Impact of an information booklet on patient satisfaction in anesthesia

OBJECTIVE: The aim of this study was to evaluate the satisfaction of adult surgical patients before and after an information booklet concerning anaesthetic techniques and complications, and postoperative management has been proposed during preanaesthetic visits. STUDY DESIGN: Survey. METHOD: Three surveys have been performed using an anonymous questionnaire of 25 items with graduated answers (very good, good, bad, very bad, no opinion) concerning patient satisfaction on structure, physician behavior, information and well being. As the results of the first two surveys were not significantly different, an information booklet was proposed to patients during preanaesthetic visits, then a third survey ("After") was realized. The results of this survey were compared to the combined results of the first two surveys ("Before"). RESULTS: In the "before" survey, 60 to 76% of the patients were satisfied (very good and good) of the information delivered during preanaesthetic visits. The proportion of patients satisfied of the information concerning anaesthetic techniques, transfusion and recovery were significantly higher in the "after" survey (P < 0.05). CONCLUSION: An information booklet on anaesthesia increases patient satisfaction on information provided during preanaesthetic visits.     

Risk of unanticipated intraoperative events in patients assessed at a preanaesthetic clinic

Purpose

To determine the risk of unanticipated intraoperative events (UIE) in patients assessed at a preanaesthetic clinic compared with those not assessed at the clinic.

Methods

Preoperative and intraoperative data were collected on 6130 elective surgical patients by procedural anaesthetists over a 12-month period at an Australian tertiary referral hospital. The procedural anaesthetists rated the level of preparation and identified predefined unanticipated intraoperative events. A logistic regression model was used to identify significant risk factors of UIE and was further validated on another sample of 482 patients (one month) by a goodness-of-fit test.

Results

Of the 6130 elective surgical patients, 2000 (33%) had been assessed at the preanaesthetic clinic. There was a greater proportion of ASA II to IV patients seen at the clinic than patients not assessed at the clinic (χ₂ ³=689.92, P < 0.001). Nondinic patients were more likely to be inadequately prepared than clinic patients (RR_unadjusted= 1.61, 95%Cl: 1.25 to 2.04. P < 0.001). The overall incidence of intraoperative events was 4.14% (95%Cl: 3.64% to 4.64%). Despite adjusting for the preparation level, type of anaesthesia, admission category, ASA physical status and duration of anaesthesia, clinic patients were 1.94 (95%Cl: 1.42 to 2.64) times more likely to experience an UIE than nondinic patients (P < 0.001).

Conclusion

Although clinic patients were more often optimally prepared, their adjusted risk of UIE was higher than nondinic patients. The procedural anaesthetist needs to be vigilant with these high risk patients, even if they have been assessed at a preanaesthetic clinic.     

Difficult intubation in patients with endotracheal prosthesis

We report a case of two consecutive episodes of difficult intubation in a patient with an endotracheal Dumon's prosthesis inserted two years before. Despite several preanaesthetic visits and ENT examination, the absence of recollection by the patient and the lack of information in her previous medical records led to the impossibility to introduce a normal tube into her trachea during two consecutive anaesthetic procedures. This case points out the limits of preanaesthetic visits. It allows to remind special measures that must be taken in patients having tracheal prosthesis and scheduled for anaesthesia and surgery.     

Evaluation of the off-site preanaesthetic consult in Lorraine

OBJECTIVES: To evaluate the results of Off Site preanaesthetic consult in Lorraine and to draw up a method for these pre-operative visits. STUDY DESIGN: Two surveys of the Lorraine-regional practice (from both the anaesthetists and surgeons from Lorraine) and one survey of patient satisfaction. PATIENTS AND METHOD: Questionnaires were sent by mail to all anaesthetists (n=270) and surgeons (n=339) in the Lorraine region. In the immediate postoperative period, specific questionnaires were sent by mail to selected patient groups (n=73 in each group), one group having and the other (control) not having Off Site preanaesthetic consult. RESULTS: Anaesthetists' survey: 48.4% of interviewed anaesthetists belonged to the pre-anaesthetic consult network. 81.2% of these anaesthetists performed Off Site pre-anaesthetic consult. The main recognized advantages were patient comfort (89.6%) and cost effectiveness (57.3%). 26.1% of anaesthetists who did not participate to the network were strongly opposed to this practice, while 60.9% were prepared to enter the network. Surgeons' survey: 15.6% of surgeons were not satisfied that anaesthetists in their institutions practiced the Off Site pre-anaesthetic consult. Patients' survey: no difference in satisfaction towards the quality of information delivered during the consultation (anaesthetic technique, analgesia and evaluation of the perioperative risk) nor in terms of perioperative anxiety. The average transportation distance spared by Off Site preanaesthetic Consult was 98 miles. CONCLUSION: Off Site preanaesthetic consult may have real benefits in terms of, patient satisfaction, comfort and cost-effectiveness. In the Lorraine region, a majority of anaesthetists has experience with this practice.     

