Climate change and human health: Last call to arms for us

Climate change,now the foremost global health hazard,poses multifaceted challenges to human health.This editorial elucidates the extensive impact of climate change on health,emphasising the increasing burden of diseases and the exacerbation of health disparities.It highlights the critical role of the healthcare sector,particularly anaesthesia,in both contributing to and mitigating climate change.It is a call to action for the medical community to recognise and respond to the health challenges posed by climate change.

An Inventory of Fluorspar Production, Industrial Use, and Emissions of Trifluoroacetic Acid (TFA) in the Period 1930 to 1999

There is a generally accepted conclusion that trifluoroacetic acid (TFA) does occur naturally, in part based on the large quantities of TFA in the oceans (61 - 205 million tonnes, measured in 1998-2002). However, the recent review paper “Insufficient evidence for the existence of natural trifluoroacetic acid” concludes that “the presence of TFA in the deep ocean and lack of closed TFA budget is not sufficient evidence that TFA occurs naturally, especially without a reasonable mechanism of formation”. Industrial sources of TFA can only result from the use of fluoride minerals in industrial processes. Major industrial uses of fluorspar started significant expansion from about the same time (1930s). Over 190 million tonnes of fluorspar have been mined in the period 1930 to 1999. An inventory has been developed (1930-1999), accounting for most of the fluorspar production (86%) and estimating emissions of TFA. Industrial emissions of TFA are estimated as 230,000 to 470,000 tonnes. Significant other industrial uses of fluorides have not been identified that could account for the large burden of TFA in the oceans. This inventory provides complementary evidence that the quantity of TFA in the oceans must include a large natural burden.

Efficacy and safety of local anaesthetics for prematurejaculation： a systematic review and meta-analysis

To assess the efficacy and safety of local anaesthetics for premature ejaculation （PE）, a systematic review of the literature was performed using the Cochrane Library, PUBMED and EMBASE. We screened and retrieved the randomized controlled trials on the treatment of PE with local anaesthetics. End points included intravaginal ejaculation latency time （IELT）, patient-reported outcome assessments and adverse events. Meta-analyses were conducted with Stata 11.0. In total, seven publications involving 566 patients with local anaesthetics and 388 with placebos strictly met our eligibility criteria. Meta-analyses showed that after the patients were treated with the local anaesthetics, the value of the standardized mean difference of the changes in IELT was 5.02 （95% Ch 3.03- 7.00）. A higher rate of adverse events occurred compared with placebos （odds ratio： 3.30, 95% Ch 1.71-6.36）, but these events were restricted to local side effects. In addition, significantly greater improvement was observed in patient-reported outcomes. In summary, local anaesthetics can prolong IELT and improve ejaculatory control and sexual satisfaction.

A survey of anaesthetic preferences in cataract surgery

AIM:To identify current trends in anaesthesia technique for cataract surgery and make this information available to ophthalmologists.METHODS:An electronic survey was created and distributed to members of online ophthalmology forums;results were subsequently analysed in spreadsheet software.RESULTS:In total there were 71 completed surveys.The most preferred anaesthesia technique in cataract cases was topical anaesthesia with intracameral injection(n=34,47.9%),and the least preferred techniques were retrobulbar(n=1,1.4%) and peribulbar blocks(n=1,1.4%).The most commonly preferred local anaesthetic was lidocaine 2%(n=41,57.7%).CONCLUSION:Topical anaesthesia techniques with lidocaine 2% appear to be the most preferred method of anaesthesia in cataract surgery in our survey.Compared with previous literature our survey shows that topical anaesthesia is being increasingly used in cataract surgery,especially in conjunction with intracameral injection.The predominant reasons for this seem to be patient comfort and ease of technique.

