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Stüve-Wiedemann syndrome (SWS) is a rare, autosomal recessive disorder, causing dysautonomia and multisystem failure. Symptoms include skeletal malformations, restricted joint mobility and desensitisation to pain. Patients with SWS presenting with intraoral lesions are extremely rare and this is probably due to their shortened lifespan. We present a case of a 9-month-old patient who presented to our Oral and Maxillofacial Surgery (OMFS)Unit with a chronic inflamed ulcer affecting the tongue, secondary to trauma from erupting central incisors. We believe that depapillation in conjunction with an increased pain threshold contributed to its development. The patient was successfully treated by extraction of the lower central incisors and intralesional steroid injections under general anaesthetic. This case highlights that patients with SWS can present to the OMFS clinician with oral lesions and that they can be safely managed under general anaesthesia.

Summary Introduction Axillary sentinel node biopsy for melanoma is routinely performed under general anaesthesia. Emerging evidence has shown general anaesthetics are associated with increased mortality in the context of the COVID-19 pandemic. In the interest of patient safety, we have designed a series of bespoke axillary regional blocks enabling surgeons to remove nodes up to and including level III without the need for a general anaesthetic. The aim of this study was to assess the feasibility of performing axillary sentinel node biopsy under such blocks. Methods Approval was granted by the Joint Study Review Committee on behalf of the Research and Ethics Department. Ten consecutive patients having axillary sentinel node biopsy for melanoma were included in this prospective study. Patients completed a Quality of Recovery-15 (QoR15) questionnaire preoperatively and 24 h postoperatively. Discussion One patient had a positive sentinel node, the remining were negative. A significant reduction in time spent in hospital post-operatively (p = 0.0008) was observed. QoR15 patient reported outcome measures demonstrated high levels of satisfaction evidenced by lack of statistical difference between pre and post-operative scores (p = 0.0118). 80% of patients were happy to have a regional block and 90% were happy to attend hospital during the pandemic. Conclusion ASNB under regional block is safe, negates risks associated with performing GAs during the COVID-19 pandemic and facilitates quicker theatre turnover and discharge from hospital. Collaboration between anaesthetic and surgical teams has enabled this change in practice. There is a learning curve with both patient selection, education and development of technique.

Postoperative nausea and vomiting (PONV) is a prevalent side effect following general anaesthetic and surgery. Areas of the brainstem that coordinate the process of vomiting receive inputs from a number of areas, including high cortical areas and, importantly, the chemoreceptor trigger zone of the area postrema in the medulla oblongata of the brainstem, which can be affected directly by anaesthetic agents. A number of risk factors for PONV have been identified, and scores developed to help stratify risk. Based on this stratified risk pharmacological therapy can be given prophylactically intraoperatively, or as rescue postoperatively. The mechanisms and side effects of these drugs is discussed alongside a recent review of efficacy, and some potential future developments.

Основні зусилля анестезіолога під час знеболювання оперативного втручання з приводу гострої кишкової непрохідності повинні бути спрямованими на стабілізацію гемодинаміки пацієнта і компенсацію водно-електролітних розладів, які виникли в передопераційному періоді. Для цього слід широко використовувати сучасні засоби моніторингу гемодинаміки, температури, респіраторної механіки і функції газообміну. Ефективне моніторування вказаних функцій і раннє застосування при артеріальній гіпотензії помірних доз вазопресорів дозволяють стабілізувати гемодинаміку та обмежити обсяг інтраопераційної інфузії. Препарати для інфузії слід цілеспрямовано обирати з урахуванням виду електролітних порушень, а як базові розчини доцільно застосувати збалансовані кристалоїди. При виборі засобів, а також доз препаратів для знеболювання та анестезії перевагу слід надавати тим, що дозволяють якнайшвидше пробудити хворого після анестезії та сприяти його ранній активізації та реабілітації. Де це можливо, методи загальної анестезії слід доповнювати регіонарною анестезією та післяопераційною регіонарною аналгезією. Питання про уникнення інтраопераційної інтубації кишечника, а також раннє видалення назоєюнального та/чи назогастрального зондів у післяопераційному періоді повинно вирішуватися разом із хірургами, що часто дозволяє зменшити відчуття нудоти та пришвидшувати післяопераційну реабілітацію хворих. Для ефективного післяопераційного контролю нудоти та блювання в разі гострої кишкової непрохідності часто необхідно застосовувати комбінацію препаратів, що знижують гастроінтестинальну секрецію, з препаратами, які пригнічують регуляцію блювотного рефлексу в центральній нервовій системі, а також із прокінетиками, що покращують евакуацію шлункового вмісту.

The burden of dental care in Amelogenesis Imperfecta (AI) has not been well described. This condition results in weak, discoloured and often sensitive teeth. Specialist paediatric care is available for AI patients in the UK, but treatment protocols and care provided are inconsistent. The aim of this study was therefore to analyse the provision of treatment and burden of care for children and families with AI across four Paediatric Dentistry centres in the UK. A retrospective evaluation of AI patient clinical records across four UK consultant-led Paediatric Dentistry centres was completed. Frequency and duration of care were recorded along with treatment and experience of inhalation sedation, local and general anaesthetic. In total, 138 records were available for analysis. The average patient age at first referral was 7.7 years (range 1–16 years) and families travelled an average 21.8 miles per appointment (range 0.2–286 miles). Patients attended on average 4.5 appointments per year for 5.8 years. In total, 65.2% had experience of local anaesthetic, 27.5% inhalation sedation and 31.9% general anaesthetic. Dental treatment including restorations and extractions were commonly required on multiple teeth per patient. AI carries a high burden of specialist dental care to patients and families. Specialist centres are required to provide longitudinal, comprehensive care.

