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In this article, we describe an extension of general anaesthesia - beyond facilitating surgery - to the relief of suffering during dying. Some refractory symptoms at the end of life (pain, delirium, distress, dyspnoea) might be managed by analgesia, but in high doses, adverse effects (e.g. respiratory depression) can hasten death. Sedation may be needed for agitation or distress and can be administered as continuous deep sedation (also referred to as terminal or palliative sedation) generally using benzodiazepines. However, for some patients these interventions are not enough, and others may express a clear desire to be completely unconscious as they die. We summarise the historical background of an established practice that we refer to as 'general anaesthesia in end-of-life care'. We discuss its contexts and some ethical and legal issues that it raises, arguing that these are largely similar issues to those already raised by continuous deep sedation. To be a valid option, general anaesthesia in end-of-life care will require a clear multidisciplinary framework and consensus practice guidelines. We see these as an impending development for which the specialty should prepare. General anaesthesia in end-of-life care raises an important debate about the possible role of anaesthesia in the relief of suffering beyond the context of surgical/diagnostic interventions., (© 2021 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

Background: Regional and general anesthesia were widely available in the United States in the late 1960s. The risk of permanent neurological sequelae resulting from spinal anesthesia had largely been dismissed. Although many academic departments of anesthesiology had gained independent status, a significant number operated as divisions within the department of surgery. We present a case report from Peter Bent Brigham Hospital to illustrate the state of anesthetic techniques in use during the late 1960s, and the power dynamics vis-à-vis physician anesthesiologists and surgeons., Sources: Hospital records and interviews with individuals familiar with the case., Findings: An otherwise healthy patient underwent inguinal hernia repair. The resident anesthesiologist conducted a preoperative assessment the evening prior to surgery with the patient consenting to the spinal anesthesia, a plan agreeable to the faculty anesthesiologist. The attending surgeon was one of the most prominent surgeons in America and the chairman of their department. He disapproved of the planned anesthetic. Subsequent modifications to the anesthetic plans are discussed, as is the fallout from those actions., Conclusion: Spinal anesthesia remained a popular anesthetic option during the late 1960s. General anesthesia with ether, halothane, and other agents an alternative. This case highlights various aspects of perioperative management during a period when many American academic departments of anesthesiology existed as divisions within the department of surgery. It also touches upon the careers of two prominent American physicians., (Copyright © 2020 Anesthesia History Association. Published by Elsevier Inc. All rights reserved.)

Whereas only a few years ago the only expectation of skilful anesthesia was an undisturbed execution of surgical procedures, today this has changed to a perioperative responsibility in which all physicians involved in the treatment process try to optimize the existing circumstances and risks of the patient before, during and after surgery. Thus, the tasks for the anesthesiologist have been mainly extended to a rapid recovery strategy with as few side effects as possible, such as nausea and vomiting or postoperative cognitive deficits (POCD). The establishment of evident structures and the introduction of suitable perioperative procedures with the goal of maintaining homeostasis, adequate opioid-sparing pain treatment and rapid postoperative convalescence determine the anesthesiological fast-track concept.

The effect of anaesthetic drugs on the cortex are commonly estimated from the electroencephalogram (EEG) by quantitative EEG monitors such as the Bispectral Index (BIS). These monitors use ratios of high to low frequency power which assumes that each neurological process contributes a unique frequency pattern. However, recent research of the effect of deep brain stimulation on EEG beta oscillations suggests that wave shape, a non-sinusoidal feature that is only measurable in the time-domain, can change the frequency 'signature' of a neurological rhythmical process by the inclusion or removal of harmonic frequencies. If wave shape variations are present in the EEG of anaesthetised patients, then quantitative EEG monitors likely overestimate the anaesthetic drug effect. The purpose of this paper is to investigate alpha-wave shape in the EEG of anaesthetised patients and demonstrate the effect of wave shape on the frequency ratios that are commonly utilised in the BIS quantitative EEG monitor. EEG data, demographic information, and surgery details were collected prospectively from 305 patients undergoing a general anaesthetic for elective surgery. Alpha-wave shape was categorised by triangularity of the EEG extrema, a measure of how peaked (towards a sawtooth wave) or flat (towards a square wave) the extremum was. The alpha-wave was then artificially modified to either a sawtooth wave or square wave, and BetaRatio and PowerFastSlow metrics calculated. Age was found to be the only significant predictor of alpha wave triangularity. The artificially modified square-alpha waves increased the power in the frequency spectrum at 26 Hz by 1-5 dB, and increased the BetaRatio by 0.7. The alpha-wave of anaesthetised patients contains non-sinusoidal components which likely impact depth of anaesthesia calculations.

