SummarySixty gynaecological day-case patients were anaesthetised with either desflurane or sevoflurane in oxygen/nitrous oxide, following intravenous induction. Mean end-tidal desflurane was 4.5% at 5 and 10 min post induction, whereas mean end-tidal sevoflurane was 1.7%. There were five untoward airway events (coughing, hiccoughs) in the desflurane group and three in the sevoflurane group, including one laryngospasm. Time to eye opening and orientation following anaesthesia were significantly faster in the desflurane group (2.8 min/4.8 min) than in the sevoflurane group (7.0 min/9.8 min; p , 0.0001). Time to being ready for discharge home was also significantly earlier in the desflurane group (3 h compared with 3.5 h). Telephone interview on the first postoperative day showed that in the desflurane group 29 of 31 were fully returned to normal activity compared with only 15 out of 29 in the sevoflurane group (p , 0.01).Keywords Anaesthetics, volatile: desflurane; sevoflurane. Surgery: day-case; gynaecology. The use of low-solubility inhalation agents can be of benefit to day-case anaesthesia as it allows more rapid emergence and recovery [1±3] and should hasten return to street fitness, although there are comparatively few studies to support this. The inhalation agents sevoflurane and desflurane have lower blood-gas solubility, which should result in rapid induction but, more importantly, rapid awakening [4]. However, there have been few direct comparisons of the two agents. A study on ventilated gynaecological laparosocopy patients showed a faster early recovery with desflurane than with sevoflurane [5], and another on day-case orthopaedic arthroscopy patients found faster recovery, but no faster discharge [6].However, although it possesses lower blood-gas solubility than sevoflurane, desflurane can be irritant to airways [7]. Therefore, sevoflurane is generally considered to be the agent of choice for day-case anaesthesia with spontaneous respiration for short cases, despite possibly faster recovery with desflurane. We wished to compare the efficacy of desflurane and sevoflurane for short daycase procedures in gynaecological day-case surgery. MethodsFollowing local research committee approval, 63 patients scheduled for minor day-case gynaecological surgery (D & C, hysteroscopy and suction termination of pregnancy) were randomly allocated to one of two groups. All patients were aged between 16 and 75 years, ASA 1 and 2, could speak English and would be contactable by telephone the next day. No patient was distressed by the forthcoming procedure and all had satisfactory domestic arrangements following the planned day-case discharge. They all had the nature of the study explained on the day of admission and gave written informed consent. No premedication was given.On arrival in the anaesthetic room, all patients had a venous cannula inserted and were given metoclopamide q 2001 Blackwell Science Ltd 171 10 mg, fentanyl 50 mg and propofol 2 mg.kg 21 . Patients were randomly allocated by sealed envelope to receive e...
SummaryDrug related incidents are a common form of reported medical errors. This paper reviews the critical incidents related to drug errors reported from the main operating theatre suite in a teaching hospital in a developing country from January 1997 to December 2002. Each report was evaluated individually by two reviewers using a structured process. During this period, 44 874 anaesthetics were administered; 768 critical incidents were reported, 165 (21%) of which were related to drug errors. Underdosage, side-effect ⁄ drug reaction and syringe swap were the most common. A total of 76% were classified as preventable; 56% due to human error and 19% due to system error. High risk incidents accounted for 10% of all drug errors and most of these were related to the use of neuromuscular blocking drugs. This analysis has been found useful in addressing some issues about priorities.
Background and Aims:Propofol, the most commonly used intravenous (IV) anesthetic agent is associated with hypotension on induction of anesthesia. Different methods have been used to prevent hypotension but with variable results. The objective of this study was to evaluate efficacy of equipotent doses of phenylpehrine and ephedrine in preventing the hypotensive response to the induction dose of propofol.Material and Methods:One hundred thirty five adult patients were randomised to one of the study groups: propofol-saline (PS), propofol-phenylephrine (PP) or propofol-ephedrine (PE) by adding study drugs to propofol. Anesthesia was induced with a mixture of propofol and the study drug. Patients were manually mask-ventilated for 5 min using 40% oxygen in nitrous oxide and isoflurane at 1%. A baseline mean arterial pressure (MAP) was recorded prior to induction of anesthesia. Systolic, diastolic and mean blood pressure and heart rate were recorded every minute for up to 5 min after induction. Hypotension was defined as a 20% decrease from the baseline MAP.Results:There were no significant demographic differences between the groups. Overall incidence of hypotension in this study was 38.5% (52/135). Rate of hypotension was significantly higher in group PS than group PP (60% vs. 24.4% P = 0.001) and group PE (60% vs. 31.1% P = 0.005). In contrast, a significant difference in rate of hypotension was not observed between groups PP and group PE.Conclusion:In equipotent doses, phenylephrine is as good as ephedrine in preventing the hypotensive response to an induction dose of propofol.