Purpose The aim of this retrospective study is to determine children’s attendance and experience of preventative interventions and operative treatment (restorations and extractions) with their primary care dentist (PCD) in the 12 months before and after their caries management under dental general anaesthetic (DGA). Methods A record of all children who had an elective DGA in 2016 across two hospital sites was retrospectively obtained (n = 1308). A representative sample of 300 was randomly selected encompassing 114 dental practices. An online questionnaire to the children’s PCDs collated quantitative and qualitative data regarding participation in the pre- and post-DGA period. Results Data was collated and analysed for 80 children (mean age: 6 years 10 months [SD = 2.49; range: 2 years 1 month – 14 years 3 months]; equal sex distribution) with 43 responding PCDs. Attendance for examination declined significantly from 85% (n = 68) pre-DGA to 57.5% (n = 46) post-DGA (p ≤ 0.001). Attendance at emergency appointments pre-DGA was high (33.75% [n = 27]); a significant reduction post-DGA was recorded (p ≤ 0.001). Over one third of children (37.5% [n = 30]) did not receive any form of preventative intervention over 24 months. A non-significant reduction in the provision of operative treatment was observed post-DGA (p = 0.06 [fill, primary]; p = 0.78 [fill, permanent]; p = 0.66 [ext, primary]). No statistical difference between age and treatment experience was found. Qualitative analysis revealed challenges in providing care included behavioural difficulties and poor attendance. Conclusion Improvements are required in strategies employed to support high caries risk children pre- and post-DGA to facilitate a higher incidence of attendance and preventative intervention with PCDs.

Clinicians and patients must weigh the risk of treatment of prostate cancer during a global pandemic with the risk of cancer treatment delays. With the possibility of another peak, public confidence in cancer treatments requiring general anaesthetic will be critical. We report on the safety of performing focal therapy in the UK during the initial Covid-19 peak. Patients and Methods: Consecutive patients treated in 8 centres (23/3/20-23/7/20) were contacted at least 2 weeks after receiving focal ablative therapy. Treatment modalities included high intensity focused ultrasound (HIFU, n=90), cryotherapy (n=32) or irreversible electroporation (IRE, n=6). Results: 128/129 patients treated during the study period were successfully contacted. 107/ 128 (83.5%) underwent primary focal treatment, all had D'Amico intermediate or high-risk disease. National guidelines varied throughout the period. Treating sites requested formal shielding from May 2020 and done in 48/128 (37.5%). 20/128 (15.6%) underwent pre-operative swab tests and 5/128 (3.9%) pre-operative chest imaging. Two (1.6%) had intra-operative complications secondary to catheterisation, but none required overnight admission. No COVID-19 related post-treatment admissions were reported;2 (1.6%) had Covid-19 related symptoms but were not tested as symptoms spontaneously resolved. 3 were admitted for non- COVID-19 issues and one was directly due to treatment related clot retention resulting in the only reported Clavien-Dindo score >2 complication [Table 1]. Conclusions: Focal therapy for non-metastatic prostate cancer was a safe treatment option during a COVID-19 pandemic when appropriate precautions are taken and should be discussed with eligible patients.

Background Structural brain abnormalities in newborn animals after prolonged exposure to all routinely used general anaesthetics have raised substantial concerns for similar effects occurring in millions of children undergoing surgeries annually. Combining a general anaesthetic with non-injurious sedatives may provide a safer anaesthetic technique. We tested dexmedetomidine as a mitigating therapy in a sevoflurane dose-sparing approach. Methods Neonatal rats were randomised to 6 h of sevoflurane 2.5%, sevoflurane 1% with or without three injections of dexmedetomidine every 2 h (resulting in 2.5, 5, 10, 25, 37.5, or 50 μg kg−1 h−1), or fasting in room air. Heart rate, oxygen saturation, level of hypnosis, and response to pain were measured during exposure. Neuronal cell death was quantified histologically after exposure. Results Sevoflurane at 2.5% was more injurious than at 1% in the hippocampal cornu ammonis (CA)1 and CA2/3 subfields; ventral posterior and lateral dorsal thalamic nuclei; prefrontal, retrosplenial, and somatosensory cortices; and subiculum. Although sevoflurane 1% did not provide complete anaesthesia, supplementation with dexmedetomidine dose dependently increased depth of anaesthesia and diminished responses to pain. The combination of sevoflurane 1% and dexmedetomidine did not reliably reduce neuronal apoptosis relative to an equianaesthetic dose of sevoflurane 2.5%. Conclusions A sub-anaesthetic dose of sevoflurane combined with dexmedetomidine achieved a level of anaesthesia comparable with that of sevoflurane 2.5%. Similar levels of anaesthesia caused comparable programmed cell death in several developing brain regions. Depth of anaesthesia may be an important factor when comparing the neurotoxic effects of different anaesthetic regimens.

