Tablet computers as effective as sedatives for children before operations

ScienceDaily | Published online: August 29, 2016


Mobile interactive tools have been found to be effective to reduce child anxiety at parental separation in the operating theatre. The authors’ aim in this study was to compare the effects of midazolam (a sedative used regularly before anaesthesia) in premedication with age-appropriate game apps (on an iPad tablet) on children aged 4-10 years during and after ambulatory (day) surgery. Anxiety was assessed both in children and in parents.

Children were randomly allocated to one of the two groups (MDZ [midazolam-54 children] or TAB [iPad — 58 children]). Patients in group MDZ received midazolam 0.3mg/kg orally or rectally, or, in group TAB, were given an electronic tablet (iPAD) 20 min before anaesthesia. Child anxiety (using m-YPAS scale) was measured by 2 independent psychologists at four time points: 1) at arrival at hospital 2) at separation from the parents 3) during induction and 4) in the post anaesthesia care unit (PACU). Parental (using STAI score) anxiety was measured at the same time points except during induction as they were not present at that point. Anaesthetic nurses ranked from 0 (not satisfied) to 10 (highly satisfied) the quality of induction of anaesthesia.

Then, 30 minutes after the child received their last dose of nalbuphine anaesthestic or 45 min after arrival in the PACU, the children were transferred to the ambulatory surgery ward where parental anxiety (STAI 3) and children anxiety (m-YPAS 4) were again evaluated for the final time. In addition, parents’ satisfaction with the anaesthesia procedure was rated from 0 to 10. Postoperative behaviour changes were assessed with the Post Hospital Behaviour Questionnaire (PHBQ).

The researchers found both parental and child anxiety levels to be similar in both groups, with a similar pattern of evolution. Both parents and nurses found anaesthesia more satisfying in the iPad group.

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Psychological interventions in managing postoperative pain in children: a systematic review

Davidson, F. et al. (2016) Pain. 157(9). pp. 1872–1886


Pediatric surgeries are common and painful for children. Postoperative pain is commonly managed with analgesics; however, pain is often still problematic. Despite evidence for psychological interventions for procedural pain, there is currently no evidence synthesis for psychological interventions in managing postoperative pain in children.

The purpose of this review was to assess the efficacy of psychological interventions for postoperative pain in youth. Psychological interventions included Preparation/education, distraction/imagery, and mixed. Four databases (PsycINFO, PubMed, EMBASE, and Certified Index to Nursing and Allied Health Literature) were searched to July 2015 for published articles and dissertations.

We screened 1401 citations and included 20 studies of youth aged 2 to 18 years undergoing surgery. Two reviewers independently screened articles, extracted data, and assessed risk of bias. Standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated using RevMan 5.3. Fourteen studies (1096 participants) were included in meta-analyses. Primary outcome was pain intensity (0-10 metric).

Results indicated that psychological interventions as a whole were effective in reducing children’s self-reported pain in the short term (SMD = −0.47, 95% CI = −0.76 to −0.18). Subgroup analysis indicated that distraction/imagery interventions were effective in reducing self-reported pain in the short term (24 hours, SMD = −0.63, 95% CI = −1.04 to −0.23), whereas preparation/education interventions were not effective (SMD = −0.27, 95% CI = −0.61 to 0.08).

Data on the effects of interventions on longer term pain outcomes were limited. Psychological interventions may be effective in reducing short-term postoperative pain intensity in children, as well as longer term pain and other outcomes (eg, adverse events) require further study.

