Bio

Bio


Dr. Pervez Sultan is an Associate Professor of Obstetric Anesthesiology, at Stanford University School of Medicine. He received his medical degree from the University of Edinburgh and completed the majority of his anesthetic training in Edinburgh and London, within the United Kingdom. He was also previously an Obstetric Anesthesia Fellow at Stanford, after which he completed an MD (Res) research degree exploring “Molecular mechanisms of perioperative lymphopenia.” Subsequently Dr. Sultan has practiced as an Attending at University College London Hospital with an Honorary Faculty position (Senior Lecturer) at University College London.

He is currently Chief Investigator for 3 funded multi-center studies and 1 funded single-center study within the United Kingdom and has multiple active International collaborative projects globally. His research interests include Obstetric Anesthesia, recovery following childbirth and peripartum immune function. He has published over 90 peer-reviewed manuscripts, book chapters and editorials. Dr. Sultan currently serves on the Society for Obstetric Anesthesia and Perinatology Research Committee, the International Outreach Committee in addition to SOAP Guideline Committees.

Researchgate profile: https://www.researchgate.net/profile/Pervez_Sultan2
Google Scholar profile: https://scholar.google.com/citations?user=Z2ftv_IAAAAJ&hl=en
Twitter: @PervezSultanMD

Clinical Focus


  • Anesthesia

Academic Appointments


Honors & Awards


  • Best paper award, Oral finalist, British Journal of Anaesthesia research forum, Royal College of Anaesthetists, London, UK (2018)
  • Best paper award. Oral finalist, Obstetric Anaesthesia Association, Belfast (2018)
  • 2nd place poster prize, Association of Anaesthetists of Great Britain and Ireland, Winter scientific meeting, London, UK (2017)
  • Best poster prize., Society of Obstetric Anesthesia and Perinatology meeting, Seattle (2017)
  • 1st place poster prize., Obstetric Anaesthesia Association meeting, Manchester. (2016)
  • Clinical Excellence Award, University College London Hospital, UK (2016)
  • National Institute of Academic Anaesthesia Research award, Royal College of Anaesthetists, London, UK (2016)
  • Best paper award., Society of Obstetric Anesthesia and Perinatology meeting, Toronto (2014)
  • Best paper award. Oral finalist, Obstetric Anaesthesia Association, Dublin (2014)
  • Best paper award, Oral finalist., Society of Obstetric Anesthesia and Perinatology meeting, San Juan, Puerto Rico (2013)
  • 1st place poster prize., 5th London Peri-operative Trainee Research Forum (2012)
  • 2nd place history prize., Society of Obstetric Anesthesia and Perinatology meeting, Monterey (2012)
  • 3rd prize Gertie Marx research award, Society of Obstetric Anesthesia and Perinatology meeting, Monterey (2012)
  • Best paper award, Canadian Anesthesiologists’ Society meeting, Quebec (2012)
  • Best paper award, Oral finalist., Obstetric Anaesthesia Association meeting, Liverpool (2012)
  • Young historians’ essay competition. Oral finalist., International Symposium on the History of Anaesthesia, Sydney, Australia (2012)
  • 1st Prize in C. Ronald Stephen Resident’s Essay Contest., Anaesthesia History Association, Grapevine, Texas, USA (2011)
  • Best case report., Society of Obstetric Anesthesia and Perinatology, Las Vegas, USA (2011)
  • Best paper, Oral finalist., Western anaesthesia residents’ conference, Tucson, Arizona, USA (2011)
  • Certificate of merit., Group of Anaesthetists in Training conference, Cardiff, UK (2010)
  • 2nd place poster prize., South East. Scotland Society of Anaesthesia Annual Trainees’ Meeting, Dunfermline, UK (2006)

Boards, Advisory Committees, Professional Organizations


  • Steering committee member formulating guidelines for enhanced recovery after cesarean delivery, Society of Obstetric Anesthesiology and Perinatology (2019 - Present)
  • International Outreach Committee, Society of Obstetric Anesthesiology and Perinatology (2018 - Present)
  • Research committee member, Society of Obstetric Anesthesiology and Perinatology (2018 - Present)
  • Steering committee member formulating guidelines for postoperative monitoring following neuraxial opioid administration in obstetrics, Society of Obstetric Anesthesiology and Perinatology (2017 - 2018)

Professional Education


  • MD (Res), University College London, UK, Molecular mechanisms of postoperative lymphopenia (2016)
  • FRCA, Royal College of Anaesthetists, London, UK, Board Certification (2007)
  • MBChB, University of Edinburgh (2003)
  • Fellowship:North Central London Training Number (2013) England
  • Residency:SE Scotland SHO Anaesthesia Rotation (2007) Scotland
  • Residency:Wythenshawe Hospital Accident and Emergency (2005) England
  • Internship:University Of Edinburgh Western General Hospital (2004) Scotland

