Guidelines for day-case surgery 2019: Guidelines from the Association of Anaesthetists and the British Association of Day Surgery.

Guidelines are presented for the organisational and clinical management of anaesthesia for day-case surgery in adults and children. The advice presented is based on previously published recommendations, clinical studies and expert opinion.

Retrospective, cross-sectional review of delayed discharge after paediatric tracheostomy.

OBJECTIVES: To investigate reasons for prolonged hospitalisation of children with tracheostomies once they are medically fit for discharge. METHODS: Retrospective, cross-sectional study of 101 children undergoing tracheostomy between 2000 and 2010. RESULTS: Of the study patients, 44.6 per cent did not spend any time in hospital once medically fit, 19.8 per cent spent up to two weeks, 12.9 per cent spent between two weeks and one month, and 22.8 per cent spent over one month. Of the 56 cases with delayed discharge, the majority (22 children, 39.3 per cent) were delayed due to time taken obtaining parental competencies in tracheostomy management. A number of external factors were identified in these delays: parental substance abuse; single parenting; concerns about parenting ability, and English not being the parents' first language. CONCLUSION: Paediatric tracheostomy may lead to prolonged hospitalisation, but this is often influenced by social factors. Better use of dedicated specialist paediatric tracheostomy nurses may reduce unnecessary hospitalisation.

The use of ice-lollies for pain relief post-paediatric tonsillectomy. A single-blinded, randomised, controlled trial.

OBJECTIVES: To assess whether the use of ice-lollies after tonsillectomy with or without adenoidectomy in children aged 2-12 reduces pain in the immediate postoperative period. DESIGN: A prospective, randomised, single-blinded study design consisting of two groups with an intention to treat analysis. SETTING: Tertiary referral centre. PARTICIPANTS: Children aged 2-12 undergoing tonsillectomy with or without adenoidectomy. MAIN OUTCOME MEASURES: Pain assessment by nursing staff in the form of the validated modified Children's Hospital of Eastern Ontario Pain Scale at 15, 30 and 60 min and 4 h. RESULTS: Ninety-two patients were recruited into the study with 46 allocated to receive an ice-lolly and 41 not to receive an ice-lolly after exclusion of those with incomplete data. The two groups were comparable for number, age, sex and diagnosis. The pain score at every time interval was lower in the group that had received the ice-lolly compared with the group that had not. This was statistically significant at 30 (P = 0.008) and 60 min (P = 0.049). CONCLUSION: Our data suggest that ice-lollies are a cheap, effective and safe method of reducing postoperative pain up to one hour following paediatric tonsillectomy.

Tonsillectomy and adenoidectomy in children with sleep-related breathing disorders: consensus statement of a UK multidisciplinary working party.

During 2008, ENT-UK received a number of professional enquiries from colleagues about the management of children with upper airway obstruction and uncomplicated obstructive sleep apnoea (OSA). These children with sleep-related breathing disorders (SRBDs) are usually referred to paediatricians and ENT surgeons. In some district general hospitals, (DGHs) where paediatric intensive care (PICU) facilities to ventilate children were not available, paediatrician and anaesthetist colleagues were expressing concern about children with a clinical diagnosis of OSA having routine tonsillectomy, with or without adenoidectomy. As BAPO President, I was asked by the ENT-UK President, Professor Richard Ramsden, to investigate the issues and rapidly develop a working consensus statement to support safe but local treatment of these children. The Royal Colleges of Anaesthetists and Paediatrics and Child Health and the Association of Paediatric Anaesthetists nominated expert members from both secondary and tertiary care to contribute and develop a consensus statement based on the limited evidence base available. Our terms of reference were to produce a statement that was brief, with a limited number of references, to inform decision-making at the present time. With patient safety as the first priority, the working party wished to support practice that facilitated referral to a tertiary centre of those children who could be expected, on clinical assessment alone, potentially to require PICU facilities. In contrast, the majority of children who could be safely managed in a secondary care setting should be managed closer to home in a DGH. BAPO, ENT-UK, APA, RCS-CSF and RCoA have endorsed the consensus statement; the RCPCH has no mechanism for endorsing consensus statements, but the RCPCH Clinical Effectiveness Committee reviewed the statement, concluding it was a 'concise, accurate and helpful document'. The consensus statement is an interim working tool, based on level-five evidence. It is intended as the starting point to catalyze further development towards a fully structured, evidence-based guideline; to this end, feedback and comment are welcomed. This and the constructive feedback from APA and RCPCH will be incorporated into a future guideline proposal.