The Effect of Intraperitoneal Ropivacaine for Post-Operative Pain Management in Patients Undergoing Laparoscopic Cholecystectomy: A Prospective Double-Blind Randomized Control Study

Objective: To compare the effect of intraperitoneal ropivacaine with placebo for post-operative pain management in patients undergoing laparoscopic cholecystectomy. Material and Methods: All patients were pre-medicated with glycopyrrolate 0.2 mg, ondansetron 4 mg and ranitidine 150 mg intravenously half an hour prior to induction of anesthesia. All patients were given standard general anaesthesia with propofol (2-2.5 mg/kg), fentanyl 2 μg/kg, and succinylcholine (2 mg/kg) to facilitate tracheal intubation. Anesthesia was maintained with 60% N2O in oxygen with 0.5% to 1% Halothane. Group A: Patients received 20 ml of 0.9% normal saline as placebo (n = 25). Group B: Patients received 20 ml of 0.5% ropivacaine (n = 25). Results: The age and sex distribution of both the groups was similar. The heart rate, systolic & diastolic blood pressure, mean blood pressure and mean trend of SpO2 in both groups remained similar over the periods. The mean VAS varied considerably within (between time) and between the groups (treatment) and was especially comparatively higher in Group A at initial hours 15 min to 30 min and at end hours 12-24 hrs as compared with Group B. On an average, the frequent dosing of rescue analgesia and mean No. of rescue analgesia doses were higher in Group A followed by Group B. In both groups, the treatment related adverse events were mostly emetic symptoms and shoulder pain with the highest being in Group A. Conclusion: We conclude that intraperitoneal instillation of local anaesthetic is an easy, cheap, and non-invasive method which provides good analgesia in the immediate postoperative period after laparoscopic surgery.

Knowledge of Anaesthesia Providers on Exposure to Inhalational Anaesthetic Agents in Ghana

Background: Chronic exposure to inhaled anaesthetic agents poses an occupational hazard related to the practice of anaesthesia. Therefore, this study sought to find out the perception of anaesthesia providers on exposure to inhalational anaesthetics, evaluate their knowledge on the effects of chronic exposure and strategies to reduce chronic exposure to operating room inhalational anaesthetic agents. Method: This cross-sectional survey was conducted by administering a self-administered questionnaire to 71 anaesthesia providers in Ghana who attended the annual refresher course of the faculty of Anaesthesia, West African College of Surgeons, in 2016. Data collected were analysed and presented as frequencies and percentages. Results: Halothane and isoflurane were the most frequently used inhalational agents by the respondents. Majority (90.1%) of the respondents perceived they are exposed to inhalational anaesthetics in their working environment. Majority of the anaesthetic providers cited poorly functioning scavenging systems (28.2%) and use of paediatric Ayre’s T-piece (28.2%) as sources of exposure to inhalational anaesthetics. All respondents admitted making attempts to reduce their exposure to inhalational anaesthetics. Majority of the respondents mentioned teratogenicity (77.5%) and hepatotoxicity (67.6%) as effects of chronic exposure to inhaled anaesthetic agents. Conclusion: Anaesthesia providers in Ghana perceived they are chronically exposed to inhalational anaesthetic agents in their work environment. They are aware of the sources of inhalational anaesthetic agent exposure, associated health risks and strategies required to reduce chronic exposure to inhaled anaesthetic agents.

Risk Management of Obese Women Undergoing Major Gynaecological Surgery

Obesity is a big problem which is growing. Thus clinicians and surgeons are likely to treat obese patients more frequently. Obesity can affect medical practice in a number of ways. In order to protect ourselves from potential litigation, we need to focus on risk management efforts on creating a safe environment for patients of all sizes. The aim of our study was to review the risk management strategies of obese women prior to surgery, perioperatively and following surgery. We then identified the strategies and have brought them forward in our article.

Improved Hemodynamics with the Use of Prophylactic Infusion of Epinephrine and/or Norepinephrine during Transcatheter Aortic Valve Replacement (TAVR)

Background: Transcatheter Aortic Valve Replacement (TAVR) is a new minimally-invasive surgical procedure in which a bioprosthetic aortic valve is placed via a small skin incision in the groin, over either the left or right iliac artery. TAVR was recently approved by the FDA as a treatment option for aortic stenosis in patients who may be too frail to undergo open heart surgery. Anesthetic management of TAVR is complicated by the fact that rapid left ventricular pacing (to at least 180 beats per minute) is required at multiple points throughout the procedure. Aim: This rapid pacing creates a profound pathophysiologic stress on the heart, sometimes leading to severe left ventricular dysfunction and resultant complete hemodynamic collapse. We report that the use of prophylactic infusion of epinephrine and/or norepinephrine in patients undergoing TAVR results in improved recovery from rapid pacing as reflected by intraoperative trends in systolic systemic blood pressure and systolic pulmonary arterial pressure. Cases: Here we report three cases. During the first of these, we reacted to intraoperative hemodynamic changes by administering boluses of vasoactive medications as needed. During the other two cases, we preemptively infused vasopressors to facilitate a more rapid recovery from some of the hemodynamic disturbance associated with either TAVR or rapid pacing. Conclusion: The two patients in this series who were managed with a preemptive strategy had higher ratios of systemic systolic blood pressure to pulmonary arterial systolic blood pressure at the end of the case than did the patient who was managed reactively. This suggests that the preemptive strategy may lead to decreased left ventricular impairment and improved overall cardiac function after TAVR.