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Emergency Manual Uses During Actual Critical Events and Changes in Safety Culture From the Perspective of Anesthesia Residents: A Pilot Study

Goldhaber-Fiebert, S. et al. Anesthesia & Analgesia. 123(3) pp. 641–649


Background: Emergency manuals (EMs), context-relevant sets of cognitive aids or crisis checklists, have been used in high-hazard industries for decades, although this is a nascent field in health care. In the fall of 2012, Stanford clinically implemented EMs, including hanging physical copies in all Stanford operating rooms (ORs) and training OR clinicians on the use of, and rationale for, EMs. Although simulation studies have shown the effectiveness of EMs and similar tools when used by OR teams during crises, there are little data on clinical implementations and uses. In a subset of clinical users (ie, anesthesia residents), the objectives of this pilot study were to (1) assess perspectives on local OR safety culture regarding cognitive aid use before and after a systematic clinical implementation of EMs, although in the context of long-standing resident simulation trainings; and (2) to describe early clinical uses of EMs during critical events.

Methods: Surveys collecting both quantitative and qualitative data were used to assess clinical adoption of EMs in the OR. A pre-implementation survey was e-mailed to Stanford anesthesia residents in mid-2011, followed by a post-implementation survey to a new cohort of residents in early 2014. The post-implementation survey included pre-implementation survey questions for exploratory comparison and additional questions for mixed-methods descriptive analyses regarding EM implementation, training, and clinical use during critical events since implementation.

Results: Response rates were similar for the pre- and post-implementation surveys, 52% and 57%, respectively. Comparing post- versus pre-implementation surveys in this pilot study, more residents: agreed or strongly agreed “the culture in the ORs where I work supports consulting a cognitive aid when appropriate” (73.8%, n = 31 vs 52.9%, n = 18, P = .0017) and chose more types of anesthesia professionals that “should use cognitive aids in some way,” including fully trained anesthesiologists (z = −2.151, P = .0315). Fifteen months after clinical implementation of EMs, 19 respondents (45%) had used an EM during an actual critical event and 15 (78.9% of these) agreed or strongly agreed “the EM helped the team deliver better care to the patient” during that event, with the rest neutral. We present qualitative data for 16 of the 19 EM clinical use reports from free-text responses within the following domains: (1) triggering EM use, (2) reader role, (3) diagnosis and treatment, (4) patient care impact, and (5) barriers to EM use.

Conclusions: Since Stanford’s clinical implementation of EMs in 2012, many residents’ self-report successful use of EMs during clinical critical events. Although these reports all come from a pilot study at a single institution, they serve as an early proof of concept for feasibility of clinical EM implementation and use. Larger, mixed-methods studies will be needed to better understand emerging facilitators and barriers and to determine generalizability.

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British Journal of Anaesthsia – TOC Spetmeber 2016

BJA. (2016) Volume 117 Issue 3.

BJA spet

Image source: BJA

Articles in the September issue include:

  • Continuing to excel in anaesthesia through the ‘big five’: teaching, training, testing, quality, and research | Abstract available here

  • I spy with my little eye something beginning with S: spotting sepsis | Abstract available here
  • Predicting arterial blood gas and lactate from central venous blood analysis in critically ill patients: a multicentre, prospective, diagnostic accuracy study | Abstract available here
  • Patient coping and expectations about recovery predict the development of chronic post-surgical pain after traumatic tibial fracture repair | Abstract available here

  • The impact of the acute respiratory distress syndrome on outcome after oesophagectomy | Abstract available here

Read the full table of contents here


Fluid resuscitation management in patients with burns: update

Guilabert, P. et al. (2016) British Journal of Anaesthesia. 117 (3). pp.284-296.


Image source: LeoCarbajal – Wikipedia // CC BY-SA 3.0

Since 1968, when Baxter and Shires developed the Parkland formula, little progress has been made in the field of fluid therapy for burn resuscitation, despite advances in haemodynamic monitoring, establishment of the ‘goal-directed therapy’ concept, and the development of new colloid and crystalloid solutions.

Burn patients receive a larger amount of fluids in the first hours than any other trauma patients. Initial resuscitation is based on crystalloids because of the increased capillary permeability occurring during the first 24 h. After that time, some colloids, but not all, are accepted. Since the emergence of the Pharmacovigilance Risk Assessment Committee alert from the European Medicines Agency concerning hydroxyethyl starches, solutions containing this component are not recommended for burns. But the question is: what do we really know about fluid resuscitation in burns?

