Closing the gaps: consent and preoperative assessment for children and young people.

The changing ethical and legal landscape in the UK means that anaesthetists should routinely be discussing the risk of death during the consent process. To do this effectively means expanding anaesthetic preassessment services for children and young people, something that has been recognised as a priority, but which still needs investment and an appreciation of its value at the trust level.

Patient Consent for Medical Student Pelvic Exams under Anesthesia: An Exploratory Retrospective Chart Review.

AbstractObjective: We performed this study to examine patients' choices to permit or refuse medical student pelvic examinations under anesthesia (EUAs) during planned gynecologic procedures. DESIGN: We conducted an exploratory retrospective chart review of electronic consent forms at a single academic medical center using contingency tables, logistic regression, and nonparametric tests to explore relationships between patient and physician characteristics and consent. RESULTS: We identified and downloaded electronic consent forms for a census of 4,000 patients undergoing gynecologic surgery from September 2020 through calendar year 2022. Forms were linked to anonymized medical record information. Of the 4,000 patients, 142 (3.6%) were removed from analysis because consent forms were incomplete. Of 3,858 patients, 308 (8.0%) were asked for EUA consent more than once, 46 of whom were not consistent. Overall, 3,308 (85.7%) patients consented every time asked, and 550 (14.2%) refused or limited EUA consent at least once. Nine patients limited their consent to female students, and two patients refused medical student participation at all. We performed exploratory multiple logistic regression analyses exploring differences in rates of consent across patient and physician demographic groups. CONCLUSIONS: We find that some patients are more likely than others to refuse a pelvic EUA, magnifying the dignitary harm from a nonconsensual invasion of intimate bodily integrity and perpetuating historic wrongs visited upon vulnerable people of color and religious minorities. Patients' rights to respect and control over their bodies require that physicians take seriously the ethical obligation to inform their patients and ask them for permission.

Prehospital anesthesia in postcardiac arrest patients: a multicenter retrospective cohort study.

BACKGROUND: Currently, the data regarding the impact of prehospital postcardiac arrest anesthesia on target hemodynamic and ventilatory parameters of early postresuscitation care and recommendations on its implementation are rare. The present study examines the incidence and impact of prehospital postcardiac arrest anesthesia on hemodynamic and ventilatory target parameters of postresuscitation care. METHODS: In this multicentre observational study between 2019 and 2021 unconscious adult patients after out-of-hospital-cardiac arrest with the presence of a return-of-spontaneous circulation until hospital admission were included. Primary endpoint was the application of postarrest anesthesia. Secondary endpoints included the medication group used, predisposing factors to its implementation, and its influence on achieving target parameters of postresuscitation care (systolic blood pressure: ≥ 100 mmHg, etCO2:35-45 mmHg, SpO2: 94-98%) at hospital handover. RESULTS: During the study period 2,335 out-of-hospital resuscitations out of 391,305 prehospital emergency operations (incidence: 0.58%; 95% CI 0.54-0.63) were observed with a return of spontaneous circulation to hospital admission in 706 patients (30.7%; 95% CI 28.8-32.6; female: 34.3%; age:68.3 ± 14.2 years). Postcardiac arrest anesthesia was performed in 482 patients (68.3%; 95% CI 64.7-71.7) with application of hypnotics in 93.4% (n = 451), analgesics in 53.7% (n = 259) and relaxants in 45.6% (n = 220). Factors influencing postcardiac arrest sedation were emergency care by an anesthetist (odds ratio: 2.10; 95% CI 1.34-3.30; P < 0.001) and treatment-free interval ≤ 5 min (odds ratio: 1.59; 95% CI 1.01-2.49; P = 0.04). Although there was no evidence of the impact of performing postcardiac arrest anesthesia on achieving a systolic blood pressure ≥ 100 mmHg at the end of operation (odds ratio: 1.14; 95% CI 0.78-1.68; P = 0.48), patients with postcardiac arrest anesthesia were significantly more likely to achieve the recommended ventilation (odds ratio: 1.59; 95% CI 1.06-2.40; P = 0.02) and oxygenation (odds ratio:1.56; 95% CI 1.04-2.35; P = 0.03) targets. Comparing the substance groups, the use of hypnotics significantly more often enabled the target values for etCO2 to be reached alone (odds ratio:2.79; 95% CI 1.04-7.50; P = 0.04) as well as in combination with a systolic blood pressure ≥ 100 mmHg (odds ratio:4.42; 95% CI 1.03-19.01; P = 0.04). CONCLUSIONS: Postcardiac arrest anesthesia in out-of-hospital cardiac arrest is associated with early achievement of respiratory target parameters in prehospital postresuscitation care without evidence of more frequent hemodynamic complications.