The obesity epidemic is swelling to epic proportions. Obese patients often suffer from a combination of hypertension, dyslipidemia, and type 2 diabetes mellitus (T2DM), also known as the "metabolic syndrome." The metabolic syndrome is an independent predictor of cardiac dysfunction and cardiovascular disease and a risk factor for perioperative morbidity and mortality. In this paper, we discuss the perioperative risk factors and the need for advanced care of obese patients needing general anesthesia for (bariatric) surgical procedures based on physiological principles.

Purpose of Review: Total patient care is of extreme importance during the administration of anesthesia. Proper care of the eye is necessary during all anesthetic administrations, especially during the administration of general anesthesia or monitored anesthesia care. By paying attention to details, the likelihood of an occurrence of eye injuries is reduced., Recent Findings: Though perioperative eye injuries are rare during general anesthesia, they do account for 2-3% of claims against anesthesiologists. Ocular injuries may occur during general anesthesia even when tape has been utilized for eye closure. Corneal abrasions are the most common injuries that have been attributed to direct trauma to the eye, exposure keratopathy, or chemical injury. Using a hydrogel patch during general anesthesia is also associated with more frequent corneal injury than previously thought. Prevention of anesthesia-related eye injuries assumes a high priority since the eye is one of the major sense organs of the body. The eye can be damaged during anesthesia for both non-ophthalmic and ophthalmic surgeries.

This review aims to give an overview of the current state of monitoring depth of anaesthesia and detecting the moment of loss of consciousness, from the first clinical signs involved in anaesthesia to the latest technologies used in this area. Such techniques are extremely important for the development of automatic systems for anaesthesia control, including preventing intraoperative awareness episodes and overdoses. A search in the databases Pubmed and IEEE Xplore was performed using terms such anaesthetic monitoring, depth of anaesthesia, loss of consciousness, as well as anaesthesia indexes, namely BIS. Despite the several methods capable of monitoring the hypnotic state of anaesthesia, there is still no methodology to accurate detect the moment of loss of consciousness during induction of general anaesthesia., (Copyright © 2018 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Both under-dosage and over-dosage of general anaesthetics can harm frail patients. We hypothesised that computer-assisted anaesthesia using pharmacokinetic/pharmacodynamic models guided by SmartPilot® View (SPV) software could optimise depth of anaesthesia and improve outcomes in patients undergoing hip fracture surgery., Methods: This prospective, randomized, single-centre, blinded trial included patients undergoing hip fracture surgery under general anaesthesia. In the intervention group, anaesthesia was guided using SPV with predefined targets. In the control group, anaesthesia was delivered by usual practice using the same agents (propofol, sufentanil and desflurane). The primary endpoint was the time spent in the "appropriate anaesthesia zone" defined as bispectral index (BIS) (blinded to the anaesthetist during surgery) of 45-60 and systolic arterial pressure of 80-140 mm Hg. Postoperative complications were recorded for one month in a blinded manner., Results: Of 100 subjects randomised, 97 were analysed (n=47 in SPV and 50 in control group). Anaesthetic drug consumption was reduced in the SPV group (for propofol and desflurane). Intraoperative duration of low BIS (<45) was similar, but cumulative time of low systolic arterial pressure (<80 mm Hg) was significantly shorter in the SPV group (median (Q1-Q3); 3 (0-40) vs 5 (0-116) min, P=0.013). SPV subjects experienced fewer moderate or major postoperative complications at 30-days (8 (17)% vs 18 (36)%, P=0.035) and shorter length of hospitalisation (8 (2-20) vs 8 (2-60) days, P=0.017)., Conclusions: SmartPilot® View-guided anaesthesia reduces intraoperative hypotension duration, occurrence of postoperative complications and length of stay in hip fracture surgery patients., Clinical Trial Registration: NCT 02556658., (© The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

With the motivation of providing safety for a patient under anesthesia, this paper suggests conditions for evaluating the correctness of an available user interface for systems under shared control based on observability and predictability requirements. Situation awareness is necessary for the user to make correct decisions about the inputs. In this article, we develop a technique to investigate the conditions under which an anesthetists can attain situation awareness about a limited but important aspect of anesthesia, namely depth of hypnosis (DOH). Furthermore, we consider that, in practice, to attain situation awareness, the estimation of the task states does not necessarily need to be precise but can be bounded within certain margins. Hence, attaining situation awareness about DOH is modeled as a bounded-error delayed functional observation/prediction. Unless such an observer/predictor exists for a system with a given user-interface, the safety of the operation may be compromised. The suggested technique proves that, in order to provide safety for the patient under anesthesia, it is necessary for the anesthetist to have access to the predictive information from a clinical decision support system.

