[Spanish Society of Anaesthesia (SEDAR) guidelines for pre-anaesthesia checking procedures]. / Directrices de procedimientos de comprobación y validación («chequeo¼) previos a la anestesia de la Sociedad Española de Anestesiología.

We present this document as a guide to preparing a specific institutional pre-anaesthesia checklist, as recommended in the Helsinki declaration on patient safety in anaesthesiology. Also, the recently recommended WHO "safe surgery check-list" includes a check-list for anaesthesia. A working group was established in accordance with the charter of the Spanish Society of Anaesthesiology and Resuscitation (Sociedad Española de Anestesiología y Reanimación [SEDAR]). The new patient safety culture introduced into medicine, and the recommendations of European anaesthesia societies has led us to design and update protocols in order to improve results in this important part of our speciality. We have prepared these recommendations or guidelines using, as examples, updates of pre-anaesthesia check-lists by other American (ASA), British, or Canadian societies of anaesthesia. With that aim, we enlisted the help of anaesthesia ventilator experts and the participation and advice of experienced anaesthesiologists from all parts of Spain. After various corrections and modifications, the document was available at www.sedar.es, so that any anaesthesiologist could propose any correction, or give their opinion. Finally, these guidelines have been approved by the SEDAR Board of Directors, before it was sent for publication in this journal. The aims of this document are to provide: a guideline applicable to all anaesthesia machines, a descriptive pre-anaesthesia check-list that include everything necessary for the anaesthesia procedure, and a resumed check-list to be available in all the anaesthesia machines or other equivalent, but prepared for each institution, which should include anaesthetic equipment and drugs. So, in order to ensure the aims and requirements of the European Board of Anaesthesiology, the European Society of Anaesthesiology, and the WHO are met, each institution should have a protocol for checking equipment and drugs. These guidelines are applicable to any anaesthesia equipment, enabling every institution to develop their own checking protocols, adapted to their anaesthesia machines and their procedures. With the consent of the SEDAR, this group will collaborate with anaesthesia machines providers in order to develop specific checklists for each of their models that will be available at www.sedar.es.

A comparative study of paediatric oral premedication: midazolam, ketamine and low dose combination of midazolam and ketamine.

In a prospective randomised double-blind trial, 90 patients aged 1-7 years (ASA I) undergoing elective surgery less than 90 minutes duration were allocated into three separate groups to compare the safety and effectiveness of oral midazolam, ketamine, and low dose combination of midazolam and ketamine for premedication in paediatric patients. Group M received midazolam 0.5 mg kg(-1), group K received ketamine 6mg kg(-1) and group C received combination of ketamine 2.5 mg kg(-1) and midazolam 0.25 mg kg(-1) orally in 0.2ml kg(-1) of sugar syrup to make it palatable. The sedation score and emotional state on a four -point scale, ease of parental separation, cooperation for venepuncture, ease of mask acceptance and peri-operative cardiorespiratory status were evaluated. Peri-operative incidence of vomiting, nystagmus, emergence phenomenon and postanesthetic recovery time were noted. In the present study it was found that C group was more effective in sedating the children within 10 minutes and 20 minutes, whereas, the combination and midazolam groups are comparable in sedating the children at 30 minutes. Side-effects and recovery time were more in ketamine group. The recovery time was significantly less in group C. In conclusion oral combination of low dose ketamine and midazolam produced quick onset of satisfactory conscious sedation and more rapid recovery without significant side-effects, so that more children could be separated easily from their parents and provides smooth induction than the individual drug.

Respuesta a la carta al director "Comentarios al artículo comparación de la eficacia y seguridad de tres técnicas analgésicas (epidural, bloqueo femoral y bloqueo femoral-ciático) en el postoperatorio de prótesis total de rodilla" / No disponible

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Subcutaneous pre-anaesthetic medication with acepromazine-buprenorphine is effective as and less painful than the intramuscular route.

