The low-down on fresh gas flows (2016)

Type of publication:
Conference abstract

Author(s):
*Keogh T., *Elcock D.

Citation:
Anaesthesia, June 2016, vol./is. 71, Supplement 3, p. 26

Abstract:
Inhalational anaesthetic agents are minimally metabolised and mostly exhaled unchanged; using a closed breathing system with CO<inf>2</inf> absorption, reduces waste of volatiles and permits the reduction of fresh gas flow (FGF) to providing only the patient’s metabolic requirements [1]. In addition to reducing wastage of volatiles, low FGF benefits the environment and improves cost effectiveness with a potentially advantageous impact on care. We looked at practice in a typical district general hospital (The Royal Shrewsbury Hospital), with the aim of identifying potential cost savings; we surveyed FGF and investigated whether our volatile costs were influenced by use of the relatively expensive sevoflurane. Methods Theatre lists were inspected to identify cases anticipated to last > 60 min, and were then audited by going into theatre and recording data. A maximum of one case was analysed from each list per day so as to avoid bias by targeting a particular anaesthetist and to avoid influences on an individual’s practice once they realised they were being surveyed. A range of specialities was audited and data were collected after at least 30 min on table to allow time for the anaesthetist to modify flows. Results Median flow rates (n = 49) were found to be 0.95 l.min<sup>-1</sup> with an interquartile range of between 0.70 l.min<sup>-1</sup> and 1.10 l.min<sup>-1</sup> (Fig. 1). While these are low flows compared with those required by non-circle systems, they are not basal flow rates and therefore an estimated saving of around 50% could be made if typical flows were < 0.5 l.min<sup>-1</sup> (roughly equal to 70 000/pa in the Trust). Based on our pharmacy costs, we estimate equivalent doses of sevoflurane to be roughly 14x the cost of isoflurane, suggesting a saving of up to 93% per case if only the latter were used. However we acknowledge that this is simplistic and may not offset the disadvantages of isoflurane. Discussion We may have underestimated FGF being used; it is probable that people do not use low-flows in the anaesthetic room, at the beginning of cases, or possibly at all in shorter cases. Results have shown a generally responsible use of FGF rates, and perhaps limiting the type of volatiles used would not be as cost-effective as may have been thought, but rather encouraging the use of ‘minimal flows'(< 500 ml) may be more promising. The introduction of self-adjusting low FGF on newer anaesthetic machines will also weaken any case for preferring isoflurane on grounds of cost alone – indeed manufacturers may argue the cost of this type of technology is quickly offset by the savings made in volatile costs. We think that rather than trying to reduce costs by limiting use of sevoflurane, there is more to gain by promoting the use of ‘minimal flow’. (Figure Presented) .

Link to more details or full-text: http://onlinelibrary.wiley.com/doi/10.1111/anae.13519/epdf

Anesthetic agents in patients with very long-chain acyl-coenzyme A dehydrogenase deficiency: a literature review (2014)

Type of publication:
Journal article

Author(s):
*Redshaw C, *Stewart C

Citation:
Pediatric Anesthesia, 11 2014, vol./is. 24/11(1115-9), 1155-5645;1460-9592 (2014 Nov)

Abstract:
Very long-chain acyl-coenzyme A dehydrongenase deficiency (VLCADD) is a rare disorder of fatty acid metabolism that renders sufferers susceptible to hypoglycemia, liver failure, cardiomyopathy, and rhabdomyolysis. The literature about the management of these patients is hugely conflicting, suggesting that both propofol and volatile anesthesia should be avoided. We have reviewed the literature and have concluded that the source papers do not support the statements that volatile anesthetic agents are unsafe. The reports on rhabdomyolysis secondary to anesthesia appear to be due to inadequate supply of carbohydrate not volatile agents. Catabolism must be avoided with minimal fasting, glucose infusions based on age and weight, and attenuation of emotional and physical stress. General anesthesia appears to be protective of stress-induced catabolism and may offer benefits in children and anxious patients over regional anesthesia. Propofol has not been demonstrated to be harmful in VLCADD but is presented in an emulsion containing very long-chain fatty acids which can cause organ lipidosis and itself can inhibit mitochondrial fatty acid metabolism. It is therefore not recommended. Suxamethonium-induced myalgia may mimic symptoms of rhabdomyolysis and cause raised CK therefore should be avoided. Opioids, NSAIDS, regional anesthesia, and local anesthetic techniques have all been used without complication.

Link to more details or full-text:

Rapid sequence induction in urgent care settings. (2014)

Type of publication:
Journal article

Author(s):
*Fenwick R

Citation:
Emergency Nurse, 03 2014, vol./is. 21/10(16-24), 1354-5752;1354-5752 (2014 Mar)

Abstract:
In the management of critically ill patients in emergency departments, rapid sequence induction (RSI) of anaesthesia is often required. This article examines the elements of RSI that are necessary before before endotracheal tube placement and reviews the findings of a national audit project, conducted by Royal College of Anaesthetists and Difficult Airway Society. It also considers the role of nurses in RSI procedures.

Link to more details or full-text: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=2012497882&authtype=athens&site=ehost-live