The number of children with caries requiring general anesthesia to achieve comprehensive dental care and the demand for dentist anesthesiologists to provide ambulatory anesthesia for these patients is increasing. No current published studies examine the safety and outcomes of ambulatory anesthesia performed by dentist anesthesiologists for dental procedures in pediatric patients, and there is no national requirement for reporting outcomes of these procedures. In 2010, the Society for Ambulatory Anesthesia Clinical Outcomes Registry was developed. This Web-based database allows providers of ambulatory anesthesia to track patient demographics and various outcomes of procedures. Our study is a secondary analysis of data collected in the registry over a 4-year period, 2010-2014. Of the 7041 cases reviewed, no cases resulted in serious complications, including death, anaphylaxis, aspiration, cardiovascular adverse events, or neurologic adverse events. Of the 7041 cases reviewed, 196 (3.0%) resulted in a predischarge or postdischarge adverse event. The predischarge adverse event occurring with the highest frequency was laryngospasm, occurring in 35 cases (0.50%). The postdischarge adverse event occurring with the highest frequency was nausea, reported by 99 patients (5.0%). This study provides strong clinical outcomes data to support the safety of office-based anesthesia as performed by dentist anesthesiologists in the treatment of pediatric dental patients.

Current practice of sedation and anesthesia for patients undergoing pediatric and congenital cardiac catheterization laboratory (PCCCL) procedures is known to vary among institutions, a multi-society expert panel with representatives from the Congenital Heart Disease Council of the Society for Cardiovascular Angiography and Interventions, the Society for Pediatric Anesthesia and the Congenital Cardiac Anesthesia Society was convened to evaluate the types of sedation and personnel necessary for procedures performed in the PCCCL. The goal of this panel was to provide practitioners and institutions performing these procedures with guidance consistent with national standards and to provide clinicians and institutions with consensus-based recommendations and the supporting references to encourage their application in quality improvement programs. Recommendations can neither encompass all clinical circumstances nor replace the judgment of individual clinicians in the management of each patient. The science of medicine is rooted in evidence, and the art of medicine is based on the application of this evidence to the individual patient. This expert consensus statement has adhered to these principles for optimal management of patients requiring sedation and anesthesia. What follows are recommendations for patient monitoring in the PCCCL regardless of whether minimal or no sedation is being used or general anesthesia is being provided by an anesthesiologist.

Background: Airway assessment and management are cornerstones of anaesthesia, yet airway complications remain an important source of morbidity., Objective: We performed a before-and-after evaluation of a collaborative intervention to improve adherence to airway assessment and management guidelines in patients scheduled for surgery under general anaesthesia., Design: A prospective, multicentre before-and-after evaluation of a collaborative intervention., Setting: Collaborative intervention to improve adherence to airway assessment and management guidelines in patients scheduled for surgery under general anaesthesia. Data were collected on 21 consecutive days before and after the intervention., Participants: Anaesthetists with staff or residency positions at 22 hospitals. Patients aged 18 years or older undergoing nonemergency surgery were recruited., Intervention: Establishing a learning network that included local leaders, meetings to share experiences and knowledge, interactive sessions and provision of printed materials on airway assessment and management. Clinical airway management for general anaesthesia was provided by the anaesthetists participating in the study., Main Outcome Measures: Outcomes were the completion of airway assessment at the preanaesthetic visit, rates of unanticipated difficult airway, algorithm adherence and related airway complications., Results: The study included 3753 patients (1947 preintervention and 1806 postintervention). The percentage of patients with a complete airway assessment increased from 25.1% preintervention to 48.4% postintervention (P <0.001). The incidences of unanticipated difficult airway were 4.1% before the intervention and 3% after it (P = 0.433). Rates of adherence to the algorithms for anticipated and unanticipated difficult airway management were similar in the two periods. The incidences of related adverse events were also similar., Conclusion: The collaborative intervention was effective in improving airway assessment but not in changing difficult airway management practices.