OBJECTIVES: To compare reaction to injection, sedation and propofol induction dose in dogs receiving acepromazine-buprenorphine pre-anaesthetic medication by the intramuscular or subcutaneous routes. METHODS: Fifty-two client owned dogs of American Society of Anesthesiologists grade I or II anaesthetised for diagnostic imaging. Dogs were randomly assigned to receive acepromazine 0.03 mg/kg and buprenorphine 0.02 mg/kg either intramuscular or subcutaneous. Reaction to injection was scored. Sedation was compared before and one hour after pre-anaesthetic medication. Propofol was administered in 1 mg/kg incremental injections until tracheal intubation was achieved. Total propofol dose was recorded. RESULTS: Reaction to injection was significantly greater (P=0.009) in the intramuscular group compared to the subcutaneous group. Sedation scores were not significantly different (P=0.523) between the intramuscular and the subcutaneous group. There was no statistically significant difference in propofol dose for induction (P=0.7). CLINICAL SIGNIFICANCE: Acepromazine-buprenorphine pre-anaesthetic medication provides a similar degree of sedation whether administered by the intramuscular or subcutaneous route. The intramuscular route is more painful compared to the subcutaneous route.

Thymectomy in a cat with myasthenia gravis: a case report focusing on perianaesthetic management.

An 8 years old male persian cat with a diagnosis of myasthenia gravis was scheduled for transternal thoracotomy. An anterior mediastinal mass, suspected to be a thymoma, had to be resected. Progressive paraparesis and reduced ocular reflexes and menace response were the main clinical features. At the preoperative examination the cat appeared free of significant myocardial or respiratory diseases. The possibility of compromised respiratory function due to muscle weakness was addressed by the choice of a balanced anesthesia protocol without the use of muscle-relaxants. Intravenous induction was followed by intubation, administration of isoflurane in oxygen and ventilatory support. Thorough cardiorespiratory monitoring was performed during anaesthesia. Epidural morphin was given to reduce the amount of inhalation agent required to maintain anaesthesia and supplemental intravenous analgesia was given. At the end of the surgery, intrapleural bupivacaine was administered to help controlling poststernotomy pain, while reducing the need for systemic analgesics. Although rapid returning of swallowing reflex and spontaneous breathing followed the disconnection from the anaesthetic circuit, the cat needed to breath oxygen enriched air to maintain a normal hemoglobin saturation in the early postoperative phase.

[Prevention of regurgitation and aspiration during emergency care of patients under general anesthesia].

This study has provided new data on methods for preventing regurgitation and aspiration under general anesthesia, by using parenteral and enteral antacids as premedication in urgent surgery. There is evidence that with 60-minute delay in starting surgery, omeprazole, 40 mg, has the highest alkalizing effect. Second- and third-generation H2-blockers have a persistent and good antacid effect. In emergencies, 30 ml of 3% sodium citrate solution show a rapid and effective antacid effect, which eliminates or drastically reduces the likelihood of aspiration pulmonitis even in case of regurgitation and aspiration of the gastric contents. Based on the findings, the authors have developed a patient preparation protocol for general anesthesia in urgent surgery as the standard for the practical use in general anesthesiology.

The effective management and administration of premedication.

Nurses play an essential role in preparing patients for surgical procedures, whether the operation is planned or an emergency. Part of this preparation may include administration of premedication. Government initiatives such as The NHS Plan (Department of Health, 2000) and Essence of Care (DoH, 2001) emphasise the need to get the fundamental aspects of nursing care right, and nurses have a professional responsibility to deliver evidence-based care (NMC, 2002). Additionally, the publication of Building a Safer NHS for Patients: Improving Medication Safety (DoH, 2004) aims to improve patient safety by reducing the incidence of drug errors. This article looks at why pharmacological intervention is no longer a routine preoperative preparation. It will discuss drugs that are used to aid anaesthesia and those used as prophylaxis to aid postoperative recovery, consider the ways in which premedication can now include psychological interventions, and look at the nurse's role.

Effect of BL-21 (Wei-Yu) acupoint stimulation on gastric motility following preanesthetic treatment in dogs.

In acupuncture practice of animals, preanesthetics sometimes are needed. The purpose of this study was to select the ideal chemical restraint at acupuncture for gastric motility. Nine healthy mixed breed dogs weighed 10-21 kg and aged 1-3 years old were used in this study. Two EMG surface electrodes were placed between the seromuscular and the mucosal layer of pylorus. Twenty minutes after feeding normal gastric motility was recorded for 60 minutes using physiograph (Narco-Biosystem). Then preanesthetic treated-gastric motility was observed for 30 minutes. Preanesthetics used were xylazine, diazepam, and acepromazine. Acupuncture needles were inserted to BL-21 (Wei-Yu) acupoint, and then changes of gastric motility were recorded for 60 minutes. The gastric motility following xylazine administration (1 mg/kg, IV) was markedly decreased. BL-21 (Wei-Yu) acupoints stimulation did not alter xylazine-induced depression of gastric motility. The diazepam (1 mg/kg IV) treated-gastric motility was increased mildly 20 minutes after drug administration. BL-21 (Wei-Yu) acupoint stimulation after diazepam administration enhanced gastric motility significantly. The gastric motility following acepromazine (0.3 mg/kg, IM) administration was not changed compared with normal gastric motility. Application of traditional acupuncture at BL-21 (Wei-Yu) significantly increased the gastric motility. Based on these results, acepromazine and diazepam could be acceptable chemical restraints for acupuncture therapy of gastric motility, but xylazine couldn't be.

