Substance use disorder in the anaesthetist: Guidelines from the Association of Anaesthetists: Guidelines from the Association of Anaesthetists.

Anaesthetists have a higher incidence of substance use disorder when compared with other doctors. This might be due to the ease of access to intravenous opioids, propofol, midazolam, inhalational agents and other anaesthetic drugs. Alcohol use disorder continues to be the most common problem. Unfortunately, the first sign that something is amiss might be the anaesthetist's death from an accidental or deliberate overdose. While there are few accurate data, suicide is presumed to be the cause of death in approximately 6-10% of all anaesthetists. If we are to prevent this, substance use disorder must be recognised early, we should ensure the anaesthetist is supported by their department and hospital management and that the anaesthetist engages fully with treatment. Over 75% of anaesthetists return to full practice if they co-operate fully with the required treatment and supervision.

Malignant hyperthermia 2020: Guideline from the Association of Anaesthetists.

Malignant hyperthermia is defined in the International Classification of Diseases as a progressive life-threatening hyperthermic reaction occurring during general anaesthesia. Malignant hyperthermia has an underlying genetic basis, and genetically susceptible individuals are at risk of developing malignant hyperthermia if they are exposed to any of the potent inhalational anaesthetics or suxamethonium. It can also be described as a malignant hypermetabolic syndrome. There are no specific clinical features of malignant hyperthermia and the condition may prove fatal unless it is recognised in its early stages and treatment is promptly and aggressively implemented. The Association of Anaesthetists has previously produced crisis management guidelines intended to be displayed in all anaesthetic rooms as an aide memoire should a malignant hyperthermia reaction occur. The last iteration was produced in 2011 and since then there have been some developments requiring an update. In these guidelines we will provide background information that has been used in updating the crisis management recommendations but will also provide more detailed guidance on the clinical diagnosis of malignant hyperthermia. The scope of these guidelines is extended to include practical guidance for anaesthetists dealing with a case of suspected malignant hyperthermia once the acute reaction has been reversed. This includes information on care and monitoring during and after the event; appropriate equipment and resuscitative measures within the operating theatre and ICU; the importance of communication and teamwork; guidance on counselling of the patient and their family; and how to make a referral of the patient for confirmation of the diagnosis. We also review which patients presenting for surgery may be at increased risk of developing malignant hyperthermia under anaesthesia and what precautions should be taken during the peri-operative management of the patients.

Achondroplasia: anaesthetic challenges for caesarean section.

Pregnancy in women with achondroplasia presents major challenges for anaesthetists and obstetricians. We report the case of a woman with achondroplasia who underwent general anaesthesia for an elective caesarean section. She was 99cm in height and her condition was further complicated by severe kyphoscoliosis and previous back surgery. She was reviewed in the first trimester at the anaesthetic high-risk clinic. A multidisciplinary team was convened to plan her peripartum care. Because of increasing dyspnoea caesarean section was performed at 32weeks of gestation. She received a general anaesthetic using a modified rapid-sequence technique with remifentanil and rocuronium. The intraoperative period was complicated by desaturation and high airway pressures. The woman's postoperative care was complicated by respiratory compromise requiring high dependency care.

The introduction of a surgical safety checklist in a tertiary referral obstetric centre.

BACKGROUND Surgery-related adverse events remain a significant and often under-reported problem. In a recent study, the introduction of a perioperative checklist by the WHO reduced deaths and complications by 46% and 36% respectively. The authors wished to evaluate the introduction of a surgical safety checklist in a busy obstetric tertiary referral centre by assessing staff attitudes, checklist compliance and effects upon patients. METHODS A questionnaire-based assessment was performed on staff working in obstetric theatres before and after the introduction of the surgical safety checklist. Checklist compliance was assessed at 3 months and 1 year. Patients were asked questions relating to the performance of the surgical safety checklist in order to evaluate any anxiety caused. RESULTS Non-medical staff were significantly more likely than medical staff to feel familiar with other team members both before (p<0.001) and after (p=0.03) the introduction of the checklist. 69.6% of all staff felt that interprofessional communication had improved following the introduction of the checklist. Compliance with pre- and postoperative checks was 61.2% and 67.6%, respectively, improving to 79.7% and 84.7% after 1 year. Although the majority of patients were aware of the checks being performed, this did not provoke anxiety. CONCLUSION Following consultation with staff and patients, the authors managed to institute and sustain the performance of a surgical safety checklist for elective cases in obstetric theatres. While significant progress has been made, the authors recognise that further work is required in order to further evaluate and optimise this process.

