A clinical trial was undertaken using three different inhalant anaesthetic agents and one intravenous anaesthetic agent in dogs undergoing routine desexing surgery. Healthy adult dogs undergoing either ovariohysterectomy or castration were assessed as to their demeanour, with the more excitable dogs being placed in groups receiving premedication with acepromazine and morphine. All dogs were then randomly assigned an anaesthetic agent for induction of general anaesthesia. The agents were the inhalants halothane, isoflurane and sevoflurane, and the intravenous agent propofol. Inhalant inductions were undertaken using a tight fitting mask attached to a standard anaesthetic machine with a rebreathing circuit, with the maximum dose of inhalant available from a standard vaporiser. Propofol inductions were undertaken via intravenous catheter. Dogs induced with propofol were randomly assigned one of the three inhalant agents for maintenance. Those induced by inhalant agent were maintained using the same agent. The surgical procedure was undertaken in standard fashion, as was recovery from anaesthesia. All dogs received the non-steroidal anti-inflammatory agent meloxicam. Data collection was divided into three stages: induction, maintenance, and recovery from anaesthesia. Variables measured at induction of anaesthesia were time to intubation, number of intubation attempts, tolerance of mask, quality of induction and quality of transfer to the maintenance stage. Standard variables for monitoring of anaesthesia were recorded throughout the maintenance of anaesthesia. Variables measured at recovery were time to righting, time to standing and quality of recovery. The mean time to intubation when using the newer inhalant sevoflurane (196.2 � 14.8sec, mean � SE) was not significantly different to that for halothane (221.4 � 14.0sec) or isoflurane (172.4 � 15.0sec). Time to intubation with isoflurane was significantly faster than with halothane. Mean time to intubation with propofol (85.4 � 7.7sec) was significantly faster than that for any of the three inhalants. Choice of inhalant had no effect on quality of induction. The use of premedication significantly improved the quality of induction. The use of propofol for induction likewise significantly improved the quality of induction. Standard cardiorespiratory variables measured during the maintenance phase of anaesthesia remained within normal clinical ranges for all three inhalants, and were therefore not further analysed. Choice of inhalant agent had no significant effect on the time to righting or standing in recovery. The use of propofol for induction had no effect on these variables. Animals placed in groups receiving premedication had significantly longer times to righting and standing. The oesophageal temperature at the end of the procedure had a significant effect on times to righting and standing, with lower temperatures contributing to slower recoveries. Independent of procedure time, male dogs had shorter times to righting than female dogs.

During a finite developmental phase – the brain growth spurt – the brain grows and matures at an accelerated rate. During this period the brain is more sensitive to harmful substances such as ethanol and environmental toxins than before or after. This period extends from the last trimester to the second year in humans and occurs postnatally in the mice used for these studies. The aims of this thesis were; to investigate common anaesthetics ability to promote acute apoptosis and late persistant behavioural aberrations measured with spontaneous behaviour in a novel home environment, learning in a radial arm maze and anxiety-like behaviour in an elevated plus maze, to measure alterations in BDNF, CaMKII, GAP-43, synaptophysin and tau after anaesthesia exposure, to evaluate clonidine as a potentially protecting agent and examine if theophylline, a chemically unrelated compound, causes similar effects as anaesthetics. Some of the results are: combinations of anaesthetics acting on the GABAA receptor (propofol or pentothal) and NMDA receptor (ketamine) exhibit more apoptosis and behavioural alterations than single anaesthetics. Ketamine, but not propofol, alters the content of CaMKII and GAP-43 proteins important in brain development. Propofol exposure alters the content of BDNF (brain derived neurotrophic factor) in hippocampus, frontal and parietal cortex. Neonatal propofol exposure leads to less sensitiveness to diazepam in adult age as measured with induced spontaneous behaviour and an elevated plus maze. Clonidine, an alpha2 adrenergic agonist does not cause any aberrations and appears to prevent apoptosis and behavioural alterations after ketamine. Theophylline, used as apnoea treatment in neonates, also increases apoptosis and alters normal behaviour. Thus, alterations both in neuronal survival, function and protein expression is apparent after neonatal exposure to anaesthetics. This is also shown in studies of Rhesus monkeys. However, it is still difficult to assess how these findings should extrapolate to humans. Epidemiological studies give conflicting results. Insufficient anaesthesia is not a solution as pain and stress cause even more pronounced problems. Minimizing anaesthetic exposure, delaying procedures until after the sensitive phase and finding protective agents, such as clonidine, are possible strategies. Evaluation of other substances that infants are exposed to is needed.

