[Use of thoracic and lung ultrasound in general anesthesia]. / A mellkas és a tüdo ultrahangvizsgálatának szerepe az általános érzéstelenítés során.

The use of ultrasound became an essential tool in the everyday practice of anesthesiology and intensive care as an indispensable prerequisite for the precise guidance of invasive procedures and also as a point-of-care diagnostic method. Despite the limitations of imaging the lung and thoracic structures, the COVID-19 pandemic and recent advances made this technology an evolving field. The intensive therapy applies these methods with important experience for differential diagnosis and assessment of disease severity or prognosis. Minor modifications of these results make the method beneficial for anesthesia and perioperative medicine. In the present review, the authors accentuate the most important imaging artefacts of lung ultrasonography and the principles of lung ultrasound diagnostic steps. Methods and artefacts of high importance supported by evidence for the assessment of airway management, attuning of intraoperative mechanical ventilation, respiratory disorders during surgery, and postoperative prognosis are articulated. This review intends to focus on evolving subfields in which technological or scientific novelties are expected. Orv Hetil. 2023; 164(22): 864-870.

Evaluation of pre-induction dynamic arterial elastance as an adjustable predictor of post-induction hypotension: A prospective observational study.

STUDY OBJECTIVE: Dynamic arterial elastance (Eadyn) has been suggested as a functional measure of arterial load. We aimed to evaluate whether pre-induction Eadyn can predict post-induction hypotension. DESIGN: Prospective observational study. PATIENTS: Adult patients undergoing general anesthesia with invasive and non-invasive arterial pressure monitoring systems. MEASUREMENTS: We collected invasive and non-invasive Eadyns (n = 38 in each), respectively. In both invasive and non-invasive Eadyns, pre-induction Eadyns were obtained during one-minute tidal and deep breathing in each patient before anesthetic induction. Post-induction hypotension was defined as a decrease of >30% in mean blood pressure from the baseline value or any absolute mean blood pressure value of <65 mmHg for 10 min after anesthetic induction. The predictabilities of Eadyns for the development of post-induction hypotension were tested using receiver-operating characteristic curve analysis. MAIN RESULTS: Invasive Eadyn during deep breathing showed significant predictability with an area under the curve (AUC) of 0.78 (95% Confidence interval [CI], 0.61-0.90, P = 0.001). But non-invasive Eadyn during tidal breathing (AUC = 0.66, 95% CI, 0.49-0.81, P = 0.096) and deep breathing (AUC = 0.53, 95% CI, 0.36-0.70, P = 0.75), and invasive Eadyn during tidal breathing (AUC = 0.66, 95% CI, 0.41-0.74, P = 0.095) failed to predict post-induction hypotension. CONCLUSION: In our study, invasive pre-induction Eadyn during deep breathing -could predict post-induction hypotension. Despite its invasiveness, future studies will be needed to evaluate the usefulness of Eadyn as a predictor of post-induction hypotension because it is an adjustable parameter.

Effects of EEG burst suppression on cerebral oxygen metabolism and postoperative cognitive function in elderly surgical patients: A randomized clinical trial.

BACKGROUND: This randomized clinical trial determined the effects of electroencephalographic burst suppression on cerebral oxygen metabolism and postoperative cognitive function in elderly surgical patients. METHODS: The patients were placed into burst suppression (BS) and non-burst suppression (NBS) groups. All patients were under bispectral index monitoring of an etomidate target-controlled infusion for anesthesia induction and intraoperative combination sevoflurane and remifentanil for anesthesia maintenance. The cerebral oxygen extraction ratio (CERO2), jugular bulb venous saturation (SjvO2), and difference in arteriovenous oxygen (Da-jvO2) were measured at T0, T1, and T2. One day before surgery, and 1, 3, and 7 days after surgery, postoperative cognitive dysfunction was assessed using the mini-mental state examination (MMSE). RESULTS: Compared with T0, the Da-jvO2 and CERO2 values were decreased, and SjvO2 was increased in the 2 groups at T1 and T2 (P < .05). There was no statistical difference in the SjvO2, Da-jvO2, and CERO2 values between T1 and T2. Compared with the NBS group, the SjvO2 value increased, and the Da-jvO2 and CERO2 values decreased at T1 and T2 in the BS group (P < .05). The MMSE scores on the 1st and 3rd days postoperatively were significantly lower in the 2 groups compared to the preoperative MMSE scores (P < .05). The MMSE scores of the NBS group were higher than the BS group on the 1st and 3rd days postoperatively (P < .05). CONCLUSION: In elderly patients undergoing surgery, intraoperative BS significantly reduced cerebral oxygen metabolism, which temporarily affected postoperative neurocognitive function.