Evaluation of M43B Lumbar puncture simulator-II as a training tool for identification of the epidural space and lumbar puncture.

The identification of the epidural space, insertion of an epidural catheter and lumbar puncture are advanced technical skills that can be challenging to teach to novice anaesthetists. The M43B Lumbar puncture simulator-II (Limbs & Things Ltd., Sussex Street, Bristol, UK) is a teaching aid designed for epidural and spinal insertion. The aim of this study was to determine if experienced anaesthetists thought this simulator may be a useful tool for training novice anaesthetists in these procedures. Experienced anaesthetists performed an epidural insertion followed by a lumbar puncture procedure on the simulator model. Various aspects of both epidural and lumbar puncture insertions were scored by the anaesthetists for likeness to a real patient using a Likert scale (0--strongly disagree; 1--disagree; 2--neither agree nor disagree; 3--agree; 4--strongly agree). The simulator was found to be life-like for most aspects of epidural insertion. Median (IQR [range]) scores were: iliac crests 3.0 (3.0-3.2 [3-4]); spinous processes 3.0 (3.0-3.2 [2-4]); skin puncture 3.0 (3.0-3.0 [1-4]); subcutaneous tissues 3.0 (2.7-3.0 [1-4]); and loss of resistance 3.0 (3.0-4.0 [3-4]). The scores for supraspinous ligament 2.0 (1.0-3.0 [0-3]), interspinous ligament 2.5 (1.7-3.0 [0-3]) and ligamentum flavum 2.0 (1.0-3.0 [0-4]) were borderline for life-likeness. The volunteers found threading of the epidural catheter difficult and rated it unlike a real patient (score 1.0 (0.2-2.0 [0-3])). During lumbar puncture, dural puncture scored 3.0 (3.0-4.0 [2-4]) and intrathecal injection scored 2.5 (1.0-3.0 [1-4]). However, the overall impression was that the simulator could be a useful tool for training of both epidurals (score 3.0 (3.0-4.0 [3-4])) and spinals (score 3.0 (3.0-3.5 [2-4])).

Effects of normobaric hyperoxia on haemodynamic parameters of healthy full-term parturients.

Fifteen healthy, full-term women with singleton pregnancies were exposed to an increased F(I)o(2) of 0.4 and their haemodynamic responses measured with a non-invasive transthoracic bio-impedance monitor. There was a mean reduction in cardiac index from 3.18 to 3.03 l x min(-1) x m(-2) (4.7%, p = 0.004). The mean indexed systemic vascular resistance increased from 2049 to 2178 dynes x cm(-5) x m(-2) (5.7%, p = 0.005). There were no significant changes in stroke index, heart rate or mean arterial pressure. This study demonstrates that even a moderate increase in inspired oxygen fraction has significant effects on the cardiovascular system of the term parturient.

Cardiomyopathy in pregnancy and caesarean section: four case reports.

We present the clinical details of four women with cardiomyopathy who required caesarean section. Two women had peripartum cardiomyopathy and two had hypertrophic obstructive cardiomyopathy, one of whom has had two caesarean sections. Those with peripartum cardiomyopathy were more compromised than those with hypertrophic obstructive cardiomyopathy. Co-operation between obstetric and cardiac anaesthetists ensured optimum experience was available. An incremental combined spinal-epidural technique with invasive monitoring was used for three women and one received general anaesthesia. The risks and benefits of different anaesthetic techniques are discussed.

Comparison of patient-controlled epidural bolus administration of 0.1% ropivacaine and 0.1% levobupivacaine, both with 0.0002% fentanyl, for analgesia during labour.