Minimally invasive surgery is usually performed due to various benefits, such as reduced postoperative pain, faster recovery, and reduced postoperative pulmonary complications. Combining different surgical interventions into one group on the principle of technological generality, and not depending on the etiopathogenesis of the patient or the operated organ from the point of view of the anesthesiologist is quite justified, since it allows us to develop a single methodological approach to intraoperative protection of the patient. This approach is formed on the basis of taking into account both general anaesthetic and specific requirements for this type of operation. At the same time, the procedure should be painless and comfortably tolerated by the patient, as well as anesthesia should contribute to the fastest possible rehabilitation of the patient and his social rehabilitation. Naturally, the implementation of the above requirements should not be at the expense of the effectiveness, safety and reliability of anesthetic during the perioperative period. The purpose of the work is to consider the features of anesthesia in minimally invasive surgery.

Purpose: To determine the analgesic effects of sevoflurane (Sev) and propofol (Pro) in children whounderwent otolaryngology surgical procedures, and their post-operative conditions.Methods: A total of 62 (ASA I or ASA II) pre-medicated children who were about to undergootolaryngology surgical procedures were chosen and divided equally into Sev and Pro groups, with 31patients per group. During the surgical procedure, Sev was administered via a mask, while Pro wasgiven i.v. Each anesthesia was followed with fentanyl administration.Results: Pain scores such as verbal rating scale (VRS) and visual analogue scale (VAS) were slightlylower in Sev group than in Pro group. However, post-operative conditions such as emergence delirium(ED) and emergence agitation (EA) were significantly elevated in Sev group, when compared to Progroup (p < 0.05). In addition, patients in Sev group had higher levels of hemodynamic parameters(blood pressure), and much higher number of adverse events than those in Pro group. Thus, the overallsatisfaction score and recovery characteristics, i.e., hospitalization time and recovery were slightlybetter in Pro-anesthetized children than in those given Sev.Conclusion: These results suggest that except for pain score, Pro-anesthetized children fared better interms of speedy recovery and reduced adverse effects than those given Pro. Thus, Pro may berecommended as general anaesthetic for children undergoing otolaryngology surgical procedures.Keywords: Sevoflurane, Propofol, Pain score, Emergence agitation, Otolaryngology

Neuron irritation lies at the heart of intraoperative motor mapping and varies with the general anaesthetic type and dose. Basing on the analysis of 63 cases (male/female 25/38, aged 21–69) of brain tumors (glial tumors, metastasis, cavernous angiomas) the study explores the role of propofol and sevoflurane in the affectability of cortex neurons during the intraoperative neurophysiological mapping. The study has clearly demonstrated that the liminal current strength is notably higher when inhalation anaesthesia (sevoflurane) is used, than in the case of TIVA (propofol). The propofol activity in the doses causing brain activity depression results in a sharp increase in the excitability threshold. In contrast, sevoflurane causes a steady dose-related rise in the liminal current strength during the motor area galvanic stimulation due to the suppression of affectability and conduction in the nervous system.

Purpose Current guidelines recommend offering patients both options of a spinal or general anaesthetic. At local level we attempt to ensure whether similar outcome is reflected in our practice regarding difference between General anaesthesia(GA) and Spinal Anaesthesia(SA) in morbidity and mortality. Methods Data from spreadsheet maintained for NHFD was used to identify patients with Neck of Femur Fracture in 2018.Mortality data was retrieved from the Welsh Clinical Portal. Data was organised according to the type of anaesthetic received. Outcome measures for Morbidity (length of stay in hospital) and Mortality (at both 30 days and 120 days) following surgery, were then inputted for these patients. Statistical analysis was performed using SPSS software. A Mann Whitney U Test was performed for length of stay and Kaplan-Meier Estimates for survival at 30 and 120 days. Log Rank (Mantel Cox) Hypothesis Test is used to compare mortality between two Anaesthetic groups. Results We reviewed 203 patients elderly hip fracture with mean age of 83 (range 60–99), there were 142 Female and 61 males.4 patients were treated non operatively, and 2 patients had no data available 0.146 patient received GA and 46 received spinal anaesthesia. Hemiarthroplasty and DHS are commonest procedure in both groups. On applying Mann Whitney U test There is no statistical difference between the length of stay There is no statistical difference between the length of stay for SA and GA Patients. (p = 0.483). for SA and GA Patients (p = 0.483). On APPLYING Log Rank (Mantel-Cox) Analysis there is no statically difference in mortality at 30 days and 120 days with p value 0.087 and 0.397 respectively. Conclusion In summary, this audit remains in line with current literature, that there is not a significant difference between the length of stay, survival at 30 days and at 120 days between the two different groups.