Effect of a repeated verbal reminder of orientation on emergence agitation after general anaesthesia for minimally invasive abdominal surgery: a randomised controlled trial.

BACKGROUND: An orientation strategy providing repeated verbal reminders of time, place, and person has been widely used for the non-pharmacological management of delirium. We hypothesised that using this strategy could reduce emergence agitation and improve recovery profiles. METHODS: This prospective observer-blinded RCT included male and female patients aged 18-70 yr undergoing minimally invasive abdominal surgery. During emergence from general anaesthesia, subjects in the orientation group (n=57) were provided a repeated reminder, including orientation: '(Patient's name), you are now recovering from general anaesthesia after surgery at Seoul National University Hospital, open your eyes!' via noise-cancelling headphones, whereas those in the control group (n=57) only heard their name: '(Patient's name), open your eyes!'. The primary outcome was the incidence of emergence agitation (Riker sedation agitation scale [SAS] ≥5). The incidence of dangerous agitation (SAS=7), maximal SAS score in the operating room, and recovery profile until 24 h postoperatively were evaluated as secondary outcomes. RESULTS: The incidence of emergence agitation in the operating room was significantly lower in the orientation group than in the control group (16/57 [28.1%] vs 38/57 [66.7%]; relative risk [95% confidence interval], 0.5 [0.3-0.7]; P<0.001). The incidence of dangerous agitation (0 [0.0%] vs 10 [17.5%], P=0.001) and the median maximal SAS score (4 [4-5] vs 5 [4-6], P<0.001) were also lower in the orientation group. Secondary outcomes, other than agitation-related variables, were comparable between the two groups. CONCLUSIONS: Repeated verbal stimulation of orientation may serve as a simple and easily applicable strategy to reduce emergence agitation after general anaesthesia. CLINICAL TRIAL REGISTRATION: NCT05105178.

Patient characteristics, anaesthetic workload and techniques in the UK: an analysis from the 7th National Audit Project (NAP7) activity survey.

Detailed contemporary knowledge of the characteristics of the surgical population, national anaesthetic workload, anaesthetic techniques and behaviours are essential to monitor productivity, inform policy and direct research themes. Every 3-4 years, the Royal College of Anaesthetists, as part of its National Audit Projects (NAP), performs a snapshot activity survey in all UK hospitals delivering anaesthesia, collecting patient-level encounter data from all cases under the care of an anaesthetist. During November 2021, as part of NAP7, anaesthetists recorded details of all cases undertaken over 4 days at their site through an online survey capturing anonymous patient characteristics and anaesthetic details. Of 416 hospital sites invited to participate, 352 (85%) completed the activity survey. From these, 24,177 reports were returned, of which 24,172 (99%) were included in the final dataset. The work patterns by day of the week, time of day and surgical specialty were similar to previous NAP activity surveys. However, in non-obstetric patients, between NAP5 (2013) and NAP7 (2021) activity surveys, the estimated median age of patients increased by 2.3 years from median (IQR) of 50.5 (28.4-69.1) to 52.8 (32.1-69.2) years. The median (IQR) BMI increased from 24.9 (21.5-29.5) to 26.7 (22.3-31.7) kg.m-2 . The proportion of patients who scored as ASA physical status 1 decreased from 37% in NAP5 to 24% in NAP7. The use of total intravenous anaesthesia increased from 8% of general anaesthesia cases to 26% between NAP5 and NAP7. Some changes may reflect the impact of the COVID-19 pandemic on the anaesthetic population, though patients with confirmed COVID-19 accounted for only 149 (1%) cases. These data show a rising burden of age, obesity and comorbidity in patients requiring anaesthesia care, likely to impact UK peri-operative services significantly.

The effect of the COVID-19 pandemic on anesthesia techniques in tertiary hospital: general anesthesia or regional anesthesia - a retrospective cohort study.