The aim of the study was to compare the relative potencies and clinical characteristics of epidural ropivacaine and levobupivacaine in labour using patient-controlled epidural analgesia (PCEA). In a randomised double-blinded study, 60 ASA I or II primigravidae requesting epidural analgesia in early labour were allocated to receive either 0.1% ropivacaine with fentanyl 0.0002% or 0.1% levobupivacaine with 0.0002% fentanyl via a patient-controlled analgesia pump. Analgesia was established with 15 ml of study solution and maintained using 5-ml boluses of study solution with a 5-min lockout interval. There were no significant differences in onset time, duration and quality of analgesia, motor and sensory blockade, local anaesthetic consumption, mode of delivery, neonatal outcome or maternal satisfaction between the groups. We conclude that 0.1% ropivacaine with 0.0002% fentanyl and 0.1% levobupivacaine with 0.0002% fentanyl are clinically indistinguishable for labour analgesia and appear pharmacologically equipotent when using PCEA.

Patient controlled administration of intravenous alfentanil during elective caesarean section under subarachnoid anaesthesia.

In this observational study, an alfentanil-containing patient controlled analgesia device was evaluated for the relief of visceral pain during elective caesarean section under subarachnoid anaesthesia. Forty healthy women at term received 2.5 mL of intrathecal hyperbaric 0.5% bupivacaine in the sitting position. Surgery began when loss of cold appreciation to the fourth thoracic dermatome was demonstrated. The patient controlled analgesia device was configured to deliver 3 microg.kg(-1) of alfentanil when first actuated. Each subsequent demand delivered 1.5 microg.kg(-1) with a 2-min lock-out interval. Sixty-five percent of women used alfentanil during surgery. The median (IQR) consumption of alfentanil was 360 (278-720) microg. Patient controlled analgesia is a useful method of supplementing subarachnoid anaesthesia for caesarean section. The technique is simple to use and in this group there were no troublesome side effects.

Complementary medicine: viable models.

Complementary medicine has had a quiet, consumer-based, grassroots evolution, generally spearheaded by individual champions. In this article, McGrady describes six models of complementary medicine and details specific practitioners who have implemented these models. Solo practitioners, physician-based practices, academic and research initiatives, wellness centers, provider networks, and hospital-based initiatives are discussed to display the diversity of options for complementary medicine. In addition, the author touches upon the legalities and credentialing of practitioners, as well as the financial considerations that health systems must face.

Comparison of 0.25% S(-)-bupivacaine with 0.25% RS-bupivacaine for epidural analgesia in labour.

We have compared the efficacy of 0.25% S(-)-bupivacaine with 0.25% RS-bupivacaine in providing epidural analgesia for labour in a randomized, multicentre, double-blind study. Analgesia was initiated with 10 ml of the study solution and maintained with 10-ml top-ups. We studied 137 women and treatments were found to be equivalent for onset, duration and quality of block. Median onset of pain relief was 12 min for both drugs and median duration was 49 (range 3-129) min and 51 (7-157) min for S(-)-bupivacaine and RS bupivacaine, respectively. The estimated treatment difference for duration of pain relief was -4 (90% CI -13, 6) min. Thirty patients failed to achieve pain relief after the first injection (20 patients after S(-)-bupivacaine and 10 after RS-bupivacaine; P = 0.039). However, median duration of pain relief from the first top-up was 82 (range 3-164) min for S(-)-bupivacaine and 76 (22-221) min for RS-bupivacaine. There were no significant differences in the quality of analgesia, as assessed by the investigators. There were no significant differences in the extent of sensory block, percentage of patients with motor block or incidence of adverse events.

Comparison of epidural bolus administration of 0.25% bupivacaine and 0.1% bupivacaine with 0.0002% fentanyl for analgesia during labour.

We have compared analgesia during labour provided by two epidural drug regimens, in a double-blind, randomized, controlled study. Group A received 10-ml bolus doses of 0.1% bupivacaine with fentanyl 2 micrograms ml-1 while group B received 0.25% plain bupivacaine 10 ml. Analgesia provided by both techniques was similar, but women in group A retained motor power in their legs and 60% chose to get out of bed. Duration of labour and time from insertion of the epidural to delivery was similar in both groups, but in group A, duration of the second stage was significantly shorter (P = 0.0003; 95% confidence interval (CI) -1.17, -0.27 h) and the incidence of forceps delivery was lower (P = 0.032). Maternal satisfaction with epidural analgesia, as assessed by VAS, was higher in group A (P = 0.04; 95% CI -0.001, 10.001).

Combined spinal-extradural anaesthesia for preterm and term caesarean section: is there a difference in local anaesthetic requirements?

