Dexmedetomidine: perioperative applications in children

Dexmedetomidine is a highly specific and selective alpha‐2‐adrenergic agonist with sedative, anxiolytic, and organ protective effects. Its clinical applications in children include premedication, prevention of emergence delirium, as part of multimodal anesthetic regimen and sedation in the pediatric intensive care unit. Its role in neuroprotection in children undergoing anesthesia should be explored. In this review, various uses of dexmedetomidine are discussed in detail.     

A baseline audit of the efficacy and safety of an acute pain service (APS) for cesarean section patients

This study was conducted as a baseline audit to evaluate the efficacy and safety of an acute pain service (APS) using recent new postoperative analgesic techniques for Chinese patients undergoing cesarean delivery, against which to assess future practice. This was a prospective study conducted in a 12-month period on ASA one to two women presenting at term for elective or emergency cesarean section in our hospital. All patients received a standard general anaesthesia, spinal or epidural anaesthesia for surgery deemed suitable by the attending anaesthetist. The patients were allocated to either receive intrathecal morphine or intravenous patient-controlled analgesia (PCA) morphine for postoperative analgesia. Intrathecal morphine was given to patients that received spinal anaesthesia and patient approval. The rest of the patients received a PCA. In addition, all patients were given non-opioid analgesics, for postoperative analgesia. Postoperative pain, patient satisfaction, adverse effects and complications were assessed. Four hundred and sixty-five patients were treated with patient-controlled analgesia (244 patients) or intrathecal morphine (221 patients). The mean age was 31 (17–44) years and body weight 67 (46–101) kg. Method of anaesthesia included general anaesthesia (45 patients), spinal anaesthesia (305 patients) and epidural anaesthesia (115 patients). Pain control was good: less than 1.3% of patients complained of severe postoperative pain. Complete patient satisfaction with the method of analgesia was 92.2%; partial satisfaction 7.3% and less than 0.5% was dissatisfied. Adverse effects and complications included nausea and vomiting (11%), pruritus (29%), sedation (0.2%), dizziness (10%), urinary retention (51%), postdural puncture headache (0.4%) and wound infection (2%). Our experience provides a useful baseline audit data in the Chinese population against which to assess and improve future practice.     

What outcomes should be measured after anaesthesia?

Assessment of the quality of anaesthesia care requires clinically orientated, process of care measures and the measurement of client-assessed (patient and surgeon) outcomes. Anaesthetists and patients believe that mortality, post-operative nausea and vomiting, post-operative pain and awareness are important clinical outcomes to avoid. Process of care measures, such as prolonged stay in the recovery room, unanticipated intensive care unit admissions and unanticipated admission to hospital in ambulatory surgical patients are surrogate markers of anaesthetic outcomes. Patient and surgeons' satisfaction and quality of recovery measures are increasingly being used but require further research to establish reliability and validity before they are widely accepted in clinical trials, economic analyses and quality assurance programmes. Outcomes may be used to set standards of practice after considering their limitations.     

Quality in healthcare: process

Recent studies have shown startling rates of adverse events and preventable mortality in hospitalised patients around the world. Research using root cause analysis and incident monitoring has improved our understanding of why these errors occur. These approaches are useful in identifying contributing factors and stakeholders involved in adverse and sentinel events. The factors that contribute to these events have been well described, and range from institutional and management decisions down to the individual health care professionals involved and the environment they work in. We discuss healthcare processes, and present a proactive approach of workflow process modelling using sequence diagrams to identify the factors involved. These diagrams can then be used in conjunction with simple calculations for risk analysis to prioritise the value of interventions at different steps of the healthcare process. We discuss how these analyses can be used to plan interventions to improve patient safety and quality of healthcare.     

Postincisional local anaesthetic infiltration of the rectus muscle decreases early pain and morphine consumption after abdominal hysterectomy

We conducted a randomized, double-blind study to evaluate the degree to which selective infiltration of the rectus muscle may influence pain and morphine requirements after major intra-abdominal surgery 6 h postoperatively. One hundred Chinese patients presenting for elective total abdominal hysterectomy received a standard general anaesthetic and were randomly divided into two groups to receive intramuscular injection of 0.4 ml kg⁻¹ of either bupivacaine 0.5 or 0.9% saline (maximum to 20 ml) to the rectus muscle wound at the end of surgery. The mean hourly pain (visual analogue score (VAS)) was statistically significant at 0–2 and 4 h while mean hourly morphine consumption was statistically significant at 1, 2 and 4 h postoperatively between the two groups (P<0.05). Total morphine consumption at 6 h postoperative was significantly reduced from 21.7 mg (mean) and 20 mg (median) in the saline group to 12.8 mg (mean) and 12 mg (median) in the bupivacaine group respectively (P<0.05). These results indicate that the rectus muscle is an important origin, and injury and spasm of this muscle potential mechanisms, of pain in the early postoperative period after abdominal hysterectomy.     

Patient-controlled sedation: A comparison of sedation prior to and until the end of minor oral surgery

In order to find out whether patient-controlled sedation carried out only prior to surgery was sufficient for patients to undergo minor oral surgery, 30 patients of either sex between the ages of 16 and 30 years were selected. Each was scheduled to undergo bilateral third molar surgery, one side only at a visit. At the first visit each patient was randomly allocated to receive patient-controlled sedation with midazolam either only prior to, or to the end of surgery. At the second visit they received the alternative method of sedation when the operation was carried out on the opposite side. With both techniques the majority of the patients were relaxed and provided good operating conditions with stable vital signs and without loss of consciousness. However, when given the opportunity to sedate themselves until the end of surgery, 70 percent obtained increments during surgery; four were assessed to have marked sedation and in five the button dropped off. When questioned at the end of both procedures, 87 per cent preferred to have increments during surgery.