Publications

All Publications


  • Evaluation of patient-reported outcome measures of functional recovery following caesarean section: a systematic review using the consensus-based standards for the selection of health measurement instruments (COSMIN) checklist. Anaesthesia Sharawi, N., Klima, L., Shah, R., Blake, L., Carvalho, B., Sultan, P. 2019

    Abstract

    We performed a systematic review using 'consensus-based standards for the selection of health measurement instruments' (COSMIN) criteria to identify and evaluate the quality of patient-reported outcome measures (PROM) instruments that have been utilised to assess functional recovery following caesarean section, and determine the optimal instrument for use in this setting. A literature search was performed using five databases. Studies were included if a psychometrically validated instrument was used to assess functional recovery following caesarean section. The COSMIN appraisal checklist was utilised to: assess the quality of included studies reporting PROMs; determine psychometric quality of instruments; and identify the most promising instruments for use after caesarean section. We identified 13 PROMs used to assess the quality of recovery after caesarean section in 20 studies that included 9214 patients. All PROMs contained between two and seven domains. Five out of the 13 PROMs were specific to postpartum recovery. Only two of these PROM instruments were specifically designed for use after caesarean section (Obstetric Quality of Recovery-11 and Recovery from Caesarean SectionScale). We found very few adequate measures of functional recovery following caesarean section. Overall, the Obstetric Quality of Recovery-11 achieved the highest COSMIN standards for any PROM. Future development of PROMs for use after caesarean section should include multiple domains, and undergo validation as outlined by the COSMIN criteria.

    View details for DOI 10.1111/anae.14807

    View details for PubMedID 31429919

  • Society for Obstetric Anesthesia and Perinatology Consensus Statement: Monitoring Recommendations for Prevention and Detection of Respiratory Depression Associated With Administration of Neuraxial Morphine for Cesarean Delivery Analgesia ANESTHESIA AND ANALGESIA Bauchat, J. R., Weiniger, C. F., Sultan, P., Habib, A. S., Ando, K., Kowalczyk, J. J., Kato, R., George, R. B., Palmer, C. M., Carvalho, B. 2019; 129 (2): 458–74
  • Oral vs intravenous iron therapy for postpartum anemia: a systematic review and meta-analysis AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Sultan, P., Bampoe, S., Shah, R., Guo, N., Estes, J., Stave, C., Goodnough, L., Halpern, S., Butwick, A. 2019; 222 (1): 19-+
  • Evaluation of the Obstetric Quality-of-Recovery score (ObsQoR-11) following non-elective caesarean delivery. International journal of obstetric anesthesia Ciechanowicz, S., Howle, R., Heppolette, C., Nakhjavani, B., Carvalho, B., Sultan, P. 2019

    Abstract

    BACKGROUND: Few robust scoring tools exist to assess recovery following caesarean delivery (CD). We evaluated a new obstetric quality of recovery score (ObsQoR-11, initially formulated for elective CD) following non-elective CD.METHODS: ObsQoR-11 questionnaires were completed by women at day one post non-elective CD. Convergent validity was assessed by correlation of ObsQoR-11 with a 100 mm numerical rating scale (NRS) of general health status; discriminant validity by correlation with good versus poor recovery (NRS of ≥70 vs. <70 mm, respectively); and content validity by correlation with length of stay (LOS), CD category, parity, gestation, previous CD, duration, blood loss, haemoglobin, age and body mass index. Cronbach's alpha, inter-item, split-half and test-retest correlation assessed reliability. Feasibility was tested by recruitment rate and time for ObsQoR-11 completion.RESULTS: 100 women completed ObsQoR-11 at 24 h and 20 women repeated it at 25 h. ObsQoR-11 correlated strongly with NRS (r = 0.72 [95% CI 0.61 to 0.81], P <0.0001); discriminated well between good versus poor recovery (median [IQR] score 97 [86.5-101] versus 64 [50.5-78.5], P <0.0001); correlated to LOS (r = -0.24 [-0.42 to -0.04], P=0.02) and parity (r = 0.24 [0.04 to 0.42], P=0.02). Reliability was acceptable: Cronbach's alpha 0.75; inter-item correlation >0.15; split-half reliability 0.96; and intra-class correlation >0.6; no floor or ceiling effects. One hundred percent completed the ObsQoR-11 (median [IQR] completion time 117 [89-156] s).CONCLUSIONS: ObsQoR-11 is valid and reliable in assessing recovery after non-elective CD. Further research should assess generalisability and use following vaginal delivery.