Videoassistierte Patientenaufklärung in der Anästhesiologie

In video-assisted patient education (ViPa), patients watch an educational video about the process and the risks of anaesthesia in addition to the preanaesthetic interview with the anaesthesiologist. Used as a supplement to the preanaesthetic visit, the videos can increase patients' knowledge and satisfaction without having any negative effect on perioperative anxiety. Because the video graphically depicts the basic information, the preanaesthetic visit can then focus on specific aspects of the individual patient, i.e. high anxiety or specific questions. The redundant and monotonous explanations about the procedures and risks of anaesthesia by the interviewing anaesthesiologist are partly replaced by the video, but for medico-legal reasons the ViPa cannot totally replace the preanesthetic interview. It can be used in pediatric anaesthesia and reduces parental anxiety. Because of the lack of studies, the effects of the ViPa on perioperative patient compliance, especially for outpatient surgery, and on the economics of anaesthesia clinics are unclear.     

Anaesthetic management of Osler-Weber-Rendu syndrome with coexisting congenital methaemoglobinaemia

A 9-year-old cyanosed child suffering from Osler-Weber-Rendu syndrome with bilateral pulmonary arteriovenous malformations (PAVMs) was posted for cerebral angiography under general anaesthesia. Careful preanaesthetic evaluation led to the diagnosis of coexisting congenital methaemoglobinaemia. There is no previous report of Osler-Weber-Rendu syndrome coexisting with congenital methaemoglobinaemia. This report emphasizes that a second contributory cause of cyanosis must be suspected and meticulously looked for if the symptomatology in a patient cannot be explained by a single established diagnosis. Positive-pressure ventilation was associated with reduction in arterial oxygenation despite an increasing inspired oxygen concentration, which returned to preanaesthetic levels only after extubation and resumption of spontaneous respiration.     

Precursor B-cell lymphoblastic leukemia as a cause of a bilateral nephromegaly

Nephromegaly and non-oliguric acute renal failure is an unusual manifestation of lymphoblastic infiltration of the kidneys. We report the clinical history of a female child where a precursor B-cell lymphoblastic proliferation was diagnosed at the age of 21 months by a surgical renal biopsy for an unexplained bilateral nephromegaly. Lymphoblastic infiltration should be suspected in any patient presenting with unexplained renal failure and enlarged kidneys. The importance of renal biopsy to identify the etiology of renal failure and nephromegaly is emphasized.     

Anaesthetic management of a patient with glycogen storage disease type 1b

Purpose

A rare case of a ten-year old patient with type 1b glycogen storage disease (CSD), scheduled for extracorporeal shockwave lithotripsy (ESWL), is described.

Clinical features

Patients with type 1b GSD manifest a range of clinical symptoms, including mental retardation, hepato-splenomegaly, renal enlargement, stomatitis, hypoglycaemic convulsions, bleeding diathesis, lactic acidosis and leukopaenia, thus creating a challenge for the anaesthetist. Following preanaesthetic administration of glucose-containing fluids, general anaesthesia was induced and the patient was mechanically ventilated. Except for mild hypoglycaemia after induction of anaesthesia, and moderate intraoperative metabolic acidosis which was attributed to the underlying disorder, anaesthesia was uneventful. No postoperative complications occurred and the patient was discharged home three days after lithotripsy. Clinical features of this rare inborn error of metabolism are reviewed and the approach for the anaesthetic management is discussed.

Conclusions

A skillful perioperative management of patients with type 1b CSD can be achieved by cautious attention to the metabolic and homeostatic derangements that occur with the disease.     

