Fatigue among anaesthesiologists in Europe: Findings from a joint EBA/NASC survey.

BACKGROUND: Anaesthesiologists deliver an increasing amount of patient care and often work long hours in operating theatres and intensive care units, with frequent on-calls and insufficient rest in between. In the long term, this will negatively influence mental and physical health and well being. As fatigue becomes more prevalent, this has predictable implications for patient safety and clinical effectiveness. 1. OBJECTIVE: This study aimed to evaluate the prevalence, severity, causes and implications of work-related fatigue amongst specialist anaesthesiologists. DESIGN: An online survey of specialist anaesthesiologists. PARTICIPANTS: The survey was sent to anaesthesiologists in 42 European countries by electronic mail. MAIN OUTCOME MEASURES: Responses from a 36-item online survey assessed work-related fatigue and its impact on anaesthesiologists in European countries. RESULTS: Work-related fatigue was experienced in 91.6% of the 1508 respondents from 32 European countries. Fatigue was caused by their working patterns, clinical and nonclinical workloads, staffing issues and excessive work hours. Over 70% reported that work-related fatigue negatively impacted on their physical and mental health, emotional well being and safe commuting. Most respondents did not feel supported by their organisation to maintain good health and well being. CONCLUSION: Work-related fatigue is a significant and widespread problem amongst anaesthesiologists. More education and increased awareness of fatigue and its adverse effects on patient safety, staff well being and physical and mental health are needed. Departments should ensure that their rotas and job plans comply with the European Working Time Directive (EWTD) and introduce a fatigue risk management system to mitigate the effects of fatigue.

ULTRASOUND SKILLS IN LOWER EXTREMITY TRAUMATOLOGY AND ORTHOPEDICS - REGIONAL ANESTHESIA AND BEYOND.

During the last two decades ultrasound guidance has been established as an invaluable tool for performing peripheral nerve blocks. Ultrasound guidance reduces block performance time, volume of local anesthetic, risk of intravascular injection and need for opioid rescue analgesia compared to landmark based and neurostimulator guided techniques. The use of ultrasound guidance must not be understood as a surrogate to, but should complement a thorough understanding of anatomy. The purpose of this overview is to present ultrasound guided techniques for performing basic lower extremity blocks, as well as to discuss more recent trends in providing regional analgesia for patients undergoing lower extremity surgery.

Tranexamic acid for the reduction of blood loss in total knee arthroplasty.

The Journal of Arthroplasty recently published a paper entitled "The Efficacy of Combined Use of Intraarticular and Intravenous Tranexamic Acid on Reducing Blood Loss and Transfusion Rate in Total Knee Arthroplasty". Tranexamic acid (TXA) is an antifibrinolytic drug whose administration during the perioperative period either by intravenous route or topically applied to the surgical field has been shown to reliably reduce blood loss and need for transfusion in patients undergoing total knee arthroplasty (TKA). Although randomized trials and meta-analyses did not show an increase in thromboembolic events, concerns remain about its repeated systemic application. The authors of the study introduced a novel regimen of TXA administration combining a preoperative intravenous bolus followed by local infiltration at the end of surgery with the idea of maximizing drug concentration at the surgical site while minimizing systemic antifibrinolytic effects. The combined dosage regimen appears to be more effective than single dose local application in reducing blood loss and transfusion rate without any complications noted.

Influence of tranexamic acid on postoperative autologous blood retransfusion in primary total hip and knee arthroplasty: a randomized controlled trial.

BACKGROUND: Postoperatively shed blood salvage is commonly used to reduce allogenic blood transfusion in patients undergoing total hip (THA) and knee arthroplasty (TKA). Autologous blood retransfusion is not devoid of risk. We hypothesized that adding tranexamic acid (TXA) to a restrictive blood transfusion protocol would reduce the need for postoperative autologous blood retransfusion in primary knee and hip arthroplasty. STUDY DESIGN AND METHODS: Ninety-eight adult patients undergoing primary THA or TKA were randomly assigned to receive an intraoperative intravenous loading dose of 1.0 g of TXA followed by another 1.0-g dose 3 hours later (TXA group) or a matching volume 0.9% saline placebo (control group). A postoperatively shed autologous blood recovery system was used in all patients and the minimum reinfusion volume set at 250 mL. Red blood cells were transfused if hemoglobin level was less than 8 or if 8 to 10 g/dL with symptoms of anemia. RESULTS: The proportion of patients receiving autologous blood reinfusion was significantly lower in the TXA group (5/49) compared to placebo (42/49) with an absolute difference of -75.5% (adjusted relative risk, 0.005), and none of the patients in the TXA group received more than 400 mL retransfused. Median total external blood loss during the first 24 hours was lower in the TXA group, 320 mL (range, 80-930 mL), compared to 970 mL (range, 100-2600 mL) in the placebo group (p < 0.001). There were no significant differences in homologous blood transfusions and hematologic variables between groups. Treatment differences were consistent by size and significance when the analysis was repeated separately in patients undergoing TKA or THA. CONCLUSION: Addition of TXA to a restrictive transfusion protocol makes the use of a postoperative blood salvage system in patients undergoing primary hip and knee arthroplasty unnecessary.

[Fast track surgery--enhanced multimodal rehabilitation after surgery]. / "Fast track" kirurgija--ubrzana multimodalna rehabilitacija kirurskih bolesnika.

Despite constant improvements in surgical technique and perioperative care which led to significant reductions in mortality and morbidity after general surgery, complication rates after major abdominal surgery still reach 15-40%. The main cause of postoperative complications (not linked to surgical technique itself) is the perioperative stress reaction potentiated by pain, inadequate perioperative fluid management, immobilisation and hypothermia. Multimodal rehabilitation of surgical patients represents the practical application of advances in surgery, anaesthesiology and postoperative rehabilitation with the aim of reducing perioperative stressors and facilitating an early return of the patient to his/her preoperative functional status. Besides discussing various aspects of multimodal rehabilitation, the authors present their own first experiences with its introduction into everyday clinical practice.

Hyperbaric oxygenation combined with streptokinase for treatment of arterial thromboembolism of the lower leg.

Thromboembolic occlusion of peripheral arteries is a common problem in patients referred to vascular surgery departments. Standard treatments include catheter aspiration techniques, use of fibrinolytic agents and surgical thrombendarterectomy. Recent reports have described the use of hyperbaric oxygen therapy in patients with limb ischemia, yet their main focus has been on patients with chronic disorders. We present the case of a 74-year-old woman with atrial fibrillation and acute thromboembolic occlusion of the posterior tibial artery. The patient presented with severe pain in the right calf, unresponsive to non-opioid parenteral analgesia and accompanied by coldness, numbness and partial motor palsy of the right foot. After 60 minutes of oxygenation in a hyperbaric chamber with a pressure of 2.2 bar, the pain receded, although without signs of restored blood flow in the occluded artery. After fibrinolytic therapy with streptokinase, patency of the posterior tibial artery was verified by return of palpable pulsations and color Doppler ultrasonography. By combining hyperbaric oxygenation and streptokinase in the treatment of lower-leg arterial thromboembolism we achieved regression of ischemic pain, prolongation of the survival time of tissues compromised by ischemia and resolved the cause of the ischemia. We believe the use of this therapeutic strategy in selected cases of peripheral arterial thromboembolism is justified.