General anaesthesia or conscious sedation for painful procedures in childhood cancer: the family's perspective

Background: Until recently, midazolam sedation was routinely used in our institution for bone marrow aspirates and lumbar punctures in children with cancer. It has been perceived by many doctors and nurses as being well tolerated by children and their families.

Aim: To compare the efficacy of inhalational general anaesthesia and midazolam sedation for these procedures.

Methods: A total of 96 children with neoplastic disorders, who received either inhalational general anaesthesia with sevoflurane, nitrous oxide, and oxygen (GA) or sedation with oral or nasal midazolam (SED) as part of their routine preparation for procedures were studied. The experiences of these childen were examined during their current procedure and during their first ever procedure. Main outcome measures were the degree of physical restraint used on the child, and the levels of distress and pain experienced by the child during the current procedure and during the first procedure. The family‘s preference for future procedures was also determined.

Results: During 102 procedures under GA, restraint was needed on four occasions (4%) when the anaesthetic mask was first applied, minimal pain was reported, and children were reported as distressed about 25% of the time. During 80 SED procedures, restraint was required in 94%, firm restraint was required in 66%, the child could not be restrained in 14%, median pain score was 6 (scale 0 (no pain) to 6 (maximum pain)), and 90% of the parents reported distress in their child. Ninety per cent of families wanted GA for future procedures. Many families reported dissatisfaction with the sedation regime and raised concerns about the restraint used on their child.

Conclusions: This general anaesthetic regime minimised the need for restraint and was associated with low levels of pain and distress. The sedation regime, by contrast, was much less effective. There was a significant disparity between the perceptions of health professionals and those of families with respect to how children coped with painful procedures.

Anaesthesia monitoring using fuzzy logic

Objective. Humans have a limited ability to accurately and continuously analyse large amount of data. In recent times, there has been a rapid growth in patient monitoring and medical data analysis using smart monitoring systems. Fuzzy logic-based expert systems, which can mimic human thought processes in complex circumstances, have indicated potential to improve clinicians' performance and accurately execute repetitive tasks to which humans are ill-suited. The main goal of this study is to develop a clinically useful diagnostic alarm system based on fuzzy logic for detecting critical events during anaesthesia administration. Method. The proposed diagnostic alarm system called fuzzy logic monitoring system (FLMS) is presented. New diagnostic rules and membership functions (MFs) are developed. In addition, fuzzy inference system (FIS), adaptive neuro fuzzy inference system (ANFIS), and clustering techniques are explored for developing the FLMS' diagnostic modules. The performance of FLMS which is based on fuzzy logic expert diagnostic systems is validated through a series of offline tests. The training and testing data set are selected randomly from 30 sets of patients' data. Results. The accuracy of diagnoses generated by the FLMS was validated by comparing the diagnostic information with the one provided by an anaesthetist for each patient. Kappa-analysis was used for measuring the level of agreement between the anaesthetist's and FLMS's diagnoses. When detecting hypovolaemia, a substantial level of agreement was observed between FLMS and the human expert (the anaesthetist) during surgical procedures. Conclusion. The diagnostic alarm system FLMS demonstrated that evidence-based expert diagnostic systems can diagnose hypovolaemia, with a substantial degree of accuracy, in anaesthetized patients and could be useful in delivering decision support to anaesthetists.

The microbiological and sustainability effects of washing anaesthesia breathing circuits less frequently

In the presence of single-use airway filters, we quantified anaesthetic circuit aerobic microbial contamination rates when changed every 24 h, 48 h and 7 days. Microbiological samples were taken from the interior of 305 anaesthetic breathing circuits over a 15-month period (3197 operations). There was no significant difference in the proportion of contaminated circuits when changed every 24 h (57/105 (54%, 95% CI 45–64%)) compared with 48 h (43/100 (43%, 95% CI 33–53%, p = 0.12)) and up to 7 days (46/100 (46%, 95% CI 36–56%, p = 0.26)). Median bacterial counts were not increased at 48 h or 7 days provided circuits were routinely emptied of condensate. Annual savings for one hospital (six operating theatres) were $AU 5219 (£3079, €3654, $US 4846) and a 57% decrease in anaesthesia circuit steriliser loads associated with a yearly saving of 2760 kWh of electricity and 48 000 l of water. Our findings suggest that extended circuit use from 24 h up to 7 days does not significantly increase bacterial contamination, and is associated with labour, energy, water and financial savings.

Perioperative Mortality Rate (POMR): a global indicator of access to safe surgery and anaesthesia

The unmet global burden of surgical disease is substantial. Currently, two billion people do not have access to emergency and essential surgical care. This results in unnecessary deaths from injury, infection, complications of pregnancy, and abdominal emergencies. Inadequately treated surgical disease results in disability, and many children suffer deformity without corrective surgery.