Anaesthetic Management of Malignant Granulosa Cell Tumour of Ovary in a Paediatric Patient: A Case Report

Juvenile granulosa cell tumour (JGCT) is very uncommon gynaecological malignancy that occurs mostly commonly in less than five years of age. Only 0.1 percent of all ovarian tumours and 4 - 5 percent of granulosa cell tumours present as JGCT. The most common presentation of these tumours in children is precocious puberty. We describe anaesthetic management of a case of JGCT in a 1-year-old girl. The malignancy is assigned to International Federation of Gynaecology and Obstetrics staging system (FIGO stage I). It was treated with complete excision and histological examination confirmed the diagnosis.

Intravenous Lidocaine for Perioperative Use

Introduction and Background: Lidocaine was recognised only as a local anesthetic and anti-arrhythmic drug for past decades. Nonetheless, more recently its utility in perioperative setting is being appreciated globally. This review aims to analyse its work beyond its traditional use when employed intravenously in perioperative setting and overall impact on postoperative period. Content: A total of 41 articles were selected for study while 13 of them were chosen for data presentation. Databases such as CENTRAL, MEDLINE/Pubmed, LILACS, Ovid and Scielo were used to search the articles using keywords like Intravenous lidocaine, local anesthetics, perioperative analgesia or postoperative pain. A bolus dose of 1.5 mg/kg and maintenance dose of 2 - 3 mg/kg/h of intravenous lidocaine was used to bring out its analgesic effect and its positive impact on postoperative stage in nearly all the selected studies. Its anti-inflammatory, antinociceptive and immunomodulatory effects were also addressed. Conclusion: Perioperative implication of systemic lidocaine not only lessens pain perception but also assures early return of bowel function, lower incidence of postoperative nausea and vomiting, opioid sparing effect and shorter length of hospital stay. Thus, implementation of lidocaine as a part of perioperative approach should be seriously considered. Its role in surgeries other than abdominal needs more detailed study. In spite of current results encouraging, it may be too early to claim its similar impact in other types of surgeries.

Perioperative Clinical Interventions That Modify the Immune Response in Cancer Patients

The immune system plays a pivotal role against cancer. The development of a successful immune response involves the balance between the Th1 (antitumor) and Th2 (protumor) responses. Once this balance is lost, diseases such as cancer may become apparent. Surgical stress, volatile anaesthetics, opioids and blood transfusions are known to favour a Th2 response that manifests as immune suppression. During surgery the load of circulating malignant cancer cells is increased by tumour manipulation. These cancer cells can migrate and seed in distant tissues and form metastasis. Also, some cancer patients may present with micrometastasis that may become invasive if left untreated. Therefore, the perioperative period is a moment of immunological vulnerability in cancer patients. A better understanding of the factors that affect the Th1/Th2 balance may allow anaesthesiologists to identify patients at high risk for cancer recurrence. This review describes the perioperative interventions that can alter the Th1/Th2 balance, during the perioperative period of oncological surgery.

Preoperative Laboratory Testing by Surgeons: Implication on Anaesthetic Management

