Anaesthesia essentials: Overview

Regional Anesthesia & Pain Medicine, the official publication of the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine), is a monthly journal that publishes peer-reviewed scientific and clinical studies to advance the understanding and clinical application of regional techniques for surgical anesthesia and postoperative analgesia. Coverage includes intraoperative regional techniques, perioperative pain, chronic pain, obstetric anesthesia, paediatric anesthesia, outcome studies, and complications.

Abstract
In 2023, a Diploma of Rural Generalist Anaesthesia (DipRGA) was implemented across Australia. Developed collaboratively by the Australian and New Zealand College of Anaesthetists (ANZCA), the Australian College of Rural and Remote Medicine (ACRRM) and the Royal Australian College of General Practitioners (RACGP), the 12-month qualification is completed during or following ACRRM or RACGP Rural Generalist Fellowship training. Focused on the needs of rural and remote communities for elective and emergency surgery, maternity care, resuscitative care for medical illness or injury, and stabilisation for retrieval, the DipRGA supports rural generalist anaesthetists working within collaborative teams in geographically isolated settings. The goal is a graduate who can anaesthetise American Society of Anesthesiologists physical status class 1, 2 and stable 3 patients for elective surgery, provide obstetric anaesthesia and analgesia, anaesthetise paediatric patients and undertake advanced crisis care within their scope of practice. Crucially, they also recognise both limitations of their skills and local resources available when considering whether to provide care, defer, refer or transfer patients. DipRGA curriculum design commenced by adapting the ANZCA specialist training curriculum with consideration of the training approach of both the ACRRM and the RACGP, particularly the rural and remote context. Curriculum content is addressed in seven entrustable professional activities supported by workplace-based assessments and multisource feedback. Trainees are supervised by rural generalist anaesthetists and specialist anaesthetists, and complete flexible learning activities to accommodate geographical dispersion. Standardised summative assessments include an early test of knowledge and an examination, adapted from the ACRRM structured assessment using multiple patient scenarios.

Abstract
Purpose: Gas leakage around the cuff of a tracheal tube may frequently occur after tracheal intubation and inflation of the cuff. We assessed if the SmartCuff (Smiths Medical Japan, Tokyo, Japan), an automatic cuff pressure controller, would effectively prevent gas leakage.

Methods: Seventy adult patients were allocated randomly to one of two groups. After induction of general anesthesia and tracheal intubation, in one group (Syringe group), a syringe was used to inflate the cuff, until there was no audible gas leakage, at the airway pressure at 20 cmH2O. In the other group (SmartCuff group), the SmartCuff was used to maintain the cuff pressure to be 20 cmH2O. The mechanical ventilation (tidal volume of 8 ml.kg-1 and 12 breaths per min) was started. The incidence and percentage of gas leakage, and the proportion of adequate seal (defined as gas leakage of < 10%) between the groups were compared.

Results: The incidence of audible gas leakage was significantly higher in the Syringe group (10 of 35 patients (28%)) than in the SmartCuff group (none of 35 patients (0%)) (P = 0.00046, 95%CI for difference: 15-43%), and the proportion of adequate seal was significantly lower in the Syringe group (19 of 35 patients (54%)) than in the Smart cuff group (33 of 35 patients (94%)) (P = 0.0001, 95% CI for difference: 20-58%).

Conclusion: Gas leakage may frequently occur after tracheal intubation, and the use of the SmartCuff can effectively maintain the sealing effect of the cuff.

Abstract
Minimally invasive cardiac surgery (MICS) has been used since the 1990s and encompasses a wide range of techniques that lack full sternotomy, including valve and coronary artery graft surgery as well as transcatheter procedures. Due to the potential benefits offered to patients by MICS, these procedures are becoming more common. Unique anaesthetic knowledge and skills are required to overcome the specific challenges presented by MICS, including mastery of transoesophageal echocardiography (TOE) and the provision of thoracic regional analgesia. This review evaluates the relevance of MICS to the anaesthetist and discusses pre-operative assessment, the relevant adjustments to intra-operative conduct that are necessary for these techniques, as well as post-operative care and what is known about outcomes.

Abstract
Background: Opioid-free anesthesia (OFA) is increasingly being adopted to reduce opioid consumption, but its impact on early postoperative recovery following major surgery has not been evaluated in comparative trials. We hypothesized that an OFA protocol would enhance the early quality of recovery (QoR) for patients undergoing scheduled major surgery under general anesthesia.

Methods: The SOFA study was a monocentric, randomized, controlled, assessor- and patient-blinded clinical trial conducted from July 10, 2021, to February 12, 2022. The eligible population included male and female patients undergoing scheduled major surgery, excluding bone procedure, that typically require opioids for postoperative pain management. Patients in the intervention group received a combination of at least two drugs among ketamine, lidocaine, clonidine, and magnesium sulfate, without opioids for anesthesia. The standard group received opioids. The primary outcome was early postoperative QoR, assessed by QoR-15 score at 24 hours (H24) after surgery. Secondary outcomes were QoR-15 at 48 hours (H48) and 72 hours (H72) after surgery, incidence of chronic pain, and quality of life at three months.

Results: Of the 136 randomized patients, 135 were included in the primary analysis (mean age: 45.9±15.7 years; 116 females (87.2%); 85 underwent major plastic surgery (63.9%)), with 67 patients in the OFA group and 68 in the standard group. The mean QoR-15 at H24 was 114.9±15.2 in the OFA group versus 108.7±18.1 in the standard group (difference of 6.2, 95% CI, 0.4-12.0; p=0.026). QoR-15 scores also differed significantly at H48 (difference of 8.7, CI 95% 2.9-14.5); p=0.004) and at H72 (difference of 7.3, CI 95% 1.6-13.0, p=0.013). There was no difference in other secondary outcomes. No major adverse events were noticed.

Conclusion: The OFA protocol improved QoR after major elective surgery in a statistically but not clinically significant manner when compared to standard anesthesia.