The purpose of this study was to evaluate the clinical relevance of access targets for elective dental general anaesthesia (GA) by assessing incremental changes in dental disease burden over wait times at SickKids. A retrospective review of dental records were completed for 378 children who were prioritized by their dental and medical status. A scale was developed to measure cumulative dental disease burden over time. Statistically significant correlations were identified between cumulative disease burden and wait times for priority IV (p = 0.004), the entire sample (p < 0.003), DOSDCADCA (p = 0.005), comorbid (p = 0.036), healthy (p = 0.0002), female (p = 0.014) and male (p = 0.008) groups. The mean cumulative disease burden was not different between matched healthy and cormorbid groups (p = 0.38). A trend of increasing dental disease burden for children with longer wait times for dental GA was found but not clinically significant.

The purpose of this study was to evaluate the clinical relevance of access targets for elective dental general anaesthesia (GA) by assessing incremental changes in dental disease burden over wait times at SickKids. A retrospective review of dental records were completed for 378 children who were prioritized by their dental and medical status. A scale was developed to measure cumulative dental disease burden over time. Statistically significant correlations were identified between cumulative disease burden and wait times for priority IV (p = 0.004), the entire sample (p < 0.003), DOSDCADCA (p = 0.005), comorbid (p = 0.036), healthy (p = 0.0002), female (p = 0.014) and male (p = 0.008) groups. The mean cumulative disease burden was not different between matched healthy and cormorbid groups (p = 0.38). A trend of increasing dental disease burden for children with longer wait times for dental GA was found but not clinically significant.

Bakgrund: En stor del av vårdskadorna som uppstår i vården beror på brister i kommunikation. Rapportering är en del av det dagliga arbetet som sjuksköterska, där målet är att föra vidare information om en patientens tillstånd för att säkerställa den fortsatta vården och patientsäkerheten. Syfte: att beskriva hur anestesisjuksköterskan och vårdavdelningens sjuksköterska ser på rapportering vid överföring av patient från UVA till vårdavdelning. Metod: Kvalitativ studie. Studien har analyserats med hjälp av innehållsanalys där ett tema, två kategorier och nio subkategorier har framkommit. Fokusgruppsintervjuer med sammanlagt tio sjuksköterskor från vårdavdelningar med erfarenhet av att hämta patienter på UVA samt åtta sjuksköterskor från anestesin. Resultat: För att en rapport skall bli bra krävs att rapporten följer en viss procedur och struktur. Det är viktigt att rapporten följer en röd tråd och att informationen inte blir överflödig. Vårdmiljön vid rapporteringen har också stor betydelse. Det blir svårt att lämna en bra rapport då det är mycket stress runtomkring och då det är svårt att hålla sekretessen. Från både anestesin och vårdavdelningarna finns en vilja att ha förståelse för varandra för att skapa en god miljö vid rapporteringen. I rapporteringen är det viktigt att lagom mycket information om patienten lämnas annars finns risk att personen som tar emot rapporten slutar lyssna. Diskussion: Vårdavdelningarnas sjuksköterskor saknar kunskap om de specifika läkemedel som administreras av anestesisjuksköterskan under narkosen. Detta kan få ödesdigna konsekvenser då det finns en risk att drabbas av återfall av läkemedel med andningshämmande effekt, en så kallad recurarisering. / Background: A great deal of the related care injuries that develops in the hospitals often depends on communications failures. Reporting handovers is a great part of nurse’s daily work, the where report handovers purpose is to transfer information related to the patient between staff so that the patient safety can be ensured. Aim: To describe how the anaesthesia nurse and the ward nurse perception in the report handover of an postoperative patient. Method: Qualitative studies where made. Focus group interviews with total of ten nurses from the wards, nurses with experience from giving and taking reports in handover situations from the postoperative anaesthesia care unit (PACU), and eight nurses from the anaesthetic ward. The result where analysed with help from a content analysis, that resulted in one theme, two categories and nine sub categories. Result: Areport requires that the reporter follow a particular procedure and structure. It’s important that the report makes a common line for the listener, and that the information is not redundant. The environment is also important, it becomes difficult to make a good report when it’s stressful around, that also makes it difficult to maintain confidentiality. From both the anaesthesia and ward it’s a willingness to understand each other when it comes to patient handover, regarding to the stressfulness and the lack of care places at the wards. It’s important that the right amount of information about the patient is given, otherwise there’s a risk that the person receiving the report, stop listening. Discussion: The ward nurses lack the knowledge about the specific drugs during anaesthesia that are administrated by the anaesthesia nurse. That can bring a fatal consequence if the patient gets a residual paralysis of the muscle relaxant drug.

