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The International Standards for a Safe Practice of Anesthesia were developed on behalf of the World Federation of Societies of Anaesthesiologists (WFSA), a non-profit organization representing anesthesiologists in 150 countries, and the World Health Organization (WHO). The recommendations have been approved by WHO and the membership of WFSA. These Standards are applicable to all anesthesia providers throughout the world. They are intended to provide guidance and assistance to anesthesia providers, their professional organizations, hospital and facility administrators, and governments for maintaining and improving the quality and safety of anesthesia care. The Standards cover professional aspects; facilities and equipment; medications and intravenous fluids; monitoring; and the conduct of anesthesia. HIGHLY RECOMMENDED standards, the functional equivalent of mandatory standards, include (amongst other things): the continuous presence of a trained and vigilant anesthesia provider; continuous monitoring of tissue oxygenation and perfusion by clinical observation and a pulse oximeter; intermittent monitoring of blood pressure; confirmation of correct placement of an endotracheal tube (if used) by auscultation and carbon dioxide detection; the use of the WHO Safe Surgery Checklist; and a system for transfer of care at the end of an anesthetic. The International Standards represent minimum standards and the goal should always be to practice to the highest possible standards, preferably exceeding the standards outlined in this document.

Background and Objectives: High-grade gliomas (HGGs) are aggressive primary brain tumors with a poor prognosis despite multimodal treatment. The anesthetic technique used during surgery may influence tumor progression and survival, but its role in HGGs remains unclear. This meta-analysis evaluated the effect of total intravenous anesthesia (TIVA) versus inhalational anesthesia (INHA) on overall survival (OS) and progression-free survival (PFS) in HGG patients. Materials and Methods: A systematic search was conducted in PubMed, Scopus, and Cochrane databases for studies assessing the impact of TIVA versus INHA on OS and PFS in HGG patients. Statistical analysis was performed using R version 4.3.1. Heterogeneity across studies was quantified using the Cochrane Q test alongside the I2 statistic. A random-effects model was employed to derive the pooled hazard ratios (HRs). Results: A total of five studies involving 827 participants (mean age 58 years, mean females 38%) were included, of whom 406 (49%) received TIVA. No statistically significant differences were observed in OS (HR 0.77; 95% CI [0.58–1.02]; p = 0.07; I2 = 67%) or PFS (HR 0.88; 95% CI [0.70–1.10]; p = 0.27; I2 = 51%) between the groups. A subgroup analysis revealed that TIVA was associated with improved OS in patients with grade IV tumors (HR 0.70; 95% CI [0.51–0.96]; p = 0.03), while no significant effect was observed in the mixed grade III–IV subgroup. However, the test for subgroup differences was not statistically significant (p = 0.0669), and this finding should be interpreted with caution. No significant differences were observed in median OS or PFS, or in single-arm meta-analyses. Conclusions: This meta-analysis found no statistically significant differences in overall or progression-free survival between TIVA and INHA in patients undergoing surgery for HGGs. Although a subgroup analysis suggested a possible survival advantage of TIVA in grade IV tumors, the lack of a statistically significant subgroup difference test limits the strength of this finding. Further investigation is needed to determine whether anesthetic technique influences outcomes in this subgroup.

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.

The American Society of Regional Anesthesia and Pain Medicine (ASRA) Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine includes an evidence- and expert opinion-based section on performing procedures on anesthetized or heavily sedated patients. This practice advisory is based on existing scientific literature, pathophysiological principles, and expert opinion. The advisory panel examined the ability of anesthetized or heavily sedated patients to recognize and report intravascular injection of local anesthetic or impending neurologic injury. The advisory panel also considered whether or not the ability to recognize and report symptoms could actually affect the occurrence of nerve injury or local anesthetic systemic toxicity. The advisory contains recommendations pertaining to both adult and pediatric patients.

