A prospective study of awareness and recall associated with general anaesthesia for caesarean section.

BACKGROUND: The obstetric population is considered at high risk of awareness and recall when undergoing general anaesthesia for caesarean section. In recent years the incidence may have been altered by developments in obstetric anaesthesia. METHODS: A prospective observational study of general anaesthesia for caesarean section was conducted during 2005 and 2006 in 13 maternity hospitals dealing with approximately 49,500 deliveries per annum in Australia and New Zealand. As a component of this study the frequency of recall of intraoperative events was examined using a structured postoperative interview on two occasions. RESULTS: There were 1095 general anaesthetics surveyed with 47% being performed for urgent fetal delivery. Thiopental was the most common induction agent (83%) with sevoflurane being used for maintenance in 63%. In 32% of cases a depth-of-anaesthesia monitor was used. In 763 cases (70%) there was least one postoperative interview enquiring into dreaming and awareness. There were two cases deemed to be consistent with awareness (incidence 0.26%, CI 0.03-0.9%, or 1 in 382) and three cases of possible awareness. CONCLUSION: Awareness with recall of intraoperative events remains a significant complication of obstetric general anaesthesia but was potentially avoidable in all cases detected in this study.

Difficult and failed intubation in obstetric anaesthesia: an observational study of airway management and complications associated with general anaesthesia for caesarean section.

BACKGROUND: Recent developments in anaesthesia and patient demographics have potentially changed the practice of obstetric general anaesthesia. There are few contemporary data on Australasian practice of general anaesthesia for caesarean section, especially relating to airway management, anaesthetic techniques and complications. METHODS: Using a standardised case record form, a prospective observational study was conducted during 2005-06 in 13 maternity hospitals dealing with approximately 49 500 deliveries per annum. Patient demographics, airway management, anaesthetic techniques and major complications were evaluated in those given general anaesthesia. RESULTS: Data were obtained from 1095 women receiving general anaesthesia for caesarean section, 47% of which were classified as category 1 and 18% as category 4. Tracheal intubation was planned in all cases with rapid-sequence induction used in 97%. A grade 3 or 4 laryngoscopic view was obtained in 3.6 and 0.6% of cases respectively, with 3.3% considered a difficult intubation. There were four failed intubations (0.4%, 95% CI 0.01-0.9%), of which three were subsequently managed using a laryngeal mask airway. Antacid prophylaxis was used in 94% of elective cases and 64% of emergencies. Regurgitation of gastric contents was noted in eight cases (0.7%, 95% CI 0.2-1.2%), with one confirmed case of aspiration (0.1%, 95% CI 0.002-0.5%). There were no cases of serious airway-related morbidity. CONCLUSIONS: General anaesthesia is most commonly used in emergency situations. Tracheal intubation after rapid-sequence induction remains the predominant approach to airway management in Australasia. The incidence of failed intubation is consistent with previous studies. Aspiration prophylaxis is not routinely used for emergency surgery.

Anticoagulation, bleeding and blood transfusion practices in Australasian cardiac surgical practice.

We surveyed contemporary Australasian cardiac surgical and anaesthetic practice, focusing on antiplatelet and antifibrinolytic therapies and blood transfusion practices. The cohort included 499 sequential adult cardiac surgical patients in 12 Australasian teaching hospitals. A total of 282 (57%) patients received red cell or component transfusion. The median (IQR) red cell transfusion threshold haemogloblin levels were 66 (61-73) g/l intraoperatively and 79 (74-85) g/l postoperatively. Many (40%) patients had aspirin within five days of surgery but this was not associated with blood loss or transfusion; 15% had clopidogrel within seven days of surgery. In all, 30 patients (6%) required surgical re-exploration for bleeding. Factors associated with transfusion and excessive bleeding include pre-existing renal impairment, preoperative clopidogrel therapy, and complex or emergency surgery. Despite frequent (67%) use of antifibrinolytic therapy, there was a marked variability in red cell transfusion rates between centres (range 17 to 79%, P < 0.001). This suggests opportunities for improvement in implementation of guidelines and effective blood-sparing interventions. Many patients presenting for surgery receive antiplatelet and/or antifibrinolytic therapy, yet the subsequent benefits and risks remain unclear.

An introductory guide to survey research in anaesthesia.

Surveys allow convenient and inexpensive research. Surveys include mail-out questionnaires, email questionnaires, telephone interviews, and personal interviews. Despite a widespread perception that surveys are easy to conduct, good surveys need rigorous design, implementation and analysis. This requires substantial planning, time and effort. The most important step in designing a survey is to clearly define the question(s) the survey aims to answer The target population, measured variables and types of associations being investigated should be specific and unambiguous. Investigators should concentrate on what they 'need to know' rather than what would be 'nice to know'. During development surveys should be piloted to identify problems. The main goal when implementing a survey is to maximize the response rate to avoid misleading results. Evidence-based strategies, including brief personalized surveys with stamped return envelopes, can be used to maximize the response rate. A poorly conducted survey can lead to misleading or invalid conclusions and may undermine participation in subsequent surveys by the target population.

Interventions for treating cholestasis in pregnancy.

