Morbidity and Mortality during Anaesthesia in Patients with versus without Diabetes: Single-Centre Cohort Study

Background and objective: Classically, diabetic subjects are at high risk of anaesthesia compared with general population. However, some recent publications have shown contrasting and sometimes contrary results. The aim of our study was to evaluate morbidity and mortality during and after anaesthesia in patients with versus without diabetes operated on at Monkole Hospital over the last ten years. Methods: Retrospective cohort study including all patients who underwent all-comers surgery excluding cardiac surgery between 2011 and 2021. Each diabetic patient was matched to 2 non-diabetic controls on age and sex. The evaluation criterion was the frequency of occurrence of at least one perioperative complication and/or death up to day 30. A multivariate analysis using a Cox model was used to determine the factors associated with the occurrence of this morbidity and mortality. The model was adjusted for comorbidities, preoperative hyperglycaemia, ASA score, type of anaesthesia and severity of surgery. Results: A total of 351 diabetic patients (mean age 53.3 ± 14.18 years) and 701 non-diabetic patients (mean age 53.52 ± 14.7 years) were included and analysed. Preoperatively, hyperglycaemia (blood glucose > 180 mg/dl) was observed in 24.3% of diabetic patients compared with 1.6% of non-diabetic patients. The incidence of overall perioperative complications was 25.6% in diabetic patients compared with 28.6% in non-diabetic patients (p = 0.27). The risk factors associated with this morbidity were general anaesthesia with oro-tracheal intubation vs loco-regional anaesthesia (OR = 3.06 [95%CI: 1.91 - 4.94];p Conclusion: This study shows that there is not significant increase in perioperative morbidity and mortality in diabetic patients compared with non-diabetic ones of similar severity. These results suggest that diabetes itself (excluding associated comorbidities) has only a minor impact on perioperative morbidity and mortality.

Study of wrist-ankle acupuncture therapy for optimizing anaesthesia scheme of painless gastroscopy and improving painless gastroscopy related complications

BACKGROUND Painless gastroscopy is a widely used diagnostic and therapeutic technology in clinical practice.Propofol combined with opioids is a common drug for painless endoscopic sedation and anaesthesia.In clinical work,adverse drug reactions of anaesthesia schemes are often one of the important areas of concern for doctors and patients.With the increase in propofol dosage,the risk of serious adverse drug reactions,such as respiratory depression and hypotension,increases significantly;the use of opioids often causes gastrointestinal reactions in patients after examination,such as nausea,vomiting,delayed recovery of gastrointestinal function and other complications,which seriously affect their quality of life.AIM To observe the effect of wrist-ankle acupuncture therapy on the anaesthesia regimen and anaesthesia-related complications during and after painless gastroscopy examination.METHODS Two hundred patients were selected and randomly divided into a treatment group(n=100)and a control group(n=100).Both groups were routinely anaesthetized with the nalbuphine and propofol regimen,gastroscopy began after the patient lost consciousness,and given supportive treatment and vital sign monitoring.If the patient interrupted the surgery due to intraoperative torsion,intravenous propofol was used to relieve his or her discomfort.The treatment group received wrist-ankle acupuncture on this basis.RESULTS The general data before treatment,American Society of Anesthesiologist(ASA)grade and operation time between the two groups was no significant difference.The Wakeup time,and the Selfambulation time in the treatment group was significantly faster than that in the control group(P<0.05).The total dose of propofol in the treatment group was 109±8.17 mg,significantly lower than that in the control group(P<0.05).The incidence of respiratory depression and hypotension was not significantly different,but the incidence of hiccups was significantly lower than that in the control group(P<0.05).After the examination,the incidence of nausea,vomiting,abdominal distension,and abdominal pain was 11%,8%,6%,and 5%,respectively,which was significantly lower than that in the control group(P<0.05).In addition,both the operators and the patients were more satisfied with this examination,with no significant difference between the groups(P>0.05).CONCLUSION Wrist-ankle acupuncture treatment can optimize the painless gastroscopy and anaesthesia scheme,reduces propofol total dose;shortens patient Wakeup time and Self-ambulation time,improves patient compliance and tolerance,is beneficial to clinical application.