Anesthesiologists play a critical role in facilitating a positive perioperative experience and early recovery for patients. Depending on the kind of procedure or surgery, a wide variety of agents and techniques are currently available to anesthesiologists to administer safe and efficacious anesthesia. Notably, the fast-track or ambulatory surgery environment requires the use of agents that enable rapid induction, maintenance, and emergence combined with minimal adverse effects. Short-acting opioids demonstrate a safe and rapid onset/offset of effect; that short effect is both predictable and precise. It also ensures easier titration and reduced or rapidly reversed side effects. Due to their distinct pharmacokinetic and pharmacodynamic properties, and, in one case, rapid extra-hepatic clearance of remifentanil, these agents have several applications in general anesthesia., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Monitoring is crucial to assure safety during difficult airway management. Several reports have indicated that the most of the adverse outcomes associated with difficult airway management could have been avoided with the use of necessary monitors, such as a pulse oximeter and a capnometer. Nevertheless, airway complications continue to be major problems during anesthesia, in particular, in patients with difficult airways. In this brief review, I stress the role of monitoring in detecting inadvertent esophageal intubation, during sedation for awake tracheal intubation, during general anesthesia, and during emergence from anesthesia, in patients with difficult airways.

Background: Canadian physicians are faced with an increasing frequency of drug shortages. We hypothesized that drug shortages have a clinical impact on anesthesia care in Canada., Methods: We conducted a self-administered survey of anesthesiologists in Canada using the membership list of the Canadian Anesthesiologists' Society. For survey development, we identified key domains, including types of drug shortages, impact on the ability of anesthesia practitioners to provide general anesthesia care, and impact on patient outcomes. We undertook assessments of face validity, clinical sensibility, and content validity. Respondents were surveyed from January-April 2012., Results: Completed valid questionnaires were submitted by 1,187 respondents (61.4%), and 779 (65.7%) of respondents described a shortage of one or more anesthesia or critical care drugs. Changes in anesthesia practice resulting from drug shortages were common; 586 (49%) respondents thought they had given an inferior anesthetic, and 361 (30%) reported administering medications with which they were unfamiliar. Respondents also reported that drug shortages were, at times, responsible for changes in the conduct of patient care, with 28 (2.4%) noting cancellation or postponement of surgery and 92 (7.8%) witnessing a drug error. One hundred sixty-five (13.9%) respondents regarded drug shortages as having prolonged recovery from anesthesia, and 124 (10.5%) viewed drug shortages as resulting in an increased number of postoperative complications, such as postoperative nausea and vomiting., Interpretation: Drug shortages are common in anesthetic practice in Canada. This state of affairs may have a negative effect on how anesthesiologists practice anesthesia and may be associated with adverse patient outcomes.

As part of the 5th National Audit Project of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland concerning accidental awareness during general anaesthesia, we issued a questionnaire to every consultant and staff and associate specialist anaesthetist in the UK. The survey was designed to ascertain the number of new cases of accidental awareness that became known to them, for patients under their direct or supervised care, for a calendar year, and also to estimate how many cases they had experienced during their careers. The survey also asked about use of monitoring designed to measure the depth of anaesthesia. All local co-ordinators responsible for each of 329 hospitals (organised into 265 'centres') in the UK responded, as did 7125 anaesthetists (82%). There were 153 new cases of accidental awareness notified to respondents in 2011, an estimated incidence of 1:15 414, lower than the 1-2:1000 previously reported in prospective clinical trials. Almost half the cases (72, 47%) occurred at or after induction of anaesthesia but before surgery, with 46 (30%) occurring during surgery and 35 (23%) after surgery before full recovery. Awareness during surgery appeared to lead more frequently to pain or distress than at induction and emergence (62% vs 28% and 23%, respectively). Depth of anaesthesia monitors were available in 164 centres (62%), but routinely used by only 132 (1.8%) of anaesthetists. The disparity between the incidence of awareness as notified to anaesthetists and that reported in trials warrants further examination and explanation., (© 2013 The Authors Anaesthesia © 2013 The Association of Anaesthetists of Great Britain and Ireland.)