Massive blood loss during tonsillectomy in a child with congenital venous malformation

Tonsillectomy and adenoidectomy have become frequently performed outpatient procedures and are generally considered to have a low morbidity profile. Postoperative haemorrhage remains a rare but important complication, while intraoperative uncontrollable bleeding is extremely uncommon. A child with congenital vascular malformation of the lip and oropharynx undergoing tonsillectomy experienced massive blood loss, subsequent resuscitation and significant perioperative morbidity including a prolonged intensive care unit stay. Preoperative/preanaesthetic nasopharyngoscopic exam and magnetic resonance imaging did not reveal vascular prominence of the tonsils. Preoperative consideration of angiography or magnetic resonance angiography may be prudent to avoid this potentially fatal complication.     

How much diagnostics in patients with pancreatic cancer?

The possibilities which actually exist in order to obtain an earlier diagnosis in pancreatic carcinoma, a better differentiation of mass-forming pancreatitis and of other pancreatic tumors and an improved staging for reducing unnecessary operations are presented and evaluated. Possible relevant hints of the history and indicators for diagnostic procedures in view of a pancreatic carcinoma are upper abdominal complaints especially in relation to a new developed diabetes mellitus and/or unexplained elevations of pancreatic enzymes. The endosonography in combination with a target biopsy is of important value as well for the diagnosis of pancreatic cancer as for differentiation against a segmental chronic pancreatitis. In cases where differentiation is impossible even intraoperatively, we recommend the use of intraoperative fine needle biopsy.     

Perioperative transoesophageal echocardiography with low-dose dobutamine stress for evaluation of myocardial viability: a feasible approach?

Background : The feasibility of low-dose dobutamine stress combined with transoesophageal echocardiography (TEE) to detect viable left ventricular myocardium was evaluated in 22 anaesthetised patients prior to sternotomy for elective coronary artery bypass grafting (CABG). Methods :After baseline measurements, a dobutamine infusion beginning with 5 μg . kg^-1 . min^-1 was started and eventually increased to 10 μg . kg^-1 . min^-1. Viability was assessed as visual improvement of left ventricular wall motion (LVWM). The criteria for discontinuation of the infusion were: 1. any changes in LVWM, 2. an increase in preanaesthetic blood pressure exceeding 40 MMHg, and/or a >20% increase in preanaesthetic heart rate compared to preanaesthetic levels. An off-line evaluation of LVWM was based upon visualisation of the left ventricle in a transgastric short-axis mid-papillary (mid-P) view, and the left ventricle was divided into anterior, septal, inferior, and lateral segments. Moreover, an off-line semiautomatic analysing system was used for assessing regional and global LVWM. With this analysis the effects on LVWM from changes in preload and afterload could be addressed. Results : 19 patients showed a decreased LVWM in one or several segments at baseline. A total of 36 segments exhibited decreased LVWM (an average of 1.9 segments/patient). Of these, 22 segments (61%) improved with dobutamine, while 12 segments (33%) did not, and 2 (6%) became more dysfunctional. Another 6 segments with normal motion at baseline became dysfunctional with dobutamine. According to the off-line semiautomatic analysing system for LVWM, there were no statistically significant changes with dobutamine stimulation. Only one patient showed an increased postoperative aspartateamino-transferase (ASAT) value (3.0 mmol . 1^-1) but no ECG changes. Conclusion : Since we regard the visual assessment of LVWM as being more applicable for this protocol than the semiautomatic analysis, we conclude that low-dose dobutamine stress echocardiography seems to be a feasible method for detecting viable myocardium in the anaesthetised patient scheduled for elective CABG surgery. However, the semiautomatic analysis complemented our findings, since the variations in pre- and afterload did not significantly change the size of the left ventricle, which hereby would imply LVWM changes.     

Informed consent and patient participation in the medical encounter: a list of questions for an informed choice about the type of anaesthesia

The present study was undertaken to evaluate the impact of a new procedure for eliciting informed consent by patients undergoing minor surgical procedures, in which the choice between general anaesthesia (GA) and regional anaesthesia (RA) was possible. In this prospective study, two randomly selected groups of patients were compared: study group (SG), 52 patients, received from the nurse before the preoperative interview, a list of seven questions, which they were invited to ask the anaesthetist; while the control group (CG), 73 patients, did not receive any suggested questions. There were two end points: the proportion that chose RA and the number of questions actually addressed to the doctor at the preanaesthetic interview. Psychological aspects were taken into account by collecting the Hospital Anxiety and Depression (HAD) scale before the preanaesthetic interview. Satisfaction with the interview was recorded using a telephone questionnaire 2 weeks after the operation. The results from the two groups were compared by calculating the odds ratio according to Mantel-Haenszel and by logistic analysis. Altogether, 71.2% of the patients chose RA without any difference between the groups. The average number of questions asked by each SG patient was higher than for the CG (1.67 vs. 0.96). The satisfaction level was similar in the two groups. Our list of questions was designed to facilitate patient autonomy. It offered an aid to those requesting more information and assisted communication. The method did not change the proportion who chose a specific kind of anaesthesia, but does seem to improve patient participation in the decision-making process.     