Aim Cutaneous abscesses are one of the most common acute general surgery presentations. This study aimed to understand the current practice in the management of cutaneous abscesses in the United Kingdom (UK), once the decision has been made that acute surgical incision and drainage (I&D) is required. Method General surgeons from across the UK were surveyed on their opinions on the optimum management of cutaneous abscesses. Outcomes measured included anaesthesia, incision technique, antibiotic administration, departmental abscess pathways, and post-drainage management. A combination of Likert scales, multiple-choice questions, and short answer questions were used. Comparisons were made of Likert scales between regions using a two-sample independent t-test. The survey was peer reviewed and distributed through the Association of Coloproctology of Great Britain and Ireland (ACPGBI) network between April and June 2018. Results Sixty-one responses were collected from surgeons throughout the UK. Of these respondents, 69% indicated that cutaneous abscesses would always or usually require a General Anaesthetic (GA) for treatment, and 82% indicated that abscesses were at least sometimes not treated until the next day due to a lack of resources. While 79% of surgeons stated that pus swabs are always or are usually taken, 44% of respondents never or rarely chased the results. The main indications for giving antibiotics were sepsis/systemically unwell patients, and cellulitis. 31% of responding centres had an abscess management protocol, and 82% of respondents confirmed that they would always pack the abscess wound post-operatively. Conclusion ‘Incision and drainage’ is currently the most widely used technique for the surgical management of cutaneous abscess. However, this study demonstrates the significant variability in the use of anaesthesia, antibiotics, packing and the use of protocols to guide and streamline patient management., Highlights • There are no current NICE guidelines specifically covering cutaneous abscess management. • There is significant practice variation in the management of cutaneous abscesses across the UK. • Wound packing is still commonplace, despite guidelines recommending that there is evidence that it should be avoided. • New recommendations on the use of antibiotics whilst treating cutaneous abscesses are yet to be taken up by most surgeons. • Surgically managed cutaneous abscesses in the UK are preferably managed under a general anaesthetic.

The patients suspected to have cancer in the head and neck region including pharynx and larynx undergo biopsy of the suspicious lesion under general anaesthetic. This is a long established practice but lately, biopsy of such lesions under local anaesthetic in the outpatient setting is promoted. During the current COVID-19 pandemic our access to operating theatre is significantly reduced. We have, therefore, modified our practice to allow us to carry out such biopsies under local anaesthetic in the outpatient setting. We share our experience with 20 patients who successfully underwent this procedure. The patients reported no side effects and were happy to avoid undergoing a general anaesthetic and its associated risks. We would encourage colleagues in other units to consider this option when dealing with such patients.

At the onset of the global pandemic of COVID-19 (SARS-CoV-2), guidelines recommended using regional anaesthesia for caesarean section in preference to general anaesthesia. National figures from the UK suggest that 8.75% of over 170,000 caesarean sections are performed under general anaesthetic. We explored whether general anaesthesia rates for caesarean section changed during the peak of the pandemic across six maternity units in the north-west of England. We analysed anaesthetic information for 2480 caesarean sections across six maternity units from 1 April to 1 July 2020 (during the pandemic) and compared this information with data from 2555 caesarean sections performed at the same hospitals over a similar period in 2019. Primary outcome was change in general anaesthesia rate for caesarean section. Secondary outcomes included overall caesarean section rates, obstetric indications for caesarean section and regional to general anaesthesia conversion rates. A significant reduction (7.7 to 3.7%, p

Background The role of spinal anaesthesia in patients having a transperitoneal hand-assisted laparoscopic donor nephrectomy in an enhanced recovery setting has never been investigated. Objective We explored whether substituting a rectus sheath block (RSB) with spinal anaesthesia, as an adjunct to a general anaesthetic technique, influenced time-to-readiness for discharge in patients undergoing hand-assisted laparoscopic donor nephrectomy. Design Prospective randomised open blinded end-point (PROBE) study with two parallel groups. Setting Tertiary University Hospital. Patients Ninety-seven patients undergoing a trans-peritoneal hand-assisted laparoscopic donor nephrectomy. Intervention Patients (n=52) were randomly assigned to receive a general anaesthetic and a surgical RSB with 2 mg kg-1 of levobupivacaine at the time of surgical closure or a spinal anaesthetic with hyperbaric bupivacaine 12.5 mg and diamorphine 0.5 mg (n=45) before general anaesthesia. Primary outcome The primary outcome was the time-to-readiness for discharge following surgery. Results Median [IQR] times-to-readiness for discharge were 75 [56 to 83] and 79 [67 to 101] h for RSB and spinal anaesthesia and there was no significant difference in times-to-readiness for discharge (median difference 4 (95% CI, 0 to 20h; P = 0.07)). There were no significant differences in pain scores at rest (P = 0.91) or on movement (P = 0.66). Median 24-h oxycodone consumptions were similar (P = 0.80). Nausea and vomiting scores were similar (P = 0.57) and urinary retention occurred in one vs. four patients with RSB and spinal anaesthesia, respectively (P = 0.077). Conclusion Substitution of RSB with spinal anaesthesia using 12.5 mg hyperbaric bupivacaine and 0.5 mg diamorphine, together with a general anaesthetic failed to confer any benefit on time-to-discharge readiness following transperitoneal hand-assisted laparoscopic donor nephrectomy. RSB provided similar analgesia in the immediate postoperative period with a low frequency of side-effects in this cohort. Trial registration ClinicalTrial.gov identifier: NCT02700217.