Obstructive sleep apnoea adenotonsillectomy in children: when to refer to a centre with a paediatric intensive care unit?

OBJECTIVE: To identify regional surgical referral patterns for adenotonsillectomy in children with obstructive sleep apnoea to our tertiary centre with paediatric intensive care unit facilities and to establish guidelines for elective paediatric intensive care unit referral and admission. METHODS: Two methods were used. A questionnaire was sent to ENT consultants in five surrounding hospitals with no in-house paediatric intensive care facilities. The second was a prospective observational study undertaken in our tertiary centre for a sub-set of patients undergoing obstructive sleep apnoea adenotonsillectomy between January 2002 and February 2005. These children were considered high risk as judged clinically by an ENT surgeon. Most had obstructive sleep apnoea and a co-morbidity. Otherwise healthy children with simple obstructive sleep apnoea were excluded. RESULTS: 15 out of 20 consultants responded to the questionnaire. Four referred on the grounds of clinical history, five referred based on pulse oximetry, nine referred syndromal children and four did not refer electively. Of the 49 high risk patients operated on, only 12 required paediatric intensive care admission with no emergency paediatric intensive care admissions. No otherwise healthy children with uncomplicated obstructive sleep apnoea symptoms required paediatric intensive care admission during the study period. CONCLUSION: There was no regional consensus regarding paediatric intensive care unit referral for obstructive sleep apnoea adenotonsillectomy. Clinical judgement without complex sleep studies by those experienced in this area was sufficient to detect complicated cases of obstructive sleep apnoea with co-morbidity requiring paediatric intensive care.

Aryepiglottoplasty for laryngomalacia: results and recommendations following a case series of 84.

OBJECTIVES: To examine one consultant's experience of aryepiglottoplasty at Leeds General Infirmary. To identify risk factors for post-operative complications. Comparing the outcomes of surgery with the published literature on aryepiglottoplasty. DESIGN: A retrospective case series of consecutive patients undergoing aryepiglottoplasty identified from theatre records. SETTING: The Otolaryngology Department, Leeds General Infirmary. This is part of Leeds Teaching Hospitals NHS Trust and is a tertiary referral centre with regional paediatric intensive care unit (PICU) and specialises in managing paediatric airway pathology. PARTICIPANTS: Ninety-one consecutive cases of aryepiglottoplasties, between 1997 and 2005. The medical records for 84 cases were reviewed. MAIN OUTCOME MEASURES: Unplanned admissions to PICU, complication rate, length of post-operative hospital stay, and successful resolution of symptoms amongst our patient group. RESULTS: The primary indication for surgery was found to be severe stridor. There was a low rate (3.6%) of unplanned admissions to the PICU. 7.1% of patients suffered a post-operative aspiration pneumonia. The majority (66.7%) of patients were able to return home after just one night in hospital. 11.9% of patients continued to have some stridor at follow-up. CONCLUSIONS: The majority of patients undergoing aryepiglottoplasty for isolated laryngomalacia can be monitored overnight on a paediatric surgical ward and return home the following day (85%). Furthermore, they should expect improvement of their stridor with a single procedure (90%). Aryepiglottoplasty at an experienced unit is a low-risk procedure with a high success rate.

Epidural analgesia and arterial reconstructive surgery to the leg: effects on fibrinolysis and platelet degranulation.