Therapeutic plasma apheresis or exchange (TPE) in the pediatric population is technically challenging. Moreover, there is generally an apprehension in using TPE in children compared to adults. Recently, usage of TPE has evolved and is now being used in heterogenous clinical conditions. Its usefulness is classified by the American Society for Apheresis (ASFA) into various categories ranging from I to IV. The objective of this paper was to review the procedure in context of clinical indications, complications and outcomes in children. For this purpose, we retrospectively reviewed all TPE procedures performed on inpatients of 3 to 16 years of age during a 6-year period (2007-2012). A total of 130 procedures were performed on 28 patients (M : F ratio of 1:1) with median age (range) of 8.8 (4-16) years. All procedures were done using the continuous cell-separator centrifugal method. Due to organ dysfunctions, the majority of procedures (N = 26 of 28 or 92% patients) were performed in the pediatric intensive care unit. Twenty-three, four and one patient belonged to ASFA categories I, II and III, respectively. The most common indications were neurological disorders (N = 13 or 46.4%), comprised of Guillain-Barré syndrome (N = 10) and myasthenia gravis (N = 3). Hematological disorders (N = 10 or 35.7%) including thrombotic thrombocytopenic purpura-hemolytic uremic syndrome were a close second. Complete recovery was seen in 23 patients (84%). Trivial adverse effects were observed in 18/130 (13.8%) procedures. Major complications including cardiac arrest, hypotension and transfusion-related acute lung injury were observed in 5/130 or 3.8% of procedures. However, there was no procedure-related death though five patients died during treatment due to underlying pathology. In conclusion, TPE is a safe and effective option in sick children for appropriate indications. An experienced staff with sound procedural skills is imperative for successful therapy.
BackgroundDiarrhoeal disease accounts for millions of child deaths every year. Although the role of flies as vectors of infectious diarrhoea has been established, fly control is not often mentioned as an approach to decrease childhood diarrhoea. Theoretically, fly control for decreasing diarrhoea incidence can be achieved by intervening at four different levels: reduction or elimination of fly breeding sites; reduction of sources that attract houseflies; prevention of contact between flies and disease‐causing organisms; and protection of people, food, and food utensils from contact with flies.ObjectivesTo assess the impact of various housefly control measures on the incidence of diarrhoea and its related morbidity and mortality in children under five years of age.Search methodsWe searched electronic databases including the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase, CINAHL, and LILACS, from database inception to 24 May 2018. We also searched trial registries for relevant grey literature and ongoing trials. We checked the references of the identified studies and reviews. We did not apply any filters for language, publication status (published, unpublished, in press, and ongoing), or publication date.Selection criteriaWe planned to include randomized controlled trials (RCTs), quasi‐RCTs, and controlled before‐and‐after studies that studied the effect of fly control on diarrhoea in children under five years of age.Data collection and analysisTwo review authors extracted the data and independently assessed the risk of bias in the included study. We planned to contact study authors for additional information, where necessary. We assessed the certainty of the evidence using the GRADE approach.Main resultsWe included one cluster‐RCT (491 participants) conducted in Pakistan that evaluated insecticide spraying in the first two years and baited fly traps in the third year. Insecticide spraying reduced the fly population (house index) in the intervention group during the four months of the year when both flies and cases of diarrhoea were more common, but not at other times. On average, this was associated with a reduction in the incidence of diarrhoea in the first year (illustrative mean episodes per child‐year in the intervention group was 6.3 while in the control group was 7.1) and second year of the intervention (illustrative mean episodes per child‒year in the intervention group was 4.4 while in the control group was 6.5; rate ratio (RaR) 0.77, 95% confidence interval (CI) 0.67 to 0.89, low‐certainty evidence). In the third year of the intervention, the baited fly traps did not demonstrate an effect on the fly population or on diarrhoea incidence (RaR 1.15, 95% CI 0.90 to 1.47, low‐certainty evidence).Authors' conclusionsThe trial, conducted in a setting where there were clear seasonal peaks in fly numbers and associated diarrhoea, shows insecticide spraying may reduce diarrhoea in children. Further research on whether this finding is applicable to other setting is r...
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