    View details for PubMedID 30885691

  • Development and evaluation of an obstetric quality-of-recovery score (ObsQoR-11) after elective Caesarean delivery. British journal of anaesthesia Ciechanowicz, S., Setty, T., Robson, E., Sathasivam, C., Chazapis, M., Dick, J., Carvalho, B., Sultan, P. 2019; 122 (1): 69–78

    Abstract

    BACKGROUND: Whilst validated quality-of-recovery (QoR) tools exist for general surgery, there is no specific obstetric equivalent. We aimed to develop and evaluate a modified QoR score after elective Caesarean delivery.METHODS: Twenty-two obstetric specific items were selected following review and modification of the QoR-40 survey by 16 experts and interviews with 50 stakeholders. Item selection was based on relevance to Caesarean delivery and endorsement by >66% of stakeholders. Items were tested on women pre-delivery, at 24 h, and 25 h post-delivery. An 11-item obstetric-specific QoR score (ObsQoR-11) was created based on correlation with a numerical rating scale (NRS) of global health status (r>0.20) at all time points. Reliability, responsiveness, acceptability, and feasibility were tested.RESULTS: One hundred and fifty-two women responded to the 22-item questionnaire pre-delivery (complete in 146), 100 at 24 h, and 10 at 25 h. The ObsQoR-11 correlated with the global health status NRS (r=0.53; 95% confidence interval: 0.43-0.62; P<0.0001) and discriminated good vs poor recovery (NRS score ≥70 vs <70 mm) at 24 h. There was a negative correlation between the ObsQoR-11 score at 24 h and hospital length of stay (r=-0.39; P=0.003). ObsQoR-11 was reliable (internal consistency: 0.85; split-half 0.76; test-retest intra-class correlation coefficient ri>0.6 in 82% of items) and responsive (Cohen effect size: 1.36; standardised response mean: 0.85). A longer 22-item ObsQoR had high (97%) completion rates and short (median: 2 min) completion times.CONCLUSIONS: The ObsQoR-11 provides a valid, reliable, and responsive global assessment of recovery after elective Caesarean delivery.

    View details for PubMedID 30579408

  • A Systematic Review Evaluating Neuraxial Morphine and Diamorphine-Associated Respiratory Depression After Cesarean Delivery ANESTHESIA AND ANALGESIA Sharawi, N., Carvalho, B., Habib, A. S., Blake, L., Mhyre, J. M., Sultan, P. 2018; 127 (6): 1385–95

    Abstract

    The prevalence of neuraxial opioid-induced clinically significant respiratory depression (CSRD) after cesarean delivery is unknown. We sought to review reported cases of author-reported respiratory depression (ARD) to calculate CSRD prevalence. A 6-database literature search was performed to identify ARD secondary to neuraxial morphine or diamorphine, in parturients undergoing cesarean delivery. "Highest" (definite and probable/possible) and "lowest" (definite) prevalences of CSRD were calculated. Secondary outcomes included: (1) prevalence of CSRD associated with contemporary doses of neuraxial opioid, (2) prevalence of ARD as defined by each study's own criteria, (3) case reports of ARD, and (4) reports of ARD reported by the Anesthesia Closed Claims Project database between 1990 and 2016. We identified 78 articles with 18,455 parturients receiving neuraxial morphine or diamorphine for cesarean delivery. The highest and lowest prevalences of CSRD with all doses of neuraxial opioids were 8.67 per 10,000 (95% CI, 4.20-15.16) and 5.96 per 10,000 (95% CI, 2.23-11.28), respectively. The highest and lowest prevalences of CSRD with the use of clinically relevant doses of neuraxial morphine ranged between 1.63 per 10,000 (95% CI, 0.62-8.77) and 1.08 per 10,000 (95% CI, 0.24-7.22), respectively. The prevalence of ARD as defined by each individual paper was 61 per 10,000 (95% CI, 51-74). One published case report of ARD met our inclusion criteria, and there were no cases of ARD from the Closed Claims database analysis. These results indicate that the prevalence of CSRD due to neuraxial morphine or diamorphine in the obstetric population is low.

    View details for PubMedID 30004934

  • The Effect of Intrathecal Morphine Dose on Outcomes After Elective Cesarean Delivery: A Meta-Analysis ANESTHESIA AND ANALGESIA Sultan, P., Halpern, S. H., Pushpanathan, E., Patel, S., Carvalho, B. 2016; 123 (1): 154-164