Effects of Combined Spinal Epidural Anaesthesia and Spinal Anaesthesia on Peri-Operative Pulmonary Status in Geriatric Patients in Lower Extremity Surgery

Background: Lower extremity surgeries performed in elderly people usually have high prevalence of peri-operative medical problems related to anaesthesia. The overall objective of peri-operative care of geriatric population is to fast recovery from anaesthesia and avoid functional decline. Objective: To compare the peri-operative pulmonary status of combined spinal epidural anaesthesia (CSEA) and spinal anaesthesia (SA) in geriatric patients underwent lower extremity surgeries. Methods: This prospective comparative study was conducted at Department of Anaesthesia, Analgesia and Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from July 2016 to June 2018. A total of 70 geriatric cases that underwent lower extremity surgeries were included in this study. Cases were randomly allocated into two groups;35 in Group A (CSEA) and 35 in Group B (SAB). The different outcome variables between the groups like-duration of anaesthesia, respiratory rates (RR), oxygen saturation (SpO2), end tidal CO2 (EtCO2), peak expiratory flow rate (PEFR), breath holding test (BHT), peri-operative side effects of anaesthesia and post-operative visual analogue score (VAS) were analyzed and compared by statistical tests. Results: The mean age, weight, BMI of Group A and Group B patients were not significantly different (p > 0.05). No significant differences were observed in duration of surgery, gender and ASA grade between the groups (p > 0.05). Mean duration of anaesthesia, mean time to achieve target level of sensory block and mean time to achieve complete motor block were significantly higher in Group A (p < 0.001). Mean RR, SpO2, EtCO2, PEFR and BHT of both groups were not significantly different (p > 0.05). Peri-operative side effects of anaesthesia and post-operative VAS were significantly less in group A patients (p < 0.05). Conclusion: Combined spinal epidural anaesthesia is effective and safe;produces stable peri-operative pulmonary status with prolonging analgesia and fewer side effects as compared to spinal anaesthesia in geriatric patients.

Epidural anaesthesia restores pancreatic microcirculation and decreases the severity of acute pancreatitis

AIM： To investigate the effect of epidural anaesthesia （EA） on pancreatic microcirculation during acute pancreatitis （AP）. METHODS： AP was induced by injection of sodium taurocholate into the pancreatic duct of Sprague-Dawley rats. To realize EA, a catheter was introduced into the epidural space between T7 and T9 and bupivacaine was injected. Microcirculatory flow was measured by laser Doppler flowmetry. Arterial blood gas analyses were performed. At the end of the experiment （≤ 5 h）, pancreas was removed for histology. The animals were divided into three groups： Group 1 （n =9）, AP without EA, Group 2 （n = 4）, EA without AP; and Group 3 （n = 6）, AP treated by EA. RESULTS： In Group 1, pancreatic microcirculatory flow prior to AP was 1414, 39 perfusion units （PU）. After AP, microcirculatory flow obviously decreased to 9 4-6 PU （P〈0.05）. Metabolic acidosis developed with base excess （BE） of - 14 4, 3 mmol/L. Histology revealed extensive edema and tissue necrosis. In Group 2, EA did not significantly modify microcirculatory flow. BE remained unchanged and histological analysis showed normal pancreatic tissue. In Group 3, AP initially caused a significant decrease in microcirculatory flow from 155 ± 25 to 11± 7 PU （P〈0.05）. After initiation of EA, microcirculatory flow obviously increased again to 81±31 PU （P〈0.05）. BE was -6±4 retool/L, which was significantly different compared to Group 1 （P〈0.05）. Furthermore, histology revealed less extensive edema and necrosis in pancreatic tissue in Group 3 than that in Group 1. CONCLUSION： AP caused dramatic microcirculatory changes within the pancreas, with development of metabolic acidosis and tissue necrosis. EA allowed partial restoration of microcirculatory flow and prevented development of tissue necrosis and systemic complications. Therefore, EA should be considered as therapeutic option to prevent evolution from edematous to necrotic AP.