Identifying risk factors for hypoxemia during emergence from anesthesia in patients undergoing robot-assisted laparoscopic radical prostatectomy.

Robot-assisted laparoscopic radical prostatectomy (RALP) has emerged as an effective treatment for prostate cancer with obvious advantages. This study aims to identify risk factors related to hypoxemia during the emergence from anesthesia in patients undergoing RALP. A cohort of 316 patients undergoing RALP was divided into two groups: the hypoxemia group (N = 134) and the non-hypoxemia group (N = 182), based on their postoperative oxygen fraction. Comprehensive data were collected from the hospital information system, including preoperative baseline parameters, intraoperative data, and postoperative recovery profiles. Risk factors were examined using multiple logistic regression analysis. The study showed that 38.9% of patients had low preoperative partial pressure of oxygen (PaO2) levels. Several clinical parameters showed significant differences between the hypoxemia group and the non-hypoxemia group, including weight (P < 0.0001), BMI (P < 0.0001), diabetes mellitus (P = 0.044), history of emphysema and pulmonary alveoli (P < 0.0001), low preoperative PaO2 (P < 0.0001), preoperative white blood cell count (P = 0.012), preoperative albumin (P = 0.048), intraoperative bleeding (P = 0.043), intraoperative CO2 accumulation (P = 0.001), duration of surgery (P = 0.046), postoperative hemoglobin level (P = 0.002), postoperative hypoxemia (P = 0.002), and early postoperative fever (P = 0.006). Multiple logistic regression analysis revealed BMI (adjusted odds ratio = 0.696, 95% confidence interval 0.612-0.719), low preoperative PaO2 (adjusted odds ratio = 9.119, 95% confidence interval 4.834-17.203), and history of emphysema and pulmonary alveoli (adjusted odds ratio = 2.804, 95% confidence interval 1.432-5.491) as independent factors significantly associated with hypoxemia on emergence from anesthesia in patients undergoing RALP. Our results demonstrate that BMI, lower preoperative PaO2, and a history of emphysema and pulmonary alveolar disease are independent risk factors associated with hypoxemia on emergence from anesthesia in patients undergoing RALP. These findings provide a theoretical framework for surgeons and anesthesiologists to facilitate strategies to mitigate postoperative hypoxemia in this unique patient population.

The impact of scheduling ketamine as an internationally controlled substance on anaesthesia care in Sub-Saharan Africa: a case study and key informant interviews.

BACKGROUND: Access to anaesthesia and surgical care is a major problem for people living in Sub-Saharan Africa. In this region, ketamine is critical for the provision of anaesthesia care. However, efforts to control ketamine internationally as a controlled substance may significantly impact its accessibility. This research therefore aims to estimate the importance of ketamine for anaesthesia and surgical care in Sub-Saharan Africa and assess the potential impact on access to ketamine if it were to be scheduled. METHODS: This research is a mixed-methods study, comprising of a cross-sectional survey at the hospital level in Rwanda, and key informant interviews with experts on anaesthesia care in Sub-Saharan Africa. Data on availability of four anaesthetic agents were collected from hospitals (n = 54) in Rwanda. Semi-structured interviews with 10 key informants were conducted, collecting information on the importance of ketamine, the potential impact of scheduling ketamine internationally, and opinions on misuse of ketamine. Interviews were transcribed verbatim and analysed using a thematic analysis approach. RESULTS: The survey conducted in Rwanda found that availability of ketamine and propofol was comparable at around 80%, while thiopental and inhalational agents were available at only about half of the hospitals. Significant barriers impeding access to anaesthesia care were identified, including a general lack of attention given to the specialty by governments, a shortage of anaesthesiologists and migration of trained anaesthesiologists, and a scarcity of medicines and equipment. Ketamine was described as critical for the provision of anaesthesia care as a consequence of these barriers. Misuse of ketamine was not believed to be an issue by the informants. CONCLUSION: Ketamine is critical for the provision of anaesthesia care in Sub-Saharan Africa, and its scheduling would have a significantly negative impact on its availability for anaesthesia care.