    Abstract

    The intrathecal morphine dose achieving optimal analgesia for cesarean delivery while minimizing side effects has not yet been deduced. In this meta-analysis, our objective was to determine whether low- or high-dose intrathecal morphine provides acceptable duration and intensity of analgesia with fewer side effects.A literature search (PubMed, EMBASE, MEDLINE, Scopus, Web of Science, and CINAHL) was performed to identify randomized controlled trials involving patients undergoing elective cesarean delivery under spinal anesthesia comparing low-dose (LD; 50-100 μg) morphine with higher dose (HD; >100-250 μg). The primary outcome was the time for first request for supplemental analgesia. The secondary outcomes included pain scores, morphine use, maternal side effects (vomiting and pruritus), and Apgar scores. Mean differences (MDs) and odds ratios (ORs) were calculated using random effects modeling with 95% confidence intervals (CIs).Eleven articles met our inclusion criteria. Four hundred eighty patients were recruited in all study groups (233 patients in the HD and 247 in the LD groups). The mean time to first analgesic request was longer (MD, 4.49 hours [95% CI, 1.85-7.13]; P = 0.0008) in the HD group compared with the LD group. Pain scores (0-100 scale) at 12 hours (MD, 2.54 [95% CI, -2.55 to 7.63]; P = 0.33) as well as morphine consumption at 24 hours (MD, 1.31 mg [95% CI, -3.06 to 7.31]; P = 0.42) were not significantly different. The incidence of nausea or vomiting (OR, 0.44 [95% CI, 0.27-0.73]; P = 0.002) and pruritus (OR, 0.34 [95% CI, 0.20-0.59]; P = 0.0001) was lower in the LD group. The incidence of Apgar scores <7 at 1 minute was not different between groups (OR, 1.11 [95% CI, 0.06-20.49]; P = 0.94).This meta-analysis shows that HDs of intrathecal morphine prolong analgesia after cesarean delivery compared with lower doses. The MD of 4.5 hours (95% CI, 1.9-7.1 and 99% CI, 1.0-8.2 hours) of pain relief must be balanced against the increased risk of maternal pruritus and vomiting. Results from this study can be used by clinicians to weigh the benefits and potential side effects of using HDs of intrathecal morphine for cesarean delivery.

    View details for DOI 10.1213/ANE.0000000000001255

    View details for PubMedID 27089000

  • The Effect of patient warming during Caesarean delivery on maternal and neonatal outcomes: a meta-analysis BRITISH JOURNAL OF ANAESTHESIA Sultan, P., Habib, A. S., Cho, Y., Carvalho, B. 2015; 115 (4): 500-510

    View details for DOI 10.1093/bja/aev325

    View details for Web of Science ID 000362305700007

    View details for PubMedID 26385660

  • The effect of low concentrations versus high concentrations of local anesthetics for labour analgesia on obstetric and anesthetic outcomes: a meta-analysis CANADIAN JOURNAL OF ANESTHESIA-JOURNAL CANADIEN D ANESTHESIE Sultan, P., Murphy, C., Halpern, S., Carvalho, B. 2013; 60 (9): 840-854

    Abstract

    The influence that different concentrations of labour epidural local anesthetic have on assisted vaginal delivery (AVD) and many obstetric outcomes and side effects is uncertain. The purpose of this meta-analysis was to determine whether local anesthetics utilized at low concentrations (LCs) during labour are associated with a decreased incidence of AVD when compared with high concentrations (HCs).We searched PubMed, Ovid EMBASE, Ovid MEDLINE, CINAHL, Scopus, clinicaltrials.gov, and Cochrane databases for randomized controlled trials of labouring patients that compared LCs (defined as ≤ 0.1% epidural bupivacaine or ≤ 0.17% ropivacaine) of epidural local anesthetic with HCs for maintenance of analgesia. The primary outcome was AVD and secondary outcomes included Cesarean delivery, duration of labour, analgesia, side effects (nausea and vomiting, motor block, hypotension, pruritus, and urinary retention), and neonatal outcomes. The odds ratios (OR) or weighted mean differences (WMD) and 95% confidence intervals (CI) were calculated using random effects modelling. An OR < 1 or a WMD < 0 favoured LCs.Eleven studies met our criteria (eight bupivacaine and three ropivacaine studies), providing 1,145 patients in the LCs group and 852 patients in the HCs group for analysis of the primary outcome. Low concentrations were associated with a reduction in the incidence of AVD (OR = 0.70; 95% CI 0.56 to 0.86; P < 0.001). There was no difference in the incidence of Cesarean delivery (OR 1.05; 95% CI 0.82 to 1.33; P = 0.7). The LCs group had less motor block (OR 3.9; 95% CI 1.59 to 9.55; P = 0.003), greater ambulation (OR 2.8; 95% CI 1.1 to 7.14; P = 0.03), less urinary retention (OR 0.42; 95% CI 0.23 to 0.73; P = 0.002), and a shorter second stage of labour (WMD -14.03; 95% CI -27.52 to -0.55; P = 0.04) compared with the HCs group. There were no differences between groups in pain scores, maternal nausea and vomiting, hypotension, fetal heart rate abnormalities, five-minute Apgar scores, and need for neonatal resuscitation. One-minute Apgar scores < 7 favoured the HCs group (OR 1.53; 95% CI 1.07 to 2.21; P = 0.02), and there was more pruritus in the LCs group (OR 3.36; 95% CI 1.00 to 11.31; P = 0.05).When compared with HCs of local anesthetics, the use of LCs for labour epidural analgesia reduces the incidence of AVD. This may be due to a reduction in the amount of local anesthetic used and the subsequent decrease in motor blockade. We therefore recommend the use of LCs of local anesthetics for epidural analgesia to optimize obstetric outcome.