Depth of anaesthesia monitors and the latest algorithms

This paper reviews the existing depth of anaesthesia(DoA) monitors and their algorithms and also proposes to improve their performance from four aspects.\n ideal DoA monitor should be able to suggest a personalised drug dosages,to predict and provide early warnings when dosages are inappropriate,to he porlalile and highty cost—effective.The limitations of the existing DoA monitors commonly include unsatisfied data filtering techniques.time delay for the monitoring responses,and inflexible and low noise immunity problems.The latest research results show that their performance can be improved using up—to—date computing technology and neurophysiology.The findings in Chinese market review show that neither the imported nor the Chinese domestic DoA monitors are widely utilised at hospitals.but the demand for DoA monitors is very high.Clearly there is a high demand which encourages the development of a better DoA monitor and its mass production in China.

ACUPUNCTURE ANAESTHESIA IN TREATING URINARY TRACT STONE WITH EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY

The anaesthetic effect of acupuncture on 40 patients during extracorporeal shockwave lithotripsy was observed in this study.The anaesthetic rate in 20 eases under manual acupunc-ture was 85％,and that in the other 20 patients under electro-acupuncture anaesthesia was 90％.Under the anaesthesia the patients were conscious and in normal physical conditions.The observationsindicate that the electro-acupuncture anaesthesia is safe,economical and effective.Additionally.it lib-erates acupuncturists from heavy needling manipulation.The relationship between the analgesic ef-fects antI the ages is analysed as well.

Thoracic Unilateral Spinal Cord Syndrome Following Neuraxial Anaesthesia for Periprosthetic Knee Fracture: A Case Report

Neuraxial anaesthesia is widely used in surgical procedures;overall, epidural and intrathecal techniques. Nevertheless, several outcomes should be considered. The incidence of neurologic complications after neuraxial anaesthesia is not perfectly clear (0% - 0.08%), although there are several described cases of spinal cord ischemia. We present a case of thoracic unilateral spinal cord syndrome following lumbar spinal anaesthesia for periprosthetic knee fracture. Our patient suffered monoparesis in her left lower limb as well as decreasing of muscle strength and loss of tendon reflexes. The MNR showed left hyperintense intra-cord images from T7 to T12 attributed to spinal cord oedema and a lineal hypointensity related to minimal haematic component. What made this case surprising was the fact that spinal anaesthesia was performed between L3 and L4 and the patient did not suffer paraesthesia associated with local anaesthetic injection. She was treated with glucocorticoids, gabapentin and amitriptyline. She also was checked by physical rehabilitators, neurologists and Pain Unit physicians. We have found another case reported in the literature about thoracic cord injury after lumbar spinal puncture. In this paper, we report possible aetiologies according to a review and neurological evolution of the patient seven months later.

Diagnosis of Vocal Cord Paralysis in Anaesthesia

Vocal cord paralysis can occur as a complication o surgery or anaesthesia,if permanent is a significant clinica problem.Early detection is important to optimize the chance o repair,and avoid complications associated with an impaired swallow.An algorithm to detect altered vocal cord function was presented based on wavelet packet analysis(WPA) and suppor vector machines(SVM),and compared with the Hoarseness Diagram method(HDm),which was reported as an objective voice quality evaluation approach and could be used for pathological voice discrimination.Experiments using voice signals recorded from subjects before and after the procedure show high classification accuracy with the new algorithm,whereas HDm fails in the detection of a hoarse voice.This finding would help to develop a screening tool to detect the vocal structure damage during surgery.

Intentional and unintentional impacts of anaesthesia： insights from experiments in pain and injury

The study of brain function in the presence of pain and injury is a rapidly expanding field of experimental research.Clinically,the presence of pain and injury is often accompanied by reports of behavioural change and altered cognition.Even in a highly controlled environment such as the surgical operating theatre postoperative behavioural changes including posttraumatic stress disorder,depression,chronic fatigue,

CLINICAL OBSERVATION ON AURICULAR ACUPUNCTURE COMBINED WITH LOCAL ANAESTHESIA IN CERVICAL LAMINOPLASTY FOR CERVICAL SPONDYLISIS

