Allan M Cyna

A comparison of emergence delirium scales following general anesthesia in children.

Background:  Emergence delirium (ED) is of increasing interest since the introduction of short‐acting volatiles such as sevoflurane.

Use of invasive placebos in research on local anaesthetic interventions

Placebos play a vital role in clinical research, but their invasive use in the context of local anaesthetic blocks is controversial. We assessed whether recently published randomised controlled trials of local anaesthetic blocks risked harming control group patients in contravention of the Declaration of Helsinki. We developed the ‘SHAM’ (Serious Harm and Morbidity) scale to assess risk: grade 0 = no risk (no intervention); grade 1 = minimal risk (for example, skin allergy to dressing); grade 2 = minor risk (for example, subcutaneous haematoma, infection); grade 3 = moderate risk (with or without placebo injection) (for example, neuropraxia); and grade 4 = major risk (such as blindness, pneumothorax, or liver laceration). Placebo interventions of the 59 included trials were given a SHAM grade. Nine hundred and nineteen patients in 31 studies, including six studies with 183 children, received an invasive placebo assessed as SHAM grade ≥ 3. A high level of agreement (78%, κ = 0.80, p < 0.001) for SHAM grades 0–4 increased to 100% following discussion between assessors. More than half of the randomised controlled study designs subjected patients in control groups to risks of serious or irreversible harm. A debate on whether it is justifiable to expose control group patients to risks of serious harm is overdue.

Aseptic precautions for inserting an epidural catheter: a survey of obstetric anaesthetists

Summary We performed a postal survey of Fellows of the Australian and New Zealand College of Anaesthetists with a special interest in obstetric practice, about their beliefs regarding aseptic precautions for insertion of an epidural catheter in the labour ward. Of the 435 consultant anaesthetists surveyed, 367 responded (84%), revealing a wide variation in practice. It was not thought to be essential practice to remove a watch before washing hands by 51 respondents (14%), to wear a facemask by 105 (29%) or to wear a sterile gown by 45 (12%). Three anaesthetists (1%) did not believe sterile gloves were essential. However, all respondents indicated that an antiseptic skin preparation was essential. Our results raise questions regarding an acceptable standard of aseptic practice for the insertion of an epidural catheter in labour and we propose a minimal standard of essential precautions.

Communication skills for the anaesthetist

Anaesthetists have traditionally focused on technological and pharmacological advances when considering the provision of anaesthetic care. Anaesthetists are expected to be able to communicate effectively with peers, patients, their families and others in the medical community; however, few details are provided regarding how this might be achieved. Recent evidence suggests that communication practices should include a consideration of conscious and subconscious processes and responses. This model has potential relevance when learning and teaching how to communicate effectively in the stressful environment of anaesthetic clinical practice, and includes: reflective listening; observing; acceptance; utilisation; and suggestion. Understanding these processes could allow the development of a learnable framework for effective communication when the usual strategies are not working. This concept could also be used to facilitate communicating with surgeons and other colleagues, with potential benefits to patients.

Pain relief for childbirth: the preferences of pregnant women, midwives and obstetricians.

OBJECTIVE To compare the personal preferences of pregnant women, midwives and obstetricians regarding a range of physical, psychosocial and pharmacological methods of pain relief for childbirth. METHOD Self-completed questionnaires were posted to a consecutive sample of 400 pregnant women booked-in to a large tertiary referral centre for maternity care in South Australia. A similar questionnaire was distributed to a national sample of 500 obstetricians as well as 425 midwives at: (1) the same hospital as the pregnant women, (2) an outer-metropolitan teaching hospital and (3) a district hospital. Eligible response rates were: pregnant women 31% (n=123), obstetricians 50% (n=242) and midwives 49% (n=210). FINDINGS Overall, midwives had a greater personal preference for most of the physical pain relief methods and obstetricians a greater personal preference for pharmacological methods than the other groups. Pregnant womens preferences were generally located between the two care provider groups, though somewhat closer to the midwives. All groups had the greatest preference for having a support person for labour with more than 90% of all participants wanting such support. The least preferred method for pregnant women was pethidine/morphine (14%). CONCLUSION There are differences in the personal preferences of pregnant women, midwives and obstetricians regarding pain relief for childbirth. It is important that the pain relief methods available in maternity care settings reflect the informed preferences of pregnant women.

Transition to propofol after sevoflurane anesthesia to prevent emergence agitation: a randomized controlled trial

Emergence agitation (EA) is a common behavioral disturbance after sevoflurane anesthesia in children. Propofol 1 mg·kg−1 bolus at the end of sevoflurane anesthesia has had mixed results in reducing the incidence of EA, whereas propofol infusion throughout anesthesia maintenance seems effective but is more complex to administer. If a simple, short transition to propofol anesthesia was found to be effective in reducing EA, this could enhance the recovery of children following sevoflurane anesthesia. We therefore aimed to determine whether transition to propofol over 3 min at the end of sevoflurane anesthesia reduces the incidence of EA in children.

Hypnosis Antenatal Training for Childbirth: a randomised controlled trial

To determine the use of pharmacologic analgesia during childbirth when antenatal hypnosis is added to standard care.

The Effect of Pregnancy on Hypnotizability

Abstract Hypnosis during pregnancy and childbirth has been shown to reduce labor analgesia use and other medical interventions. We aimed to investigate whether there was a difference in hypnotizability in pregnant and non-pregnant women. Study participants had hypnotizability measured by the Creative Imagination Scale (CIS) in the third trimester of pregnancy and subsequently between 14 and 28 months postpartum and when not pregnant. The 37 participants who completed the study gave birth in the largest maternity unit in South Australia between January 2006 and March 2007. CIS scores were increased in women when pregnant (Mean 23.5, SD 6.9) compared to when they were not pregnant (Mean 18.7, SD 6.6), p < 0.001. The mean effect size was 0.84 suggesting that the hypnotizability change was both statistically significant and clinically meaningful. Our study findings support previous evidence showing that women are more hypnotizable when pregnant than when not pregnant.

A comparison of fentanyl with pethidine for pain relief during childbirth: a randomised controlled trial

To compare the efficacy of fentanyl administered via the subcutaneous (s.c.) or intranasal (i.n.) route with intramuscular (i.m.) pethidine in labouring women requesting analgesia.

Subacute airway obstruction from a tracheal mucosal flap

We report the case of a 15‐year‐old girl with a near fatal obstructive tracheal lesion following tracheal intubation. The patient developed stridor and acute respiratory distress 29 h following tracheal extubation, after 35 h intubation in the intensive care unit. The failure of conventional management of stridor, including re‐intubation, to provide a satisfactory airway prompted an urgent bronchoscopy, which revealed a tracheal mucosal flap causing 80% obstruction of the subglottic trachea. The fibreoptic bronchoscope allowed careful placement of a tracheal tube distal to the obstruction. The patient eventually made a full recovery. The low incidence of similar lesions and the lack of distinguishing clinical features from other causes of post‐extubation stridor make diagnosis and appropriate management of this life‐threatening condition difficult. We discuss how early consideration of the diagnosis and optimal initial management reduce the risk of an adverse outcome.