OBJECTIVE: We aimed to find out how the pandemic process changed the anesthesia methods applied in Çorum Single Tertiary Region Hospital. In our hospital, we investigated the anesthesia methods used for surgical procedures before and during the pandemic, the number of cases, and the impact of the pandemic on emergency and elective surgeries. MATERIALS AND METHODS: This is a retrospective cohort study comparing COVID-19 pandemic's effect on the number of surgical operations and anesthesia techniques. The 22-month surgeries during the pandemic period and the 22-month pre-pandemic surgeries were compared in terms of anesthesia methods, branch-specific, and overall case changes. The data obtained were analyzed comparatively in terms of anesthetic techniques, branch-specific and overall case changes of the patients operated on in the operating room before and during the pandemic. RESULTS: While 65,984 surgical procedures were performed in the pre-pandemic period, only 54,352 were performed during the COVID-19 pandemic. The total number of surgical procedures decreased by 17.63% during the pandemic. While there was a 21.1% decrease in elective surgeries due to the pandemic, there was a 71.43% increase in emergency surgeries during the pandemic period. There was a significant disparity in the distribution of both elective and emergency cases by surgical specialty. It was found that the surgical specialties that received the most cases during the pandemic were General Surgery, Obstetrics-Gynecologic Surgery, Urologic Surgery and Orthopedic Surgery. During the COVID-19 pandemic, regional anesthesia (RA) was used in 16.95% of cases (as the primary technique). The use of RA as the primary anesthetic technique was significantly higher (10.61%) than in the pre-pandemic data. It was observed that specialties such as General Surgery, Obstetrics-Gynecologic Surgery, Urologic Surgery, And Orthopedic Surgery were prominent in the distribution of regional anesthesia. CONCLUSIONS: The COVID-19 pandemic was not the first and will not be the last and during this period we saw how important the personnel and material management are. Our study plays an important role in showing the uneven distribution of expected surgical procedures in operating rooms during the pandemic situation. It may provide guidance on the distribution of limited and essential personnel and personal protective equipment (PPE, medications, etc.) during the pandemic period. In this context, regional anesthesia may play an important role in the future because it can provide high-quality perioperative care to patients while minimizing the preference for general anesthesia during surgical procedures, thus minimizing personnel burden and limited resource use.

Ophthalmology service recovery with 'general anaesthesia to local anaesthesia conversion' or GALA initiative: a new surgical service pilot.

We report on the establishment of "general anaesthesia (GA) to local anaesthesia (LA) conversion" or GALA initiative at Sheffield Teaching Hospitals NHS Foundation Trust. Through GALA initiative, long waiters for cataract surgery under GA or LA with intravenous sedation were counselled for LA surgery. With careful surgical planning and personalised solutions to LA barriers, LA-converted patients reported good visual and surgical experience outcomes. The GALA initiative reduced cataract surgery waiting times of participants by 11 weeks and increased GA list capacity by three to four theatre lists in its four months of pilot run. This initiative did not limit training opportunities for ophthalmology trainees whose training was affected significantly during the pandemic.

Compound lidocaine/prilocaine cream combined with tetracaine prevents cough caused by extubation after general anaesthesia: a randomised controlled trial.