The Post-Anaesthesia N-acetylcysteine Cognitive Evaluation (PANACEA) trial: study protocol for a randomised controlled trial

BACKGROUND: Some degree of cognitive decline after surgery occurs in as many as one quarter of elderly surgical patients, and this decline is associated with increased morbidity and mortality. Cognition may be affected across a range of domains, including memory, psychomotor skills, and executive function. Whilst the exact mechanisms of cognitive change after surgery are not precisely known, oxidative stress and subsequent neuroinflammation have been implicated. N-acetylcysteine (NAC) acts via multiple interrelated mechanisms to influence oxidative homeostasis, neuronal transmission, and inflammation. NAC has been shown to reduce oxidative stress and inflammation in both human and animal models. There is clinical evidence to suggest that NAC may be beneficial in preventing the cognitive decline associated with both acute physiological insults and dementia-related disorders. To date, no trials have examined perioperative NAC as a potential moderator of postoperative cognitive changes in the noncardiac surgery setting.

METHODS AND DESIGN: This is a single-centre, randomised, double-blind, placebo-controlled clinical trial, with a between-group, repeated-measures, longitudinal design. The study will recruit 370 noncardiac surgical patients at the University Hospital Geelong, aged 60 years or older. Participants are randomly assigned to receive either NAC or placebo (1:1 ratio), and groups are stratified by age and surgery type. Participants undergo a series of neuropsychological tests prior to surgery, 7 days, 3 months, and 12 months post surgery. It is hypothesised that the perioperative administration of NAC will reduce the degree of postoperative cognitive changes at early and long-term follow-up, as measured by changes on individual measures of the neurocognitive battery, when compared with placebo. Serum samples are taken on the day of surgery and on day 2 post surgery to quantitate any changes in levels of biomarkers of inflammation and oxidative stress.

DISCUSSION: The PANACEA trial aims to examine the potential efficacy of perioperative NAC to reduce the severity of postoperative cognitive dysfunction in an elderly, noncardiac surgery population. This is an entirely novel approach to the prevention of postoperative cognitive dysfunction and will have high impact and translatable outcomes if NAC is found to be beneficial.

Early childhood caries: current evidence for aetiology and prevention

Background: Despite the fact that it is largely preventable, dental caries (decay) remains one of the most common chronic diseases of early childhood. Dental decay in young children frequently leads to pain and infection necessitating hospitalization for dental extractions under general anaesthesia. Dental problems in early childhood have been shown to be predictive of not only future dental problems but also on growth and cognitive development by interfering with comfort nutrition, concentration and school participation. Objective: To review the current evidence base in relation to the aetiology and prevention of dental caries in preschool-aged children. Methods: A search of MEDLINE, CINALH and Cochrane electronic databases was conducted using a search strategy which restricted the search to randomized controlled trials, meta-analyses, clinical trials, systematic reviews and other quasi-experimental designs. The retrieved studies were then limited to articles including children aged 5 years and under and published in English. The evidence of effectiveness was then summarized by the authors. Conclusions: The review highlighted the complex aetiology of early childhood caries (ECC). Contemporary evidence suggests that potentially effective interventions should occur in the first 2 years of a child's life. Dental attendance before the age of 2 years is uncommon; however, contact with other health professionals is high. Primary care providers who have contact with children well before the age of the first dental visit may be well placed to offer anticipatory advice to reduce the incidence of ECC.

Weaning and growth of Anguilla australis glass eels and elvers

Anguilla australis glass eels proved to be resilient and present strong aquaculture potential. General husbandry techniques, anaesthesia and prophylactic treatments were established for glass eels between 0.1 g and 2.0 g and elvers between 2.0 g and 8.0 g, caught in rivers and estuaries along the South East Coast of Victoria. The protozoan parasites Ichthyobodo and Trichodina were found to be present on arrival to the hatchery developed during different rearing treatments, and were successfully eradicated. A. australis glass eels accepted artificial food, but it was recommended first be fed a preweaning diet of minced fish flesh. A weaning regime from minced fish flesh to commercially available eel grower mash, over 15 days was established. Growth rate proved to be highly variable, both between and within groups. The highest growth rate of 2.71%/day was found when the natural diet of minced fish and Artemia was fed. The maximum growth rate when reared on an artificial diet of 1.63%/day was observed at 25°C. Growth was affected by the presence or absence of a preweaning diet, weaning diet, weaning period, temperature, but not by size or density. Once weaned, glass eels were found to perform better on commercially available grower mash than on the minced fish flesh, which was used to aid in weaning them to artificial diets. Of the water quality parameters measured stocking density was found to affect pH, Total Ammonia Nitrogen, Total Phosphorus, and Dissolved Oxygen, through not to an extent which affected growth.