Context: A comparison of the efficacy and safety of the Laryngeal Mask Airway (LMA) Supreme (LMAS) versus the LMA Proseal (LMAP) in elective laparoscopic cholecystectomy., Objectives: To compare the LMAS with LMAP in terms of ventilatory efficacy, airway leak pressure (airway protection), ease-of-use and complications., Design: Prospective, single-blind, randomised, controlled study., Setting: The Hospital del Sureste and Hospital Ramon y Cajal, Madrid, between May 2009 and March 2011. The Hospital del Sureste is a secondary hospital and Hospital Ramon y Cajal is a tertiary hospital., Patients: Patients undergoing elective laparoscopic cholecystectomy were studied following informed consent. Inclusion criteria were American Society of Anesthesiologists physical status I to III and age 18 or more. Exclusion criteria were BMI more than 40 kg m, symptomatic hiatus hernia or severe gastro-oesophageal reflux., Interventions: Anaesthesiologists experienced in the use of LMAP and LMAS participated in the trial. One hundred twenty-two patients were randomly allocated to LMAS or LMAP., Main Outcome Measures: Our primary outcome measure was the oropharyngeal leak pressure (OLP). Secondary outcomes were the time and number of attempts for insertion, ease of insertion of the drain tube, adequacy of ventilation and the incidence of complication. Patients were interviewed postoperatively to evaluate the presence of sore throat, dysphagia or dysphonia., Results: Two patients were excluded when surgery changed from laparoscopic to open. A total of 120 patients were finally included in the analysis. The mean OLP in the LMAP group was significantly higher than that in the LMAS group (30.7 ± 6.2 versus 26.8 ± 4.1 cmH2O;P < 0.01). This was consistent with a higher maximum tidal volume achieved with the LMAP compared to the LMAS (511 ± 68 versus 475 ± 55 ml; P = 0.04). The success rate of the first attempt insertion was higher for the LMAS group than the LMAP group (96.7 and 71.2%, respectively; P < 0.01). The time taken for insertion, ease of insertion of the drain tube, complications and postoperative pharyngolaryngeal adverse events were similar in both groups., Conclusion: The LMAP has a higher OLP and achieves a higher maximum tidal volume compared to the LMAS, in patients undergoing elective laparoscopic cholecystectomy. The success of the first attempt insertion was higher for the LMAS.

Purpose: Artifacts in anesthesia information management system (AIMS) databases may influence research results. Filtering during data capturing can prevent artifacts from being stored. In this prospective study, we assessed the reliability of AIMS data by determining the incidence of artifactual values stored in the AIMS., Methods: Vital parameter values regarding 86 surgical patients were collected in the AIMS both manually and automatically after filtering using the median value per minute. The percentage of artifactual values with a 95% confidence interval (CI) was calculated for each parameter. Secondary outcomes included the number of values that deviated from a predefined baseline, the percentage of these deviations that were caused by artifacts, the number of episodes across which these artifacts were distributed, and the most common causes of artifacts., Results: Altogether, 9,534 min of anesthesia time were recorded. The overall percentages of artifacts were: 0.0 for heart rate (95% CI: 0.0 to 0.1), 0.3 for oxygen saturation (95% CI: 0.2 to 0.4), 4.7 for ST-segment (95% CI: 4.3 to 5.2), 2.3 for noninvasive blood pressure values (95% CI: 1.8 to 2.9), and 14 for invasive blood pressure values (95% CI: 12 to 15). Artifacts as a percentage of deviations from baseline were: 1.6 for heart rate (95% CI: 0.4 to 5.7), 24 for saturation (95% CI: 18 to 32), 83 for ST-segment (95% CI: 76 to 87), 3.3 for noninvasive blood pressure values (95% CI: 2.5 to 87), and 27 for invasive blood pressure values (95% CI: 24 to 31)., Conclusions: Storing a median value per minute to filter capturing of vital parameter values in an AIMS database provides reliable data for heart rate and oxygen saturation and acceptable reliability for noninvasive blood pressure data. Knowledge about the method of artifact filtering is essential in studies using AIMS data.