BACKGROUND: Coughing caused by tracheal extubation is common following general anaesthesia. Heavy aerosol production by coughing during recovery from general anaesthesia in patients with respiratory infections (especially COVID-19) may be one of the highest risk factors for infection in healthcare workers. The application of local anaesthetics to the endotracheal tube is an effective method to reduce coughing. The most commonly used anaesthetics are compound lidocaine/prilocaine cream and tetracaine spray. However, coughing still occurs when the two anaesthetics are used alone. We speculated that the application of compound lidocaine/prilocaine combined with tetracaine spray would better prevent coughing caused by tracheal extubation. METHODS: Patients scheduled for laparoscopic cholecystectomy or cholecystectomy combined with common bile duct exploration under general anaesthesia were randomly assigned to Group C (saline spray), Group L (2 g compound lidocaine/prilocaine cream contains 5 mg of lidocaine and 5 mg prilocaine)), Group T (tetracaine) and Group F (compound lidocaine/prilocaine cream combined with tetracaine). The incidence of coughing, the endotracheal tube tolerance assessment, the incidence of agitation, the active extubation rate, the incidence of postoperative pharyngeal pain and the incidence of postoperative cough were recorded and analysed. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and the plasma concentrations of epinephrine and norepinephrine were measured immediately before extubation and 1 min after extubation. RESULTS: A total of 211 patients were randomly assigned to Group C (53 cases), Group L (52 cases), Group T (52 cases) and Group F (54 cases). The primary result is assessment of the incidence of cough. The patients emerged from general anaesthesia, 96% of Group C had cough, which was significantly reduced in Group L (61.5%, P < 0.001), Group T (75%, P < 0.05) and Group F (22.2%, P < 0.001). Group F had a significantly reduced incidence of cough compared to Group L and Group T (P < 0.05 or P < 0.01, respectively). The secondary results were assessed. The endotracheal tube tolerance score in Group C ((1, 3) 4, P < 0.001) was higher than Group L ((0, 1) 2), Group T ((0, 1.25) 3) and Group F ((0, 0) 1). Group F had a significantly lower score than Group L and Group T (P < 0.05, P < 0.01, respectively). The incidence of agitation and the active extubation rate were also higher in Group C (96.2% and 71.7%, respectively, P < 0.001) than Group L (48.1% and 15.4%, respectively), Group T (61.5% and 26.9%, respectively) and Group F (17.3% and 7.7%, respectively). Blood pressure, HR and plasma concentrations of epinephrine and norepinephrine were significantly higher in Group C than in all other groups at the time of extubation and 1 min after extubation (P < 0.001). Group F exhibited significantly reduced blood pressure, heart rate and plasma concentrations of epinephrine and norepinephrine compared to Group L and Group T (P < 0.05, P < 0.01 or P < 0.001, respectively). The incidence of postoperative pharyngeal pain and the incidence of postoperative cough were not significantly different among the groups. CONCLUSIONS: Compound lidocaine/prilocaine cream combined with tetracaine may be a more effective approach for preventing coughing and stabilising circulation during extubation following general anaesthesia. This may play an important role in preventing medical staff from contracting respiratory infectious diseases. TRIAL REGISTRATION: Chinese Clinical Trial Registry: ChiCTR2200058429 (registration date: 09-04-2022) "retrospectively registered".

The Incidence of Acute Respiratory Infection Was Higher in the Older Adults with Lower Limb Fracture Who Receive Spinal Anesthesia Than Those Who Receive General Anesthesia.

INTRODUCTION: Acute respiratory infection (ARI) can significantly reduce postoperative quality of life and impair the recovery of older adult patients with lower-limb fractures, and its relationship with methods of anesthesia remains inconclusive. Using data from the National Health Insurance Research Database (NHIRD) of Taiwan, this study examined the data of patients who received surgical management for lower-limb fractures and compared those who underwent general anesthesia (GA) with those who underwent regional anesthesia (RA) in terms of their incidence of acute upper and lower respiratory infection during the one-month postoperative period. The study also identified related risk factors. MATERIAL AND METHODS: Approximately two million patients were randomly sampled from the NHIRD registry. We identified and enrolled patients with lower-limb fractures who were over 60 years old and underwent GA or RA during surgeries conducted between 2010 and 2017. We divided these patients into two groups for further analysis. The outcome of this study was the development of ARI during the one-month postoperative period. RESULTS: In total, 45,032 patients (GA group, 19,580 patients; RA group, 25,452 patients) with a mean age of 75.0 ± 8.9 years were included in our study. The incidence of postoperative ARI within one month of surgery was 8.0% (1562 patients) in the GA group and 9.5% (2412 patients) in the RA group, revealing a significant difference. The significant risk factors for the incidence of ARI were the application of RA for surgery, older age, hypertension, liver disease, and chronic obstructive pulmonary disease (COPD). A subgroup analysis revealed that the RA method was associated with a significantly higher ARI incidence relative to the GA method among patients aged between 60 and 80 years, among male patients, among the patients with or without any comorbidity and among the patients without COPD. CONCLUSION: The incidence of postoperative ARI within one month of surgery was higher among older patients with lower-limb fractures who received RA for surgery than among those who received GA for surgery. The other major risk factors for ARI were older age, hypertension, liver disease, and COPD. Therefore, we should focus on patients with a high risk of developing ARI, especially during the COVID-19 pandemic.

Ad-hoc preoperative management and respiratory events in pediatric anesthesia during the first COVID-19 lockdown-an observational cohort study.