Paraduodenal hernia: an uncommon cause of recurrent abdominal pain

Internal abdominal hernias are a rare entity and may cause unexplained abdominal pain. This report concerns a 46 year old male patient, with a four year history of episodic colicky peristaltic abdominal pains, in whom a left paraduodenal hernia was found at surgical exploration after a negative diagnostic screening by ultrasound, CT and small bowel enema. Upon laparotomy the Authors found a left-sided paraduodenal hernia with an empty herniated sack. Repair of the hernial defect resulted in the complete and stable resolution of abdominal symptoms. The importance of considering paraduodenal hernias in the differential diagnosis of unexplained intermittent abdominal pain is discussed.     

非体外循环冠状动脉旁路移植术患者术中急性心功能失代偿的危险因素

目的 筛选非体外循环冠状动脉旁路移植术(OPCABG)患者术中发生急性心功能失代偿的危险因素.方法 选择本院2007年11月至2009年2月行OPCABG的患者2379例,记录术前、术中与急性心功能失代偿可能有关的因素.根据是否发生急性心功能失代偿,分为2组:急性心功能失代偿组和非急性心功能失代偿组.采用1ogistic多元回归分析,筛选发生急性心功能失代偿的危险因素.结果 术中发生急性心功能失代偿368例(发生率15.5%),无一例患者死亡.logistic多元回归分析显示,室壁瘤、术中房颤、术中频发性室性期前收缩、术前射血分数＜40%、术前室性期前收缩、合并瓣膜病、心肌梗死史、入室心动过速、急诊手术、左主干病变为术中发生急性心功能失代偿的危险因素.结论 术前合并室壁瘤、瓣膜病变、左主干病变、心肌梗死史、术前室性期前收缩、射血分数＜40%,术中房颤、频发性室性期前收缩、入室心动过速和急诊手术为OPCABG患者术中发生急性心功能失代偿的危险因素.     

Laparoscopic cholecystectomy: new indications.

Laparoscopic cholecystectomy was performed on 65 unselected and consecutive patients, regardless of age, weight, history of abdominal surgery or presence of acute cholecystitis. All procedures were completed successfully, with only two patients converted to an open cholecystectomy. There were no intra-abdominal intraoperative complications; n o intraoperative transfusions were required. There were no intra-abdominal injuries, and no patient required repeat surgery for postoperative complications. Hospital stays averaged 30 hours, and the average time until patients resumed normal activities was 6 days.     

Spontaneous chronic subdural hematomas in young adults with a deficiency in coagulation factor XIII. Report of three cases

Chronic subdural hematomas (SDHs) generally occur in elderly patients. Its pathogenesis is usually related to head trauma with tearing and rupture of the bridging veins, although in some cases a history of trauma is not recognizable. There are many reports regarding the association between spontaneous chronic SDHs and an alteration in coagulative parameters. A coagulative disorder should be suspected when an unexplained hemorrhage occurs, especially in a young patient. The authors report on three young men with a deficiency in coagulation factor XIII (FXIII) who underwent surgery for chronic SDHs. The role of FXIII in the pathogenesis of chronic SDH is emphasized. In patients with unexplained chronic SDH all coagulation parameters and factors should be screened to identify an eventual coagulative disorder.     