    View details for DOI 10.1007/s12630-013-9981-z

    View details for Web of Science ID 000323340700002

    View details for PubMedID 23925722

  • General Anesthesia for Cesarean Delivery Occasionally Essential but Best Avoided ANESTHESIOLOGY Mhyre, J. M., Sultan, P. 2019; 130 (6): 864–66
  • Preoperative systemic inflammation and perioperative myocardial injury: prospective observational multicentre cohort study of patients undergoing non-cardiac surgery. British journal of anaesthesia Ackland, G. L., Abbott, T. E., Cain, D., Edwards, M. R., Sultan, P., Karmali, S. N., Fowler, A. J., Whittle, J. R., MacDonald, N. J., Reyes, A., Paredes, L. G., Stephens, R. C., Del Arroyo, A. G., Woldman, S., Archbold, R. A., Wragg, A., Kam, E., Ahmad, T., Khan, A. W., Niebrzegowska, E., Pearse, R. M. 2019; 122 (2): 180–87

    Abstract

    Systemic inflammation is pivotal in the pathogenesis of cardiovascular disease. As inflammation can directly cause cardiomyocyte injury, we hypothesised that established systemic inflammation, as reflected by elevated preoperative neutrophil-lymphocyte ratio (NLR) >4, predisposes patients to perioperative myocardial injury.We prospectively recruited 1652 patients aged ≥45 yr who underwent non-cardiac surgery in two UK centres. Serum high sensitivity troponin T (hsTnT) concentrations were measured on the first three postoperative days. Clinicians and investigators were blinded to the troponin results. The primary outcome was perioperative myocardial injury, defined as hsTnT≥14 ng L-1 within 3 days after surgery. We assessed whether myocardial injury was associated with preoperative NLR>4, activated reactive oxygen species (ROS) generation in circulating monocytes, or both. Multivariable logistic regression analysis explored associations between age, sex, NLR, Revised Cardiac Risk Index, individual leukocyte subsets, and myocardial injury. Flow cytometric quantification of ROS was done in 21 patients. Data are presented as n (%) or odds ratio (OR) with 95% confidence intervals.Preoperative NLR>4 was present in 239/1652 (14.5%) patients. Myocardial injury occurred in 405/1652 (24.5%) patients and was more common in patients with preoperative NLR>4 [OR: 2.56 (1.92-3.41); P<0.0001]. Myocardial injury was independently associated with lower absolute preoperative lymphocyte count [OR 1.80 (1.50-2.17); P<0.0001] and higher absolute preoperative monocyte count [OR 1.93 (1.12-3.30); P=0.017]. Monocyte ROS generation correlated with NLR (r=0.47; P=0.03).Preoperative NLR>4 is associated with perioperative myocardial injury, independent of conventional risk factors. Systemic inflammation may contribute to the development of perioperative myocardial injury.NCT01842568.

    View details for DOI 10.1016/j.bja.2018.09.002

    View details for PubMedID 30686303

    View details for PubMedCentralID PMC6354048

  • Role of leucocyte caspase-1 activity in epidural-related maternal fever: a single-centre, observational, mechanistic cohort study. British journal of anaesthesia Del Arroyo, A. G., Sanchez, J., Patel, S., Phillips, S., Reyes, A., Cubillos, C., Fernando, R., David, A. L., Sultan, P., Ackland, G. L. 2019; 122 (1): 92–102

