From Anaesthesia

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Wiley Online Library : Anaesthesia
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Reliability of pressure waveform analysis to determine correct epidural needle placement in labouring women

17. April 2017 - 12:00
Summary

Pressure waveform analysis provides a reliable confirmatory adjunct to the loss-of-resistance technique to identify the epidural space during thoracic epidural anaesthesia, but its role remains controversial in lumbar epidural analgesia during labour. We performed an observational study in 100 labouring women of the sensitivity and specificity of waveform analysis to determine the correct location of the epidural needle. After obtaining loss-of-resistance, the anaesthetist injected 5 ml saline through the epidural needle (accounting for the volume already used in the loss-of-resistance). Sterile extension tubing, connected to a pressure transducer, was attached to the needle. An investigator determined the presence or absence of a pulsatile waveform, synchronised with the heart rate, on a monitor screen that was not in the view of the anaesthetist or the parturient. A bolus of 4 ml lidocaine 2% with adrenaline 5 μg.ml−1 was administered, and the epidural block was assessed after 15 min. Three women displayed no sensory block at 15 min. The results showed: epidural block present, epidural waveform present 93; epidural block absent, epidural waveform absent 2; epidural block present, epidural waveform absent 4; epidural block absent, epidural waveform present 1. Compared with the use of a local anaesthetic bolus to ascertain the epidural space, the sensitivity, specificity, positive and negative predictive values of waveform analysis were 95.9%, 66.7%, 98.9% and 33.3%, respectively. Epidural waveform analysis provides a simple adjunct to loss-of-resistance for confirming needle placement during performance of obstetric epidurals, however, further studies are required before its routine implementation in clinical practice.

Categories: From Anaesthesia

Long-term alterations in monocyte function after elective cardiac surgery

13. April 2017 - 16:16
Summary

Optimal immunological homoeostasis determines the long-term recovery of patients in the postoperative period. The functional adaptability of monocytes plays a pivotal role in adjusting the host's response to an insult, immunostasis and long-term health, and may help to determine successful recovery. We undertook a longitudinal analysis of the functional adaptability of monocytes in 20 patients undergoing heart surgery with cardiopulmonary bypass, as a model of severe stress. Using each patient's pre-cardiopulmonary bypass data as a baseline, we investigated the characteristics of peripheral blood monocytes’ functional plasticity in-vitro before elective bypass, and three months afterwards. Approximately 30% of subjects showed diminished monocyte plasticity, as demonstrated by decreased monocyte differentiation into dendritic cells three months after bypass. Diminished monocyte functional plasticity was related to over-production of macrophage colony-stimulating factor. Adding a neutralising antibody to macrophage colony-stimulating factor corrected the monocytes’ differentiation defect. Finally, patients with reduced monocyte plasticity had significantly elevated serum C-reactive protein, with a concomitant increase in cytomegalovirus IgG antibody titres, suggestive of the acquisition of immuno-suppressive traits. Our study shows that severe surgical stress resulted in a lasting immunological defect in individuals who had seemingly recovered.

Categories: From Anaesthesia

Mock before you block – a reply

12. April 2017 - 7:52
Categories: From Anaesthesia

Mock before you block

12. April 2017 - 7:52
Categories: From Anaesthesia

Issue Information – Editorial Board

12. April 2017 - 7:52
Categories: From Anaesthesia

Non-sticky sticky syringe labels

12. April 2017 - 7:52
Categories: From Anaesthesia

Effect of prophylactic placement of internal iliac artery balloon catheters on outcomes of women with placenta accreta: an impact study

12. April 2017 - 6:20
Summary

We performed an impact study on the introduction of routine placement of internal iliac artery balloon catheters for the management of haemorrhage during caesarean section in women with placenta accreta. We identified 11 women, with prenatally diagnosed placenta accreta/increta/percreta before this change in practice, who acted as controls, and 30 women who had iliac artery balloons placed. The balloons were inflated in 27 cases. The median (IQR [range]) intra-operative blood loss was 1100 (800–2600 [500–6000]) ml in controls, compared with 1000 (600–2513 [400–15000]) ml in women with iliac artery balloons (p = 0.64). Six (54%) controls received intra-operative blood transfusion compared with 14 (47%) women with iliac artery balloons (p = 0.66). Caesarean hysterectomy was performed in 3 (27.3%) controls and 13 (43.3%) women with iliac artery balloons (p = 0.48). Balloon catheter insertion was associated with a shortened postoperative hospital stay, 6 (5–7 [4–12] days in controls vs. 5 (4–6 [3–10]) in the iliac artery balloon group (p = 0.033). General anaesthesia was used in six (54%) controls, but all women with iliac artery balloons. This study demonstrates that prophylactic balloon occlusion of the internal iliac arteries did not reduce intra-operative haemorrhage or caesarean hysterectomy in women with placenta accreta undergoing caesarean section. In addition, it has a significant impact on the choice of anaesthetic technique.

Categories: From Anaesthesia

Pain-related unscheduled contact with healthcare services after outpatient surgery

10. April 2017 - 12:21
Summary

This prospective, observational study explored the need for pain-related unscheduled contact with healthcare services after outpatient surgery. We hypothesised that 10% of outpatients would have pain-related unscheduled contact with healthcare services, and that the incidence would differ depending on the type of surgical procedure. In total, 905 patients who had undergone one of five common outpatient surgical procedures (knee or shoulder arthroscopy, surgical correction of hallux valgus, laparoscopic cholecystectomy or laparoscopic gynaecological procedures) completed an electronic questionnaire one week and eight weeks after surgery. Data from 732 patients (81%) were available for analysis. Within the first eight weeks after surgery, 150 patients (20.5%) had made unscheduled contact with healthcare professionals, in 247 cases due to pain that was most frequent in the first postoperative week. Risk factors were female sex, unemployment and laparoscopic cholecystectomy. The most frequent healthcare contact was with the general practitioner (46.4%), and the most frequent outcome was further information and guidance (41.2%). We have demonstrated that a minority of patients still needed to make contact with health services after outpatient surgery, most often due to inadequate pain management. This finding should be considered when planning postoperative monitoring and care, and developing postoperative patient education.

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