BACKGROUND: Early pre-anesthetic management for surgery is aimed at identifying risk factors, which notably in children are mostly airway related. The first COVID-19 lockdown opened a unique 'window of opportunity' to study what impact an ad-hoc management strategy would bring to bear on intraoperative respiratory events. METHODS: In this observational cohort study we included all patients with an American Society of Anesthesiology (ASA) Physical Status of I or II, aged 0 to ≤18 years, who underwent elective surgery at our center during the first national COVID-19 lockdown (March 15th to May 31st, 2020) and all analogue cases during the same calendar period of 2017-2019. The primary outcome parameter was a drop in peripheral oxygen saturation (SpO2) below 90% during anesthesia management. The study is completed and registered with the German Clinical Trials Register, DRKS00024128. RESULTS: Given 125 of 796 evaluable cases during the early 2020 lockdown, significant differences over the years did not emerge for the primary outcome or event counts (p>0.05). Events were exceedingly rare even under general anesthesia (n = 3) and non-existent under regional anesthesia (apart from block failures: n = 4). Regression analysis for SpO2 events <90% yielded no significant difference for ad-hoc vs standard preoperative management (p = 0.367) but more events based on younger patients (p = 0.007), endotracheal intubation (p = 0.007), and bronchopulmonary procedures (p = 0.001). CONCLUSIONS: Early assessment may not add to the safety of pediatric anesthesia. As a potential caveat for other centers, the high rate of anesthesia without airway manipulation at our center may contribute to our low rate of respiratory events.

Cost comparison between spinal versus general anesthesia for hip and knee arthroplasty: an incremental cost study.

PURPOSE: Wait list times for total joint arthroplasties have been growing, particularly in the aftermath of the COVID-19 pandemic. Increasing operating room (OR) efficiency by reducing OR time and associated costs while maintaining quality allows the greatest number of patients to receive care. METHODS: We used propensity score matching to compare parallel processing with spinal anesthesia in a block room vs general anesthesia in a retrospective cohort of adult patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). We compared perioperative costs, hospital costs, OR time intervals, and complications between the groups with nonparametric tests using an intention-to-treat approach. RESULTS: After matching, we included 636 patients (315 TKA; 321 THA). Median [interquartile range (IQR)] perioperative costs were CAD 7,417 [6,521-8,109], and hospital costs were CAD 10,293 [9,344-11,304]. Perioperative costs were not significantly different between groups (pseudo-median difference [MD], CAD -47 (95% confidence interval [CI], -214 to -130; P = 0.60); nor were total hospital costs (MD, CAD -78; 95% CI, -340 to 178; P = 0.57). Anesthesia-controlled time and total intraoperative time were significantly shorter for spinal anesthesia (MD, 14.6 min; 95% CI, 13.4 to 15.9; P < 0.001; MD, 15.9; 95% CI, 11.0 to 20.9; P < 0.001, respectively). There were no significant differences in complications. CONCLUSION: Spinal anesthesia in the context of a dedicated block room reduced both anesthesia-controlled time and total OR time. This did not translate into a reduction in incremental cost in the spinal anesthesia group.

RéSUMé: OBJECTIF: Les temps d'attente pour les arthroplasties articulaires totales ont augmenté, en particulier à la suite de la pandémie de COVID-19. Une augmentation de l'efficacité de la salle d'opération (SOP) fondée sur une réduction du temps en salle d'opération et des coûts associés, tout en maintenant la qualité, permettrait à un plus grand nombre de patients de recevoir des soins. MéTHODE: Nous avons utilisé l'appariement par score de propension pour comparer en parallèle des traitements par rachianesthésie dans une salle de bloc vs par anesthésie générale dans une cohorte rétrospective de patients adultes bénéficiant d'une arthroplastie totale de la hanche (ATH) et d'une arthroplastie totale du genou (ATG) primaires. Nous avons comparé les coûts périopératoires, les coûts hospitaliers, les intervalles de temps en SOP et les complications entre les groupes avec des tests non paramétriques en utilisant une approche d'intention de traiter. RéSULTATS: Après appariement, nous avons inclus 636 patients (315 ATG; 321 ATH). Les coûts périopératoires médians [écart interquartile (ÉIQ)] étaient de 7417 $ CA [6521 ­ 8109] et les coûts hospitaliers de 10 293 $ CA [9344 ­ 11 304]. Les coûts périopératoires n'étaient pas significativement différents entre les groupes (différence pseudomédiane [DM], −47 $ CA (intervalle de confiance à 95 % [IC], −214 à −130; P = 0,60), pas plus que les coûts hospitaliers totaux (DM, −78 $ CA; IC 95 %, −340 à 178; P = 0,57). Le temps sous anesthésie et le temps peropératoire total étaient significativement plus courts pour la rachianesthésie (DM, 14,6 min; IC 95 %, 13,4 à 15,9; P < 0,001; DM, 15,9; IC 95 %, 11,0 à 20,9; P < 0,001, respectivement). Aucune différence significative n'a été observée dans les complications. CONCLUSION: La rachianesthésie dans un contexte de salle de bloc dédiée a réduit à la fois le temps sous anesthésie et le temps total de SOP. Cela ne s'est pas traduit par une réduction du coût différentiel dans le groupe recevant une rachianesthésie.