    Abstract

    Epidural-related maternal fever (ERMF) has been reported in ∼26% of labouring women. The underlying mechanisms remain unclear. We hypothesised that ERMF is promoted by bupivacaine disrupting cytokine production/release from mononuclear leucocytes [mononuclear fraction (MNF)]. We examined whether bupivacaine (i) reduces caspase-1 activity and release of the anti-pyrogenic cytokine interleukin (IL)-1 receptor antagonist (IL-1ra), and (ii) is pro-inflammatory through mitochondrial injury/IL-1β.In labouring women, blood samples were obtained before/after epidural analgesia was implemented. Maternal temperature was recorded hourly for the first 4 h of epidural analgesia. Time-matched samples/temperatures were obtained from labouring women without epidural analgesia, pregnant non-labouring, and non-pregnant women. The primary clinical outcome was change in maternal temperature over 4 h after the onset of siting epidural catheter/enrolment. The secondary clinical outcome was development of ERMF (temperature ≥ 38°C). The effect of bupivacaine/saline on apoptosis, caspase-1 activity, intracellular IL-1ra, and plasma IL-1ra/IL-1β ratio was quantified in MNF from labouring women or THP-1 monocytes (using flow cytometry, respirometry, or enzyme-linked immunosorbent assay).Maternal temperature increased by 0.06°C h-1 [95% confidence interval (CI): 0.03-0.09; P=0.003; n=38] after labour epidural placement. ERMF only occurred in women receiving epidural analgesia (five of 38; 13.2%). Bupivacaine did not alter MNF or THP-1 apoptosis compared with saline control, but reduced caspase-1 activity by 11% (95% CI: 5-17; n=10) in MNF from women in established labour. Bupivacaine increased intracellular MNF IL-1ra by 25% (95% CI: 10-41; P<0.001; n=10) compared with saline-control. Epidural analgesia reduced plasma IL-1ra/IL-1β ratio (mean reduction: 14; 95% CI: 7-30; n=30) compared with women without epidural analgesia.Impaired release of anti-pyrogenic IL-1ra might explain ERMF mechanistically. Immunomodulation by bupivacaine during labour could promote ERMF.

    View details for DOI 10.1016/j.bja.2018.09.024

    View details for PubMedID 30579413

  • Validation of an obstetric quality-of-recovery scoring tool (ObsQoR-10) following vaginal delivery: an interim analysis Obstetric Anesthesia Association Nishimura, S., Kormendy, F., Ciechanowicz, S., Papageorgiou, C., Sultan, P. 2019
  • Local anaesthetic techniques for post-caesarean delivery analgesia. International journal of obstetric anesthesia Patel, S. D., Sharawi, N., Sultan, P. 2019

    Abstract

    In this narrative review we summarise pertinent data from published studies investigating the use of local anaesthetic techniques as adjuncts for managing post caesarean delivery pain. Based on currently available evidence, ultrasound-guided transversus abdominis plane (TAP), quadratus lumborum (QL) and ilio-inguinal and iliohypogastric (ILIH) blocks are preferable to landmark techniques. When intrathecal morphine is used for caesarean delivery analgesia, TAP blocks do not confer any additional benefit. In the absence of intrathecal morphine, TAP blocks have been shown to reduce pain scores and opioid consumption in the first 24 hours postoperatively. In the absence of intrathecal morphine, single-dose local anaesthetic wound infiltration also results in a moderate reduction in opioid consumption postoperatively. If a wound catheter is to be incorporated into a multimodal analgesic regimen, a position below the fascia and a continuous infusion of low-concentration local anaesthetic solutions should be considered. Intraperitoneal local anaesthetic instillation may be of benefit in patients who undergo peritoneal closure but larger studies are still needed. Quadratus lumborum and ILIH blocks show promising results but the data are limited, so recommendations for routine use cannot be made. In summary, evidence supports the use of local anaesthetic techniques for post-caesarean delivery pain but additional research is required to determine the optimum dosing regimens, and the potential role of liposomal local anaesthetics. Further studies are required to compare techniques and determine their role in conjunction with low-dose long-acting neuraxial opioids.

    View details for DOI 10.1016/j.ijoa.2019.06.002

    View details for PubMedID 31262444

  • Management of Thromboembolic Phenomena in Pregnancy In T. Husain, R. Fernando, & S. Segal (Eds.), Obstetric Anesthesiology: An Illustrated Case-Based Approach. Cambridge: Pushpanathan, E., Sultan, P. Cambridge University Press. 2019; 1: 263–267
  • Abnormal placentation T. Husain, R. Fernando, & S. Segal (Eds.), Obstetric Anesthesiology: An Illustrated Case-Based Approach. Cambridge: Olearo, ., Sultan, P., David, A. Cambridge University Press. 2019; 1: 107–113
  • Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) oxygen in women having planned caesarean delivery Obstetric Anaesthesia Association Al-Sulttan, S., Bampoe, S., Howle, R., Setty, T., Columb, M., Sultan, P. 2019: 40–41
  • Does the addition of active body warming to in-line intravenous fluid warming prevent maternal hypothermia during elective caesarean section? A randomised controlled trial INTERNATIONAL JOURNAL OF OBSTETRIC ANESTHESIA Sultan, P., Carvalho, B. 2018; 35: 115–16

    View details for PubMedID 29343417

  • High-Frequency Jet Ventilation During Cryoablation of Small Renal Tumours CARDIOVASCULAR AND INTERVENTIONAL RADIOLOGY Buchan, T., Walkden, M., Jenkins, K., Sultan, P., Bandula, S. 2018; 41 (7): 1067–73

