Guidelines for the safe practice of total intravenous anaesthesia (TIVA): Joint Guidelines from the Association of Anaesthetists and the Society for Intravenous Anaesthesia.

Guidelines are presented for safe practice in the use of intravenous drug infusions for general anaesthesia. When maintenance of general anaesthesia is by intravenous infusion, this is referred to as total intravenous anaesthesia. Although total intravenous anaesthesia has advantages for some patients, the commonest technique used for maintenance of anaesthesia in the UK and Ireland remains the administration of an inhaled volatile anaesthetic. However, the use of an inhalational technique is sometimes not possible, and in some situations, inhalational anaesthesia is contraindicated. Therefore, all anaesthetists should be able to deliver total intravenous anaesthesia competently and safely. For the purposes of simplicity, these guidelines will use the term total intravenous anaesthesia but also encompass techniques involving a combination of intravenous infusion and inhalational anaesthesia. This document is intended as a guideline for safe practice when total intravenous anaesthesia is being used, and not as a review of the pros and cons of total intravenous anaesthesia vs. inhalational anaesthesia in situations where both techniques are possible.

Increased recurrence in Scarf osteotomy for mild & moderate hallux valgus with Meary's line disruption.

BACKGROUND: Scarf osteotomy for hallux valgus is a successful procedure. Neverthless recurrence of deformity is reported as 5-8%. First ray instability is a recognised risk factor for recurrence. We investigate whether a radiographic marker such as Meary's line can be used to predict recurrence. This paper aims to test the null hypothesis that there is no difference in recurrence for mild and moderate hallux valgus treated with Scarf osteotomy in the presence of a disrupted Meary's line compared to an intact line. METHODS: At a minimum of 3 months follow up we retrospectively analysed radiographs, theatre and clinic notes of 74 (n=74) consecutive patients treated with Scarf osteotomy for mild and moderate hallux valgus at a single centre. The patients were divided into Group A (n=30) - patients who on pre-operative weight bearing radiographs had a disrupted Meary's line, and Group B (n=44) - those with a normal Meary's line on pre-operative weight bearing radiographs. RESULTS: Our results demonstrate statistically significant five times higher odds of recurrence in Group A compared to Group B with an odds ratio of 5.2 p=0.006 [95% CI 1.6-17]. On this basis we reject the Null hypothesis. CONCLUSION: In this paper, we link a disrupted Meary's line with risk of recurrence of deformity. We demonstrate that, when Scarf osteotomy is used to correct mild and moderate hallux valgus in the presence of a broken Meary's line, the odds of recurrence as compared to the same procedure being performed with an intact line are 5.2 times higher. Alternative corrective techniques such as the Lapidus procedure warrant further investigation for the treatment of mild and moderate hallux valgus in the presence of Meary's line disruption.

A randomised controlled trial of two analgesic techniques for paediatric tonsillectomy*.

Investigators from Bristol described a fentanyl- and diclofenac-based analgesic technique for tonsillectomy with low postoperative nausea and vomiting rates and low pain scores. This study compared the effectiveness of a modified Bristol technique with a codeine-based regimen with respect to PONV and analgesia. Sixty-five children, ASA 1-2, were randomly assigned to either the Bristol group (fentanyl 1-2 µg.kg(-1) and diclofenac 1-2 mg.kg(-1)) or codeine group (codeine 1.5 mg.kg(-1)). All children received paracetamol 15 mg.kg(-1) and dexamethasone 0.1 mg.kg(-1) . Postoperative nausea and vomiting and pain scores were recorded hourly, and fitness for discharge was assessed at 4 h. The overall incidence of postoperative nausea and vomiting was 21% with no difference between groups (Bristol group 8/30, codeine group 5/32, p = 0.29). Children in the Bristol group required analgesia earlier than those in the codeine group (p < 0.005), but maximum pain scores were not different (Bristol group median (IQR [range) 4.5 (3-5 [0-5]), codeine group 4.0 (2-5 [1-5]), p = 0.15). Twenty-three per cent of children were assessed as not fit for discharge at 4 h. The codeine-based regimen may have a small advantage over the Bristol regimen, but neither technique seems ideally suited for a day-case service without a longer period of observation. You can respond to this article at http://www.anaesthesiacorrespondence.com.