Developing a placebo-controlled trial in surgery : issues of design, acceptability and feasibility

Background: Surgical placebos are controversial. This in-depth study explored the design, acceptability, and feasibility issues relevant to designing a surgical placebo-controlled trial for the evaluation of the clinical and cost effectiveness of arthroscopic lavage for the management of people with osteoarthritis of the knee in the UK.
Methods: Two surgeon focus groups at a UK national meeting for orthopaedic surgeons and one regional surgeon focus group (41 surgeons); plenary discussion at a UK national meeting for orthopaedic anaesthetists (130 anaesthetists); three focus groups with anaesthetists (one national, two regional; 58 anaesthetists); two focus groups with members of the patient organisation Arthritis Care (7 participants); telephone interviews with people on consultant waiting lists from two UK regional centres (15 participants); interviews with Chairs of UK ethics committees (6 individuals); postal surveys of members of the British Association of Surgeons of the Knee (382 surgeons) and members of the British Society of Orthopaedic Anaesthetists (398 anaesthetists); two centre pilot (49 patients assessed).
Results: There was widespread acceptance that evaluation of arthroscopic lavage had to be conducted with a placebo control if scientific rigour was not to be compromised. The choice of placebo surgical procedure (three small incisions) proved easier than the method of anaesthesia (general anaesthesia). General anaesthesia, while an excellent mimic, was more intrusive and raised concerns among some stakeholders and caused extensive discussion with local decision-makers when seeking formal approval for the pilot. Patients were willing to participate in a pilot with a placebo arm; although some patients when allocated to surgery became apprehensive about the possibility of receiving placebo, and withdrew. Placebo surgery was undertaken successfully.
Conclusions: Our study illustrated the opposing and often strongly held opinions about surgical placebos, the ethical issues underpinning this controversy, and the challenges that exist even when ethics committee approval has been granted. It showed that a placebo-controlled trial could be conducted in principle, albeit with difficulty. It also highlighted that not only does a placebo-controlled trial in surgery have to be ethically and scientifically acceptable but that it also must be a feasible course of action. The place of placebo-controlled surgical trials more generally is likely to be limited and require specific circumstances to be met. Suggested criteria are presented.

Enhanced recovery after surgery program for elective adbominal surgery at three Victorian hospitals

The aim of this study was to evaluate the anaesthesia care of an enhanced recovery after surgery (ERAS) program for patients having abdominal surgical in Victorian hospitals. The man outcome measure was the number of ERAS items implemented following introduction of the ERAS program. Secondary endpoints included process of care measures, outcomes and hospital stay. We used a before-and-after design; the control group was a prospective cohort (n=154) representing pre-existing practice for elective abdominal surgical patients from July 2009. The introduction of a comprehensive ERAS program took place over two months and included the education of surgeons, anaesthetists, nurses and allied health professionals. A post-implementation cohort (n=169) was enrolled in early 2010. From a total of 14 ERAS-recommended items, there were significantly more implemented in the post-ERAS period, median 8 (interquartile range of 7 to 9) vs 9 (8 to 10), P <0.0001. There were, however, persistent low rates of intravenous fluid restriction (25%) and early removal of urinary catheter (31%) in the post-ERAS period. ERAS patients had less pain and faster recovery parameters, and this was associated with a reduced hospital stay, geometric mean (SD) 5.7 (2.5) vs 7.4 (2.1) days, P=0.006. We found that perioperative anaesthesia practices can be readily modified to incorporate an enhanced recovery program in Victorian hospitals.

Enhanced Recovery After Surgery program for elective abdominal surgery at three Victorian hospitals

The aim of this study was to evaluate the anaesthesia care of an enhanced recovery after surgery (ERAS) program for patients having abdominal surgical in Victorian hospitals. The main outcome measure was the number of ERAS items implemented following introduction of the ERAS program. Secondary endpoints included process of care measures, outcomes and hospital stay. We used a before-and-after design; the control group was a prospective cohort (n=154) representing pre-existing practice for elective abdominal surgical patients from July 2009. The introduction of a comprehensive ERAS program took place over two months and included the education of surgeons, anaesthetists, nurses and allied health professionals. A post-implementation cohort (n=169) was enrolled in early 2010. From a total of 14 ERAS-recommended items, there were significantly more implemented in the post-ERAS period, median 8 (interquartile range 7 to 9) vs 9 (8 to 10), P <0.0001. There were, however, persistent low rates of intravenous fluid restriction (25%) and early removal of urinary catheter (31%) in the post-ERAS period. ERAS patients had less pain and faster recovery parameters, and this was associated with a reduced hospital stay, geometric mean (SD) 5.7 (2.5) vs 7.4 (2.1) days, P=0.006. We found that perioperative anaesthesia practices can be readily modified to incorporate an enhanced recovery program in Victorian hospitals.