No abstract

There is a wide variety of patients who present for shoulder surgery, ranging from the fit, robust patient with a sports injury requiring a stabilization procedure, to the frail, elderly rheumatoid patient requiring joint decompression or arthroplasty. Recent surgical advances have resulted in the development of minimal access arthroscopic procedures with resulting improvements in speed of convalescence. However, the management of severe postoperative pain remains a major challenge for many anaesthetists. Regional anaesthetic techniques have the ability to control pain effectively both at rest and on movement, reduce muscle spasm, and allow earlier mobilization and cooperation with physiotherapy. Therefore, these techniques have the potential to improve both patient recovery and outcome after both open and arthroscopic surgeries. Management of these patients requires thorough preoperative assessment, careful intraoperative management, and appropriate use of regional anaesthetic techniques to provide adequate dynamic pain relief in the initial postoperative period.

Patients undergoing surgery are at increased risk of acute kidney injury (AKI). AKI is associated with adverse outcomes such as increased mortality and future risk of developing chronic kidney disease. We have developed a validated preoperative scoring tool to predict postoperative AKI in patients undergoing orthopaedic surgery using seven readily available parameters. The aim of this project was to establish the use of this scoring tool with a target compliance of 80% in patients undergoing orthopaedic surgery requiring an overnight stay at Perth Royal Infirmary, a district general hospital in NHS Tayside. We created an intervention bundle for patients at high risk of AKI, which we defined as greater than 10%. An electronic tool available on smartphones and desktop computers was developed that can be used to calculate the score. The interventions were incorporated into the electronic tool and posters outlining the intervention were placed in clinical areas. Patients undergoing elective procedures were scored in the preassessment clinic while emergency patients were scored by the admitting doctors. The score was introduced using four PDSA cycles. This confirmed that the scoring tool functioned well and was being used accurately. Compliance for patients undergoing elective surgery was reasonable at 19/24 (79%) in the third and fourth PDSA cycles but was poorer for emergency admissions with compliance of only 3/7 (43%). There was excellent compliance with the suggested medication changes and postoperative blood test monitoring as advised by our intervention bundle for those at high risk of AKI. Fluid balance monitoring was advised for all patients but the outcome was similar following our intervention at 27/41 (66%) compared with 23/37 (62%) in the baseline data collection. Compliance with fluid balance monitoring was higher in patients at high risk of AKI (9/12, 75%).

A 61-yr-old woman presented with severe tetanus. Her intensive care management was complicated by severe generalized tetanic spasms despite the use of propofol, midazolam, alfentanil, magnesium sulphate, and atracurium. We describe the management of this problem with a variable dose remifentanil infusion.