This survey provides a snapshot of current practice and acts a useful reference for the development of enhanced techniques and new equipment in the future.
Introduction: Caudal extradural anaesthesia (CEA) is a common technique with wide application in paediatric anaesthesia [1]. An ‘on line’ World Wide Web survey of paediatric anaesthetists was undertaken to delineate any differences in the practice of this procedure. Methods: A web based questionnaire was devised to survey the practice of caudal extradural anaesthesia in children by anaesthetists who were members of the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI). The questionnaire was designed to collect information on the experience of the anaesthetist, techniques employed, drugs used and the use of the caudal extradural catheter technique for continuous extradural anaesthesia and analgesia. Results: E‐mails were sent to 600 anaesthetists and there were 366 useable on‐line replies. The majority of respondents had greater than 5 years of paediatric anaesthetic experience and performed up to ten caudal extradural procedures a month. The commonest device used was a cannula (69.7%) with 68.6% using a 22G device. Those with less than 15 years experience tended to employ a cannula while anaesthetists with greater than 15 years experience favoured a needle technique. Most anaesthetists (91.5%) did not believe that there was a clinically significant risk of implantation of dermoid tissue into the caudal extradural space. The majority of anaesthetists used a combination of clinical methods to confirm correct placement of a needle or cannula and injection of local anaesthetic into the caudal extradural space. Only 27 respondents indicated that they used ultrasound. The local anaesthetic agents used were bupivacaine (43.4%), levobupivacaine (41.7%), ropivacaine (13.4%) and lignocaine (1.5%). A total of 104 anaesthetists used more than one type of local anaesthetic. Drug additives used included clonidine (42.3%), ketamine (37.5%) and opioids (18.1%). The caudal catheter technique was used by 43.6% of anaesthetists. For a single shot caudal injection most anaesthetists (74%) used gloves only with fewer adopting the ‘no touch’ technique (15.2%) or use of glove, gown and mask (10.8%). Anaesthetists with greater than 10 years experience tended to use a ‘no touch’ technique. Discussion: Caudal extradural anaesthesia is an extremely common technique among those surveyed. Most anaesthetists use a cannula to access the caudal space which is in variance with the description of the technique in the peer review literature. However, the needle technique still tends to be used by anaesthetists with more than 15 years of experience. The majority of anaesthetists concur with the lack of evidence that there is a risk of implantation of dermoid tissue into the caudal extradural space. The anaesthetists surveyed tended to use a combination of simple clinical methods to identify correct placement of local anaesthetic in the caudal space. Ultrasound is rarely used. This may change when ultrasound become more readily available. Despite the greater safety margin of levobupivacaine, bupivacaine is used slight...
Anemic patients are at increased risk of intraoperative and postoperative transfusion, infection and mortality. Anemia is common in surgical patients, previous studies report a prevalence of 30-40%. While patient blood management programs advise screening for anemia, other perioperative initiatives advocate limiting preoperative laboratory testing. Therefore, a large number of surgical patients may not be screened, missing the opportunity for further investigation and management. In our single-center retrospective cohort study of all adult surgical patients over one year, we sought to estimate the proportion of anemia in patients without a preoperative blood test and their associated intraoperative and postoperative transfusion risk using multiple imputation to estimate missing hemoglobin values and inverse-probability-of-treatment-weighting to balance the study groups. Multiple imputation generated 39 datasets containing plausible hemoglobin values for patients missing a hemoglobin. Patients were classified as known-anemic, known-not-anemic, imputed-anemic and imputed-not-anemic if the hemoglobin was measured or imputed. We then compared red-cell transfusion yes/no by logistic regression, and number of red-cell units transfused by linear regression, pooling the results. Thirty-nine percent of 7879 patients were missing a hemoglobin, of whom 20-35% may be anemic. Only known-anemic patients had an increased intraoperative transfusion risk (odds ratio (OR) 3.13, 95% confidence interval (95%CI) 2.19 to 4.48). Both known-anemic and imputed-anemic patients had increased postoperative transfusion risk (OR 3.93 (95%CI 2.92 to 5.29), OR 2.99 (95%CI 1.61 to 5.56), respectively). Anemia may be common in patients missing a haemoglobin, and may confer an increased risk of postoperative transfusion compared to known-anemic patients. Removing them from observation studies on anemia risks sample bias. Excluding patients from pre-operative testing may miss the opportunity to identify anemia and modify postoperative transfusion risk and other adverse health outcomes. Future research could use point-of-care tests to reduce screening costs, and further investigate adverse outcomes risks in these missing patients.
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