Role of multimodal anaesthetic in post-operative analgesic requirement for robotic assisted radical prostatectomy (2021)

Type of publication:
Journal article

Author(s):
*Masilamani, Murugu Kalai Selvan; Sukumar, Aiswarya; Cooke, Pete William; Rangaswamy, Chandrashekar

Citation:
Urologia; Aug 2021 [epub ahead of print]

Abstract:
PURPOSE Robotic assisted laparoscopic radical prostatectomy (RARP) is considered as standard of care for surgical management of localised prostate cancer. Procedure specific postoperative pain management (PROSPECT) guidelines are available for open radical prostatectomy. There is a lack of evidence for optimal pain management protocol in patients undergoing robotic radical prostatectomy. This study investigates the impact of multimodal anaesthetic on post-operative analgesic requirements. METHODS AND MATERIALS In our Institute, RARP is performed with a multimodal anaesthetic technique. Forty-one consecutive cases from October 2018 to March 2019 operated on by the same surgeon and anaesthetised by the same anaesthetic consultant were included in the study. All the patients received standardised multimodal anaesthetic technique. Data from visual analogue pain scores, nausea, vomiting and requirement of analgesics were collected from hospital records and results were analysed. RESULTS Our results showed that 60% of patients reported either no pain or mild pain. None of the patients required stronger opioids or parenteral analgesic. Only three patients required antiemetic. Length of hospital stay was 1.19 days which is comparable to published outcomes from high volume centres performing RARP. CONCLUSION Our study adds to the currently published literature that RARP when combined with the multimodal anaesthetic technique can significantly reduce stronger opioid analgesic requirement in the post-operative period without compromising LOS

Survey of Foundation Year 1 doctors in managing and preparing patients for anaesthesia (2021)

Type of publication:
Conference abstract

Author(s):
Cheng Y.; *Noakes A.

Citation:
Anaesthesia; Jul 2021; vol. 76 ; p. 95

Abstract:
Introduction Good management of surgical patients on the ward before surgery has a significant impact on postoperative outcome. Foundation Year 1 (FY1) doctors are fundamental in ensuring all patients are managed and prepared for anaesthesia and surgery appropriately. Our initial survey showed FY1 doctors lacked confidence in managing patients pre-operatively and preparing them for anaesthesia. Therefore, a teaching session was organised, which all FY1 doctors found useful. Methods An online survey was sent to all FY1 doctors in Royal Shrewsbury and Telford hospital asking about their confidence level in managing pre-operative conditions using five scales ranging from no confidence to very confident. After the teaching session, feedback was collected to assess the usefulness of the teaching. Results In our survey, 22 responses were collected. Only 31.8% of respondents were confident in fasting guidelines and pre-procedure cessation regime for warfarin, anticoagulants and anti-platelets and bridging therapy for anticoagulants. Of the respondents, 18.2% were confident in managing peri-operative medications (e.g. withholding certain medications), 27.3% of respondents were confident in managing pre-operative anaemia and 72.7% of respondents had little or no confidence in preparing patients with cardiac implantable electronic devices for surgery. In feedback that was collected after the teaching (n = 25), 90% of attendees found it extremely and very useful. Discussion The survey results showed low confidence in FY1 doctors in preparing patients for surgery and anaesthesia. This led to a teaching session facilitated by anaesthetic registrars and consultants. They were introduced to local hospital guidelines, which all of them found useful. Topics covered in the teaching session included fasting guidelines, management of perioperative medications, management of pre-operative anaemia, pre-procedure cessation for anticoagulants and bridging therapies and pre-operative management of diabetic, hypertensive, cardiac and renal patients. With good feedback, this teaching will be incorporated into their weekly teaching and will be taught yearly to all FY1 doctors. Feedback was also collected to improve our delivery of the teaching sessions

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Environmental impact of anaesthetic gases at a tertiary hospital: A comparison of subspecialties and analysis of anaesthetic choices (2021)

Type of publication:
Conference abstract

Author(s):
Ito Y.; Takacs R.; Mittal R.; *Damm E.; Daley H.