Anesthesia for the Patient Undergoing Shoulder Surgery.

Shoulder surgery introduces important anesthesia considerations. The interscalene nerve block is considered the gold standard regional anesthetic technique and can serve as the primary anesthetic or can be used for postoperative analgesia. Phrenic nerve blockade is a limitation of the interscalene block and various phrenic-sparing strategies and techniques have been described. Patient positioning is another important anesthetic consideration and can be associated with significant hemodynamic effects and position-related injuries.

Anesthesia for the Patient Undergoing Foot and Ankle Surgery.

Modern anesthetic management for foot and ankle surgery includes a variety of anesthesia techniques including general anesthesia, neuraxial anesthesia, or MAC in combination with peripheral nerve blocks and/or multimodal analgesic agents. The choice of techniques should be tailored to the nature of the procedure, patient comorbidities, anesthesiologist skill level, intensity of anticipated postoperative pain, and surgeon preference.

Computer vision digitization of smartphone images of anesthesia paper health records from low-middle income countries.

BACKGROUND: In low-middle income countries, healthcare providers primarily use paper health records for capturing data. Paper health records are utilized predominately due to the prohibitive cost of acquisition and maintenance of automated data capture devices and electronic medical records. Data recorded on paper health records is not easily accessible in a digital format to healthcare providers. The lack of real time accessible digital data limits healthcare providers, researchers, and quality improvement champions to leverage data to improve patient outcomes. In this project, we demonstrate the novel use of computer vision software to digitize handwritten intraoperative data elements from smartphone photographs of paper anesthesia charts from the University Teaching Hospital of Kigali. We specifically report our approach to digitize checkbox data, symbol-denoted systolic and diastolic blood pressure, and physiological data. METHODS: We implemented approaches for removing perspective distortions from smartphone photographs, removing shadows, and improving image readability through morphological operations. YOLOv8 models were used to deconstruct the anesthesia paper chart into specific data sections. Handwritten blood pressure symbols and physiological data were identified, and values were assigned using deep neural networks. Our work builds upon the contributions of previous research by improving upon their methods, updating the deep learning models to newer architectures, as well as consolidating them into a single piece of software. RESULTS: The model for extracting the sections of the anesthesia paper chart achieved an average box precision of 0.99, an average box recall of 0.99, and an mAP0.5-95 of 0.97. Our software digitizes checkbox data with greater than 99% accuracy and digitizes blood pressure data with a mean average error of 1.0 and 1.36 mmHg for systolic and diastolic blood pressure respectively. Overall accuracy for physiological data which includes oxygen saturation, inspired oxygen concentration and end tidal carbon dioxide concentration was 85.2%. CONCLUSIONS: We demonstrate that under normal photography conditions we can digitize checkbox, blood pressure and physiological data to within human accuracy when provided legible handwriting. Our contributions provide improved access to digital data to healthcare practitioners in low-middle income countries.

Anesthesia for the Patient Undergoing Knee Procedures.

Anesthesia for patients undergoing knee procedures encompasses a large patient population with significant variation in patient age, comorbidities, and type of surgery. In addition, these procedures are performed in vastly different surgical environments, including large academic hospitals, private hospitals, and out-patient surgical centers. These variabilities require a thoughtful and individualized anesthetic approach tailored toward the medical and surgical needs of each patient. This article discusses anesthetic approaches to patients with acute, subacute, and chronic knee-related pathology requiring surgery. We will also review pertinent knee anatomy and innervation and discuss regional nerve blocks and their applications to knee-related surgical procedures.

Unique Medical Considerations for the Athlete Undergoing Anesthesia.

Athletes are among a unique group such that they may possess a serious underlying pathologic condition that may often go unnoticed given their high caliber of physical fitness. However, several considerations should be investigated, especially in the perioperative period, in order to minimize morbidity and mortality. Namely, cardiac pathologic condition can result in sudden death, and pulmonary pathologic condition may affect airway and respiratory management. Moreover, patients undergoing orthopedic surgery are at the highest risk for venous thromboembolism. Regardless of the condition, it is crucial to be vigilant and explore the unique medical considerations for the athlete undergoing anesthesia.