Background It is unknown to what extent hypotension frequently observed following administration of propofol for induction of general anesthesia is caused by overdosing propofol. Unlike clinical signs, electroencephalon-based cerebral monitoring allows to detect and quantify an overdose of hypnotics. Therefore, we tested whether the use of an electroencephalon-based cerebral monitoring will cause less hypotension following induction with propofol. Methods Subjects were randomly assigned to a bispectral index (BIS)-guided (target range 40–60) or to a weight-related (2 mg.kg − 1 ) manual administration of propofol for induction of general anesthesia. The primary endpoint was the incidence of hypotension following the administration of propofol. Secondary endpoints included the degree of hypotension and correlations between BIS and drop in mean arterial pressure (MAP). Incidences were analyzed with Fisher’s Exact-test. Results Of the 240 patients enrolled into this study, 235 predominantly non-geriatric (median 48 years, 25th – 75th percentile 35–61 years) patients without severe concomitant disease (88% American Society of Anesthesiology physical status 1–2) undergoing ear, nose and throat surgery, ophthalmic surgery, and dermatologic surgery were analyzed. Patients who were manually administered propofol guided by BIS ( n  = 120) compared to those who were given propofol by weight ( n  = 115) did not differ concerning the incidence of hypotension (44% vs. 45%; p  = 0.87). Study groups were also similar regarding the maximal drop in MAP compared to baseline (33% vs. 30%) and the proportion of hypotensive events related to all measurements (17% vs. 19%). Final propofol induction doses in BIS group and NON-BIS group were similar (1.93 mg/kg vs. 2 mg/kg). There was no linear correlation between BIS and the drop in MAP at all times ( r  < 0.2 for all) except for a weak one at 6 min ( r  = 0.221). Conclusion Results of our study suggest that a BIS-guided compared to a weight-adjusted manual administration of propofol for induction of general anesthesia in non-geriatric patients will not lower the incidence and degree of arterial hypotension. Trial registration German Registry of Clinical Trials ( DRKS00010544 ), retrospectively registered on August 4, 2016.

Overview The Guidelines to the Practice of Anesthesia Revised Edition 2013 (the guidelines) were prepared by the Canadian Anesthesiologists’ Society (CAS), which reserves the right to determine their publication and distribution. Because the guidelines are subject to revision, updated versions are published annually. The Guidelines to the Practice of Anesthesia Revised Edition 2013 supersedes all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the society cannot guarantee any specific patient outcome. Each anesthesiologist should exercise his or her own professional judgement in determining the proper course of action for any patient’s circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

Children provided with general anaesthesia for dental extractions at East Surrey Hospital were audited to determine the percentage of children who were prescribed adequate pain management in accordance with guidance published by the Association of Paediatric Anaesthetists of Great Britain and Ireland. Three audit cycles were completed. Data were collected retrospectively through case note review. The results from the first cycle showed that only 47% of children were prescribed with a recommended analgesic regimen. Implementation of change included the development of a protocol for analgesic delivery, which was disseminated to the anaesthetic and dental teams. Full compliance with the audit standards was then demonstrated in the second and third cycles. This audit demonstrates the importance of multidisciplinary collaboration in order to provide high standards of care for children undergoing dental extractions under general anaesthesia. The protocol developed could be applied to other surgical day case procedures for children to improve the patient experience.

Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define-for the first time-the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally. The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries-who only made up 21% of the total attendees. To track global progress towards timely access to quality SAO care, these indicators-at the basic level-should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies.

•Accidental awareness in general anesthesia (AAGA) can result in litigations.•Bolam test states that “general medical practice” should be conformed with.•Complete documentation might protect us should AAGA happens.

Resting state-fMRI (rs-fMRI) in mice allows studying mechanisms underlying functional connectivity (FC) as well as alterations of FC occurring in murine models of neurological diseases. Mouse fMRI experiments are typically carried out under anesthesia to minimize animal movement and potential distress during examination. Yet, anesthesia inevitably affects FC patterns. Such effects have to be understood for proper interpretation of data. We have compared the influence of four commonly used anesthetics on rs-fMRI. Rs-fMRI data acquired under isoflurane, propofol, and urethane presented similar patterns when accounting for anesthesia depth. FC maps displayed bilateral correlation with respect to cortical seeds, but no significant inter-hemispheric striatal connectivity. In contrast, for medetomidine, we detected bilateral striatal but compromised inter-hemispheric cortical connectivity. The spatiotemporal patterns of the rs-fMRI signal have been rationalized considering anesthesia depth and pharmacodynamic properties of the anesthetics. Our results bridge the results from different studies from the burgeoning field of mouse rs-fMRI and offer a framework for understanding the influences of anesthetics on FC patterns. Utilizing this information, we suggest the combined use of medetomidine and isoflurane representing the two proposed classes of anesthetics; the combination of low doses of the two anesthetics retained strong correlations both within cortical and subcortical structures, without the potential seizure-inducing effects of medetomidine, rendering this regimen an attractive anesthesia for rs-fMRI in mice. •Analysis of modulatory effects by four anesthetics on mouse resting state-fMRI data.•Functional connectivity pattern relates to anesthetic depth and pharmacodynamics.•Functional connectivity patterns allow categorization of anesthetics in two classes.•Medetomidine/isoflurane combination retains cortical and subcortical connectivity.