Hinkelbein, J. et al. | European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults | European Journal of Anaesthesiology
Procedural sedation and analgesia (PSA) has become a widespread practice given the increasing demand to relieve anxiety, discomfort and pain during invasive diagnostic and therapeutic procedures.
The European Society of Anaesthesiology (ESA) and the European Board of Anaesthesiology have created a taskforce of experts that has been assigned to create an evidence-based guideline and, whenever the evidence was weak, a consensus amongst experts on: the evaluation of adult patients undergoing PSA, the role and competences required for the clinicians to safely perform PSA, the commonly used drugs for PSA, the adverse events that PSA can lead to, the minimum monitoring requirements and post-procedure discharge criteria.
A search of the literature from 2003 to 2016 was performed by a professional librarian and the retrieved articles were analysed to allow a critical appraisal according to the Grading of Recommendations Assessment, Development and Evaluation method.
These guidelines contain recommendations on PSA in the adult population. It does not address sedation performed in the ICU or in children and it does not aim to provide a legal statement on how PSA should be performed and by whom. The National Societies of Anaesthesiology and Ministries of Health should use this evidence-based document to help decision-making on how PSA should be performed in their countries.
Full document available here
Schieren, M et al. Anaesthetic management of patients with myopathies. European Journal of Anaesthesiology | October 2017 | Volume 34 |Issue 10 | p 641–649
The anaesthetic management of patients with myopathies is challenging. Considering the low incidence and heterogeneity of these disorders, most anaesthetists are unfamiliar with key symptoms, associated co-morbidities and implications for anaesthesia.
The pre-anaesthetic assessment aims at the detection of potentially undiagnosed myopathic patients and, in case of known or suspected muscular disease, on the quantification of disease progression. Ancillary testing (e.g. echocardiography, ECG, lung function testing etc.) is frequently indicated, even at a young patient age.
One must differentiate between myopathies associated with malignant hyperthermia (MH) and those that are not, as this has significant impact on preoperative preparation of the anaesthesia workstation and pharmacologic management. Only few myopathies are clearly associated with MH.
If a regional anaesthetic technique is not possible, total intravenous anaesthesia is considered the safest approach for most patients with myopathies to avoid anaesthesia-associated rhabdomyolysis. However, the use of propofol in patients with mitochondrial myopathies may be problematic, considering the risk for propofol-infusion syndrome. Succinylcholine is contra-indicated in all patients with myopathies.
Following an individual risk/benefit evaluation, the use of volatile anaesthetics in several non-MH-linked myopathies (e.g. myotonic syndromes, mitochondrial myopathies) is considered to be well tolerated. Perioperative monitoring should specifically focus on the cardiopulmonary system, the level of muscular paralysis and core temperature. Given the high risk of respiratory compromise and other postoperative complications, patients need to be closely monitored postoperatively.
Full document available here
Protecting patients from harm and abuse is the responsibility of practitioners from all medical specialties. Anaesthetists play a particularly critical role in safeguarding due to their work across the perioperative pathway | RCoA
Today, the Royal College of Anaesthetists launches SafeguardingPlus – a new resource of peer-reviewed education and information to provide advice for anaesthetists on how to identify, manage and prevent harm in patients and improve understanding of consent and ethical issues.
We hope the new webpages will help support anaesthetists to deal with a safeguarding concern, or a consent or ethical issue in the perioperative setting, whether it relates to a child, young person or an adult, wherever they work in the UK.
The web pages contain key references, bespoke resources and materials and also provide links to shorter pieces on specific topic areas, including confidentiality, duty of candour, restraint, and DNACPR, with signposting to well-developed and up-to-date guidance.