Substance specific EEG patterns in mice undergoing slow anesthesia induction.

The exact mechanisms and the neural circuits involved in anesthesia induced unconsciousness are still not fully understood. To elucidate them valid animal models are necessary. Since the most commonly used species in neuroscience are mice, we established a murine model for commonly used anesthetics/sedatives and evaluated the epidural electroencephalographic (EEG) patterns during slow anesthesia induction and emergence. Forty-four mice underwent surgery in which we inserted a central venous catheter and implanted nine intracranial electrodes above the prefrontal, motor, sensory, and visual cortex. After at least one week of recovery, mice were anesthetized either by inhalational sevoflurane or intravenous propofol, ketamine, or dexmedetomidine. We evaluated the loss and return of righting reflex (LORR/RORR) and recorded the electrocorticogram. For spectral analysis we focused on the prefrontal and visual cortex. In addition to analyzing the power spectral density at specific time points we evaluated the changes in the spectral power distribution longitudinally. The median time to LORR after start anesthesia ranged from 1080 [1st quartile: 960; 3rd quartile: 1080]s under sevoflurane anesthesia to 1541 [1455; 1890]s with ketamine. Around LORR sevoflurane as well as propofol induced a decrease in the theta/alpha band and an increase in the beta/gamma band. Dexmedetomidine infusion resulted in a shift towards lower frequencies with an increase in the delta range. Ketamine induced stronger activity in the higher frequencies. Our results showed substance-specific changes in EEG patterns during slow anesthesia induction. These patterns were partially identical to previous observations in humans, but also included significant differences, especially in the low frequencies. Our study emphasizes strengths and limitations of murine models in neuroscience and provides an important basis for future studies investigating complex neurophysiological mechanisms.

Obesity and Anesthesia: Challenges in the Perioperative Period.

The obesity epidemic has significant implications for all aspects of healthcare. The physiological changes of obesity affect every area of perioperative medicine. In this article, we discuss several anesthetic concerns regarding obesity. We will specifically discuss preoperative evaluation, perioperative challenges, and postoperative pain control and monitoring.

O-GlcNAcylation levels remain stable regardless of the anaesthesia in healthy rats.

Anaesthetics are used daily in human and veterinary medicine as well as in scientific research. Anaesthetics have an impact on cell homeostasis especially through modulation of protein post-translational modifications. O-GlcNAcylation, a ubiquitous post-translational modification, plays a role in many biological processes. The aims of this study were to evaluate whether (1) anaesthesia influences O-GlcNAcylation and (2) its stimulation affects physiological parameters. Male Wistar rats (n = 38) were anaesthetized with ketamine-xylazine or isoflurane. They randomly received either an intravenous injection of Ringer's lactate or NButGT (10mg/kg) in order to increase O-GlcNAcylation levels. One hour after induction of anaesthesia, haemodynamic parameters and plasmatic markers were evaluated. Heart, brain and lungs were harvested and O-GlcNAcylation levels and O-GlcNAc-related enzymes were evaluated by western blot. Cardiac and pulmonary O-GlcNAcylation levels and cardiac, cerebral and pulmonary O-GlcNAc associated enzyme expression were not impacted with anaesthesia. Compared with ketamine-xylazine, isoflurane had a lower impact on blood pressure, heart rate and glycaemia. Pharmacological stimulation of O-GlcNAcylation by NButGT did not affect the physiological parameters. This study offers unprecedented insights into the regulation of O-GlcNAcylation and O-GlcNAc related enzymes during anaesthesia. Pharmacological stimulation of O-GlcNAcylation over a 1-h period did not disrupt the physiological balance in healthy anaesthetized rats.

Anaesthesia management of a patient with Bethlem Myopathy for elective tonsillectomy: a case report.