Effect of BL-21 (Wei-Yu) acupoint stimulation on gastric motility following preanesthetic treatment in dogs

In acupuncture practice of animals, preanesthetics sometimes are needed. The purpose of this study was to select the ideal chemical restraint at acupuncture for gastric motility. Nine healthy mixed breed dogs weighed 10-21 kg and aged 1-3 years old were used in this study. Two EMG surface electrodes were placed between the seromuscular and the mucosal layer of pylorus. Twenty minutes after feeding normal gastric motility was recorded for 60 minutes using physiograph (Narco-Biosystem). Then preanesthetic treated-gastric motility was observed for 30 minutes. Preanesthetics used were xylazine, diazepam, and acepromazine. Acupuncture needles were inserted to BL-21 (Wei-Yu) acupoint, and then changes of gastric motility were recorded for 60 minutes. The gastric motility following xylazine administration (1 mg/kg, IV) was markedly decreased. BL-21 (Wei-Yu) acupoints stimulation did not alter xylazine-induced depression of gastric motility. The diazepam (1 mg/kg IV) treated-gastric motility was increased mildly 20 minutes after drug administration. BL-21 (Wei-Yu) acupoint stimulation after diazepam administration enhanced gastric motility significantly. The gastric motility following acepromazine (0.3 mg/kg, IM) administration was not changed compared with normal gastric motility. Application of traditional acupuncture at BL-21 (Wei-Yu) significantly increased the gastric motility. Based on these results, acepromazine and diazepam could be acceptable chemical restraints for acupuncture therapy of gastric motility, but xylazine couldn't be.

Overview of anesthesia for primary care physicians.

Primary care physicians are frequently asked to evaluate patients before elective surgery. Familiarity with anesthetic technique and physiologic processes can help primary care physicians identify risk factors for perioperative complications, optimize patient care, and enhance communication with surgeons and anesthesiologists. To this end, we review the physiologic processes accompanying tracheal intubation and general and regional anesthesia. There is no convincing evidence that regional anesthesia is safer than general anesthesia. In addition to replacing fluid losses from the surgical field and insensible losses, intraoperative fluid administration may attenuate the cardiovascular and renal effects of anesthesia. Therefore, recommendations to limit fluids should be made with caution and should be tempered with an understanding of intraoperative fluid requirements. An understanding of the physiologic processes of anesthesia, combined with preoperative risk stratification strategies, will enhance a primary care physician's ability to provide meaningful preoperative evaluations.

Detomidine-butorphanol-propofol for carotid artery translocation and castration or ovariectomy in goats.