Citation:
Anaesthesia; Jul 2021; vol. 76 ; p. 103

Abstract:
The Anthropocene has already caused warming exceeding 1.2degreeC compared to pre-industrial levels, resulting in profound, immediate and rapidly worsening health effects. The climate crisis will continue to worsen without meaningful intervention [1]. Five per cent of the total carbon footprint (CF) of the NHS is due to inhalational anaesthesia [2]. Anaesthetists therefore have a unique opportunity and obligation to intervene [2]. Methods: Data of inhaled anaesthesia during maintenance phase were collected in 13 theatres in a tertiary hospital over a 9-day period. Data were extracted from Maquet Flow-i anaesthetic machines and the Bluerspier theatre information system. Case categories included emergency, elective and trauma; covering most surgical specialties. The ‘Anaesthetic Impact Calculator’ application was used to calculate the equivalent of CO2 kg.h-1 produced, cost, and km.h-1 for a car (efficiency 122 g.km-1). End tidal (ET) sevoflurane of 2.1, flow of 0.3 l.min-1, was used to calculate a benchmark of ideal volatile use. Results One hundred and seventy-three cases with complete datasets were included. Eighty-six per cent were performed under general anaesthesia (GA). Sixty-six per cent of cases used sevoflurane, 16% isoflurane, and 4% desflurane. Desflurane increased the cost and CF significantly, whereas N2O increased CF only. Fifty per cent of desflurane usage was in neurosurgery, followed by general and thoracic surgery. N2O was used in 20% of cases, of which 64% were trauma. Thirty per cent of paediatric cases used N2O, compared to 18% in adults. The highest CO2 kg.h-1 was recorded for emergency work (17.6), followed by elective (7.7), then trauma (4.7). Our data suggest this was mostly due to excessive gas flow. General surgery was first at (19.7), followed by neuro (16), and thirdly thoracic surgery (9.4). If using ET sevoflurane of 2.1 with 0.3 l.h-1 O2, a total of 2916 kg of CO2 could have been saved; equivalent to driving 24,065 km, or saving 1284. Discussion Sixty-six per cent of cases used sevoflurane, with few at low-flow rates. An alarming 20% used N2O. Only 14% of cases used techniques that avoided GA. There was a significant variation of CF between specialties. Our project is likely to under-represent the CF/anaesthetic as induction was not included. Every effort should be taken to use anaesthetic techniques avoiding use of inhalational anaesthesia. If required, lower carbon alternatives should be used at low flow, avoiding N2O. This is in line with the NHS Long Term Plan committed to lowering the 2% of the NHS’ CF from anaesthetic gases by 40% [2].

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Is pain properly managed in children presenting with fractures? A retrospective audit of children presenting to the emergency department (2020)

Type of publication:
Conference abstract

Author(s):
*Rafie A

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 68

Abstract:
Aim: Pain is a common problem in the surgical field, especially when treating children – but how well is it managed, and documented? In this audit we aim to answer a few key questions. Is analgesia administered prehospital? Are pain scores recorded, and re-evaluated? And is analgesia offered and/or administered in the Emergency Department(ED)? Method: A retrospective audit was carried out between two hospitals on 100 patients aged between 5-15 presenting to the ED. A search was carried out using SNOMEDand ICD10 codes, to find patients presenting with fractures – and the ED CAS cards reviewed.
Result(s): The data showed poor compliance between both hospitals – pain scores were seldom recorded, or reevaluated; and in 58% of cases analgesia was not offered and no reason was documented. 28% of patients were given pre-hospital analgesia and only 2% of patients had an analgesia review.
Conclusion(s): Adequate pain management is vital, especially in children – as they often don’t self-report pain. The study found that the worst compliance was in documentation of pain scores, and their re-evaluation. However, more concerningly analgesia was only administered in 19% of cases – and in many cases there was no documentation as to why it wasn’t offered.

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The annual usage of anaesthetic gases at the Shrewsbury and Telford Hospitals NHS Trust: the environmental impact and potential solutions (2020)

Type of publication:
Conference abstract

Author(s):
*Thompson T.; *Passey S.; *Mowatt C.

Citation:
British Journal of Surgery; 2020; vol. 107 ; p. 74-75

Abstract:
Aims: The NHS is responsible for 5.5% of the UK’s net emissions, with anaesthetic gases comprising of 5% of hospital emissions. Shrewsbury and Telford hospitals (SaTH) are DGH’s with 18 combined theatres, 9 at each site. The aim of this study was to evaluate the environmental impact of anaesthetic gases used by the trust and suggest possible improvements.
Method(s): Figures from October 2018-2019 supplied by the hospital pharmacy and compared using the RCoA Anaesthetic Impact Calculator. Costs obtained from pharmacy relating to the available anaesthetic gases and drugs.
Result(s): Over the past year SaTH has emitted the equivalent of 4,819,050kg of CO2 through its anaesthetic gases alone (these gases being sevoflurane, isoflurane, desflurane and nitrous oxide). Of these gases, sevoflurane is the greenest, while nitrous oxide is the worst offender. To give this an idea of scale, to offset, this would require the planting of 10915 trees, which would take up an area of 4-10 hectares of land.
Conclusion(s): We are recommending that SaTH stops using Nitrous oxide and Isoflurane, which is currently under consideration by the consultant body. We would discourage the use of desflurane, and where possible sevoflurane. Encourage the use of total intravenous anaesthetic (TIVA). We postulate this would save the trust aminimum of 5000 per year or 15000 per year with a 10% reduction in sevoflurane use. This would reduce our CO2 equivalent production by over 4.6 million kg.