Background: Request for preoperative laboratory investigations is usually done by surgeons. On some occasions, the patient may come with laboratory investigations that have been requested by the primary physician. This occurs in situations where the primary physician saw the patient first and referred to the surgeon. There is usually no indications based on history or physical examination before these laboratory request is done but rather on speculations that the “anaesthetist may require them”. This is done in order to avoid cancellation or delay of cases. The aim of this study was to find out how tests ordered in Komfo Anokye Teaching Hospital (K.A.T.H.) by the surgeons affected the decisions of the anaesthetists in the perioperative management of the patients. Methodology: This was a prospective, cross sectional study of patients undergoing elective surgery at K.A.T.H from 1st to 31st March 2014. A quantitative technique was used to effectively quantify laboratory results that were contained in a patient’s folder before an elective surgical procedure. A close and open-ended questionnaire was developed and answered by reviewing patient’s folders during the pre-anesthesia assessment. Data were analyzed using Statistical Package of Social Sciences (SSPS) version 22. Results: The average age of patients studied was 50 years. Abnormal test results did not influence the anaesthetic management in 70.5% of cases but led to either delay or cancelation of cases or requirement for transfusion of blood or blood products in 29.5% of cases. Conclusion: Preoperative laboratory tests ordered by Surgeons in KomfoAnokye Teaching Hospital do not significantly influence the anaesthetic managements of patients.

Day case paediatric microlaryngobronchosocopy:A prospective study

AIM To assess the feasibility and parental acceptance of diagnostic microlaryngobronchoscopy(MLB) as day case surgery.METHODS A prospective study was performed over a 26 moperiod at a tertiary paediatric ENT centre. Patients were selected in clinic using set criteria. All MLBs were performed using a standardised anaesthetic protocol and patients monitored post-operatively. Six weeks following surgery, parents underwent questionnaire surveys.RESULTS Ninety-four out of 101 MLBs was successfully performed as day case surgery over the set period. Seven patients required an overnight stay for further observation. Fiftyseven parents took part in the questionnaire of which 68.4% were highly satisfied with same day discharge. CONCLUSION MLB is feasible, safe and acceptable as day case surgery in carefully selected patients.

A Successful Pregnancy Outcome after Surgical Decompression of Type I Arnold-Chiari Malformation

Type I Arnold-Chiari malformation (ACM) usually presents in adulthood and consists of a downward displacement of the cerebellar tonsils through the foramen magnum. A 25-year-old woman presented with a 5-month history of headache associated with blurred vision, tinnitus and sickness. Imaging recognised the need for surgical intervention, but whilst awaiting for surgery she fell pregnant. Considering the risks of neurological deterioration, the woman underwent surgical decompression of type I ACM at 15 weeks gestation. She subsequently presented with progressively worsening headaches during late pregnancy from 35 weeks. The obstetric plan was initially induction of labour at term but since the onset of worsening symptoms, this date was brought forward to 39 + 1 weeks gestation. She proceeded to have a normal delivery with no neonatal complications and an uneventful puerperium followed. Since the delivery, the patient reported fewer symptoms, showed no signs of neurological deficit and a repeat magnetic resonance imaging of the head showed good relief of neural compression. This case illustrates how judicious selection of the appropriate mode of delivery of women following surgically corrected ACM and a multidisciplinary approach is critical in the successful management of the antepartum period and labour.

Can repeated scorpion bite lead to development of resistance to the effect of local anesthetics? Maybe it does!

An 80 years old, bronchial asthmatic, male was posted for left cataract extraction with intra ocular lens implantation. He was administered peribulbar block/left facial nerve block. There was no sensory or motor block. Thereafter peribulbar block was repeated. Only partial akinesia was achieved, so under intermittent intra venous sedation, the surgery continued for 40 minutes. In the post-operative period, no signs of any residual/delayed block were noted. On specific enquiry, patient gave history of scorpion bite thrice, at the age of 27 years on his right foot, about 8-9 years back and again about 6-7 months back on his right hand. On 4th post-operative day after obtaining informed consent, local infiltration of the skin on the ventral aspect of the forearm, using, 6 mL, 2% lignocaine with adrenaline, was carried out. Confirming the suspicion, there was no sensory block after the injection, confirmed by pin prick method. Peribulbar block produces adequate intra-operative analgesia for cataract extraction. The cause of the failures may be due to technical inability to achieve block. However failure that occurs despite of technically correct injection of the correct drug can be mystifying. As the scorpion venom is known to affect the pumping mechanism of sodium channels in the nerve fibres, which are involved in the mechanism of action of local anaesthetic drugs, it may be responsible for the development of “resistance” to the action of local anaesthetic agents.

