Local anaesthetic agents suppress action potentials in excitable tissues by blocking voltage-gated sodium channels. In doing so they inhibit the depolarisation of nociceptive nerve fibres and so prevent the transmission of pain impulses. UK legislation allows HCPC-registered Podiatrists with POM-A annotation access to six local anaesthetic drugs and two of these with the addition of adrenaline. The use of local anaesthetia has transformed the treatment of nail pathology by Podiatrists. In the UK, the drug of choice in podiatric practice is 3% mepivacaine hydrochloride: it is a good choice of drug for digital anaesthesia. This paper will review the chemistry, pharmacology and dose calculation of mepivacaine, and challenge some of the orthodoxy over the rigid calculation of maximum safe dosages.

Background Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. Despite being rapidly taken up by practitioners, datapoints from which to derive them were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define - for the first time - the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care. Methods and findings The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a two day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high, middle, and low income countries. Considering each of the six indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2-5 (intermediate) and >5 year (full) timeframes. We removed one of the original six indicators (one of two financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. Conclusions To track global progress toward timely access to quality SAO care, these indicators – at the basic level - should be implemented universally. Intermediate and full evolutions will assist in developing national surgical plans, and collecting data for research studies.

There is a lack of data comparing sugammadex with anticholinesterase for the quality of anaesthesia recovery, especially following a single bolus dose of rocuronium. Thus, we evaluated the influence of reversal with sugammadex or neostigmine on post-operative quality of recovery by using the Post-operative Quality Recovery Scale (PQRS). A total of 86 patients undergoing trans-pars plana vitrectomy (TPPV) under general anaesthesia were intubated following a single bolus dose of rocuronium (0.6 mg/kg). At the end of surgery, patients were received either neostigmine or sugammadex. The quality of recovery was assessed using the PQRS at 15 minutes and 40 minutes after surgery, and on post-operative day 1. The recovery rate in the physiological domain was higher in the sugammadex group at 15 minutes after surgery (P = 0.02). Though there were no significant differences in the overall cognitive recovery domain, patients in the sugammadex group could recall more numbers in reverse order. However, there were no significant differences between the groups in the other domains of the PQRS. The use of sugammadex may increase the quality of the post-operative physiological recovery at early post-operative periods compared with neostigmine use following a single bolus dose of rocuronium in patients undergoing TPPV with general anaesthesia.

Study background and aims: Laparoscopic cholecystectomy is one of the most frequently performed interventions in departments of general surgery. One of the most important aims in achieving perioperative stability of these patients is diminishing the impact of general anesthesia on the hemodynamic stability and the optimization of anesthetic drug doses based on the individual clinical profile of each patient. The objective of this study is the evaluation of the impact monitoring the depth of anesthesia through Entropy (state entropy – SE and response entropy -RE) has on the hemodynamic stability and on the doses of volatile anesthetic. Material and Methods: This is a prospective, observational, randomized, monocentric study carried out between January 2019 and December 2019 in the Clinic of Anesthesia and Intensive Care from the “Pius Brînzeu” Emergency County Hospital in Timișoara, Romania. The patients included in the study were divided in two study groups; patients in Group A (target group) received multimodal monitoring that included monitoring of standard parameters and of Entropy (SE and RE), while patients in Group B (control group) only received standard monitoring. Anesthetic dose in group A were optimized to achieve a target entropy of 40-60. Results: 68 patients met the inclusion criteria and were allocated to one of the two study groups, Group A (N=43) and Group B (N=25). There were no statistically significant differences identified between the two groups for both demographical and clinical data (p>0.05). Statistically significant differences have been identified for the number of hypotensive episodes (p = 0.011, 95% CI 0.1851 to 0.7042) and for the number of episodes of bradycardia (p < 0.0001, 95% CI 0.3296 to 0.7923). Moreover, there was a significant difference in the Sevoflurane consumption between the two study groups (p = 0.0498, 95% CI -0.3942 to 0.9047). Conclusions: The implementation of the multimodal monitoring protocol that includes the standard parameters and the measurement of Entropy for determining the depth of anesthesia (SE and RE) lead to a considerable improvement in perioperative hemodynamic stability. Optimizing the doses of anesthetic drugs based on the individual clinical profile of each patient leads to a considerable decrease in drug consumption as well as to a lower incidence of hemodynamic side-effects.