OBJECTIVE: To determine the safety and efficacy of propofol, after detomidine-butorphanol premedication, for induction and anesthetic maintenance for carotid artery translocation and castration or ovariectomy in goats. STUDY DESIGN: Case series. ANIMALS: Nine 4-month-old Spanish goats (17.1 +/- 2.6 kg) were used to evaluate propofol anesthesia for carotid artery translocation and castration or ovariectomy. METHODS: Goats were premedicated with detomidine (10 micrograms/kg intramuscularly [i.m.]) and butorphanol (0.1 mg/kg i.m.) and induced with an initial bolus of propofol (3 to 4 mg/kg intravenously [i.v.]). If necessary for intubation, additional propofol was given in 5-mg (i.v.) increments. Propofol infusion (0.3 mg/kg/min i.v.) was used to maintain anesthesia, and oxygen was insufflated (5 L/min). The infusion rate was adjusted to maintain an acceptable anesthetic plane as determined by movement, muscle relaxation, ocular signs, response to surgery, and cardiopulmonary responses. Systolic (SAP), mean (MAP) and diastolic (DAP) arterial pressures, heart rate (HR), ECG, respiratory rate (RR), SpO2, and rectal temperature (T) were recorded every 5 minutes postinduction; arterial blood gas samples were collected every 15 minutes. Normally distributed data are represented as mean +/- SD; other data are medians (range). RESULTS: Propofol (4.3 +/- 0.9 mg/kg/min i.v.) produced smooth, rapid (15.2 +/- 6 sec) sternal recumbency. Propofol infusion (0.52 +/- 0.11 mg/kg/min i.v.) maintained anesthesia. Mean anesthesia time was 83 +/- 15 minutes. Muscle relaxation was good; eye signs indicated surgical anesthesia; two goats moved before surgery began; one goat moved twice during laparotomy. Means are reported over the course of the data collection period. Means during the anesthesia for pHa (arterial PH), PaCO2, PaO2, HCO3-, and BE (base excess) ranged from 7.233 +/- 0.067 to 7.319 +/- 0.026, 54.1 +/- 4.6 to 65.3 +/- 12.0 mm Hg, 133.1 +/- 45.4 to 183.8 +/- 75.1 mm Hg, 26.9 +/- 2.6 to 28.2 +/- 2.1 mEq/L, and -0.8 +/- 2.9 to 1.4 +/- 2.2 mEq/L. Means over time for MAP were 53 +/- 12 to 85 +/- 21 mm Hg. Mean HR varied over time from 81 +/- 6 to 91 +/- 11 beats/minute; mean RR, from 9 +/- 8 to 15 +/- 5 breaths/minute; SpO2 from 97 +/- 3% to 98 +/- 3%; mean T, from 36.0 +/- 0.6 degrees C to 39.1 +/- 0.7 degrees C. Over time, SpO2 and SaO2 did not change significantly; HR, RR, T, and PaCO2 decreased significantly; SAP, DAP, MAP, pHa, PaO2, and BE increased significantly. HCO3- concentrations increased significantly, peaking at 45 minutes. Recoveries were smooth and rapid; the time from the end of propofol infusion to extubation was 7.3 +/- 3 minutes, to sternal was 9.2 +/- 5 minutes, and to standing was 17.7 +/- 4 minutes. Median number of attempts to stand was two (range of one to four). Postoperative pain was mild to moderate. CONCLUSIONS: Detomidine-butorphanol-propofol provided good anesthesia for carotid artery translocation and neutering in goats. CLINICAL RELEVANCE: Detomidine-butorphanol-propofol anesthesia with oxygen insufflation may be safely used for surgical intervention in healthy goats.

Comparison of preparation and narcotic-sedative premedication in children undergoing surgery.

A psychological preparation program was developed for use prior to emergency surgery in children. The purpose of this study was to test the hypothesis that provision of specific information prior to an emergency operation would reduce the need for premedication to control anxiety and stress. Children were randomly assigned to either a verbally prepared group given narcotic-sedative premedication (control) or to a psychologically prepared group given only atropine as premedication. The child and parent rated their own anxiety on a Visual Analogue Scale (VAS). The children and parents were also assessed by a nurse preoperatively and postoperatively using a similar scale. The children's pulse, blood pressure, and cortisol were also measured. The results showed no significant difference between the psychologically prepared group and the premedicated group, suggesting that psychological preparation compares favorably with narcotic-sedative premedication.

Preoperative lumbar epidural morphine improves postoperative analgesia and ventilatory function after transsternal thymectomy in patients with myasthenia gravis.

OBJECTIVE: To test the hypothesis that preoperative lumbar epidural morphine improves postoperative pain control and ventilatory function after transsternal thymectomy in patients with myasthenia gravis. DESIGN: The study design was randomized, placebo-controlled, and double-blind. SETTING: After surgery, all patients were admitted to the Neuroscience Critical Care Unit for evaluation and treatment. PATIENTS: All patients with myasthenia gravis who presented to the hospital for thymectomy were asked to participate in the study. Twenty patients were randomized to either the placebo or epidural morphine groups. INTERVENTIONS: Patients received either epidural morphine (7 mg in 14 mL of sterile saline) or saline (14 mL) before induction of anesthesia. Supplemental iv opioids were administered intraoperatively, with need determined by the anesthesiologist. MAIN OUTCOME MEASURES: The main outcome measures were indicators of postoperative pain (e.g., Visual Analog Pain Score, requirement for supplemental opioid administration, respiratory rate) and ventilatory function (e.g., forced vital capacity, negative inspiratory pressure). RESULTS: Immediately after surgery, the Visual Analog Pain Score in the placebo group was twice as high as the score in the epidural morphine group (placebo 7.0 +/- 1.3; epidural morphine 3.5 +/- 1.2, p less than or equal to .05). During the first eight postoperative hours, the placebo group required more opioids (0.22 +/- 0.03 vs. 0.12 +/- 0.04 mg/kg morphine equivalents, p less than or equal to .06) than the epidural morphine group. Later, both groups received similar amounts of opioids. Patients receiving epidural morphine had better initial recovery of forced vital capacity (at 8 hrs: 55 +/- 6% [epidural morphine] vs. 34 +/- 5% [placebo] of preoperative value, p less than or equal to .05). Respiratory rate was lower for the first 12 postoperative hours in the epidural morphine group, without a difference in PaCO2. There was no difference between groups for the duration of postoperative intubation or ventilation. CONCLUSIONS: Preoperative lumbar epidural morphine facilitates postoperative analgesia and improves initial postoperative ventilatory performance.

