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BACKGROUND: Delay in diagnosis of anaemia during preoperative assessment poses logistic problems, leading to multiple clinic visits, inadequate preoperative management, and unnecessary delay of surgery. Therefore, we tested an instant spectrophotometric haemoglobin (SpHb) measurement technique to facilitate this assessment. METHODS: We evaluated portable instant SpHb vs standard laboratory screening of anaemia between March 2012 and December 2013. Paired Hb measurements were performed on 726 patients using SpHb (Pronto-7, Masimo Corporation, Irvine, CA, USA) and Hb measured on the same day using an automated analyser. The results were obtained from a group of 638 patients from the pre-anaesthetic clinic with expected normal Hb values, and 88 patients from the oncology clinic with known low Hb. RESULTS: Median (range) SpHb was 129.5 (67-171) compared with 136 g litre(-1) (63-178) Hb measured using the automated system. Identifying Hb below a threshold of 130 g litre(-1) for males had a high sensitivity (93%), while identifying a threshold of 120 g litre(-1) for females had lower sensitivity (75%). The specificity for males (77%) and females (81%) was similar. Mean measurement bias and agreement: tolerability interval ratio was -8.1 g litre(-1) and 2.78 for men and -3.1 g litre(-1) and 2.44 for women. CONCLUSIONS: SpHb was sensitive as a preliminary screening tool for detecting true low Hb values in males, but less sensitive in females. Instant SpHb measurement may enable prompt routine preoperative anaemia management, but its precision was lower than expected. CLINICAL TRIAL REGISTRATION: This study is approved by the Tasmanian Human Ethics Committee, Australia and was registered prospectively in the Australian and New Zealand Clinical Trials Registry (http://www.ANZCTR.org.au/ ACTRN12611001256965) and the World Health Organization Clinical Trials Registry (http://apps.who.int/trialsearch/trial.aspx?trialid=ACTRN12611001256965).

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BACKGROUND: This report describes the case management of a 32 year old special needs patient with life-threatening odontogenic infection. The combination of schizophrenia, Down and Eisenmenger syndromes presented significant challenges to managing his oral health, particularly within the rural context. In this case, dental treatment was limited to a full dental clearance during a high risk general anaesthesia session. METHOD: A comprehensive work-up prior to general anaesthesia was an essential aspect of care. This included a full medical history and examination, communication between medical specialists, the dentist and family consultation. The anaesthetic procedure was undertaken using a careful regimen of drugs and monitoring to minimize the impact on his cardiovascular system. Techniques to minimize bleeding from extraction sites were also important. RESULTS: Three weeks postsurgically the patient was reviewed and his family reported that he was interacting positively with them after years of surliness and conflict. This was attributed to a managed psychotropic medication regimen and improved dental condition, which has led to a sustained improvement in quality of life. CONCLUSIONS: The management of acute odontogenic infection for special needs patients in the rural setting requires a local interdisciplinary team approach, careful consideration of related pathophysiology and its potential impact on general anaesthesia, and close consultation with family and carers.

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In April 2002 our practice ceased routine use of epidural analgesia for colorectal laparotomy in favour of a six-drug multimodal regimen comprising ketamine, clonidine, morphine, tramadol, paracetamol and a non-steroidal anti-inflammatory drug. The records of 54 patients who received this multimodal analgesia regimen (MM) after April 2002 were compared to the 59 patients who had previously received epidural analgesia (EPI). Patients had the same surgeon and anaesthetist. Daily pain score (verbal rated 0-10) at rest (mean) over the first three postoperative days was satisfactorily low with both MM (1.2 +/- 1.2) and EPI (0.4 +/- 0.4). Over this period there was little difference between the maximum pain score at rest (MM 2.3 +/- 1.9 vs. EPI 2.2 +/- 1.7, P = 0.58). Major complications and side-effects occurred solely in EPI patients: epidural abscess (1), respiratory depression (2), pneumonia (3), venous thromboembolism (3), delirium (7), high block (7) and motor block (3). Hypotension requiring intervention was 4.8 times more frequent in the EPI group (95% CI 2.1-11). Antiemetic use was similar between groups; on average 13 patients in the MM groups (24%) and 15 patients in the EPI groups (26%) received antiemetics each day. MM patients had shorter anaesthetic preparation time (20 +/- 8 min vs. 32 +/- 8 min, P < 0.001), shorter high-dependency unit stay (0.4 +/- 1.2 days vs. 4.5 +/- 0.9 days, P < 0.001), and shorter hospital stay (10 +/- 4 days vs. 13 +/- 8 days, P = 0.003). In our practice, changing from epidural to multimodal analgesia produced comparable pain relief with reduction in anaesthesia preparation time, high-dependency unit stay and hospital stay and the requirement for staff interventions. There was also a reduction in the incidence of major complications and side-effects.