Read the full overview here
The aim is to demonstrate that ICU physicians should play a pivotal role in developing regional anesthesia techniques that are underused in critically ill patients despite the proven facts in perioperative and long-term pain, organ dysfunction, and postsurgery patient health-related quality of life improvement | Current Opinion in Critical Care
Regional anesthesia and/or analgesia strategies in ICU reduce the surgical and trauma–stress response in surgical patients as well as complications incidence. Recent studies suggested that surgical/trauma ICU patients receive opioid–hypnotics continuous infusions to prevent pain and agitation that could increase the risk of posttraumatic stress disorder and chronic neuropathic pain symptoms, and chronic opioid use. Regional anesthesia use decrease the use of intravenous opioids and the ectopic activity of injured small fibers limiting those phenomena. In Cochrane reviews and prospective randomized trials in major surgery patients, regional anesthesia accelerates the return of the gastrointestinal transit and rehabilitation, decreases postoperative pain and opioids use, reduces ICU/hospital stay, improves pulmonary outcomes, including long period of mechanical ventilation and early extubation, reduces overall adverse cardiac events, and reduces ICU admissions when compared with general anesthesia and intravenous opiates alone. The reduction of long-term mortality has been reported in major vascular or orthopedic surgeries.
Promoting regional anesthesia/analgesia in ICU surgical/trauma patients could undoubtedly limit the risk of complications, ICU/hospital stay, and improve patient’s outcome. The use of regional anesthesia permits a high doses opioid use limitation which is mandatory and should be considered as feasible and well tolerated in ICU.
Full reference: Capdevila, M. et al. (2017) Regional anesthesia and analgesia after surgery in ICU. Current Opinion in Critical Care. Vol. 23 (Issue 5) pp. 430–439
It’s 2 am and you have just finished an emergency appendectomy when you get “that” call. Your friend down in the emergency department (ED) has a patient arriving in a few minutes who was assaulted in a local prison | Anesthesiology News
After asking for your potential assistance with his airway and mumbling something about a knife, he hangs up. You’ve been working nonstop since yesterday morning, so the only thing on your mind involves a pillow and the supine position. Nevertheless, you make your way down to the ED and arrive just as the medics roll in with their patient. He is awake and yelling as they roll him by you into the trauma bay. The emergency medical technician is applying pressure to the side of the patient’s neck and there is a large knife sticking out of the middle of the patient’s face (Figure 1). Your friend takes one look and asks you to help by managing the airway while he coordinates the rest of the trauma resuscitation. It looks like your night is about to get a lot more interesting!
Read the full article here
A Report From the Wake Up Safe Quality Improvement Initiative | Anesthesia & Analgesia
Background: Wake Up Safe is a quality improvement initiative of the Society for Pediatric Anesthesia that contains a deidentified registry of serious adverse events occurring in pediatric anesthesia. The aim of this study was to describe and characterize reported medication errors to find common patterns amenable to preventative strategies.
Conclusions: Our findings characterize the most common types of medication errors in pediatric anesthesia practice and provide guidance on future preventative strategies. Many of these errors will be almost entirely preventable with the use of prefilled medication syringes to avoid accidental ampule swap, bar-coding at the point of medication administration to prevent syringe swap and to confirm the proper dose, and 2-person checking of medication infusions for accuracy.
Full reference: Lobaugh, L. et al. (2017) Medication Errors in Pediatric Anesthesia: A Report From the Wake Up Safe Quality Improvement Initiative. Anesthesia & Analgesia. Vol. 125 (Issue 3) pp. 936–942
Obesity is an increasing problem and its burden on healthcare resources is well documented | Anaesthesia and Intensive Care Medicine
This article gives an overview of the physiological and pharmacological considerations when anaesthetizing the obese patient. It will look at key aspects of assessing obese patients, and planning and delivering a safe anaesthetic to them. Special areas of focus include correct drug dosing, as well as equipment, monitoring and environmental aspects involved in delivering the anaesthetic.
Full reference: Nelson, G & Clayton, R. (2017) Anaesthesia in the obese patient. Anaesthesia and Intensive Care Medicine. Published online: 14 August 2017