Auricular acupuncture combined with local anaesthesia in cervical larninoplasty was studied. The aim of the study was to observe the analgesic action of this anaesthesia and the effects on respiratory and circulatory function. 70 patients were included in the study. There were 55 male and 15 female patients, aged between 39 and 67 years old. The unilateral otopoints including Shenmen, cervical vertebrae, sympathetic, subcortex, external lung and kidney points were used. The sterilized filiform needle of 1 - 1. 5 cm were inserted into each otopoint and connected to 57 - 6 electrcrpulse stimulator being stimulated with continuous wave. Local infiltration anaesthesia was also used with 1 - 2 g/L Lignocaine. The results showed that all the patients were conscious, quiet and co-operative with doctors.The respiration, blood pressure and heart rate were all stable. Analgesie action was rather definite. All the patients recovered quickly after operation. We consider that this anaesthesia is a very simple and effective method for cervical laminoplasty.

Cardiopulmonary,Biochemical and Haematological Effects of the Tiletamine/Zolazepam-Xylazine-Tramadol Combination to Provide Anaesthesia in Miniature Pigs

The objective of this study was to investigate the suitability of tiletamine/zolazepam-xylazine-tramadol combination for miniature pigs. Fourteen Chinese experimental miniature pigs subjected to this study received 3.5 mg tiletamine/zolazepam kg-1 bw, 1.32 mg xylazine kg-1 bw and 1.8 mg tramadol kg-1 bw intramuscularly, as a mixture of the drugs. Cardiopulmonary, biochemical and haematological parameters were recorded before drug administration and after anaesthesia. The combination of the compounds resulted in anaesthesia lasting about 87 min and a satisfactory immobilization for handling. Cardiopulmonary parameters were changed after administration, but there were within biologically acceptable limits. Biochemical and haematological values decreased after drug administration, however, they returned to the baseline at 24 h. At the doses described, tiletamine/zolazepam-xylazine-tramadol combination produced good immobilization in miniature pigs with minimal changes over time in cardiopulmonary, biochemical and haematological parameters.

Application and Assessment of Ketamine-Xylidinothiazoline Combinations for Anaesthesia in Rhesus Monkey

The quantitative anaesthesia assessment technique was used to evaluate the effectiveness of ketamine, ketamine-xylidinothiazoline in rhesus monkey. Total 20 healthy adult rhesus monkeys were divided into two groups and anaesthetized using either intramuscular （IM） ketamine （20 mg·kg^-1） or ketamine （5 mg·kg^-1 IM） and xylidinothiazoline （1 mg·kg^-1 IM）. During anaesthesia rectal temperature, respiratory rate, heart rate, saturation of blood oxygen and blood pressure were recorded. The degree of sedation, analgesia, muscle relaxation were monitored either. The results showed that ketamine alone did not produce adequate anaesthesia, and the combination of xylidinothiazoline and ketamine provided adequate anesthesia for rhesus monkeys with no significant side effects and little effects on respiration and circulation.

Cerebrospinal fluid and plasma propofol concentration during total intravenous anaesthesia of patients undergoing elective intracranial tumor removal

Objective： The aim of this paper is to compare the propofol concentration in plasma and cerebrospinal fluid （CSF） in patients scheduled for intracranial tumor removal and anaesthetized using propofol as part of a total intravenous anaesthesia technique. Methods： Twenty-seven patients （ASA Ⅰ-Ⅱ） scheduled for elective intracranial tumor removal were studied. Anesthesia was induced with 2 mg/kg propofol for 5 min and infused at 10 mg/（kg·h） for 5 min and then stopped. CSF and arterial blood were collected simultaneously before infusion of propofol and at different time points after infusion ofpropofol according to bispectral index （BIS） values. Concentrations of propofol in plasma and CSF were measured by HPLC with fluorescence detection. The correlation coefficient and regression equation between plasma and CSF concentration of propofol were worked out by linear simple regression. Results： The propofol CSF concentration that we measured was 1.46% of the plasma concentration. The coefficient of relation between plasma and CSF concentration was 76.7%. Conclusions： The propofol CSF concentration was positively correlated with and much lower than the plasma concentration. Discrepancies may result from high plasma protein binding of propofol, intracranial pathology and sampling volume.

