Should pipeline nitrous oxide be discontinued in secondary care: A cost-benefit analysis.

Background: Nitrous oxide (N2O) has seen a marked decline in its usage in recent years due to its adverse clinical effects. We audited the practice in our department to evaluate the N2O consumption and cost-effectiveness of its supply. Methodology: Electronic anesthesia records of all patients anesthetized in our main operating rooms in a typical month were reviewed retrospectively, and utilization of N2O was noted in addition to the patient demographics, surgical procedure, and specialty. Results: A total of 950 patients were anesthetized, and 3.1% received N2O. The annual usage was estimated to be 72,871 liters, with a leakage of 3,883,105 liters to the environment, posing a safety hazard and wasting 149,612.50 SAR. Conclusion: Notable costs and environmental benefits may be achieved by substituting a piped supply of N2O with portable E-cylinders on demand in operating rooms for rational use.

Tonsillar Trauma During Video Laryngoscopy: A Case Report.

Potentially difficult airways warrant the use of airway adjuncts, which, if not used with caution, can cause trauma to the oral cavity. Although most operators are familiar with modern airway adjuncts, as they are not routinely used, adverse events can occur. Since its introduction, a video laryngoscope (VL) has been lauded as a necessary instrument for airway management in and out of the operating room. This case report highlights right tonsillar tissue perforation with a GlideScope® VL (Verathon Incorporated, Bothell, Washington, USA), requiring primary closure by an otolaryngologist.

Anesthesia management of living donor liver transplantation in a patient with scimitar syndrome.

Scimitar syndrome is a rare congenital anomaly with a hallmark of an abnormal drainage of pulmonary veins into inferior vena cava instead of the left atrium; this creates a curvilinear radiological pattern resembling a sword (scimitar) on a chest radiograph, thus attracting the name. This case report highlights the challenges during liver transplantation, and perioperative anesthetic management of a patient with an uncorrected Scimitar Syndrome.

Magnetic resonance imaging of cerebrospinal fluid spread in the epidural space and postdural puncture headache in obstetrics: A proof-of-concept study.

BACKGROUND: Currently, performing an epidural blood patch (EBP) for postdural puncture headache (PDPH) remains a subjective clinical decision. An evidence-based protocol may be of value in identifying women at high risk of developing a severe PDPH. OBJECTIVE: To investigate a potential correlation between the extent of CSF spread in the epidural space, as noted on Magnetic Resonance Imaging (MRI), and the likelihood of development of severe PDPH in obstetric patients. DESIGN: A prospective double-blind quasi-observational study. SETTING: Eight tertiary obstetric units, from NHS hospitals. PATIENTS: Parturients with accidental dural puncture (ADP) underwent T1 and T2-weighted MRI scans of the brain and lumbar spine within 48 h after delivery. All women were followed up, daily, for 1 week. MAIN OUTCOME MEASURES: For each woman, a PDPH severity score was calculated using a four-point Verbal Reporting Scale (none = 0, mild = 1, moderate = 2, severe = 3), with additional points awarded for visual, auditory and emetic symptoms. MRIs were reported by a neuroradiologist, blind to the patient details, using a predefined MRI score. RESULTS: Twenty-two parturients were recruited; 86% (n=19) developed PDPH and 10 of these (53%) required an EBP. The median (range) time for the onset of PDPH was 24 (4 to 126) hours. The median (range) cumulative PDPH severity score was 10 (0 to 21), whereas, the median (range) MRI score was 2.5 (0 to 12). Spearman (rs) analysis identified a significant positive correlation (rs = 0.46; P = 0.024) between cumulative PDPH severity and MRI scores. Of all the radiological features identified in an MRI (lumbar dural shift, caudal brain displacement, epidural or intrathecal blood), the presence of intrathecal blood was most strongly correlated with PDPH severity (P = 0.043). CONCLUSION: Following an ADP, the extent of CSF spread in the epidural space correlates with the severity of subsequent PDPH. CLINICAL TRIAL NUMBER AND REGISTRY URL: ISRCTN14959004, https://www.isrctn.com/.