To provide an answer, we carried out a non-systematic review to clarify how to quantify the amount of fluids needed, what the current evidence says about the available solutions, and which solution is the most appropriate for burn patients based on the available knowledge.

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Publication Bias and Nonreporting Found in Majority of Systematic Reviews and Meta-analyses in Anesthesiology Journals

Hedin, R.J. et al. Anesthesia & Analgesia. 17 August 2016

Background: Systematic reviews and meta-analyses are used by clinicians to derive treatment guidelines and make resource allocation decisions in anesthesiology. One cause for concern with such reviews is the possibility that results from unpublished trials are not represented in the review findings or data synthesis. This problem, known as publication bias, results when studies reporting statistically nonsignificant findings are left unpublished and, therefore, not included in meta-analyses when estimating a pooled treatment effect. In turn, publication bias may lead to skewed results with overestimated effect sizes. The primary objective of this study is to determine the extent to which evaluations for publication bias are conducted by systematic reviewers in highly ranked anesthesiology journals and which practices reviewers use to mitigate publication bias. The secondary objective of this study is to conduct publication bias analyses on the meta-analyses that did not perform these assessments and examine the adjusted pooled effect estimates after accounting for publication bias.

Methods: This study considered meta-analyses and systematic reviews from 5 peer-reviewed anesthesia journals from 2007 through 2015. A PubMed search was conducted, and full-text systematic reviews that fit inclusion criteria were downloaded and coded independently by 2 authors. Coding was then validated, and disagreements were settled by consensus. In total, 207 systematic reviews were included for analysis. In addition, publication bias evaluation was performed for 25 systematic reviews that did not do so originally. We used Egger regression, Duval and Tweedie trim and fill, and funnel plots for these analyses.

Results: Fifty-five percent (n = 114) of the reviews discussed publication bias, and 43% (n = 89) of the reviews evaluated publication bias. Funnel plots and Egger regression were the most common methods for evaluating publication bias. Publication bias was reported in 34 reviews (16%). Thirty-six of the 45 (80.0%) publication bias analyses indicated the presence of publication bias by trim and fill analysis, whereas Egger regression indicated publication bias in 23 of 45 (51.1%) analyses. The mean absolute percent difference between adjusted and observed point estimates was 15.5%, the median was 6.2%, and the range was 0% to 85.5%.

Conclusions: Many of these reviews reported following published guidelines such as PRISMA or MOOSE, yet only half appropriately addressed publication bias in their reviews. Compared with previous research, our study found fewer reviews assessing publication bias and greater likelihood of publication bias among reviews not performing these evaluations.

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Focused echocardiography: a systematic review of diagnostic and clinical decision-making in anaesthesia and critical care

Heiberg, J. et al. (2016). Anaesthesia. Volume 71(9). pp. 1091–1100


Image source: Patrick J. Lynch, medical illustrator – Wikipedia // CC BY 2.5

Image shows illustration of transesophageal echocardiography ultrasound diagram

Focused echocardiography is becoming a widely used tool to aid clinical assessment by anaesthetists and critical care physicians. At the present time, most physicians are not yet trained in focused echocardiography or believe that it may result in adverse outcomes by delaying, or otherwise interfering with, time-critical patient management.

We performed a systematic review of electronic databases on the topic of focused echocardiography in anaesthesia and critical care. We found 18 full text articles, which consistently reported that focused echocardiography may be used to identify or exclude previously unrecognised or suspected cardiac abnormalities, resulting in frequent important changes to patient management. However, most of the articles were observational studies with inherent design flaws. Thirteen prospective studies, including two that measured patient outcome, were supportive of focused echocardiography, whereas five retrospective cohort studies, including three outcome studies, did not support focused echocardiography. There is an urgent requirement for randomised controlled trials.

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