Wisdom Tooth Surgery Complications—Local Anaesthesia versus General Anaesthesia

Purpose: To compare the complication rates arising from surgical removal of lower third molars (L3M) under general anaesthesia (GA) versus local anaesthesia (LA) in the Oral and Maxillofacial Surgery (OMFS) Department, Hospital Sultanah Nora Ismail (HSNI), Batu Pahat, Johor, Malaysia. Materials and methods: This is a retrospective clinical audit of patients who underwent L3M removal under LA or GA from 1/1/2013 to 31/3/2018, with recorded complications such as surgical site infection (SSI), wound breakdown, severe pain, trismus, retained tooth structure, nerve injury and dry socket evaluated at different time intervals. Results: A total of 313 patients with 375 L3M were included in this study (male: 160, 51.1%;female: 153, 48.9%) with an age range of 18 to 40 years (mean = 27.43 years). 79 L3M were removed under GA (34.2% were classified as mild;65.8% were moderate), whereas 296 L3M were removed under LA, (31.4% were mild impaction, 63.9% moderate and 4.7% severe. Preoperative antibiotics were given before all L3M removal under GA, while only 23 out of 296 L3M removal under LA had antibiotics. 15.2% of L3M removal under GA and 16.6% of those done under LA were associated with complications. Generally, patient with GA had lesser complications;however only SSI outcome was significant (p = 0.034). Conclusion: L3M removal under LA may have a higher risk of SSI when compared to GA. This raises the possibility that a single prophylactic antibiotic dose may prevent SSI in LA procedures.

Anaesthesia for Pectoralis Major Myocutaneous Flap in a Patient with a Major Facial Defect and Restricted Mouth Opening: A Case Report

Perioperative airway management in patients with oro-facial cancers who has undergone chemo/or radiotherapy poses a great challenge to the anaesthesiologist. These challenges are mainly due to either a mass in the oral cavity or a limited mouth opening making intubation difficult or a major facial defect making mask ventilation difficult. We present our first time experience in a 27-year-old man with a malignant lymphoma of the right cheek who had undergone chemotherapy and needed plastic surgery to restore the face.

Case Report of a Patient with Swyer-James-MacLeod Syndrome Undergoing Breast Surgery under Regional Anaesthesia and Review of Literature

Swyer-James-MacLeod Syndrome is a rare acquired pulmonary disorder that develops secondary to infectious etiologies in early childhood. Patients who are affected have the potential of developing perioperative respiratory complications. While regional anaesthetic techniques are often performed as adjuncts to general anaesthesia, there is less data on breast operations being done solely under regional anaesthesia. We herein describe a patient with Swyer-James-MacLeod Syndrome who underwent breast lesion wide excision under combined paravertebral and pectoral nerves block, supplemented with propofol infusion for sedation. Choice of blocks was decided upon based on knowledge on the anatomy. Sole regional anaesthetic techniques have been the safest approach in some circumstances and should always be considered in patients who are of high risk under general anaesthesia.

Intraoperative Auditory Evoked Potential Monitoring for Anaesthesia Depth and Utilization of Inhaled Isoflurane

Background: Hypnosis monitoring has been shown to reduce the incidence of awareness. A-line ARX-IndexTM (AAI) derived from auditory evoked potentials (AEP) represents as a numerical variable depth of anaesthesia. Objectives: To study the efficacy of AEP as an indicator of anaesthetic depth and monitor intraoperative awareness in neurosurgical patients by using the AAI scale. Design: Prospective cohort study is used. Setting: The study is in Neurosurgical centre of Tertiary care hospital. Participants: Neurosurgical patients requiring general anaesthesia with duration of surgery between 90 - 150 minutes were enrolled for the study. Intervention: Patients in Group 1 (control) were monitored by conventional methods. Patients in Group 2 (study) underwent intraoperative monitoring by using the AEP monitor. Primary outcome: To study the efficacy of AEP monitoring and AAI index for monitoring the depth of anaesthesia and reducing the incidence of awareness. Results: There was no significant difference in the intraoperative haemodynamic responses measured between the two study groups (p > 0.5). There was no significant difference in the identification of intraoperative awareness by using conventional parameters between the two groups (p > 0.5). There was also a significantly faster time to recovery for patients in Group 2 (p < 0.05). Conclusion: Hypnosis monitoring using AEP monitor/AAI in neurosurgical patients under general anaesthesia did not show any significant difference in haemodynamic response and intraoperative awareness but had significant lower consumption of volatile anaesthetic with cost sparing effect and a faster recovery time as compared to conventional monitoring.