It has been suggested that the incidence of early graft occlusion after arterial reconstructive surgery to the leg may be decreased by epidural analgesia. This effect may be mediated by the suppression of the usual cortisol response to surgery, which results in increased circulating plasminogen activator inhibitor-1 with consequent adverse effects on fibrinolysis. To investigate this and other potential mechanisms, 30 patients undergoing arterial reconstructive surgery to the leg were randomized to receive either general anaesthesia or general anaesthesia plus epidural analgesia. Post-operative analgesia was provided by morphine infusion or epidural analgesia, respectively. Blood samples were collected at 0, 2, 4, 6, 12 and 24 h, and 2, 3 and 5 days and analysed for cortisol, plasminogen activator inhibitor-1 antigen, interleukin-6 and beta thromboglobulin. The incidence of graft-related and systemic complications was recorded for 30 days. Only one patient developed early graft occlusion that required embolectomy and eventually amputation. There were no significant changes from control values in either group of patients in circulating cortisol, plasminogen activator inhibitor-1 and beta thrombogobulin (a marker for platelet degranulation). Interleukin-6 values increased significantly in both groups after 4 h and remained elevated until day 3. There were no significant differences between the groups in any variable measured. We conclude that any effect of epidural analgesia on early graft patency is unlikely to be mediated by fibrinolysis or platetlet degranulation.

Kinetic resolution of alpha-acetoxy carboxylic acids with homochiral SuperQuats.

Preliminary investigations focused on the kinetic resolution of (+/-)-alpha-acetoxy mandelic carboxylic acid chloride with isopropyl SuperQuat and isopropyl Evans' homochiral auxiliaries. The addition of 2 equiv. of the acid chloride to the lithium salts of the auxiliaries (SuperQuat and Evans') at -100 degrees C in the THF afforded the corresponding N-acyl auxiliaries in high chemical yields (95% and 89%) and d.e.'s of 66% and 40%, respectively. Using the same mandelic acid chloride but incorporating SuperQuat auxiliaries derived from (S)-phenylglycine and (S)-phenylalanine yielded the corresponding N-acyl SuperQuats in 86% and 90% and d.e. 's of 66% and 30%, respectively. Substituting the phenyl group within the alpha-acetoxy mandelic acid chloride for a n-butyl, tert-butyl and cyclohexyl group changed the d.e. significantly when kinetically resolved with isopropyl SuperQuat. The yields were all similar, i.e., approximately 90% but the d.e.'s varied considerably, with values of 20%, 50%, and 82%, respectively. Attempted kinetic resolution of alpha-methoxyphenylacetyl chloride using the lithium salt of isopropyl SuperQuat revealed a diasteroselectivity of 45%, significantly lower than that obtained with the corresponding alpha-acetoxy carboxylic acid chlorides.

Effects of clonidine on the pituitary hormonal response to pelvic surgery.

We have investigated the effects of the central alpha 2 adrenoreceptor agonist, clonidine, given i.v. before induction of anaesthesia, on the haemodynamic and endocrine responses to pelvic surgery. Twenty patients were allocated randomly to receive either clonidine 3 micrograms kg-1 or an equivalent volume of 0.9% sodium chloride solution. Arterial pressure, heart rate, and circulating concentrations of cortisol, growth hormone, glucose and lactate were measured during and in the 24 h after total abdominal hysterectomy. Arterial pressure and heart rate decreased significantly in the clonidine group during surgery and in the early postoperative period. There were no differences between groups in serum cortisol or growth hormone concentrations throughout the study. Despite an effective decrease in the cardiovascular response to surgery, clonidine 3 micrograms kg-1 i.v. had no significant effect on pituitary hormone secretion.

The effect of high concentrations of inspired oxygen on middle cerebral artery blood velocity measured by transcranial Doppler.

The effects of high concentrations of inspired oxygen on cerebrovascular haemodynamics were studied in healthy human volunteers using transcranial Doppler measurements of middle cerebral artery blood velocity. If the end-tidal carbon dioxide level was kept constant, the measured blood velocity and the calculated Pulsatility Index showed no significant change when subjects were breathing 21, 40, 75 or 100% oxygen.