Background: The knowledge gap was from the fact that the type of anaesthetic drug administered during caesarean section can have effects on neonatal outcome like low Apgar score with most hospitals in developed countries now using more modern inhalational anaesthetic agents with fewer or no cardio-respiratory depressant effects e.g. Isoflurane or Sevoflurane. However at UTH, halothane is still being used for maintenance of general anaesthesia despite well documented cardio-respiratory depressant effects with very limited research done on its effects on neonatal Apgar score. The Apgar score is a means of rapid evaluation of the physical condition of infants shortly after birth. Thus this study investigated the effects of general anaesthesia with halothane versus spinal anaesthesia on neonatal Apgar score. Objective and study design: With the view of determining the type of anaesthesia administered during caesarean section with the least effects on neonatal wellbeing shortly after birth, a prospective observational cohort study was conducted at the University Teaching Hospital between May 2015 and January 2016.The scientific objective was to determine the effects of general anaesthesia with halothane versus spinal anaesthesia on neonatal Apgar score. This study involved 70 neonates, 54 were born from mothers that had undergone caesarean section under spinal anaesthesia and 16 from mothers that had undergone general anaesthesia. The data was analysed using SPSS version 16.0. Inferential analysis was conducted using logistic regression. Results: 20 neonates out of 54 (37%) in the spinal anaesthetic group had an Apgar score less than 8 at 1 minute[Fig 1]. Out of the 16 neonates in the general anaesthesia group, 14 (87.5%) had Apgar score less than 8 at 1 minute[Fig 1]. One (1.9%) neonate had an Apgar score less than 8 at 5 minutes in the spinal anaesthesia group. While 4 (25%) neonates had Apgar score less than 8 in the GA group[Fig2] The logistic regression at 1 minute Showed that it is over 11 times more likely to get a low Apgar with a general anaesthetic as compared to a spinal anaesthetic (OR 11.9), [Table 3]. The Apgar score at 1 minute in the Spinal anaesthesia group was statistically significantly higher than the general anaesthesia group (p=0.002). The logistic regression at 5 minutes Showed that it is over 17 times more likely to get a low Apgar with a general anaesthetic as compared to a spinal anaesthetic (OR 17.7), [Table 4]. Further, the 5 minutes Apgar score in the spinal anaesthesia group was statistically significantly higher than the general anaesthesia group (p=0.014),[Table 4]. Conclusion: With the results pointing to the fact that there is significant difference in neonatal Apgar score outcomes in spinal versus general anaesthesia, the researcher therefore rejected the null hypothesis. It is therefore inferred that spinal anaesthesia method has better neonatal outcomes by Apgar score measure than general anaesthesia method.

Zebrafish (Danio rerio) model is economically viable and scientifically significant to identify several human diseases. It has genetic homology to humans (80-85%). Its other advantages are high reproductive success, embryo and larvae transparency and rapid development. Also compared to mammals, the maintenance cost of Zebrafish is lower . Ethyl 3-aminobenzoate methane sulfonate (MS-222) is known as the standard fish Anaesthetic and widely used in Zebrafish, but it can have adverse effects depending on the dose and exposure like aversion, stress induction, epidermal and corneal lesions, respiratory acidosis, hypoxemia, decreased heart rate and death. To reduce such adverse effect new anaesthetic protocol is required. In this experiment, Diazepam is taken as the test drug because of a sedative-hypnotic drug with anticonvulsant properties, similarly Lignocaine as a local Anaesthetics and Ketamine as a rapid acting general Anaesthetic along with for all cases temperature modulation has an important role. During this evaluation, some levels of Anaesthesia are found in fish like normal, Deep and light sedation, Narcosis, Anaesthesia and Medullary collapse (Death). In this observation, we have to closely observe the Spontaneous movement, Muscle tone, Reflex response, and Tactile stimuli and balance respiratory rate, consciousness levels of the fish. Onset of action KETAMINE and DIAZAPAM is almost same but LIGNOCANE is lower by observing heartbeat after treatment we can see that the effect of DIAZAPAM is much lesser in compared with LIGNOCAINE and KETAMINE In comparison with LIGNOCAINE and KETAMINE, LIGNOCAINE is better than KETAMINE. Comparing to the time of shock 40 second of shock with drug is least effective.60 second of shock is most effective in all drug and dose combination. Keywords: Anaesthesia, Zebrafish, Embryo, Lignocaine, Diazepam, Ketamine, Temperature Cite this Article Samrat Bose, GouravSamajdar. Evaluation of Anaesthetic Protocol for Zebrafish Embryo (Daniorerio): Lignocaine Combined with Diazepam and Ketamine with different doses Temperature Modulation. Research & Reviews: A Journal of Drug Formulation, Development and Production . 2020; 7(2): 15–31p.

Introduction: Patients with significant comorbidities have high general anaesthetic risks and are often thought to be undesirable candidates for general anaesthesia and, therefore, surgery. External fixation uses local or regional anaesthesia, and allows patients with significant comorbidities to avoid the risks of general anaesthesia. It has been described to be successful in the management of high-risk patients with intertrochanteric fractures. However, published data have been derived from small case series, and no published literature has attempted to analyse them in totality. This review aims to pool together these case series, and to evaluate the outcomes and complications of external fixation when performed in high-risk patients with intertrochanteric fractures. Materials and Methods: The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRSIMA) guidelines. All studies that reported the outcomes of external fixation for intertrochanteric fractures of high-risk patients were included. Results: A total of 13 publications, involving 687 patients, were included in the review. All the studies reported postoperative radiological reduction and complete fracture healing with reduction of limb length discrepancy. One study using parallel placement of proximal fixation screws showed shorter operative duration as compared to convergent placement. Another study mentioned that there was no significant difference in mortality rates between patients with stable fractures and those with unstable fractures who underwent external fixation. All the studies reported a decrease in postoperative immobility, reduction in pain and improvement in clinical outcome hip scores. Conclusion: External fixation is promising and useful especially in the management of high-risk patients with intertrochanteric fractures. The procedure can help with radiological reduction of the fracture, reduction of limb length discrepancy, reduction of operative duration, decrease in postoperative immobility, reduction in pain and improvement in clinical outcome hip scores. The procedure is versatile and seems to be able to accommodate both stable and unstable fractures. However, unstable fractures may be associated with greater postoperative morbidity, and it may be worthwhile to prognosticate based on the stability of the patients’ fracture for better risk-benefit analysis preoperatively. Shorter operative times can also be achieved through parallel proximal pin placement, without impact on mortality or morbidity. Key words: External fixation; High risk; Intertrochanteric

Will the coronavirus pandemic bring about change in how we manage children with caries?