Day Case Haemorrhoidectomy under Local Anaesthesia and Conscious Sedation

Background: Excisional haemorrhoidectomy engenders considerable pain and has popularly been managed as an in-patient procedure. There has been anxiety over a major complication occurring in the community instead of in the hospital which is still pervasive in the developing world despite evidence to the contrary. Aim: It compared the post operative complications, time to bowel action, and post-operative pain scores in patients who had open haemorrhoidectomy either under spinal anaesthesia as in-patient or under local anaesthesia as day case procedure. Materials and Methods: The study involved two populations of patients who underwent open haemorrhoidectomy either under spinal anesthesia or under local anaesthesia with conscious sedation at the Korle Bu Teaching Hospital between 2008 and 2013. Results: It involved 275 patients made up of 145 and 130 in the spinal and local aneasthesia groups respectively. Their mean age was 43.1, SD ± 13.2 and median 41 years. Complications occurred in 44 patients (16%), 24 and 20 in the spinal and local aneasthesia groups respectively, with bleeding being the most frequent [11/44, (25%)] and significant. More wound bleeding occurred in the spinal than the local anaesthesia group, 7 vs. 2 patients. Except one day only (p = 0.0001) the mean pain scores on days 2, 3, 5 and 7 were statistically significantly lower in the spinal group than in the local group. The median time to bowel motion was 4 days in both groups. Conclusion: The post operative outcomes in the two populations were similar except the more frequent bleeding noted in the spinal anaesthesia group. Day case haemorrhoidectomy is safe in centres where day case surgery is routinely performed.

Errors during Paediatric Cardiac Anaesthesia: Reporting and Learning

Incident reporting is a reliable quality assurance tool, frequently used in anaesthesia to identify errors. It was introduced in anaesthesia by Cooper in 1978 and since then several institutions have adopted this system to find adverse events and near misses. We think that the incident reporting would be more beneficial for prolonged and technically complex procedures like paediatric cardiac surgery. Methods: All paediatric CHD patients scheduled for cardiac surgery were included in this audit. Thoracic and general surgery patients were excluded. Any event in preoperative area, induction room, operating room and during transfer to cardiac ICU was documented in a predesigned proforma by resident/consultant. This proforma included information regarding demographics, the type and severity and responsible factors for the event. Results: 134 patients were included in this two and half years audit. 88 patients were male (65.7%) and 46 (34.3%) were female. The age of the patients ranged from one day to 15 years. Total 105 incidents were noticed in 61 patients. 46 incidents were declared as major events which were potentially serious while 59 events were of minor nature. Cuffed endotracheal tube was used in 73% patients. The majority of events occurred in the pre-bypass period. Most of the incidents were related to cardiovascular system (73%), followed by pharmacological incidents. Human factors (74%) were mainly responsible for the incidents. Conclusion: Incident reporting is a reliable and feasible method of improving quality care in developing countries. It helps in identifying areas which need improvement and helps in developing guidelines to improve safety.

Instituting Pandemic Plans in a Singapore Anaesthesia Unit: The Challenges and Learning Points

The World Health Organization declared COVID-19 as a pandemic on 11 March 2020. Its rapid spread has put a strain on healthcare systems globally. Singapore ranked the highest in terms of reported cases outside of China in the first few weeks of this outbreak. The management of a patient with COVID-19 in the Operating Theatre (OT) presents a unique set of challenges to the Anaesthetist. Delivery of timely and quality care must be upheld while reducing the risk of transmission to healthcare staff and other patients. This article describes our Anaesthesia Unit’s experiences and challenges in instituting our pandemic plans. The authors hope that the sharing of our experience and practical approach would be useful to other Anaesthesia Units worldwide.