Negative-pressure pulmonary edema after mammoplasty: a case report.

Negative-pressure pulmonary edema (NPPE) is a rare but life-threatening postoperative complication that occurs due to the acute obstruction of the upper airway. In our case report, we present a 25-year-old female patient who underwent elective mammoplasty under general anesthesia and developed NPPE 4 hours after extubation. The patient had a preoperative mallampati score of 3. After routine anesthesia induction, the patient was intubated with an endotracheal tube with a guide wire. Aspiration wasn't observed during extubation. The patient was followed in the post-anesthesia care unit (PACU) for 30 minutes with a saturation of 95% and was subsequently transferred to the service. Four hours after the operation, the patient was re-examined due to dyspnea and shortness of breath. Due to oxygen saturation of 88% and pO2of 56mmHg despite mask ventilation, the patient was admitted to the intensive care unit (ICU). A computed tomography (CT) scan revealed extensive diffuse ground-glass opacities and consolidations in both lungs. She did not respond to mask ventilation and was given non-invasive ventilation with continuous positive airway pressure (CPAP). Forced diuresis was induced with furosemide. Tachypnea resolved within 2 hours after CPAP was initiated, the patient did not require oxygen support and COVID-19 polymerase chain reaction (PCR) testing was negative. Subsequently, the patient was discharged to the clinical ward on postoperative day 1. When considering NPPE, early diagnosis and respiratory support are associated with reduced mortality and rapid recovery. Patients who develop laryngospasm during extubation must be closely monitored, and in the case of pulmonary edema, NPPE should be considered in the differential diagnosis.

Evaluation of 254 cesarean sections with COVID-19 in terms of anesthesia and clinical course: 1-year experience.

PURPOSE: The study aims to compare anesthesia methods, clinical course, and maternal and fetal outcomes of symptomatic and asymptomatic pregnant women undergoing cesarean operation with confirmed COVID-19. METHODS: 254 pregnant women with COVID-19 who had a cesarean section in our hospital between March 2020 and March 2021 were included in the study. Demographic information, laboratory test results, radiological data, treatments, anesthesia methods, and prognoses of the patients were evaluated retrospectively. RESULTS: On admission, 160 (63%) patients were asymptomatic (Group A), and 94 (37%) patients were symptomatic (Group S). The ratio of patients who needed oxygen therapy in the obstetric ward (p < 0.001) and intraoperative period (p < 0.001) and ICU admission (p = 0.005) was higher in Group S. Neutrophil-to-lymphocyte ratio (NLR), ferritin, procalcitonin, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were higher in Group S. In both groups, spinal anesthesia was performed predominantly. The rate of general anesthesia was significantly higher in Group S (16.0% vs. 4.4%, p = 0.003). No difference was found in the amount of sedatives during the spinal anesthesia. CONCLUSION: Close follow-up of the laboratory values and comorbidities (especially asthma) of pregnant will provide information about the clinical course as in other patient groups. Spinal anesthesia is a safe and sufficient anesthesia method in both symptomatic and asymptomatic COVID-19 pregnant women when performed by experienced hands.

Respiratory decompensation with proning - when prone positioning can worsen respiratory mechanics.

Prone positioning recently gain- ed more popularity from its use in COVID-19 management. It is gene--rally considered to improve respiratory mechanics via increased lung compliance. In surgery, prone positioning is typically encountered when it is a necessity to access certain posterior anatomic structures. Though certain post-operative complications from prone positioning are well known (e.g., postoperative vision loss), the potential intraoperative complications that it can have for respiratory com-pliance and O2 saturation, in the setting of general anaesthesia, are perhaps less familiar, as only a few studies showed improved respiratory mechanics in the setting of ge-neral anaesthesia [1-3] and one study showed that prone positioning led to a 30-35% drop in respiratory compliance under general anaesthesia [4]. As the following case illustrates, proning is a critical point in the intraoperative course as it can sometimes lead to negative respiratory sequelae disrupting homeostasis.

