Anaesthesia essentials: Overview

Perioperative arrhythmias are extremely common, usually transient and typically require no intervention. Persistent arrhythmias with associated haemodynamic instability may reflect an underlying pathological process. Indeed, the clinical scenario outlined of a patient with sepsis who develops rapid atrial fibrillation describes a situation that anaesthetists and intensivists frequently encounter. In some situations, the primary cause of the arrhythmia may be evident. However, in many cases the cause is multifactorial, relating to coexisting disease, acute physiological disturbance, medications or the surgical procedure itself (e.g. cardiac or thoracic surgery).

Abstract
Purpose: We aimed to describe the current literature concerning propofol misuse in medical professionals, specifically relating to the individual demographics of those misusing propofol and the outcomes of propofol misuse.

Methods: We conducted a retrospective scoping review of the literature using a modified PRISMA approach. We used MEDLINE, EMBASE, and PsycINFO databases to identify relevant studies based on search terms. Studies describing individual medical professionals misusing propofol were included.

Results: Twenty-four articles describing 88 individual cases of propofol misuse were included for data charting and analysis. Anesthesiologists and certified registered nurse anesthetists were most commonly identified. Death was a common method of identification of misuse, while rehabilitation and death were common final outcomes associated with propofol misuse.

Conclusions: Despite knowledge of the pharmacokinetic and pharmacodynamic properties of propofol by those misusing this medication, death was a common outcome reported in the literature. Data related to long-term outcomes including re-entry to clinical practice or success of rehabilitation were limited.

Abstract
Propfol-remifentanil-based total intravenous anaesthesia has dominated recent clinical practice due to its favourable pharmacokinetic profile. Interruption in remifentanil supply has presented an opportunity to diversify or even avoid the use of opioids and consider adjuncts to propofol-based total intravenous anaesthesia. Propofol, while a potent hypnotic, is not an effective analgesic. The administration of opioids, along with other adjuncts such as α-2 adrenoceptor agonists, magnesium, lidocaine, ketamine and nitrous oxide provide surgical anaesthesia and avoids large doses of propofol being required. We provide an overview of both target-control and manual infusion regimes for the alternative opioids: alfentanil, sufentanil and fentanyl. The optimal combination of hypnotic-opioid dose, titration sequence and anticipated additional postoperative analgesia required depend on the chosen combination. In addition, we include a brief discussion on the role of non-opioid adjuncts in total intravenous anaesthesia, suggested doses and expected reduction in propofol dose.

Tanya Rochelle Farrell and Britta S. von Ungern- Sternberg are both ANZCA fellows.