In this study, the effects of music therapy on anxiety for patients undergoing regional anaesthesia in an operating room was succinctly investigated. This investigation was largely based on the adapted Hospital Anxiety and Depression Score (HADS) and Spielberger State-Trait Anxiety Inventory (STAI-S), of patients undergoing regional anaesthesia in an operating room. A randomized control trial was performed on 90 patients due for surgery. The selected patients for regional anaesthesia were allocated to either the music therapy group who listened to music using headphones for the entire surgery or the no-treatment control group. Based on the findings, it has been conclusively demonstrated that music can decrease the patient's anxiety level. According to the socio-demographic evaluation, elderly patients have the highest stress hormones levels when compared to young patients. Although elderly patients are more likely to choose religious songs to help them relax, cortisol analysis revealed an increase in cortisol levels among the elderly compared with younger patients. As a result, music is especially important to be delivered to elderly patients. Nonetheless, there is no restriction against administering music to elderly patients because evidence from the Hospital Anxiety and Depression Score (HADS) and State-Trait Anxiety Inventory (STAI-S) has shown that music helps to shift their attention away from pain and complications and makes them feel tranquil. Similarly, the HADS and modified Spielberger STAI (STAI-S) analyses demonstrate a substantial outcome for both groups, with respondents responding positively. The study found that listening to music during regional anaesthesia might help people feel less worried.

With the development of general anesthesia techniques and anesthetic substances, brought new horizons for the expansion and improvement of surgical techniques. Nevertheless, more complex surgical procedures brought a higher complexity and longer duration for general anesthesia that led to a series of adverse events such as hemodynamic instability, under- or overdosage of anesthetic drugs, as well as an increased number of post-anesthetic events. In order to adapt the anesthesia according to the particularities of each patient, the multimodal monitoring of these patients is highly recommended. Classically, general anesthesia monitoring consists of the analysis of vital functions and gas exchange. Multimodal monitoring refers to the concomitant monitoring of the degree of hypnosis and the nociceptive-antinociceptive balance. By titrating anesthetic drugs according to these parameters, clinical benefits can be obtained, such as hemodynamic stabilization, reduction of awakening times, and the reduction of post-operative complications. Another important aspect is the impact on the status of inflammation and the redox balance. By minimizing inflammatory and oxidative impact one can achieve a faster recovery that will lead to both increased patient satisfaction and an increase in patient safety. The purpose of this literature review is to present the most modern multimodal monitoring techniques, respectively to discuss the particularities of each technique.

Analgesic products for piglet castration are critically needed. This requires extensive animal experimentation such as to meet regulatory-required proof of efficacy. At present, there are no validated methods of assessing pain in neonatal piglets. This poses challenges for investigators to optimize trial design and to meet ethical obligations to minimize the number of animals needed. Pain in neonatal piglets may be subtle, transient and / or variably expressed and, in the absence of validated methods, investigators must rely on using a range of biochemical, physiological and behavioural variables, many of which appear to have very low (or unknown) sensitivity or specificity for documenting pain, or pain-relieving effects. A previous systematic review of this subject was hampered by the high degree of variability in the literature base both in terms of methods used to assess pain and pain mitigation, as well as in outcomes reported. In this setting we provide a narrative review, to assist in determining the optimal methods currently available to detect piglet pain during castration and methods to mitigate castration-induced pain. In overview, the optimal outcome variables identified are nociceptive motor and vocal response scores during castration, and quantitative sensory-threshold response testing and pain-associated behaviour scores following castration.

Global anaesthesia workforce limitations contribute to emigration of skilled anaesthesiologists from lower- to higher-income countries, jeopardizing workforce balance and patient outcomes in Pakistan. This study aims to explore challenges experienced by anaesthesiologists in Punjab, Pakistan’s most populous province, and necessary changes to encourage their retention. We conducted a qualitative study to examine perspectives of anaesthesiologists who chose to serve in Pakistan. We drew data from semi-structured interviews conducted with 25 purposively-sampled consultant anaesthesiologists. We analysed data thematically and distinguished the practice hurdles faced by anaesthesiologists in public and private hospitals of Punjab. The main reasons to work abroad could be broadly categorized under two inductive themes, i.e. practice hurdles in public and private sector. Both had distinct issues which compromised the number and quality of anaesthesia workforce in the country. The key outcomes were workplace security, promotion/incentive issues and gender inequalities in the government sector. The private sector had improper salaries and facilities, anaesthesiologist’s dependency on surgeons for getting work and lack of out-of-theatre practice which minimise the scope and earnings of anaesthesiologist within the country. There is a need to overcome surgeon dependency and hospital manipulation by fixing salary percentages for each surgical case and encouraging direct patient-anaesthesiologist relationships.