The size 1.5 laryngeal mask airway (LMA) in paediatric anaesthetic practice.

BACKGROUND: The recently introduced size 1.5 laryngeal mask airway (LMA) is specifically designed for use in children weighing 5-10 kg. METHODS: We prospectively evaluated its use in 68 patients, mean age 8.7 months, who were undergoing a variety of routine surgical procedures. RESULTS: The overall incidence of complications was high (42%) and was significantly more common in younger patients. Most of these related to poor positioning of the LMA, or airway problems such as obstruction or laryngospasm. Critical incidents occurred in seven patients, and all but one of these was related to the use of an LMA. CONCLUSIONS: The size 1.5 LMA is a useful addition to the range available, although the overall complication rate is considerable and is inversely related to the age of the child.

Nodal rhythm and bradycardia during inhalation induction with sevoflurane in infants: a comparison of incremental and high-concentration techniques.

We studied heart rate and rhythm changes during sevoflurane inhalation induction in 60 healthy, unpremedicated infants. Patients were allocated randomly to receive an incremental (2% sevoflurane, increased every four to six breaths by 2% increments, to 8%) or high-concentration induction technique (8% sevoflurane from the outset). The ECG was recorded for 330 s (30 s pre- and 300 s postinduction) using a mini-Holter device (Recollect Dual Channel, Hertford Medical) and later analysed by an independent observer. Twelve patients developed nodal rhythm (six in each group), but no other dysrhythmias were recorded. The onset of nodal rhythm was associated with bradycardia (< 80 bpm) in seven out of 12 cases, and occurred significantly earlier in the high-concentration group (median 123 (range 99-139) s versus 164 (127-138) s). Its duration was similar in both groups (62 (2-84) s versus 90 (20-167) s). These findings highlight the importance of using continuous ECG analysis when studying volatile anaesthetic agents in young children.

Remifentanil infusion for major abdominal surgery in small infants.

Neonates are known to be sensitive to volatile anaesthetic agents which may lead to prolonged recovery. In this study, a remifentanil infusion was used in conjunction with an infusion of epidural ropivacaine and isoflurane anaesthesia for major abdominal surgery in small infants. This led to a short recovery time for infants aged 7 days to 3 months but a prolonged recovery in those under the age of 7 days. Good perioperative analgesia was achieved.

A comparison of halothane and isoflurane for gaseous induction of anaesthesia in infants.

Sixty-four ASA 1 and 2 infants between the ages of 44 weeks postconceptual age and one year presenting for routine, elective surgery were randomly anaesthetized with either 3% halothane in oxygen (Group H) or 5% isoflurane in oxygen (Group I). Patients in Group I took a mean (SD) time of 70.1(13.6) s to loss of eyelash reflex and 80.0 (13.5) s to tolerating the face mask, compared with 80.2 (17.7) s and 93.4 (20.5) s in Group H (P=0.028 and 0.0072, respectively). There were no significant differences between the groups for preinduction or induction state, lowest oxygen saturation, or the incidence of airway related complications or interventions. This study demonstrates that 5% isoflurane in oxygen induces anaesthesia in infants more quickly than 3% halothane in oxygen, without any increase in the incidence or severity of airway-related complications.

A comparison of the nasal mask and the nasopharyngeal airway in paediatric chair dental anaesthesia.