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Intraoperative Infiltration of Local Anaesthetic with Adrenaline In Sliding Hip Screw Surgery: Does It Reduce the Need for Transfusion? A Comparison of Practice Over Two Hospital Sites (2019)

Type of publication:
Conference abstract

Author(s):
*T. Banks, *P. Jayawardena, *D. Ford

Citation:
British Journal of Surgery, Sep 2019; vol. 106, S6, p. 108

Abstract:
Aim: Post-operative blood transfusion is frequently required in patients undergoing Sliding Hip Screw (SHS) surgery. This is associated with transfusion related complications, increased cost and length of stay in hospital. We compared practice between two hospitals; pre-incision infiltration of local anaesthetic with adrenaline (LAAd) versus LA without adrenaline prior to wound closure, to evaluate if there was a difference in postoperative haemoglobin drop and the need for postoperative transfusion following SHS surgery.
Method: A retrospective service evaluation was performed using National Hip Fracture Database (NHFD) data in a cohort of 248 patients who underwent SHS surgery between 2017 and 2018; 110 patients had LAAd. Pre and post-operative haemoglobin, postoperative transfusion and local infiltration was recorded from the trust online patient databases. Relationships between groups was determined using z-testing on Excel.
Results: There was no significant difference in postoperative haemoglobin drop between the two cohorts (p=0.119). 32.7% of patients who had LAAd received blood transfusion in contrast with 20.3% without adrenaline.
Conclusion: Whilst surgeons using LAAd may report less bleeding from skin edges and vastus lataralis intra-operatively, and optimised regional anaesthesia, there was no significant difference in haemoglobin drop between the two cohorts. A difference in threshold for transfusion was identified between the
two hospitals.

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A quality improvement project to improve anaesthetic peri-operative documentation through excellence reporting (2019)

Type of publication:
Conference abstract

Author(s):
*Cunningham D.; *Travis M.; *Leach S.

Citation:
Anaesthesia; Jul 2019; vol. 74 ; p. 27

Abstract:
Incomplete or poor quality peri-operative documentation has both clinical and legal implications. As such, anaesthetic professional bodies issue guidance relating to documentation. It is unclear to what extent this guidance is followed by anaesthetists in our hospital. We aimed to improve the quality of documentation through excellence reporting and to test this methodology as a means of implementing change.
Methods: The completeness of anaesthetic charts (n = 50) are analysed annually over a 1- week period, using a proforma. The proforma highlights details that should be included as part of the peri-operative documentation. Several months prior to collection of the 2018 data, we initiated an excellence reporting project. This involved analysing a sample of charts on alternate weeks over a 12-week period. The five anaesthetists with the most complete charts were issued with a certificate. The anaesthetist with the highest scoring chart won a prize. Results were publicised on posters and presented at monthly governance meetings. If multiple charts scored full marks, judgement was used to determine the winner. Following this intervention period, results from the 2018 annual audit were compared with data from the previous year.
Results: The annual audit requires that the anaesthetic charts be scored on 27 key points outlined in the proforma. In 2018, 13 categories scored greater than 95% completeness with the remaining 14 categories scoring less than 95% completeness. In 2017, 10 categories scored greater than 95% completeness with 17 scoring less than 95%. The 2018 data scored greater than or equal to the 2017 data in 16 categories. In the other 11 categories, the 2017 data scored higher. Legibility is not considered in the annual audit but subjectively appeared to improve over the period of excellence reporting.
Discussion: Through the use of excellence reporting, we have seen some improvement in the completeness and legibility of peri-operative documentation in our hospital. This outcome suggests that excellence reporting is a useful tool for managing positive change. However, both data from 2017 and 2018 did not reveal 100% completeness in all categories, and with the potential legal and clinical ramifications, it is important that we continue to improve anaesthetic documentation.

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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.

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