Christopher D. Kent

Depth of anesthesia

PURPOSE OF REVIEW The present review article provides a summary of the recent literature evaluating the technology for monitoring depth of anesthesia and patient outcomes associated with its use. RECENT FINDINGS The tentative and controversial findings of a 2006 study suggesting a correlation of mortality with lower intraoperative bispectral index scores were reproduced in a more recent study, but the correlation could be accounted for by controlling for patient comorbidities, particularly malignancy. In a large trial involving patients at high risk for awareness, general anesthesia with volatile agents guided by bispectral index monitoring was associated with a low incidence of awareness, but no more so than the use of alarms for limits on volatile agent concentration. Studies comparing both emerging and more established brain function monitors suggest that, in spite of their different algorithms for processing and filtering electromyographic signal, many monitors are affected by the use of neuromuscular blocking agents. Recent evidence is consistent with previous studies that describe a nonlinear model for the dose-response of EEG parameters to increasing concentration of anesthetic agents with a dosing plateau response over a clinically relevant dose range. SUMMARY The goal of precisely dosed general anesthesia guided by brain monitoring remains elusive.

Assessment of intraoperative awareness with explicit recall: a comparison of 2 methods.

BACKGROUND:Superiority of the modified Brice interview over quality assurance techniques in detecting intraoperative awareness with explicit recall has not been demonstrated definitively. METHODS:We studied a single patient cohort to compare the detection of definite awareness using a single modified Brice interview (postoperative day 28–30) versus quality assurance data (postoperative day 1). RESULTS:The incidence of awareness based on the modified Brice interview was 19 per 18,847 or 0.1%. Fewer awareness cases (incidence 0.02%) were detected by the quality assurance approach (P < 0.0001). CONCLUSION:The modified Brice interview is the preferred modality for assessing intraoperative awareness with explicit recall.

Complications associated with peripheral nerve blocks: lessons from the ASA closed claims project.

New techniques and regional blocks have brought a renewed enthusiasm for the use of regional anesthesia for surgery. The use of ultrasound-guided anesthesia has become widespread. Meetings on regional anesthesia are focusing on new or increased use of regional blocks such as the transverse abdominus plane (TAP), ilioinguinal or iliohypogastric, lumbar plexus, psoas, and paravertebral blocks, and also continuous peripheral nerve catheters in the ambulatory setting. Some of the benefits of these changes in regional anesthesia that have been reported include greater success of blocks, improved efficiency, and improved analgesia and patient satisfaction. Typically, new procedural techniques provide both new benefits and new risks. We previously reported on complications associated with peripheral nerve blocks from

Psychological impact of unexpected explicit recall of events occurring during surgery performed under sedation, regional anaesthesia, and general anaesthesia: data from the Anesthesia Awareness Registry

BACKGROUND Anaesthetic awareness is a recognized complication of general anaesthesia (GA) and is associated with post-traumatic stress disorder (PTSD). Although complete amnesia for intraprocedural events during sedation and regional anaesthesia (RA) may occur, explicit recall is expected by anaesthesia providers. Consequently, the possibility that there could be psychological consequences associated with unexpected explicit recall of events during sedation and RA has not been investigated. This study investigated the psychological sequelae of unexpected explicit recall of events during sedation/RA that was reported to the Anesthesia Awareness Registry. METHODS The Registry recruited subjects who self-identified as having had anaesthetic awareness. Inclusion criteria were a patient-reported awareness experience in 1990 or later and availability of medical records. The sensations experienced by the subjects during their procedure and the acute and persistent psychological sequelae attributed to this explicit recall were assessed for patients receiving sedation/RA and those receiving GA. RESULTS Among the patients fulfilling the inclusion criteria, medical record review identified 27 sedation/RA and 50 GA cases. Most patients experienced distress (78% of sedation/RA vs 94% of GA). Approximately 40% of patients with sedation/RA had persistent psychological sequelae, similar to GA patients. Some sedation/RA patients reported an adverse impact on their job performance (15%), family relationships (11%), and friendships (11%), and 15% reported being diagnosed with PTSD. CONCLUSIONS Patients who self-reported to the Registry unexpected explicit recall of events during sedation/RA experienced distress and persistent psychological sequelae comparable with those who had reported anaesthetic awareness during GA. Further study is warranted to determine if patients reporting distress with explicit recall after sedation/RA require psychiatric follow-up.