    Abstract

    To evaluate the effect of high-frequency jet ventilation (HFJV) in place of standard intermittent positive-pressure ventilation (IPPV) on procedure duration, patient radiation dose, complication rates, and outcomes during CT-guided cryoablation of small renal tumours.One hundred consecutive CT-guided cryoablation procedures to treat small renal tumours under general anaesthesia were evaluated-50 with standard IPPV and 50 after the introduction of HFJV as standard practice. Anaesthesia and procedural times, ionising radiation dose, complications, and 1-month post-treatment outcomes were collected.HFJV was feasible and safe in all cases. Mean procedure time and total anaesthetic time were shorter with HFJV (p = <0.0001). The number of required CT acquisitions (p = 0.0002) and total procedure patient radiation dose (p = 0.0027) were also lower in the HFJV group compared with the IPPV group. There were a total of four complications of Clavien-Dindo classification 3 or above-three in the IPPV group and one in the HFJV group. At 1-month follow-up, two cases (both in the IPPV group) demonstrated subtotal treatment. Both cases were subsequently successfully retreated with cryoablation.By reducing target tumour motion during CT-guided renal cryoablation, HFJV can reduce procedure times and exposure to ionising radiation. HFJV provides an important adjunct to complex image-guided interventions, with potential to improve safety and treatment outcomes.

    View details for PubMedID 29516243

    View details for PubMedCentralID PMC5976690

  • Caspase-1 and epidural-related maternal fever Ackland, G., del Arroyo, A., Sanchez, J., Patel, S., Phillips, S., Reyes, A., Sultan, P., David, A. ELSEVIER SCI LTD. 2018: E20–E21
  • The Effect of Glycopyrrolate on the Incidence of Hypotension and Vasopressor Requirement During Spinal Anesthesia for Cesarean Delivery: A Meta-analysis ANESTHESIA AND ANALGESIA Patel, S. D., Habib, A. S., Phillips, S., Carvalho, B., Sultan, P. 2018; 126 (2): 552–58

    Abstract

    The objective of this meta-analysis was to determine the efficacy of glycopyrrolate at reducing spinal hypotension during cesarean delivery.A literature search was performed to identify randomized controlled trials investigating the effect of glycopyrrolate on spinal-induced hypotension during cesarean delivery. Primary outcomes were intraoperative hypotension and vasopressor requirement (phenylephrine equivalents). Secondary outcomes included heart rate (HR), nausea and vomiting, dry mouth, and Apgar scores. Risk ratios (RRs), and mean differences (MDs) were calculated using random-effects modeling with 95% confidence intervals for primary outcomes and 99% confidence intervals for secondary outcomes.Five randomized controlled trials met our inclusion criteria. A total of 311 patients were included: 153 received glycopyrrolate and 158 placebo. The incidence of spinal-induced hypotension was no different with prophylactic glycopyrrolate compared to control (RR, 0.93 [0.71-1.21]; P = .59), but the total phenylephrine dose required was significantly reduced with glycopyrrolate (MD, -62.64 μg [-107.61 to -17.66 μg]; P = .006). The maximal HR achieved in the glycopyrrolate group was significantly higher compared to controls (MD, 15.85 bpm [5.40-26.31]; P < .0001); however, the incidence of bradycardia was not statistically different. The incidence of intraoperative nausea and vomiting was not different between groups; however, glycopyrrolate increased the risk of dry mouth (RR, 5.15 [1.82-14.57]; P < .0001). Apgar scores at 1 and 5 minutes did not differ between groups.Prophylactic glycopyrrolate does not reduce the incidence of spinal-induced hypotension but results in a modest reduction in vasopressor requirements while increasing maternal HR.

    View details for PubMedID 28704246

  • High-dose versus low-dose local anaesthetic for transversus abdominis plane block post-Caesarean delivery analgesia: a meta-analysis BRITISH JOURNAL OF ANAESTHESIA Ng, S. C., Habib, A. S., Sodha, S., Carvalho, B., Sultan, P. 2018; 120 (2): 252–63

    Abstract

    The optimal local-anaesthetic (LA) dose for transversus-abdominis-plane (TAP) block is unclear. In this meta-analysis, we aimed to determine whether TAP blocks for Caesarean delivery (CD) with low-dose (LD) LA demonstrated non-inferiority in terms of analgesic efficacy, compared with high-dose (HD) LA.A literature search was performed for randomised controlled trials examining the analgesic efficacy of TAP blocks vs control after CD. The different dosing used in these studies was classified as HD or LD (bupivacaine equivalents >50 or ≤50 mg per block side, respectively). The pooled results of each dose group vs control were indirectly compared using the Q test. The primary outcome was 24 h opioid consumption. Secondary outcomes included 6 and 24 h postoperative pain scores, time to first analgesia, 6 h opioid consumption, opioid-related side-effects, and maternal satisfaction.Fourteen studies consisting of 770 women (389 TAP and 381 control) were included. Compared with controls, the 24 h opioid consumption (milligram morphine equivalents) was lower in HD [mean difference (MD) 95% confidence interval (CI) -22.41 (-38.56, -6.26); P=0.007; I2=93%] and LD [MD 95% CI -16.29 (-29.74, -2.84); P=0.02; I2=98%] TAP groups. However, no differences were demonstrated between the HD and LD groups (P=0.57). There were also no differences between the HD and LD groups for the 6 h opioid consumption, time to first analgesia, 6 and 24 h pain scores, postoperative nausea and vomiting, pruritus, and maternal satisfaction.Low-dose TAP blocks for Caesarean delivery provide analgesia and opioid-sparing effects comparable with the high-dose blocks. This suggests that lower doses can be used to reduce local anaesthetic toxicity risk without compromising the analgesic efficacy.