Aims There has been significant interest in day-case and rapid discharge pathways for unicompartmental knee replacements (UKR). Robotic-assisted surgery has the potential to improve surgical accuracy in UKR. However, to date there are no published studies reporting results of rapid-discharge pathways in patients receiving UKR using the NAVIO◊ robotic system. Methods A retrospective analysis identified 19 patients who were safely discharged within 24 h following UKR using the NAVIO◊ robotic system between June 2017 and October 2019. All patients went through a standardised UKR pathway protocol. Pre-operatively patients underwent education sessions and anaesthetic assessment, with selected patients undergoing occupational/physiotherapy assessment prior to surgery. All patients received a general anaesthetic with local anaesthetic infiltration prior to closure; nerve blocks were not used routinely. A multi-modal analgesic regime was utilised. Patients were discharged home once they were safe to mobilise on ward, had normal vital signs and pain was adequately controlled. Patients were discharged with outpatient physiotherapy referral and consultant follow up at 6 weeks. Results All patients were discharged within 24 h; there were no post-operative complications and no readmissions to hospital. The mean length of stay was 19.5 h (SD = 6.8), with patients seen twice on average by physiotherapy post-operatively. Active range of motion at 6 weeks was 105.8°, with all patients mobilising independently. The median 6-month post-operative Oxford Knee Score was 44 out of 48. Conclusion This initial feasibility study suggests that patients may be safely discharged within 24 h of UKR using the NAVIO robotic system. Appropriate patient selection will ensure successful discharge. Further prospective studies are needed.

Background Regional anaesthesia is commonly utilised for foot and ankle surgery. Debate remains at to the level of regional anaesthesia that is required. The objective of this study was to evaluate whether surgeon-delivered “blind” local anaesthetic infiltration around the first ray (metatarsal block without ultrasound guidance) was as effective as an ultrasound guided ankle block in providing post-operative analgesia after osseous first ray surgery performed under general anaesthetic. Methods 50 patients were recruited to a single surgeon and anaesthetist double-blinded randomised controlled trial at a single-centre. 20 mls of 0.5% levobupivacaine was used to perform either an ankle or metatarsal nerve block. Results Forty-eight patients completed the study: 25 in the ankle block treatment arm and 23 in the metatarsal block arm. The demographics were comparable between groups. There was no statistical difference in visual analogue pain scores at two (21.3 vs 15.2), six (23.6 vs 20.8) and 24 (42.2 vs 50.4) hours following the procedure between the two groups (metatarsal block vs ankle block). Metatarsal block groups had a faster return of normal sensation (2.3 vs 2.8 h) but there was no difference in time to safe mobilisation (2.6 vs 2.8 h). Conclusion This study demonstrates the efficacy and safety of surgeon delivered “blind” metatarsal block is comparable to an ultrasound guided ankle block for first ray surgery performed under general anaesthetic. Level of evidence 1.

IntroductionSingle operator cholangioscopy (SOC) has an important role in the diagnosis and management of biliary strictures and complex biliary stones. The evidence base is evolving, but with small numbers in reported studies. The majority of published literature discusses SOC under general anaesthetic;typically propofol. We compared successful stone clearance, stricture assessment and safety under conscious sedation and propofol.MethodsA single centre retrospective analysis was performed of consecutive SOCs over 8 years at Bristol Royal Infirmary (tertiary referral centre for SW England and South Wales). Parameters included sedation/propofol usage, stone clearance, electrohydraulic lithotripsy (EHL), histology, final diagnosis and complications.ResultsBetween Jan 2013 – Nov 2020, 471 SOCs were performed on 352 patients (175f, 177m);mean age 65.7years (17-92), referred from 18 centres. 15 SOCs were performed in 2013 compared to 99 in 2019 before restrictions from the COVID19 pandemic.228 therapeutic SOCs + EHL were performed for stone clearance, 79.8% (n=182/228) under conscious sedation (median fentanyl dose 150mcg;midazolam 7mg;comfort score 2). Complete stone clearance rose from 79.7% in the conscious sedation group to 89.2% in with propofol sedation, although the difference was not significant (p=0.19).243 diagnostic SOCs were performed, 88.9% under conscious sedation. Similar to therapeutic SOCs, median fentanyl dose 150mcg;midazolam 7mg;and comfort score 2. Overall macroscopic assessment of strictures correlating with malignancy had a sensitivity, specificity and diagnostic accuracy of 90.2% (95%CI 82.7-95.2), 92.6% (95%CI 86.3-96.5) and 91.5% (87.0-94.8%) respectively. Diagnostic accuracy with macroscopic assessment was comparable between patients receiving conscious sedation (91.4%;95%CI 86.6-94.9) vs propofol sedation (92%;95%CI 74.0-99.0). Diagnostic accuracy with histological assessment appeared greater in patients receiving propofol sedation (95%;95%CI 75.1-99.9) compared to conscious sedation (84.7%;95%CI 78.5-89.6)28 adverse events were recorded (5.9%), with post ERCP cholangitis (2.3%) and pancreatitis (2.1%) the commonest causes. Complications were marginally higher in patients receiving propofol sedation (6.8%;n=5/73) vs those receiving conscious sedation (5.8%;n=23/398) but the difference was not significant (p=0.72).ConclusionsThis is the largest single centre retrospective analysis of SOCs. Successful stone clearance is similar to results found in literature from smaller studies. There was a trend to greater successful stone clearance with propofol. Conscious sedation has previously been described as a risk factor for inadequate visualisation, but we found very similar high levels of diagnostic accuracy in both groups. Both were generally well tolerated with low rates of adverse events.