BACKGROUND: Bethlem Myopathy is a collagen VI-related myopathy presenting as a rare hereditary muscular disorder with progressive muscular weakness and joint contractures. Despite its milder clinical course relative to other myopathies, anaesthetic management can be challenging. High arched palates and fixed flexion deformities may contribute to a difficult airway. A progressive decline in pulmonary function can present later into adulthood. This respiratory decline can carry secondary cardiovascular consequences due to the progressive nature of restrictive lung disease, including right sided heart disease and pulmonary hypertension. We describe a case of a male patient with Bethlem Myopathy undergoing anaesthesia, to contribute to the limited body of literature on this condition and enhance awareness and guidance amongst anaesthesiologists on approaching patients with this condition. This is the first case report within the literature of its kind. CASE PRESENTATION: This case details a 33-year-old male with Bethlem Myopathy undergoing tonsillectomy. Diagnosed in childhood following developmental delays, the patient had no prior anaesthetic exposure and no family history of anaesthetic complications. Anaesthetic induction was achieved without complications, avoiding depolarizing muscle relaxants and careful airway management. Extreme care was taken in patient positioning to prevent complications. The surgery proceeded without incident and muscle paralysis was reversed with Suggammadex, resulting in no adverse post-operative respiratory complications. The patient was discharged on the first post-operative day without any respiratory or cardiovascular compromise. CONCLUSIONS: Bethlem Myopathy, while often exhibiting a mild clinical course, can present anaesthetic challenges. Awareness of potential complications including a difficult airway, cardiovascular and respiratory implications as well as the need for specialised monitoring and positioning is crucial to ensure a safe peri-operative course.

The Year in Review: Anesthesia for Congenital Heart Disease 2023.

This review highlights published literature in 2023 that is related to the anesthetic management of patients with congenital heart disease (CHD). Though not inclusive of all topics, 31 articles are discussed and four primary themes emerged: transfusion and hemostasis, outcomes and risk assessment, monitoring, and pharmacology.

The Effect of Depth of Anesthesia on Postoperative Pain in Laparoscopic Sleeve Gastrectomy: A Randomized Controlled Trial.

BACKGROUND: Patients with obesity are more sensitive to pain and more likely to have acute postoperative pain (APP). Studies have shown that the depth of anesthesia may affect the incidence of APP. The purpose of the study was to look into the connection between APP and depth of anesthesia in patients with obesity undergoing laparoscopic sleeve gastrectomy. METHODS: This is a prospective, double-blinded randomized clinical trial, 90 patients undergoing laparoscopic sleeve gastrectomy were randomly divided into two groups: the light anesthesia group (Bispectral Index of 50, BIS 50) and the deep anesthesia group (BIS 35). The degree of pain was evaluated by the visual analogue scale (VAS) at 0, 12, 24, 48, and 72 h after surgery. The use of analgesics, grade of postoperative nausea and vomiting (PONV), and the Quality of Recovery-15 (QoR-15) score were recorded. RESULTS: The VAS scores at rest or coughing at 0, 12, and 24 h after surgery in the BIS 35 group were lower than those in the BIS 50 group (P < 0.05). Fewer patients in the deep anesthesia group needed analgesia during the recovery period, and patient satisfaction was higher on the 3rd day after surgery (P < 0.015, P < 0.032, respectively). CONCLUSIONS: For patients with obesity, maintaining a deeper depth of anesthesia during surgery is beneficial to reduce APP causes less need for additional analgesic drugs, and improves patient satisfaction.

Obesity and anesthesia.

PURPOSE OF REVIEW: Surgical procedures on obese patients are dramatically increasing worldwide over the past few years. In this review, we discuss the physiopathology of predominantly respiratory system in obese patients, the importance of preoperative evaluation, preoxygenation and intraoperative positive end expiratory pressure (PEEP) titration to prevent pulmonary complications and the optimization of airway management and oxygenation to reduce or prevent postoperative respiratory complications. RECENT FINDINGS: Many patients are coming to preoperative clinic with medication history of glucagon-like-peptide 1 agonists ( GLP-1) agonists and it has raised many questions regarding Nil Per Os (NPO)/perioperative fasting guidelines due to delayed gastric emptying caused by these medications. American Society of Anesthesiologists (ASA) has come up with guiding document to help with such situations. Ambulatory surgery centers are doing more obesity cases in a safe manner which were deemed unsafe at one point . Quantitative train of four (TOF) monitoring, better neuromuscular reversal agents and gastric ultrasounds seemed to have made a significant impact in the care of obese patients in the perioperative period. SUMMARY: Obese patients are at higher risk of perioperative complications, mainly associated with those related to the respiratory function. An appropriate preoperative evaluation, intraoperative management, and postoperative support and monitoring is essential to improve outcome and increase the safety of the surgical procedure.