times seen in the trials can be achieved in routine practice and can be used productively, sugammadex [2 mg/kg (4 mg/kg)] is potentially cost-effective at its current list price for the routine reversal of rocuronium-induced moderate (profound) blockade, if each minute of recovery time saved can be valued at approximately 2.40 pounds (1.75 pounds) or more. This is more likely to be achieved if any reductions in recovery time are in the operating room (estimated value of 4.44 pounds per minute saved) rather than the recovery room (estimated value of 0.33 pounds per minute saved). The results were broadly similar for rocuronium- and vecuronium-induced blockade. For rapid reversal of NMB it appeared that any reduction in morbidity from adopting sugammadex is unlikely to result in significant cost savings. LIMITATIONS: The evidence base was not large and many of the published trials were dose-finding and safety studies with very small sample sizes. Also, some relevant outcomes, in particular patient experience/quality of life and resources/costs used, were either not investigated or not reported. In addition, it is likely that the patients included in the efficacy trials were relatively young and in good general health compared with the overall surgical population. Regarding the economic evaluation, there appears to be no evidence linking measures of clinical efficacy to patients' health-related quality of life and mortality risks. CONCLUSIONS: Sugammadex may be a cost-effective option compared with neostigmine + glycopyrrolate for reversal of moderate NMB and also provides the facility to recover patients from profound blockade. Rocuronium + sugammadex could be considered as a replacement for succinylcholine for rapid induction (and reversal) of NMB, although this may not be a cost-effective option in some types of patient at current list prices for sugammadex. Considerable uncertainties remain about whether the full benefits of sugammadex can be realised in clinical practice.

Introduction of bispectral index monitoring in a district general hospital operating suite: a prospective audit of clinical and economic effects.

BACKGROUND AND OBJECTIVE: Randomized controlled trials have shown several beneficial effects of intraoperative bispectral index monitoring. We conducted a prospective audit to determine whether these could be replicated in everyday clinical practice. METHODS: Recovery characteristics and drug costs from two 4-week periods were compared, immediately before (phase 1, n = 427 patients) and after (phase 2, n = 299 patients) the introduction of bispectral index monitoring in the main operating theatres of a district general hospital. RESULTS: Demographic and intraoperative variables for the two patient groups were similar. Nausea (P = 0.002), vomiting (P = 0.008) and antiemetic use (P = 0.001) in the postanaesthesia care unit all decreased in phase 2, though unrelated changes in antiemetic policy may have been partly responsible. Recovery time was unaffected. Drug costs decreased in phase 2 by an average of 0.86 pounds per patient. The cost of each semi-reusable sensor was 6.60 pounds. CONCLUSION: In a prospective audit, benefits of intraoperative bispectral index monitoring in our district general hospital were not seen to the same degree as in randomized controlled trials elsewhere.

Successful and safe delivery of anesthesia and perioperative care for children with complex special health care needs.

STUDY OBJECTIVE: To determine the utilization of anesthesia resources by children with complex special health care needs. DESIGN: Observational, inception cohort study of medical records. SETTING: Urban, pediatric, tertiary-care hospital. MEASUREMENTS: All general anesthetic cases were screened for preexisting complex special health care needs. Medical records were reviewed for demographic, clinical, and outcome data. MAIN RESULTS: 435 children with complex special health care needs accounted for 479 delivered general anesthetic cases. This figure represented 14% of the total 3,437 cases presenting during the study period. It also represented 22% (49 of 224) of all cancellations. Down syndrome was the most identifiable developmental disorder (n = 43, 9%). Another 143 (30%) cases showed preexisting technology dependence. Scheduled surgical procedures (n = 425, 89%) comprised the majority of cases. Intraoperative and recovery room complications occurred in 6 (1%) and 133 (28%) cases, respectively. Eleven (2.3%) cases required unplanned post-anesthetic hospital ward or pediatric intensive care unit admission. Documentation of health care proxy or resuscitation status was not identified in any child under 18 years, and in only 4 of 33 children older than 18 years. CONCLUSIONS: Children with complex special health care needs represented one out of 7 of all pediatric general anesthetic cases at a tertiary-care, academic center.

Anaesthesia and fatigue: an analysis of the first 10 years of the Australian Incident Monitoring Study 1987-1997.

The Australian Incident Monitoring Study (AIMS) database of the Australian Patient Safety Foundation (APSF) was reviewed from its inception in April 1987 to October 1997. A total of 5600 AIMS reports were lodged in that period. Reports in which fatigue was listed as a Factor Contributing to Incident were examined. This occurred in 152 reports, or 2.7% of all reports. Confidence interval analysis suggested that fatigue was associated with various concurrently reported factors. These included pharmacological incidents (especially syringe swaps) and time of day. Other factors significantly associated with fatigue reports were haste, distraction, inattention and failure to check equipment. Relieving anaesthetists and healthy patients were reported more often as factors minimizing incidents. Anaesthetists reporting fatigue more often reported incidents during induction. These data suggest that fatigue alleviation strategies and equipment checking routines, improved workplace design (including drug ampoule and syringe labelling protocols) and regulation of working hours will facilitate minimization of fatigue-related incidents. Definitive prospective studies might be most usefully targeted at these and related interventions.

Effects of a low-cost protocol on outcome and cost in a group practice setting.

STUDY OBJECTIVE: To investigate, in a group practice setting, the effects of combining information about drug costs with adoption of a voluntary low-cost protocol. DESIGN: Prospective before-and-after intervention comparison study. SETTING: Private practice anesthesiology group (certified registered nurse-anesthetists and anesthesiologists) of a large midwestern for-profit hospital. MEASUREMENTS AND MAIN RESULTS: Clinical outcome and anesthesia-related drug cost were examined for coronary artery bypass grafts (CABG), laparoscopic cholecystectomy (LC), and lumbar laminectomy (LL). There were no restrictions on the use of any drug if warranted by the patient's condition. 135 consecutive prospective (P) cases performed by the anesthesiology group after the intervention were retrospectively matched by surgery type and surgeon to cases done 9 months prior to the protocol to form the retrospective control group (R) resulting in a total sample of 270 subjects. Significant cost reductions were seen in LC-(57%), LL-(42%), and CABG-(37%). The largest cost reductions were opioids (78%), induction drugs (50%), and muscle relaxants (41%). There were no differences in pain, nausea, or hypertension scores between the P and R groups, but there were minor differences in recovery room, oxygen therapy, and dismissal times between the R and P groups of LC and LL patients. There were no differences in anesthetic outcome for CABG patients between the P and R groups. A follow-up survey completed 4 months after the study demonstrated that muscle relaxant costs and fresh gas flow rates and costs had returned to preintervention levels, while opioid and induction drug savings were maintained. CONCLUSIONS: A private practice anesthesia group that followed a voluntary protocol could significantly reduce drug cost with little change in clinical outcome. However, the savings may not be completely maintained after the monitoring period.