Background Carotid endarterectomy may significantly reduce the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks that may be reduced by performing the operation under local rather than general anaesthetic. This is an update of a Cochrane Review first published in 1996, and previously updated in 2004 and 2008. Objectives To determine whether carotid endarterectomy under local anaesthetic: (1) reduces the risk of perioperative stroke and death compared with general anaesthetic; (2) reduces the complication rate (other than stroke) following carotid endarterectomy; and (3) is acceptable to patients and surgeons. Search methods We searched the Cochrane Stroke Group Trials Register (September 2013), MEDLINE (1966 to September 2013), EMBASE (1980 to September 2013) and Index to Scientific and Technical Proceedings (ISTP) (1980 to September 2013). We also handsearched relevant journals, and searched the reference lists of articles identified. Selection criteria Randomised trials comparing the use of local anaesthetic to general anaesthetic for carotid endarterectomy were considered for inclusion. Data collection and analysis Three review authors independently assessed trial quality and extracted data. We calculated a pooled Peto odds ratio (OR) and corresponding 95% confidence interval (CI) for the following outcomes that occurred within 30 days of surgery: stroke, death, stroke or death, myocardial infarction, local haemorrhage, cranial nerve injuries, and shunted arteries. Main results We included 14 randomised trials involving 4596 operations, of which 3526 were from the single largest trial (GALA). In general, reporting of methodology in the included studies was poor. All studies were unable to blind patients and surgical teams to randomised treatment allocation and for most studies the blinding of outcome assessors was unclear. There was no statistically significant difference in the incidence of stroke within 30 days of surgery between the local anaesthesia group and the general anaesthesia group. The incidence of strokes in the local anaesthesia group was 3.2% compared to 3.5% in the general anaesthesia group (Peto OR 0.92, 95% CI 0.67 to 1.28). There was no statistically significant difference in the proportion of patients who had a stroke or died within 30 days of surgery. In the local anaesthesia group 3.6% of patients had a stroke or died compared to 4.2% of patients in the general anaesthesia group (Peto OR 0.85, 95% CI 0.63 to 1.16). There was a non-significant trend towards lower operative mortality with local anaesthetic. In the local anaesthesia group 0.9% of patients died within 30 days of surgery compared to 1.5% of patients in the general anaesthesia group (Peto OR 0.62, 95% CI 0.36 to 1.07). However, neither the GALA trial or the pooled analysis were adequately powered to reliably detect an effect on mortality. Authors' conclusions The proportion of patients who had a stroke or died within 30 days of surgery did not differ significantly between the two types of anaesthetic techniques used during carotid endarterectomy. This systematic review provides evidence to suggest that patients and surgeons can choose either anaesthetic technique, depending on the clinical situation and their own preferences.

Aim Inguinal hernias occur when visceral tissue protrudes through the inguinal canal [1]. Around 20 million inguinal hernia repairs (IHR) are done annually worldwide and involve re-enforcement of the compromised wall of the inguinal canal using polypropylene mesh via open anterior approach or minimally invasive laparoscopy [2,3]. Despite gold standards in surgical approach, there’s no distinctively superior practice between local anaesthetic (LA) and general anaesthetic (GA). Therefore, the objective was to review IHR under both LA and GA and investigate which method is conductive to optimal patient outcomes. Method Systematically reviewed randomised control trials (RCTs) evaluating the benefits of LA over GA in IHR, by comparing factors such as post-operative nausea, urinary retention (UR), haematoma, wound infection (WI), pain, and operating time. PubMed was utilised for finding suitable studies, and data was obtained and summarised appropriately. Results Data assembled from RCTs evaluating benefits of LA over GA in IHR indicated no significant difference between groups when comparing nausea, UR, haematoma, WI and pain [4]. Supporting studies reviewing RCTs juxtaposing GA and LA in IHR elucidated no significant variance in operating time, haematoma and WI [5]. Patients did show less rates of UR, reduced pain scores and greater patient satisfaction under LA [5]. Conclusions LA is used in specialised hernia clinics due to less cardiovascular risk however development of short-acting GA’s allows for suitability for day-case surgery. Future investigation is required taking into account factors like surgeon experience, patient anatomy and economic viability for a definitive gold standard.