Decreased factor XIII availability for thrombin and early loss of clot firmness in patients with unexplained intraoperative bleeding

To explore relevant changes in unexplained intraoperative bleeding, we evaluated elements of the final steps of the coagulation cascade in 226 consecutive patients undergoing elective surgery. Patients were stratified for the occurrence of unexplained intraoperative bleeding according to predefined criteria. Twenty patients (8.8%) developed unexplained bleeding. The median intraoperative blood loss was 1350 mL (bleeders) and 400 mL (nonbleeders) (P < 0.001). Fibrinogen and Factor XIII (F. XIII) were more rapidly consumed in bleeders (P < 0.001). Soluble fibrin formation (fibrin monomer) was increased in bleeders throughout surgery (P < or = 0.014). However, F. XIII availability per unit thrombin generated was significantly decreased in bleeders before, during, and after surgery (P < or = 0.051). Computerized thrombelastography showed a parallel, significant reduction in clot firmness. We suggest that mild preexisting coagulopathy is not rare in surgical patients and probably can result in clinically relevant intraoperative bleeding. This hemostatic disorder shows impaired clot firmness, probably secondary to decreased cross-linking (due to a loss of F. XIII, both in absolute measures and per unit thrombin generated). We suggest that the application of F. XIII might be worthwhile to test in a prospective clinical trial to increase clot firmness in patients at risk for this intraoperative coagulopathy.     

The value of anesthesia consultation in relation to the single preanesthetic visit

OBJECTIVE: In France, a preanaesthetic assessment (PAA) several days prior to hospital admission for a scheduled surgical or diagnostic procedure under anaesthesia, associated with a preanaesthetic visit (PAV) the day before, are compulsory. This study aimed at comparing the benefits of PAA with those of a PAV not preceded by a PAA. STUDY DESIGN: Prospective, controlled, randomized study. PATIENTS: The study included 296 patients undergoing either a urologic, or ophthalmologic, or ENT procedure, randomly allocated either to a PAA (followed by a PAV) group or a PAV (without previous PAA) group. METHODS: The main criterion of comparison was the duration of preanaesthetic hospital stay and the secondary criteria were the incidence of procedure postponements and patients' satisfaction respectively. RESULTS: In the PAA group, the preanaesthetic hospital stay was shorter by 0.4 days (P = 0.001). Out of the 19 postponed procedures (7%), the cause of postponement was a medical one in 15 patients: 13 in the PAV group and 2 in the PAA group respectively (P = 0.009). The PAA was not considered as a constraint by most patients. CONCLUSION: The PAA shortens the duration of preanaesthetic hospital stay and decreases the incidence of procedures postponed for a medical cause.     

Heparin-induced thrombocytopenia and the anesthesiologist.

PURPOSE: All physicians who use heparin should be aware of immune heparin-induced thrombocytopenia (HIT), including anesthesiologists who may need to provide intraoperative anticoagulation for a patient who urgently requires cardiac or vascular surgery but who has acute HIT or a history of recent HIT. SOURCE: The literature dealing with HIT of relevance to anesthesiologists was reviewed, including studies of HIT antibody formation following intraoperative use of heparin; acute respiratory or cardiac arrest following i.v. bolus heparin indicating rapid-onset HIT; acute thrombocytopenia and thrombosis complicating intraoperative heparin use; circumstances in which it might be acceptable to administer heparin despite a previous history of immune HIT; and alternative anticoagulant approaches that can be used to manage cardiac or vascular surgery in a patient with acute or recent HIT. PRINCIPAL FINDINGS: Intraoperative exposure to heparin can trigger formation of HIT antibodies, and occasionally even lead to "delayed-onset" HIT. Acute respiratory or cardiac arrest following i.v. bolus heparin, or the abrupt occurrence of intraoperative "white clots," suggests a diagnosis of rapid-onset HIT, particularly if the patient recently received heparin. Several approaches are available to manage cardiac or vascular surgery in a patient with acute or recent HIT, so the treatment chosen depends upon local experience and monitoring capabilities. Several months after acute HIT, and particularly when HIT antibodies are no longer detectable, it may be acceptable to use heparin for intraoperative anticoagulation. CONCLUSION: HIT is an infrequent but important topic for anesthesiologists because of the urgency and complexity of the various associated management issues.     

Radial neuropathy after peripheral venous puncture

We report a case of left radial neuropathy from a venipuncture, in a 59-year-old woman. She had a history of amputation of the four last fingers of the right hand, when she was 27-year-old. One year before, she had a difficult venipuncture of the left radial vein, for a preanaesthetic assessment for cataract surgery. The puncture elicited an excruciating pain, associated with hypoaesthesia in the area of the radial nerve, at forearm and the wrist. Conventional therapeutic means had only a minor efficiency. The concept of nervous system sensitizing is discussed. Prevention is essential.