Editorial "Minute Zero: an essential assessment in peri-operative ultrasound for anaesthesia".

I have attentively read the article "Minute Zero: an essential assessment in peri-operative ultrasound for anaesthesia" by Elena Segura-Grau et al. [1]. The authors have suggested using point-of-care ultrasonography (POCUS) as part of a comprehensive anaesthetic assessment in the perioperative period. Such an extension of the standard perioperative examination aimed at searching for pathologies that may affect the intra- and postoperative course performed by an anaes-thesiologist seems fully justified and may have a significant impact on treatment outcomes [2]. In the "Minute Zero" model, the authors have suggested that POCUS assessment of anaesthetised patients should be carried out twice - on admission to the operating theatre and before transfer to the postoperative ward. The described scheme is based on the well-known eFAST, FATE and BLUE protocols (assessment to determine the presence of free fluid in the body cavities, basic cardiac assessment, including IVC, and lung ultrasound assessment). The examination conducted in the manner specified by the authors provides a general but holistic picture of the patient, focused at detecting life-threatening pathologies. It is right to include a preoperative assessment of the filling of the stomach in the protocol, as the surface area of the pylorus found on ultrasound scans indicates the risk of aspiration during the induction of general anaesthesia [3, 4]. This may be of particular importance in patients undergoing emergency procedures, with gastrointestinal obstruction or in those with difficult contact (mainly children and the elderly). In the algorithm described, the assessment of bladder filling in the postoperative period has been emphasised. This is a huge asset, which is often overlooked and, as the authors rightly point out, can cause postoperative delirium, especially in the elderly. The authors have developed an examination card that enables to document the examination in a simple and transparent manner based on markings of the appropriate blanks, which makes the protocol very friendly. The additional pros of the publication are the attached sample ultrasound images, which perfectly illustrate the ease of diagnosis of basic pathologies.

Obstetric analgesia and anaesthesia in SARS-CoV-2-positive parturients across 10 maternity units in the north-west of England: a retrospective cohort study.

Since the start of the COVID-19 pandemic, few studies have reported anaesthetic outcomes in parturients with SARS-CoV-2 infection. We reviewed the labour analgesic and anaesthetic interventions utilised in symptomatic and asymptomatic parturients who had a confirmed positive test for SARS-CoV-2 across 10 hospitals in the north-west of England between 1 April 2020 and 31 May 2021. Primary outcomes analysed included the analgesic/anaesthetic technique utilised for labour and caesarean birth. Secondary outcomes included a comparison of maternal characteristics, caesarean birth rate, maternal critical care admission rate along with adverse composite neonatal outcomes. A positive SARS-CoV-2 test was recorded in 836 parturients with 263 (31.4%) reported to have symptoms of COVID-19. Neuraxial labour analgesia was utilised in 104 (20.4%) of the 509 parturients who went on to have a vaginal birth. No differences in epidural analgesia rates were observed between symptomatic and asymptomatic parturients (OR 1.03, 95%CI 0.64-1.67; p = 0.90). The neuraxial anaesthesia rate in 310 parturients who underwent caesarean delivery was 94.2% (95%CI 90.6-96.0%). The rates of general anaesthesia were similar in symptomatic and asymptomatic parturients (6% vs. 5.7%; p = 0.52). Symptomatic parturients were more likely to be multiparous (OR 1.64, 95%CI 1.19-2.22; p = 0.002); of Asian ethnicity (OR 1.54, 1.04-2.28; p = 0.03); to deliver prematurely (OR 2.16, 95%CI 1.47-3.19; p = 0.001); have a higher caesarean birth rate (44.5% vs. 33.7%; OR 1.57, 95%CI 1.16-2.12; p = 0.008); and a higher critical care utilisation rate both pre- (8% vs. 0%, p = 0.001) and post-delivery (11% vs. 3.5%; OR 3.43, 95%CI 1.83-6.52; p = 0.001). Eight neonates tested positive for SARS-CoV-2 while no differences in adverse composite neonatal outcomes were observed between those born to symptomatic and asymptomatic mothers (25.8% vs. 23.8%; OR 1.11, 95%CI 0.78-1.57; p = 0.55). In women with COVID-19, non-neuraxial analgesic regimens were commonly utilised for labour while neuraxial anaesthesia was employed for the majority of caesarean births. Symptomatic women with COVID-19 are at increased risk of significant maternal morbidity including preterm birth, caesarean birth and peripartum critical care admission.