In a non-blinded observational study, we have tested the null hypothesis that there is no difference in local anaesthetic requirements for subarachnoid anaesthesia between women presenting for Caesarean section at term or preterm (38-42 and 28-35 weeks' gestation, respectively). Using a combined spinal-extradural technique, 2.25 ml of 0.5% hyperbaric bupivacaine was given, in the sitting position, to 50 women presenting for Caesarean section. In 21 of 25 preterm women, adequate sensory block for surgery did not develop (P < 0.001) and they required supplementary extradural local anaesthetic (median 8 ml of 2% lignocaine with 1:200,000 adrenaline (interquartile range 4-12 ml)); preterm women not requiring extradural supplementation were at the upper end of the gestational range. There was a strong linear correlation between increasing gestation and block height in the preterm group (Spearman rank correlation coefficient = 0.74; 95% confidence intervals 0.49, 0.88). All women in the term group developed adequate anaesthesia with the subarachnoid dose alone. Onset of anaesthesia was slower in the preterm group (median 15 vs 5 min) with a lower incidence of hypotension (P = 0.0005).

Patient-controlled analgesia following caesarean section: a comparison of morphine and meptazinol.

Forty-eight women were investigated in a prospective double-blind study and randomised to receive intravenous patient-controlled analgesia (PCA) with meptazinol or morphine following elective caesarean section. Women received PCA boluses of 1 mg morphine or 10 mg meptazinol with no background infusion. Total drug consumption measured over a 24 h period, pain (visual analogue scores), sedation scores, incidence of nausea and vomiting, and requests for rescue analgesia were compared. Both meptazinol and morphine delivered via PCA provide satisfactory analgesia after caesarean section. There was no statistically significant difference in pain scores (P = 0.47) or the incidence of side-effects (nausea/vomiting P = 0.076, sedation P = 0.63) between the two drugs. Meptazinol is more expensive and offers no clinical advantages in this group of patients.

Spinal anaesthesia for Caesarean section: effect of Sprotte needle orientation.

We induced spinal anaesthesia in 100 women presenting for elective Caesarean section with the mother in the right lateral position. Patients were allocated randomly to have the side eye of the 24-gauge Sprotte spinal needle pointing in one of four directions: group A, cephalad; group B, right lateral; group C, left lateral; group D, caudad. Isobaric bupivacaine 0.5% (2.5 ml) was injected over 30 s before the mother was placed supine with a 15 degree left lateral tilt. Onset time and height of the subsequent analgesic and anaesthetic blocks were assessed by a blinded observer. Onset of sensory block to T4 was significantly faster in group A (P = 0.001). There were no differences in final block height, incidence of hypotension, nausea and vomiting or ephedrine requirements.

An audit cycle of blood ordering practice in a district maternity unit reduces unnecessary crossmatching.

We audited the appropriateness of blood ordering in our obstetric unit, by analysing the ratio of number of units of blood cross-matched to number transfused (C:T ratio), both overall and for specific indications. Based on this information, we devised a new blood ordering policy, and repeated the audit once this was in operation. The new policy resulted in a substantial increase in the efficiency of blood ordering. The overall C:T ratio fell from 10.9 to 3.0, and there were particularly large falls for caesarean section (from 34.3 to 6.2), high risk labours (from 67.8 to 9.1) and post-partum haemorrhage/retained placenta (from 4.3 to 1.9).

Maternal position during induction of spinal anaesthesia for caesarean section. A comparison of right lateral and sitting positions.

Forty women presenting for elective Caesarean section under spinal anaesthesia were randomly assigned to have anaesthesia induced in either the sitting or right lateral positions; 2.5 ml 0.5% hyperbaric bupivacaine was injected over 10 s before the mother was placed in a supine position with a 20 degree lateral tilt. The onset time and height of the subsequent analgesic and anaesthetic block was measured. It took longer to site spinal needles in the lateral position (240 vs 115 s, p < 0.001). There was a faster onset of sensory block to the sixth thoracic dermatomal level (8 vs 10 min, p < 0.001), in the lateral group, although onset time to T4 was comparable. There was no difference in maximum block height or degree of motor block. Mothers in the lateral group required more ephedrine in the first 10 m after siting the spinal (13.5 vs 10.5 mg, p < 0.05).