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An intellectually impaired adult with a history of escalating violence towards hospital personnel was given an anaesthetic in his home prior to transfer to hospital for surgery. We review the implications and problems encountered, and suggest means by which such a retrieval can occur smoothly.

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PURPOSE: To compare the cost and effectiveness of small-dose spinal anesthesia (SP) with general anesthesia (GA) for outpatient laparoscopy. METHODS: A retrospective record analysis of 24 patients who received SP were compared with 28 patients who received GA in our Daycare centre. The costs of anesthesia and recovery were calculated, from an institutional perspective, using 1997 Canadian Dollar values. Effectiveness was measured in terms of time for anesthesia and recovery, and postoperative antiemetic and analgesic requirements. RESULTS: Both groups were well matched for age, weight, duration and type of surgery. The mean total cost for the SP group of $53.45 +/- 10.40 was no different from that for the GA group of $48.92 +/- 10.25 (95% CI -10.3, 1.2). Time to administer anesthesia was longer in the SP group with a mean time of 18 +/- 8 min compared with 10 +/- 3 min in the GA group (CI -11.3, -4.7). Recovery time in the PACU was longer in the SP group 123 +/- 51 min compared with 94 +/- 48 min (CI -56.6,-1.4). Postoperative antiemetic requirements were similar: 8% in SP group vs 14% in GA group, whereas analgesic requirements were less in the SP group with 25% receiving analgesia compared with 75% in the GA group (P < 0.05). CONCLUSION: The total cost of anesthesia and recovery using SP is similar to that for GA when used for outpatient laparoscopy. Spinal anesthesia was less effective than GA in time to administer anesthesia and in duration of recovery. Postoperative analgesic requirements were reduced using SP.

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PURPOSE: To determine the incidence and duration of ECG abnormalities in healthy adults during short duration outpatient surgery and their relationship to important clinical events. METHOD: In 381, ASA Class I, day surgery patients undergoing short surgical procedures the ECG was monitored prospectively for evidence of abnormalities. The attending anaesthetist administered the anaesthetic and made all clinical decisions while relying on routine monitors (ECG, oximeter, BP, capnometer, oxygen analyser, low pressure alarm and anaesthetic gas monitors). Intra-operative events of clinical significance (e.g., light anaesthesia, regurgitation, coughing, hypotension, arterial desaturation, hiccoughs etc), ECG abnormalities and their duration were documented. RESULTS: Electrocardiographic abnormalities were detected in 21% of patients as follows: sinus tachycardia (11%), artifacts (7%), premature atrial contractions (1.6%), lead disconnects (1%), sinus bradycardia (0.5%) and premature ventricular contractions (0.3%). All abnormalities resolved spontaneously within three minutes. Intra-operative incidents of consequence occurred in only 2.6%: light anaesthesia (5), arterial desaturation > 5% (2), hypotension (1), hiccough (1) and regurgitation (1). All incidents were detected clinically and by pulse oximetry. The ECG did not detect any of the incidents and was normal during the events. CONCLUSION: Routine ECG monitoring did not detect intra-operative incidents in healthy adults during short outpatient procedures. Detected ECG abnormalities were benign and resolved spontaneously within three minutes. Firm conclusions as to the safety implications of withdrawing ECG monitoring cannot be drawn from this study. Guidelines may need to be reviewed to determine whether ECG monitoring in such cases should be optional rather than mandatory.

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PURPOSE: To compare the cost and effectiveness of intravenous regional anaesthesia (IVRA) with general anaesthesia (GA) for outpatient hand surgery. METHOD: A retrospective record analysis of 121 patients who received IVRA were compared with 64 patients who received GA in our Daycare centre. The costs of anaesthesia and recovery were calculated from an institutional perspective using 1995 Canadian Dollar values. Effectiveness was measured in terms of time for anaesthesia, recovery and discharge, % with unsatisfactory anaesthesia and complications. RESULTS: Both groups were well matched in terms of weight, sex and ASA class. Patients in the IVRA group were older (45 +/- 16 vs 38 +/- 13 yr) and had a lower frequency of two types of operation. The median total cost for the IVRA group of $24.60 (15.76-55.29) was less than that for the GA group of +f448.66 (35.59-73.11), (P < 0.00001). Anaesthesia was unsatisfactory in 11% of the IVRA group, but in none having GA,(P < 0.01). Recovery was faster in the IVRA group with a median time to discharge of 70 (35-180) min compared with 118 (45-320) min in the GA group, (P < 0.00001). Vomiting requiring treatment occurred in 5% of the GA group, but in none having IVRA, (P < 0.05). Dizziness which delayed discharged also occurred in 5% of the GA group, but in none having IVRA, (P < 0.05). CONCLUSION: The cost of anaesthesia and recovery using IVRA for outpatient hand surgery was half that of GA. intravenous regional anaesthesia was less effective than GA in achieving satisfactory anaesthesia, equally effective in time to administer anaesthesia, and more effective in speeding recovery and minimising postoperative complications.