Context: Assessment of Mallampati class is an integral part of preoperative airway evaluation. Increasing Mallampati class is known to be associated with greater difficulty with intubation, but some cases of airway difficulty in Mallampati 'class zero' patients have been reported., Objective(s): We undertook this study to evaluate intubation difficulty and to correlate this with indirect laryngoscopy findings in Mallampati class zero patients. The incidence of Mallampati class zero airway in Indian patients and the difficulty in mask ventilation were also evaluated., Design: Prospective double-blind observational study., Setting: A tertiary care medical college hospital in Karnataka, India., Study Period: September 2010 to April 2011., Patients: Patients of either sex, 18 years and older, presenting for preanaesthetic examination for elective surgery were evaluated. All patients with Mallampati class zero airway undergoing general anaesthesia with tracheal intubation were included. Exclusion criteria were upper airway disorder, unstable cervical spine, increased risk for aspiration, ischaemic heart disease, increased intracranial pressure, respiratory distress, those unable to sit upright, or infected with hepatitis B, hepatitis C, HIV or pulmonary tuberculosis, or requiring emergency surgery. All underwent indirect laryngoscopy performed by the otorhinolaryngologist and subsequently, direct laryngoscopy performed by the anaesthesiologist. Intubation difficulty was assessed by the Cormack & Lehane grades., Main Outcome Measures: Evaluation of intubation difficulty and correlation with indirect laryngoscopy findings in Mallampati class zero patients. Estimation of the incidence of Mallampati class zero airway in Indian patients and the difficulty in mask ventilation., Results: Twenty women and thirteen men, aged 18-65 years, of Mallampati class zero were identified out of 1937 (incidence, 1.7%). The data of 27 patients were analysed. Two patients had 'difficult' mask ventilation. All had a 'predicted easy' airway on indirect laryngoscopy and 'easy' (Cormack & Lehane grade 1 or 2) tracheal intubation. Upon direct laryngoscopy, the epiglottis was described as 'large' in 10 (37%) patients., Conclusion: A Mallampati class zero per se is not associated with difficult airway unless other airway characteristics contribute to the difficulty. Even though the epiglottis may be large and overhanging, it rarely causes airway difficulty in Mallampati class zero airway.

Children with neuromuscular diseases present a wide range of clinical manifestations and clinical implications for the anaesthesiologist. Neuromuscular diseases in children affect muscle strength by either directly weakening the muscle fibrils or indirectly by a degenerative nerve supply and weak neuromuscular junction. Of the more than 200 neuromuscular disorders known, the vast majority are genetic in origin. This review focuses on four of the more common neuromuscular disorders with emphasis on their pathophysiology and clinical implications for anaesthesiologists: malignant hyperthermia, the muscular dystrophies (Duchenne's, Becker's, and Emery-Dreifuss), mitochondrial disorders, and cerebral palsy.

Background: We developed an e-learning system, which is based on an interactive animation video that assists anesthesiologists in preanesthetic interviews., Materials and Methods: First, the feasibility of the system was investigated in 18 anesthesiologists and 95 volunteers from the general public. Content/quantity, operability, and satisfaction were assessed with a five-point scale. Secondly, a randomized controlled trial was conducted on 211 cancer patients who were scheduled to undergo general anesthesia. They were divided into an e-learning group (n = 106) and a control group (n = 105). The patients in the e-learning group watched the interactive animation before a preanesthetic interview by an anesthesiologist., Results: In 10 of the 11 items for content/quantity, operability, and satisfaction, the average score for both anesthesiologists and volunteers was ≥3.0 in feasibility study. Then, the level of patient comprehension of preoperative rounds and postoperative complications in the e-learning group was significantly higher than that in the control group (mean: 4.4 ± 0.5 versus 4.1 ± 0.7, P = 0.003, and 4.3 ± 0.5 versus 4.2 ± 0.5, P = 0.02); however, no significant difference in anxiety was seen between the two groups. Patient satisfaction in the e-learning group was significantly higher (mean: 4.3 ± 0.5 versus 4.0 ± 0.6, P = 0.002)., Conclusion: The e-learning system is an effective supplementary tool for preanesthetic interviews in cancer patients.

Objectives: To discover whether any consensus exists among the Association of Paediatric Anaesthetists of Great Britain and Ireland (APA) members regarding the use and acceptability (or otherwise) of physical restraint., Background: Despite growing recognition of children's right to be consulted regarding their healthcare, the issue of how to proceed when faced with a child unwilling to undergo induction of general anesthesia remains relatively unaddressed., Methods: APA members were surveyed regarding their use or avoidance of physical restraint and alternate techniques to facilitate induction; factors affecting choice of technique; and extent of preoperative discussion. The anonymous online survey used both structured and free text responses., Results: Of 596 surveys, 310 were returned, a 52% response rate. Use of physical restraint and extent of restraint employed declines with increasing child age. Distraction techniques are frequently employed for children under 6 years, with the use of sedative premedication increasing as child age increases. Urgency of procedure, developmental delay, and preoperative discussion all have an effect. Comments demonstrated a wide range of views and lack of consensus on what constitutes physical restraint, and what degree of restraint, if any, is acceptable., Conclusion: Our results are similar to the US Society of Pediatric Anesthesia members, suggesting this remains an issue internationally. Consideration of practices in other specialties gives some guidance. Our survey shows a range of views as to what physical restraint is or involves, and what constitutes acceptable practice regarding the use or avoidance of physical restraint. We were unable to demonstrate consensus.