Syftet med studien var att beskriva förekomst och typ av patienters eventuella oro inför anestesi. Litteraturöversikten har baserats på vetenskapliga artiklar av både kvantitativ och kvalitativ art. Trettioen artiklar granskades och 21 av dessa valdes ut till resultatet.De flesta studier som behandlade oro inför anestesi var av kvantitativ art. Oro i form av olika slags olustkänslor definierades av flera författare utförligt och på flera sätt. Resultatet påvisade att oro var ett vanligt förekommande fenomen och kunde objektivt mätas med hjälp av självskattningsskalor, där de vanligast förekommande är Visuel Analog Skala (VAS) och State Trait Anxiety Inventory (STAI). Dagkirurgin har ökat och tiden att träffa patienten för mental förberedelse har minskat, vilket var till nackdel för både patient och personal. Vi har genom den här studien och kliniska erfarenheter uppmärksammat riskfaktorer för oro, till exempel kvinnor och yngre patienter. En studie påvisade även att patienter med sen placering på operationslistan hade en signifikant högre nivå av oro. För att ge känslomässigt stöd till patienter som har behov av ökad uppmärksamhet, krävs en bred insats som omfattar bemötande, information, patientutbildning och kommunikation. Trots all kunskap som finns presenterad i resultatet av studierna förstår vi det som att den psykologiska omvårdnaden är otillräcklig och måste prioriteras.

名古屋大学博士学位論文 学位の種類 : 博士(医学)(論文) 学位授与年月日:平成5年10月13日 柴田佳久氏の博士論文として提出された

Background: This dissertation is composed of five individual studies of the stapled haemorrhoidopexy operation. The operation was launched to an international audience in 1998 by the Italian surgeon Antonio Longo. In conventional surgery the prolapsed piles are excised from the anodermal part of the prolapse up through the anal canal into the lower rectal mucosa where the pile is divided with diathermy or suture ligated and excised. It leaves open wounds throughout the anal canal. These wounds can be very painful, especially at defecation, and will take from three to six weeks to heal. In the stapled haemorrhoidopexy operation symptomatic haemorrhoids are seen as a disease of anodermal, haemorrhoidal and rectal mucosal prolapse of varying degree. The main component of the prolapse is the redundancy of rectal mucosa. By pushing back the prolapse into the anal canal followed by excision of the mucosal redundancy above the anal canal with a circular stapler devise a mucosal anastomosis is fashioned. This anastomosis is situated immediately above the haemorrhoids and will attach them to the rectal muscular wall to prevent further prolapse. The operation is associated with substantially less pain and a quicker recovery. Methods: For the five studies, a total of 334 patients were operated for haemorrhoidal prolapse. The first operations were performed in February 1998. All patients were assessed preoperatively and postoperatively with the same set of protocols as follows. The symptoms of haemorrhoids were scored with a questionnaire to patients to obtain their independent statements of the frequency of each of five cardinal symptoms: pain, bleeding, pruritus, soiling and prolapse in need of manual reduction. A diary was used by patients to report daily pain scores, use of pain medication and speed of recovery within the first 14 postoperative days. The surgeon rated the deranged anal anatomy before and after surgery. We also developed an algorithm based on the patients’ statement of digital reduction of prolapse (grade 3) and the surgeon’s assessment of lesser prolapse at proctoscopy (grade 2). Absence of prolapse was grade 1. The surgeon also provided statements about the conduct of the operation and rated the technical complexity. The information, for all patients, was entered into an electronic data base. Results: One registry based study and one prospective randomised controlled trial assessed the advantage of performing the operation under perianal local anaesthetic block. The postoperative pain and surgical outcome was independent of the type of anaesthesia. No operation under local block had to be converted to general anaesthesia. Anodermal prolapse is seen in 70 percent of the patients. In a registry-based study we found that excision of the anodermal folds did not increase the postoperative pain provided the excision stopped at the anal verge. In 270 patients with precise preoperative and postoperative classification we found that the symptomatic load was identical for grades 2 and 3. The symptoms were independent of the anodermal prolapse. The symptoms were greatly reduced when the operation turned out grade 1 prolapse. The long-term result was assessed in 153 patients operated 1 year to 6 years previously. The need for early re-intervention was 6.2 percent representing technical error to reduce the prolapse. At the final evaluation 12 patients (8.2 percent) complained of a mucoanal prolapse in need of digital reduction. The mean symptom burden had been reduced from 8.1 to 2.5 points but 17 percent had at least one cardinal symptom with a weekly frequency. Conclusions: Stapled haemorrhoidopexy should be performed as day surgery under local anaesthesia. Any remaining anodermal prolapse should be excised. The optimal long-term outcome is grade 1A or 1B with low symptom score. There was an 87 percent chance of cure of the prolapse with the first haemorrhoidopexy. About half the failures were insufficient primary surgery and half a relapse of the prolapse. / <p>The original title of article IV was "Prolapse grade and symptoms of haemorrhoids are poorly correlated: result of a classification algorithm in 270 patients. The new title after publishing the article is "Grade of prolapse and symptoms of haemorrhoids are poorly correlated: result of a classification algorithm in 270 patients".</p>