Activation of epidermal growth factor receptor mediates myocardial ischemia/reperfusion arrhythmias in anaesthetized rats

Objectives Epidermal growth factor receptor （EGFR）is a receptor protein tyrosine kinase and plays a critical role in the development and function of the heart.Previous studies have demonstrated that EGFR is involved in regulating electrical excitability of the heart.The present study was designed to investigate whether EGFR activation would mediate myocardial arrhythmias induced by ischemia/reperfu- sion in anaesthetized rats.Methods and results Myocardial ischemia/reperfusion arrhythmias were induced by 10 min ligation of the left anterior descending coronary artery,followed by a 30 min reperfusion in anaesthetized rats.Incidence and severity of cardiac arrhythmias were significantly reduced by pretreatment with the EGFR kinase inhibitor AG556.Phosphorylation level of myocardial EGFR was increased during ischemia and at early reperfusion.Intramyocardial transfection of EGFR siRNA reduced EGFR mRNA and protein,and decreased the incidence of ventricular fibrillation induced by reperfusion.Interestingly,tyrosine phosphorylation levels of cardiac Na+ channel(INa) and L-type Ca2+ channel(ICa.l) were significantly increased at corresponding time points to the alteration of phosphorylated EGFR level during reperfusion.AG556 pretreatment countered the increased tyrosine phosphorylation level of Na+ and L-type Ca2+ channels induced by reperfusion.No significant alteration was observed in tyrosine phosphorylation levels of cardiac Kv4.2 and Kir2.1 channels during the cardiac ischemia/reperfusion. Conclusions These results demonstrate for the first time that EGFR plays an important role in the genesis of myocardial ischemia/reperfusion arrhythmias,which is likely mediated at least in part by enhancing tyrosine phosphorylation of cardiac Na+ and L-type Ca2+ channels.

Should Propofol and Alfentanil Be Combined in Patient-Controlled Sedation? A Randomised Controlled Trial Using Pharmacokinetic Simulation

Background: Patient-controlled sedation (PCS) is increasingly used for moderate sedation. Detailed understanding is essential for maintaining safety and giving the most benefit. We wanted to explore the associations between patients’ characteristics, perioperative pain and anxiety, the procedure, and the calculated concentrations at the effect site (Ce) of propofol. We also wanted to analyse the pharmacokinetic profiles of propofol and alfentanil during PCS, and their association with respiratory complications. Methods: 155 patients were double-blinded and randomised to have propofol or propofol and alfentanil for PCS during gynaecological surgery. Pharmacokinetic simulation of Ce and multiple regressions aided the search for correlations between explanatory variables and concentrations of drugs. Results: In group propofol, treatment for incontinence, anterior repair, and the patient’s weight correlated the best (B-coef = 0.20, 0.20 and 0.01;r = 0.69;r&#178 = 0.48). When alfentanil was added, alfentanil and the patient’s weight were associated with Ce of propofol (B-coef = &#450.40 and 0.01;r = 0.70;r&#178 = 0.43). Logistic regression indicated that age and Ce of drugs were related to ten cases of respiratory complications. Conclusions: Patients’ weights and the type of surgery performed were associated with the Ce of propofol;this knowledge could be used for refinement of the doses given during PCS. Because the pharmacokinetic profiles of propofol and alfentanil are different, the alfentanil effect becomes predominant during the time course of sedation. In order to reduce the risk of early and late respiratory depression, alfentanil should not be added to propofol in the same syringe.

Effects of Different Combinations of Two Spices:Clove and Nutmeg Seed Extracts on Antioxidants Levels in African Catfish(Clarias gariepinus)

The effect of different combinations of botanical spices such as clove and nutmeg in different proportion on the antioxidants activities which include lipid peroxidation(LPO),superoxide dismutase(SOD),catalase(CAT),glutathione-S-transferase(GST)and glutathione peroxide(GPX)in juveniles and adults sizes of Clarias gariepinus was investigated using different combinations of clove(C),and nutmeg(C.N 0:0-Control 0%of Clove and Nutmeg;C.N 1:3-25%Clove and 75%Nutmeg;C.N 3:1-75%Clove and 25%Nutmeg;C.N 2:2-50%Clove and 50%Nutmeg;C.4-100%Clove;N4-100%)in triplicates.The results from the study indicated that the anaesthetic caused a substantial(p<0.05)modifications in the five antioxidants under examination.The highest deviations in the studied antioxidants were observed in the fish exposed to C4 combination of the anaesthetics and the lowest in the control.The results from this work therefore suggest that the anaesthetics can alter antioxidants levels in the fish which was more noticeable in the fish exposed to C.N 3:1-75%Clove and 25%Nutmeg;C.N 2:2-50%Clove and 50%Nutmeg;C.4-100%Clove;N4-100%.Hence fish farmers and scientists are advised to take caution when combining these plant extracts for use in aquaculture.