Purpose of Review: Patients with chronic obstructive lung disease experience an increased risk of perioperative pulmonary complications. This review presents an evidence-based approach to perioperative care designed to optimize management., Recent Findings: Recent research has provided guidance regarding intraoperative and postoperative administration of oxygen and the selective use of volatile agents. The significance of preoperative malnutrition and postoperative epidural analgesia on outcomes has also been explored further. The opportunity for anesthesiologists to engage in tobacco interventions and the benefits of addressing smoking cessation have been studied., Summary: Optimization for surgery includes preoperative treatment of reversible airway obstruction and respiratory infections, smoking cessation, and possibly nutritional interventions. Meticulous intraoperative monitoring combined with a sound understanding of pathophysiological mechanisms underlying air trapping will help clinicians strike a balance between permissive hypercapnia and adequate ventilation.

Purpose of Review: Minimally invasive surgery involving the thoracic cavity continues to increase. With the introduction of robotic systems, particularly the da Vinci robot system more than 10 years ago, thoracic operations have been performed with some provocative results and limited, defined advantages. The present review provides an overview of common thoracic surgical procedures performed with the robotic system and discusses the anesthetic implications., Recent Findings: The literature on this topic currently includes case reports or series of clinically prospective or retrospective observational reports with the use of robotic systems, involving the thoracic cavity (mediastinal mass resections, lobectomies, and esophagectomies); unfortunately there are very limited reports related to anesthetic implications or complications related to the use of this technology. The majority of the surgical reports involve the use of lung isolation devices for thoracic surgery, specifically the use of a double-lumen endotracheal tube (DLT); a few centers use carbon dioxide (CO2) insufflation as part of their management to achieve maximal surgical exposure while compressing the operative side of the lung away from the operative area., Summary: Anesthesiologists must be familiar with lung isolation techniques and flexible fiberoptic bronchoscopy while participating in thoracic surgical cases that require robotic systems. In addition, prevention and recognition of potential complications, such as crushing injuries or nerve damage, must be sought. Because the potential for converting to an open thoracotomy exists, all measures must be taken to manage patients accordingly if the situation arises.

Purpose of Review: The surgical management of patients partly determines the anesthetic management. A shift has taken place in thoracic surgery, with a large portion of procedures now being performed through a video-assisted thoracoscopic surgery (VATS) approach. This review is intended to provide the anesthesiologist with an update on the management of thoracic surgical patients presenting for VATS., Recent Findings: Although there are cosmetic and economical advantages to the VATS approach, large randomized controlled trials are still lacking documenting the benefit of VATS versus conventional 'thoracotomy'. The classic division in absolute and relative indications for one-lung ventilation (OLV) should be viewed as antiquated. All VATS procedures represent an indication for OLV. A better classification is to divide the purpose of OLV: separation versus isolation. Treatment for hypoxemia during OLV also needs to be modified. Patient expectations are also different as a minimal invasive approach is often falsely associated with minimal risk. This leads to an additional stress factor imposed upon the anesthesiologist., Summary: Minimal invasive VATS is gaining widespread popularity among our surgical colleagues. The anesthesiologist must recognize the impact that this change in surgical philosophy will have upon the anesthetic management of these complex patients.

One of the current challenges in medicine is monitoring the patients' depth of general anaesthesia (DGA). Accurate assessment of the depth of anaesthesia contributes to tailoring drug administration to the individual patient, thus preventing awareness or excessive anaesthetic depth and improving patients' outcomes. In the past decade, there has been a significant increase in the number of studies on the development, comparison and validation of commercial devices that estimate the DGA by analyzing electrical activity of the brain (i.e., evoked potentials or brain waves). In this paper we review the most frequently used sensors and mathematical methods for monitoring the DGA, their validation in clinical practice and discuss the central question of whether these approaches can, compared to other conventional methods, reduce the risk of patient awareness during surgical procedures.