BACKGROUND: Cholestasis of pregnancy has been linked to adverse maternal and fetal/neonatal outcomes. As the pathophysiology is unresolved, therapies have been empiric. OBJECTIVES: The objective of the review is to evaluate the effectiveness and safety of therapeutic interventions in women with a clinical diagnosis of cholestasis of pregnancy (CIP) SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group Trials Register, the Cochrane Controlled Trials Register, MEDLINE and PREMEDLINE, EMBASE, CINAHL and Current Contents. Date of last search: March 2001. SELECTION CRITERIA: Randomised controlled trials (RCTs) that compared an intervention to either a placebo or alternative treatment in women with a diagnosis of intrahepatic cholestasis of pregnancy. Trials published only as abstracts were excluded. DATA COLLECTION AND ANALYSIS: Reviewers assessed identified trials for 1) eligibility and 2) methodological quality. Attempts were made to contact authors for missing data. MAIN RESULTS: Nine RCTs involving 227 women were included but adequate data for appropriate comparisons in pruritus, bile acids or liver enzymes were not consistently reported. S-adenosylmethionine (SAMe) versus placebo (four trials, 82 women): only one trial showed significantly greater improvements in pruritus, bile salts and liver enzymes with SAMe. Ursodeoxycholic acid (UDCA) versus placebo (three trials, 56 women): in two trials a significant difference in pruritus relief was not detected. One trial observed greater reductions in bile salts and liver enzymes with UDCA. Preterm births were fewer with UDCA in one study while two studies reported no difference in fetal distress incidence. Guar gum versus placebo (one trial, 48 patients): no differences in pruritus, bile salts, or fetal/neonatal outcomes were observed. Activated charcoal versus no treatment (one trial, 20 patients): the reduction in bile salts was greater with charcoal, but no difference in pruritus relief: relative risk (RR) 9.0 95% confidence interval (CI) 0.6 - 148 or fetal/neonatal outcomes. UDCA versus SAMe (two trials, 36 patients): pruritus relief was better with UDCA in one study and with SAMe in the other. UDCA was better in reducing bile acids but not liver enzymes in one trial. UDCA + SAMe versus placebo, UDCA or SAMe (one study, eight patients/arm): UDCA + SAMe versus placebo or UDCA resulted in greater improvements in pruritus, bile salts and selected liver function assays; UDCA + SAMe versus SAMe resulted in greater improvements in bile salts and ALP only. No treatments were found to be unsafe. REVIEWER'S CONCLUSIONS: There is insufficient evidence to recommend guar gum, activated charcoal, SAMe and UDCA alone or in combination in treating women with CIP. Inconsistent and inadequate reporting of results precluded pooling the results of small studies.

Social-cognitive and perceived environment influences associated with physical activity in older Australians.

BACKGROUND: Regular physical activity in older adults can facilitate healthy aging, improve functional capacity, and prevent disease. However, factors associated with physical inactivity in older populations are poorly understood. This study attempts to identify social-cognitive and perceived environmental influences associated with physical activity participation in older populations. METHODS: In a randomly selected sample of 449 Australian adults age 60 and older, we assessed self-reported physical activity and a range of social-cognitive and perceived environmental factors. Respondents were classified as sufficiently active and inactive based on energy expenditure estimates (kcal/week) derived from self-reported physical activity. Two logistic regression models, with and without self-efficacy included, were conducted to identify modifiable independent predictors of physical activity. RESULTS: Significantly more males than females were physically active. Physical activity participation was related to age with a greater proportion of those age 65-69 being active than those age 60-64 or 70 or older. High self-efficacy, regular participation of friends and family, finding footpaths safe for walking, and access to local facilities were significantly associated with being active. CONCLUSION: Identifying predictors of physical activity in older populations, particularly social support, facility access, and neighbourhood safety, can inform the development of policy and intervention strategies to promote the health of older people.

Physical activity initiatives for male factory workers: gatekeepers' perceptions of potential motivators and barriers.

OBJECTIVE: Worksites have been argued to be a key setting for physical activity promotion, particularly for lower-paid, less-skilled workers. These occupational groups are at increased risk of cardiovascular disease. There is no strong evidence in support of the efficacy of worksite fitness and physical activity interventions. This study assessed potential motivators and barriers to worksite physical activity initiatives for less-skilled workers. METHOD: We conducted telephone interviews with 13 Victorian WorkCover insurance providers and 30 manufacturing industry worksite managers. The manufacturing industry was selected as it contains a substantial portion of workers from this high-risk occupational group. RESULTS: Most insurers incorporated physical activity elements into injury-prevention programs. Few worksite managers reported programs to encourage workers to be more active; they identified reduced premiums and lower-cost programs through insurers as possible motivators. Both groups identified workers' reluctance to participate in physical activity, lack of awareness of potential benefits and program cost as major barriers for worksite physical activity. Other barriers included potential adverse effects on productivity and increased injury risk. CONCLUSIONS: Broader occupational health and safety policies and joint initiatives between insurers and worksite managers may have the potential to provide more opportunities for workers to be more active. However, the barriers identified outweighed the perceived benefits. IMPLICATIONS: Without structural and regulatory changes or new incentives, the adoption of physical activity initiatives in Australian manufacturing-industry workplaces is unlikely.

Physical inactivity and other health risks among Australian males in less-skilled occupations.

Male workers in less-skilled occupations have higher rates of cardiovascular disease, compared with higher-skilled workers. A representative population sample of Australian male workers was used to compare physical activity levels and selected cardiovascular disease risk factors in less-skilled versus professional and skilled workers. Workers in the less-skilled occupational categories reported significantly more vigorous work and home-based activity than did those in the professional and skilled categories. In multivariate comparisons, cigarette smoking was the only factor that discriminated between the less-skilled versus the professional and skilled employees. Although worksites can potentially provide health-promoting physical activity options for higher-risk groups, our findings suggest that smoking and possibly overweight are risk factors that are more strongly present in less-skilled occupations.