Local anaesthetics have been implemented extensively in the case of a variety of painful superficial procedures, venipuncture, skin graft harvesting, anal or genital pruritus, poison ivy rashes, postherpetic neuralgia and several other dermatoses. The dilemma with commercially available local acting anaesthetics is that it may take well up to an hour to produce an anaesthetic effect. Anaesthetics have to traverse the highly efficient barrier, the stratum corneum, in order to reach the intended target site which is the free nerve endings located in the dermis. The objective of this study was to compare the transdermal delivery of an eutectic combination of two ionisable amide types of local anaesthetics, lidocaine HCI and prilocaine HCI, delivered with the novel Pheroid™ technology to that of a commercially available product in order to establish whether the lag time could be significantly reduced. Several techniques of promoting the penetration of these anaesthetics have previously been employed, including occlusive dressing, entrapment in liposomes and miscelles, iontophoretic delivery and so forth. The Pheroid™ delivery system is novel technology that entails improved delivery of several active compounds. It is a submicron emulsion type formulation that possesses the ability to be transformed in morphology and size, thereby affording it tremendous flexibility. Since it primarily consists of unsaturated essential fatty acids, it is not seen as foreign to the body but rather as a skin-friendly carrier. Vertical Franz cell diffusion studies were performed over a 12 hour period using Caucasian female abdominal skin obtained, with the consent of the donor, from abdominoplastic surgery. Comparison was made between the commercial product EMLA® cream, the active local anaesthetics dissolved in phosphate buffered solution (PBS) and the active ingredients entrapped within Pheroid™ vesicles. Distinct entrapment could be ascertained visually by confocal laser scanning microscopy (CLSM). The amount of drug that traversed the epidermal membrane into the receptor phase was then assayed by high performance liquid chromatography (HPLC). The results obtained with the Pheroid™ vesicles revealed a biphasic character with rapid permeation during the first two hours, followed by a plateau between 3 to 12 hours. The initial dramatic increase in percentage yield and flux indicates that the Pheroid™ carrier enhances the transdermal delivery of the actives in order to accelerate the onset of action. / Thesis (M.Sc. (Pharmaceutics))--North-West University, Potchefstroom Campus, 2009.

Local anaesthetics have been implemented extensively in the case of a variety of painful superficial procedures, venipuncture, skin graft harvesting, anal or genital pruritus, poison ivy rashes, postherpetic neuralgia and several other dermatoses. The dilemma with commercially available local acting anaesthetics is that it may take well up to an hour to produce an anaesthetic effect. Anaesthetics have to traverse the highly efficient barrier, the stratum corneum, in order to reach the intended target site which is the free nerve endings located in the dermis. The objective of this study was to compare the transdermal delivery of an eutectic combination of two ionisable amide types of local anaesthetics, lidocaine HCI and prilocaine HCI, delivered with the novel Pheroid™ technology to that of a commercially available product in order to establish whether the lag time could be significantly reduced. Several techniques of promoting the penetration of these anaesthetics have previously been employed, including occlusive dressing, entrapment in liposomes and miscelles, iontophoretic delivery and so forth. The Pheroid™ delivery system is novel technology that entails improved delivery of several active compounds. It is a submicron emulsion type formulation that possesses the ability to be transformed in morphology and size, thereby affording it tremendous flexibility. Since it primarily consists of unsaturated essential fatty acids, it is not seen as foreign to the body but rather as a skin-friendly carrier. Vertical Franz cell diffusion studies were performed over a 12 hour period using Caucasian female abdominal skin obtained, with the consent of the donor, from abdominoplastic surgery. Comparison was made between the commercial product EMLA® cream, the active local anaesthetics dissolved in phosphate buffered solution (PBS) and the active ingredients entrapped within Pheroid™ vesicles. Distinct entrapment could be ascertained visually by confocal laser scanning microscopy (CLSM). The amount of drug that traversed the epidermal membrane into the receptor phase was then assayed by high performance liquid chromatography (HPLC). The results obtained with the Pheroid™ vesicles revealed a biphasic character with rapid permeation during the first two hours, followed by a plateau between 3 to 12 hours. The initial dramatic increase in percentage yield and flux indicates that the Pheroid™ carrier enhances the transdermal delivery of the actives in order to accelerate the onset of action. / Thesis (M.Sc. (Pharmaceutics))--North-West University, Potchefstroom Campus, 2009.