Anesthesia Awareness: Narrative Review of Psychological Sequelae, Treatment, and Incidence

Awareness during general anesthesia occurs when patients recall events or sensations during their surgeries, although the patients should have been unconscious at the time. Anesthesiologists are cognizant of this phenomenon, but few discussions occur outside the discipline. This narrative review summarizes the patient recollections, psychological sequelae, treatment and follow-up of psychological consequences, as well as incidence and etiology of awareness during general anesthesia. Recalled memories include noises, conversations, images, mental processes, feelings of pain and/or paralysis. Psychological consequences include anxiety, flashbacks, and posttraumatic stress disorder diagnosis. Limited discussion for therapeutic treatment after an anesthesia awareness experience exists. The incidence of anesthesia awareness ranges from 0.1 to 0.2% (e.g., 1–2/1000 patients). Increased recognition of awareness during general anesthesia within the psychological/counseling community, with additional research focusing on optimal therapeutic treatment, will improve the care of these patients.

Ambulatory surgery: is the liability risk lower?

Purpose of review To summarize the currently available data on malpractice claims related to ambulatory anesthesia and provide an insight into the emerging patterns of anesthesia liability in this practice setting. Recent findings At present, studies are mixed about how the continued growth of outpatient surgery will impact liability for anesthesiologists. Data derived from the ASA Closed Claims Project suggests that malpractice claims for major damaging events are less common in the outpatient settings than in inpatient settings. Correspondingly, the payment amounts for outpatient claims are significantly lower than those for inpatients. Nevertheless, nondisabling adverse events are common and involve respiratory, cardiac, equipment-related, and drug errors. In addition, the vast majority of injuries in outpatient claims was the result of substandard care and judged preventable by better monitoring. Although major incidents leading to malpractice suits are less, new liability exposure may be on the horizon, due to the changing landscape of ambulatory practice that permits care for sicker patients who require more complex surgeries. The areas of potential concern include postoperative discharge criteria, care for the obstructive sleep apnea patient, and the choice of anesthetic techniques such as neuraxial blocks and monitored anesthesia care. Summary With steady increase in outpatient surgery, anesthesiologists are confronted with new areas of liability. More data are needed to identify these risks and reduce exposure to malpractice claims.

Patient perspectives on intraoperative awareness with explicit recall: report from a North American anaesthesia awareness registry

BACKGROUND Awareness during general anaesthesia is a source of concern for patients and anaesthetists, with potential for psychological and medicolegal sequelae. We used a registry to evaluate unintended awareness from the patients perspective with an emphasis on their experiences and healthcare provider responses. METHODS English-speaking subjects self-reported explicit recall of events during anaesthesia to the Anesthesia Awareness Registry of the ASA, completed a survey, and submitted copies of medical records. Anaesthesia awareness was defined as explicit recall of events during induction or maintenance of general anaesthesia. Patient experiences, satisfaction, and desired practitioner responses to explicit recall were based on survey responses. RESULTS Most of the 68 respondents meeting inclusion criteria (75%) were dissatisfied with the manner in which their concerns were addressed by their healthcare providers, and many reported long-term harm. Half (51%) of respondents reported that neither the anaesthesia provider nor surgeon expressed concern about their experience. Few were offered an apology (10%) or referral for counseling (15%). Patient preferences for responses after an awareness episode included validation of their experience (37%), an explanation (28%), and discussion or follow-up to the episode (26%). CONCLUSIONS Data from this registry confirm the serious impact of anaesthesia awareness for some patients, and suggest that patients need more systematic responses and follow-up by healthcare providers.

Anesthetic management of spinal muscle atrophy type II in a parturient.

We report the peripartum management of a 30-year-old wheelchair-bound nullipara woman with spinal muscular atrophy (SMA) type II, including severe restrictive lung disease and Harrington rods. At 38 weeks gestation, she was admitted for an induction of labor with neuraxial analgesia, but she subsequently had to be delivered via cesarean section under general anesthesia. We describe the anesthetic implications of SMA on labor and delivery management and review the available literature.

An analysis of risk factors and adverse events in ambulatory surgery

License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php Ambulatory Anesthesia 2014:1 3–10 Ambulatory Anesthesia Dovepress

Management of labor and delivery in a woman with Morquio syndrome

Morquio syndrome, a congenital mucopolysaccharidosis, presents several challenges for the provision of effective labor analgesia. We report the case of a woman admitted for induction of labor who received an early epidural and subsequently required cesarean delivery. Optimal bilateral labor analgesia was not achieved despite multiple adjustments, and systemic analgesia was needed for cesarean delivery.