Introduction Standard surgical practice of paediatric soft tissue facial injuries requires general anaesthetic (GA) if treatment with local anaesthetic is not tolerated. However, the Covid-19 pandemic has increased the risk of hospital admission for GA to patients and pre-operative Covid-19 testing can delay surgical treatment. In response, a service was established to facilitate short surgical procedures by the Oral and Maxillofacial surgical (OMFS) team with ketamine sedation (KS) at a tertiary level paediatric emergency department. Evaluation of this service demonstrates that KS is a suitable alternative to GA with reduced waiting times, low complications and equivalent surgical outcomes. Method 20 patients treated under KS from May- September 2020 were identified and compared to a control group of 20 patients treated under GA during the same time period. Data including patient demographics, surgical treatment and the KS/GA procedure was collected from the medical records and was analysed using Microsoft excel. Results The KS patients had shorter waits for treatment with 85% of patients waiting 1 day or less, compared with 55% for the GA group. Using the local KS protocol 1 or 2 doses of ketamine was sufficient in 79% of cases and adverse effects were minimal with 21% of KS patients suffering mild nausea and vomiting. Conclusions KS is an acceptable alternative to GA for the management of paediatric soft tissue injuries. KS reduces inpatient admission for GA which is of increased importance during the Covid-19 pandemic. Other OMFS units would benefit from access to a similar service.

This communication reports the effect of alphaxalone on motor somatosensory evoked potential (SEPs) in a rhesus macaque. The animal was deeply anaesthetised with an infusion of ketamine, medetomidine, midazolam and alfentanil. The median nerve was stimulated, and SEPs were recorded from the motor cortex. The successive administration of three doses of alphaxalone (0.5, 1 and 2 mg/kg) induced an increase of the latency time and a decrease of the amplitude of the SEPs. However, the structure of the waveforms was conserved, and hence alphaxalone might represent a suitable general anaesthetic option in neuroscience research as well as veterinary or human medicine.

IntroductionAfter general anaesthesia, children sometimes have changes in their behaviour. These alterations in behaviour can occur immediately upon emerging from anaesthesia in the recovery ward or later in the subsequent days and weeks whilst at home. There may even be a permanent impact on learning and behaviour.Our knowledge in this area has improved substantially in recent years; however, there are still major gaps in our understanding. The classification, aetiology and measurement of behaviour change still needs to be properly delineated, and treatment options and prevention strategies need to be tested.MethodsAn observational study of 4424 children who had a general anaesthetic was performed to explore the incidence of hypoactive delirium in the recovery setting. A novel measurement tool, the Cornell Assessment of Pediatric Delirium, was used to detect this type of behaviour change in the immediate postoperative period. The incidence of hypoactive delirium was compared with that of hyperactive delirium and associated risk factors were analysed.A randomised controlled trial of 249 children was conducted to determine if dexmedetomidine, an alpha-2 agonist with anxiolytic, analgesic and anti-inflammatory properties, would reduce the incidence of behaviour change in the first month after general anaesthesia. Children were randomised to receive the drug preoperatively, intraoperatively or not at all. The incidence of behaviour change was measured using two different instruments: the Post Hospitalization Behaviour Questionnaire for Ambulatory Surgery and the Strength and Difficulties Questionnaire. Differences in the incidence of behaviour change between the groups at three time points were examined. In addition, correlation of the outcomes using each of the measurement tools was explored.A review of long-term neurobehavioural outcomes was conducted to summarise the existing knowledge base and describe the current international collaboration to address this issue.Results and discussionI found that hypoactive delirium does occur in children in the immediate postoperative period and in my study, 23% of all cases of delirium in recovery were hypoactive in nature. Hypoactive delirium has been well documented in critically ill children but has not been described in this population previously. It is known that children with delirium or changes in behaviour immediately after general anaesthesia are at greater risk of problem behaviours at home and may exhibit reduced compliance with future episodes of healthcare. The Cornell Assessment of Pediatric Delirium is easy to use and can detect both hyperactive and hypoactive delirium. It is therefore a suitable metric for use in the recovery setting.Dexmedetomidine, whether given before or during general anaesthesia, had little effect on the incidence of behaviour change on postoperative days 3 and 14. However, by day 28 there were fewer problem behaviours in the group of children who received an intraoperative dose. Dexmedetomidine was also associated with less pain and less emergence delirium, but it did prolong the hospital stay by approximately 40 minutes on average. Dexmedetomidine is a useful adjunct for general anaesthesia and may have particular benefit for children at risk of anxiety and problem behaviours.There was weak to moderate correlation between the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery and the Strength and Difficulties Questionnaire. Neither instrument is ideal for measuring this outcome, and for research in this area to progress, a new, validated measurement tool is urgently needed.Conclusion and future directionsIn the immediate postoperative period, children can experience a form of delirium that is hypoactive in nature; therefore, the tools used to measure delirium during this time need to be capable of detecting these types of behaviours. Dexmedetomidine may be a useful adjunct in reducing the incidence of behaviour changes in the first month after anaesthesia and is also a promising agent for mitigating long-term neurobehavioural issues.There is a need for a new, well-validated tool to facilitate future research in the area of post-hospitalisation behaviour change. In addition to a questionnaire, which relies on subjective recall from the patient or parent, wearable technology should be explored and utilised to better inform clinicians and researchers about children’s behaviour after anaesthesia.The effect of anaesthesia on long-term neurobehavioural outcomes is currently being investigated, but results will take many years to be available. Dexmedetomidine is one of the medications being investigated in this area of research. It is a promising adjunct for general anaesthesia in children because, in addition to its analgesic and anti-inflammatory effects, it also has neuroprotective properties.