This study compared the quality of anaesthesia and surgical access afforded by two techniques for the administration of anaesthesia during paediatric chair dental procedures. A total of 50 ASA 1 paediatric day case patients were randomly assigned to receive anaesthesia through either the traditional Goldman nasal mask or through a nasopharyngeal airway. Patients in the nasal mask group were judged to have significantly worse airway patency (p = 0.0001) and significantly more episodes of airway obstruction (14 vs. 4; p = 0.0032) than those in the nasopharyngeal airway group. Anaesthetic, surgical and oxygen saturation data did not differ significantly between the two groups. Operating conditions were universally graded as excellent in the nasopharyngeal airway group, while those in the nasal mask group were graded as excellent/good in only 79% of cases (p < 0.0001). These results suggest that better quality anaesthesia and operating conditions can be achieved by using a nasopharyngeal airway rather than the traditional nasal mask for the administration of anaesthesia to paediatric chair dental patients.

Cardiopulmonary complications during anaesthesia and surgery for severe thoracic lordoscoliosis.

A 15-year old girl underwent a posterior spinal fusion procedure for severe lordoscoliosis. On turning to the prone position acute posture-related upper airway obstruction occurred. During surgery, manipulation of the spine caused several episodes of loss of cardiac output. Retrospective assessment of the pre-operative chest X rays demonstrated approximation of the sternum and thoracic vertebrae, with evidence of tracheal narrowing at the level of the thoracic inlet. We feel that both complications were directly related to the severity of the lordoscoliosis and that careful pre-operative clinical, spirometric and X ray assessment should be undertaken in such patients.

Alfentanil in daycase anaesthesia. Assessment of a single dose on the quality of anaesthesia and recovery.

The effect of the addition of a single dose of 7 micrograms.kg-1 of alfentanil to a propofol/enflurane anaesthetic on the quality of anaesthesia and recovery was assessed. A total of 53 ASA grade 1 or 2 patients who underwent daycase dental surgery were allocated randomly to receive either alfentanil or saline. The study was blinded so that neither the anaesthetist nor the assessor was aware of which solution had been given. Patients in the alfentanil group took significantly longer to recommence spontaneous ventilation (p = 0.035). Both techniques provided good quality of anaesthesia. Postoperative morbidity was common (45% of patients), but there was no difference between the groups. The rate of recovery was similar in the two groups and no patient required hospital admission after the final assessment at 3 h. Drowsiness was only mild to moderate in both groups at 24 h. A single dose of alfentanil can be administered safely as part of a daycase anaesthetic without increasing morbidity, although there appears to be little advantage in doing so.

Continuous arteriovenous haemofiltration and respiratory function in multiple organ systems failure.

OBJECTIVE: To determine what change in respiratory function occurred following prolonged and efficient continuous arteriovenous haemofiltration (CAVH) in a group of patients with multiple organ systems failure (MOSF). DESIGN: A retrospective assessment using patient notes and ICU charts. SETTING: The Intensive Care Unit of a large University Teaching Hospital. PATIENTS: All ICU patients satisfying the following criteria: (i) Failure of more than one organ system; (ii) Treatment with CAVH; (iii) Removal of more than 10 l of ultrafiltrate per day; (iv) Continuous haemofiltration for at least 5 days. Thirteen patients satisfied these criteria and 14 episodes of CAVH were analyzed. MEASUREMENTS: All data were recorded from the patient notes and ICU charts apart from the A-aDO2 and PaO2/FiO2 (PF) ratio which were calculated from available values. A mean of 3.5 different organ systems failed during the period of stay. The mean daily ultrafiltrate volume obtained was 23.7 (SD 0.95) l and the mean duration of treatment 9.6 (SD 4.3) days. Significant improvements occurred in the values for the PF ratio and ventilatory modality (p < 0.05), and the FiO2 and A-aDO2 (p = 0.001). The mean PEEP value remained unchanged at 4.8 cmH2O. Ten of the 13 patients subsequently died (77% mortality). CONCLUSIONS: A significant improvement in respiratory function occurred in patients with MOSF who had undergone a prolonged period of intensive CAVH. Haemofiltration may therefore be a useful treatment for respiratory failure in this patient group. Unfortunately the overall mortality of the group remained high.