Cost drain of anesthesia emergency drugs in a quaternary care hospital.

BACKGROUND: Anesthesiologists draw up a selection of drugs for emergency use at the start of their list; unused drugs are discarded at the end of the list, to prevent contamination and spread of infections. We audited the practice in our department to evaluate the scale and cost impact of anesthesia emergency drugs wastage. SUBJECTS AND METHODS: A questionnaire was randomly given to anesthesiologists in our department, working in some of the operating rooms in our main floor, every morning over 7 working days. Completed forms were collected at the end of respective lists. RESULTS: A total of 93 completed forms were returned. Ephedrine (96%) and phenyepherine (95%) were the most frequently drawn drugs; atropine (96%) and suxamthonium (92%) were the most frequently discarded drugs. Phenylepherine was the single most expensive item wasted, representing 160% of the cost of all other drugs wasted together, and the price of discarded ephedrine and phenylephrine together represented 3/4th of the total wastage. Some practices carried room for rationalization, such as drawing up of atropine and glycopyrolate simultaneously, of both the vasopressors in patients unsuspected for developing significant hypotension, or of suxamethonium in a patient planned to be intubated and postoperative ventilation. CONCLUSION: Significant savings may be realized through switching to prefilled syringes, making protocols available for rational use of emergency drugs, and safe pooling of expensive drugs between adjacent operating rooms, in an anesthesia department.

Ultrasound-guided continuous spinal anesthesia for cesarean section in a parturient with scoliosis corrected with Harrington's rod surgery.

With rapid improvement in healthcare in Saudi Arabia, increasing number of women with surgically corrected kyphoscoliosis are likely to present for cesarean section (CS) or vaginal delivery requiring anesthesia or analgesia. Despite the surgical correction, these patients have poor cardiopulmonary reserves which increase the risks associated with general anesthesia. Whereas altered vertebral anatomy from previous surgery and the presence of metal work in spine make performing of regional anesthesia (RA) difficult and unpredictable, we report anesthetic management of such a patient who underwent CS using continuous spinal anesthesia technique. Challenges of placement of a spinal catheter in such a patient are discussed, and use of ultrasonography to circumnavigate these challenges is described. We propose that ultrasound can prove extremely valuable in performing of RA in patients with surgically corrected kyphoscoliosis. We could not find a similar case report from Saudi Arabia in the published literature.

Above Elbow Amputation Under Brachial Plexus Block at Supraclavicular and Interscalene Levels.

INTRODUCTION: The brachial plexus block is a commonly performed procedure in the anesthetic practice today. It is performed for analgesia as well as anesthesia for upper limb procedures. It has been used for amputation and replantation surgeries of the upper limb. CASE PRESENTATION: We present the case of a 68-year-old gentleman who had brachial plexus block at supraclavicular and interscalene levels as the sole anesthetic for undergoing above elbow amputation. He was deemed to be very high risk for a general anesthetic as he suffered from severe chronic obstructive pulmonary disease (COPD) and a very poor exercise tolerance (NYHA Class III). The supraclavicular brachial plexus block was supplemented with an interscalene brachial plexus block due to inadequate surgical anesthesia encountered with the former. The procedure was successfully completed under regional anesthesia. CONCLUSIONS: The brachial plexus block can be performed at different levels in the same patient to achieve desired results, while employing sound anatomical knowledge and adhering to the maximum safe dose limit of the local anesthetic.

The safe and responsible disposal of unused controlled drugs.

There are well-defined legal requirements for the safe storage, handling and disposal of controlled drugs (CDs): The Misuse of Drugs Act 1971, and Safer Management of Controlled Drugs (Department of Health, 2007). Clinical staff involved in the prescription and administration of CDs to patients are responsible and accountable for the appropriate disposal of these drugs because of the risk of substance abuse. A review of current practice, as followed by staff involved in the use and disposal of CDs, has been evaluated in a multi-centre audit. This audit showed that a wide variation in attitude towards disposal of CDs exists among medical and non-medical staff, and that the sample hospitals are falling short of meeting proposed standards.