Optimum interval time of programmed intermittent epidural bolus of ropivacaine 0.08%with sufentanyl 0.3 mg/mL for labor analgesia:a biased-coin up-and-down sequential allocation trial

Background:The programmed intermittent epidural bolus(PIEB)technique is widely used in labor analgesia,but the parameter settings of PIEB have not yet been standardized.We designed a study to identify the optimal interval duration for PIEB using 10 mL of ropivacaine 0.08%and sufentanyl 0.3 mg/mL,a regimen commonly used to control labor pain in China,to provide effective analgesia in 90%of women during the first stage of labor without breakthrough pain.Methods:We conducted a double-blind sequential allocation trial to obtain the effective interval 90%(EI90%)during the first stage of labor between April 2019 and May 2019.This study included the American Society of Anesthesiologists physical status II–III nulliparous parturients at term,who requested epidural analgesia.The bolus volume was fixed at 10 mL of ropivacaine 0.08%with sufentanyl 0.3 mg/mL.Participants were divided into four groups(groups 60,50,40,and 30)according to the PIEB intervals(60,50,40,and 30 min,respectively).The interval duration of the first parturient was set at 60 min and that of subsequent parturients varied according to a biased-coin design.The truncated Dixon and Mood method and the isotonic regression analysis method were used to estimate the EI90%and its 95%confidence intervals(CIs).Results:Forty-four women were enrolled in this study.The estimated optimal interval was 44.1 min(95%CI 41.7–46.5 min)and 39.5 min(95%CI 32.5–50.0 min),using the truncated Dixon and Mood method and isotonic regression analysis,respectively.The maximum sensory block level above T6 was in nearly 20%of parturients in group 30;however,5.3%,0%,and 0%of the parturients presented with sensory block level above T6 in groups 40,50,and 60,respectively.There were no cases of hypotension and only one parturient complained of motor block.Conclusion:With a fixed 10 mL dose of ropivacaine 0.08%with sufentanyl 0.3 mg/mL,the optimal PIEB interval is about 42 min.Further studies are warranted to define the efficacy of this regimen throughout all stages of labor.

Stress-preventing effects of the anaesthetic agents 2-phenoxyethanol, MS-222, clove oil and metomidate in the Senegalese sole Solea senegalensis

Objective: To determine the effectiveness of the anaesthetic agents 2-phenoxyethanol, MS-222, clove oil and metomidate in attenuating acute handling stress in juvenile specimens of Solea senegalensis subjected to two routine stressful events specific to aquaculture and/or fish research. Methods: The stress-preventing effects of four anaesthetic agents (2-phenoxyethanol, 600 mg/L;metomidate, 5 mg/L;clove oil, 30 mg/L and MS-222, 75 mg/L) were evaluated in juvenile specimens of Senegalase sole (Solea senegalensis) subjected to two different types of acute (handling-related) stress: air exposure and net handling (chasing). To assess the stress-preventing effects of the four anaesthetic agents, diverse blood and plasma parameters (haematocrit, haemoglobin, glucose, lactate and cortisol levels) were determined as stress indicators. Fish were treated with the anaesthetic agents before being subjected to the different types of acute stress, and they were sacrificed 30 min, 2 and 24 h later. Control fish were processed in the same way without pretreatment with the anaesthetic agents. Results: The net handling stress was of sufficient intensity to cause a significant increase in the levels of most of the stress indicators considered. By contrast, air exposure stress only induced significant increases in cortisol and haemoglobin levels. Conclusions: The stress-preventing effects of the anaesthetic agents tested were ranked on the basis of their capacity to prevent increases in the haematocrit, haemoglobin, glucose, lactate and cortisol levels, as follows: metomidate (5 mg/L) > clove oil (30 mg/L) > MS-222 (75 mg/L)> 2-phenoxyethanol (600 mg/L).