Premedication: an audit.

A prospective study of routine premedication management was carried out at a large teaching hospital. Many patients received their premedication at times inappropriate for it to be effective. Several patients receiving regular medication had this suddenly stopped pre-operatively. Prolonged fasting occurred in both elective and emergency groups of patients. Benzodiazepines and opioids were prescribed most frequently and drying agents were used widely. Antacids, H2-blockers and agents to promote gastric emptying were used very little despite the potential of aspiration in many groups of patients. This audit of activity has revealed several areas of practice that can either be improved immediately or warrant detailed investigation.

Premedication for the pediatric patient: new and old drugs.

Over the last 15 years a rapid growth has occurred in the number of pediatric patients that are encountered in the operating room. A developing sophistication on the part of both children and parents, coupled with a rapidly expanding recognition of the need to minimize the amount of physical and psychological trauma that a child has to experience, has led to a growing use of premedication agents for children. A review of the premedication agents currently in use, their various routes of administration, as well as their associated benefits and risks, is presented.

Effect of premedication on arterial oxygen saturation in children with congenital heart disease.

The effect of a standardized intramuscular premedication (morphine, 0.1 mg/kg, scopolamine, 13 micrograms/kg, and secobarbital, 2.5 mg/kg) on the arterial oxygen saturation of hemoglobin was evaluated in 33 patients with congenital heart disease by use of the Nellcor pulse oximeter. Sixteen patients had noncyanotic congenital heart disease and 17 patients had cyanotic congenital heart disease. In the noncyanotic congenital heart disease group, pulse oximeter saturations decreased from 98.1% +/- 1.5% (mean +/- SD), before premedication, to 96.5% +/- 1.5% following premedication. Although this decrease was statistically significant (P less than 0.05), it was determined to not be clinically meaningful. In the patients with cyanotic congenital heart disease, oxygen saturation increased from 73.5% +/- 11.8 to 74.7% +/- 10.2 following premedication, but this change was not statistically significant. The effect of premedication on SaO2 was highly variable in patients with cyanotic heart disease; although the group mean appeared to increase, 6 of the 17 patients had decreases in saturation and the decrease exceeded 10% in saturation in 3 of them. Therefore, oxygen saturation should be monitored following premedication in patients with cyanotic heart disease and oxygen administered as needed.

Letter from California: conscious sedation permit.

In Britain matters of clinical judgement and practice rarely become the subject of political action and are usually not covered by legislation, but rather by 'guidelines' and well-meaning persuasion. In California, however, where the medical and dental professions are not trusted to put their own house in order, everything is covered by legislation and becomes the subject of intense political lobbying. The giving of general anaesthesia by dentists has been tightly governed since 1980 but the legislature has only just come to grips with the question of conscious sedation.

Estudio comparativo midazolam, tiopental y halotano como agentes inductores en anestesia pediatrica / Coparative study midazolam, thiopental and halotane as indution agents in pediatric anesthesia

El midazolam una nueva benzodiazepina de accion corta con propiedad ansiolitica, sedante, inductiva, miorrelajante, se compara con el tiopental sodico y halotano en induccion anestesica pediatrica. Se analizaron 45 pacientes repartidos en tres grupos ASA I-II de ambos sexos, entre 0 y 15 anos. El midazolam a dosis de 0.4 mgr. Kgr-1 no fue un buen inductor anestesico pediatrico. El tiempo de induccion es mas lento que con tiopental sodico pero con menor incidencia de efectos secundarios. No hubo diferencias hemodinamicas entre los grupos estudiados