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A randomized, single-blind trial of two spinal anesthetic solutions for outpatient laparoscopy was conducted to compare intraoperative conditions and postoperative recovery. Thirty women (ASA physical status I and II) were assigned to one of two groups. Group I patients received a small-dose hypobaric solution of 1% lidocaine 25 mg made up to 3 mL by the addition of fentanyl 25 micrograms. Group II patients received a conventional-dose hyperbaric solution of 5% lidocaine 75 mg (in 7.5% dextrose) made up to 3 mL by the addition of 1.5 mL 10% dextrose. All patients received 500 mL of crystalloid preloading. Spinal anesthesia was performed at L2-3 or L3-4 with a 27-gauge Quincke point needle. Surgery commenced when the level of sensory anesthesia reached T-6. Intraoperative hypotension requiring treatment with ephedrine occurred in 54% of Group II patients but not in any Group I patients. Median (range) time for full motor recovery was 50 (0-95) min in Group I patients compared to 90 (50-120) min in Group II patients (P = 0.0005). Sensory recovery also occurred faster in Group I patients (100 +/- 22 min) compared with Group II patients (140 +/- 27 min, P = 0.0001). Postoperative headache occurred in 38% of all patients and 70% of these were postural in nature. Oral analgesia was the only treatment required. Spinal anesthesia did not result in a significant incidence of postoperative backache. On follow-up, 96% said they found spinal needle insertion acceptable, 93% found surgery comfortable, and 90% said they would request spinal anesthesia for laparoscopy in future. Overall, this study found spinal anesthesia for outpatient laparoscopy to have high patient acceptance and a comparable complication rate to other studies. The small-dose hypobaric lidocaine-fentanyl technique has advantages over conventional-dose hyperbaric lidocaine of no hypotension and faster recovery.

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We performed a double-blind, controlled trial to determine the optimal dose of intrathecal fentanyl in small-dose hypobaric lidocaine spinal anesthesia for outpatient laparoscopy. Sixty-four gynecological patients were randomized into three groups, receiving 0, 10, or 25 micrograms fentanyl added to 20 mg lidocaine and sterile water (total 3 mL). Administration was with 27-gauge Whitacre needles and patients sat upright until the block was > T-8. One patient in the 0-microgram fentanyl group required general anesthesia 40 min after the start of surgery, leaving 21 patients per group. Three patients in each of the 0-microgram and 10-microgram fentanyl groups had mild discomfort with trocar insertion, or return of some sensation and felt discomfort or sutures toward the end of surgery. Shoulder-tip pain was less frequent in the 25-microgram than 0-microgram fentanyl group, 28% vs 67% (P < 0.0166). Intraoperative supplementation with alfentanil (+/- propofol) was needed less often in the 25-microgram than 0-microgram fentanyl group, 43% vs 76% (P = 0.028). Recovery of sensation took longer in the 25-microgram than in the 0-microgram and 10-microgram fentanyl groups, 101 +/- 21 vs 84 +/- 20 and 87 +/- 18 min (P < 0.05), although motor recovery and discharge times were the same. Postoperative analgesia was needed earlier in the 0-microgram than in the 25-microgram fentanyl group, median 54 (13-120) vs 87 (65-132) min (P < 0.05). Pruritus was the only side effect that occurred more often in the 10-microgram and 25-microgram groups than in the 0-microgram fentanyl group, 62% and 67% vs 14% (P < 0.0166). One patient required an epidural blood patch for postdural puncture headache. Based on these results, we concluded that 25 micrograms intrathecal fentanyl is required when 20 mg lidocaine is used for hypobaric spinal anesthesia (SA) to ensure reliable, durable anesthesia, reduce shoulder-tip pain, and minimize the need for intraoperative supplementation. This dose provides longer postoperative analgesia and does not increase side effects apart from pruritus. SA with small-dose hypobaric lidocaine-fentanyl was found to be a satisfactory technique for outpatient laparoscopy, although postdural puncture headache can occur in some patients.

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A double-blind, controlled trial was conducted to determine whether warming local anaesthetic reduces the onset time of axillary brachial plexus block. Forty patients were randomised into two groups. The control group received local anaesthetic solution at room temperature (22 +/- 1 degrees C), while the experimental group received the solution at body temperature (37 +/- 1 degrees C). A solution of 40 ml of lignocaine 1.5% with adrenaline 1:200,000 was used for all patients. Warming the local anaesthetic was not demonstrated to reduce the latency of onset of blockade.

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