    View details for PubMedID 29406174

  • A late presentation of acute fatty liver of pregnancy resulting in massive haemorrhage during twin delivery managed with epidural analgesia Das, D., Shah, R., Sultan, P., Bampoe, S. 2018
  • Operating room-to-incision interval and neonatal outcome in emergency caesarean section: a retrospective 5-year cohort study. Anaesthesia Palmer, E., Ciechanowicz, S., Reeve, A., Harris, S., Wong, D. J., Sultan, P. 2018; 73 (7): 825–31

    Abstract

    We conducted a 5-year retrospective cohort study on women undergoing caesarean section to investigate factors influencing the operating room-to-incision interval. Time-to-event analysis was performed for category-1 caesarean section using a Cox proportional hazards regression model. Covariates included: anaesthetic technique; body mass index; age; parity; time of delivery; and gestational age. Binary logistic regression was performed for 5-min Apgar score ≥ 7. There were 677 women who underwent category-1 caesarean section and who met the entry criteria. Unadjusted median (IQR [range]) operating room-to-incision intervals were: epidural top-up 11 (7-17 [0-87]) min; general anaesthesia 6 (4-11 [0-69]) min; spinal 13 (10-20 [0-83]) min; and combined spinal-epidural 24 (13-35 [0-75]) min. Cox regression showed general anaesthesia to be the most rapid method with a hazard ratio (95%CI) of 1.97 (1.60-2.44; p < 0.0001), followed by epidural top-up (reference group), spinal anaesthesia 0.79 (0.65-0.96; p = 0.02) and combined spinal-epidural 0.48 (0.35-0.67; p < 0.0001). Underweight and overweight body mass indexes were associated with longer operating room-to-incision intervals. General anaesthesia was associated with fewer 5-min Apgar scores ≥ 7 with an odds ratio (95%CI) of 0.28 (0.11-0.68; p < 0.01). There was no difference in neonatal outcomes between the first and fifth quintiles for operating room-to-incision intervals. General anaesthesia is associated with the most rapid operating room-to-incision interval for category-1 caesarean section, but is also associated with worse short term neonatal outcomes. Longer operating room-to-incision intervals were not associated with worse neonatal outcomes.

    View details for DOI 10.1111/anae.14296

    View details for PubMedID 29633251

  • A Systematic Review of Postoperative Pain Outcome Measurements Utilised in Regional Anesthesia Randomized Controlled Trials. Anesthesiology research and practice Pushpanathan, E., Setty, T., Carvalho, B., Sultan, P. 2018; 2018: 9050239

    Abstract

    Regional anesthesia is a rapidly growing subspecialty. There are few published meta-analyses exploring pain outcome measures utilised in regional anesthesia randomized controlled trials (RCTs), which may be due to heterogeneity in outcomes assessed. This systematic review explores postoperative pain outcomes utilised in regional anesthesia RCTs.A literature search was performed using three databases (Medline, Embase, and CINAHL). Regional anesthesia RCTs with postoperative pain as a primary outcome were included if written in English and published in one of the top 20 impact factor journals between 2005 and 2017. Study quality was assessed using the Cochrane Collaboration's tool for assessing risk of bias.From the 31 included articles, 15 different outcome measures in total were used to assess postoperative pain. The most commonly (16/31) used outcome measures were verbal numerical grading of pain out of 10, total opioid consumption, and visual analogue scale 10 cm (VAS). The need for analgesia was used as an outcome measure where studies did not use a pain rating score. Ten studies reported pain scores on activity and 27/31 studies utilised ≥2 pain outcomes. Time of measurement of pain score also varied with a total of 51 different time points used in total.Analysis of the articles demonstrated heterogeneity and inconsistency in choice of pain outcome and time of measurement within regional anesthesia studies. Identification of these pain outcomes utilised can help to create a definitive list of core outcomes, which may guide future researchers when designing such studies.

    View details for PubMedID 30151005

    View details for PubMedCentralID PMC6087609

  • Comparing TAP block and wound infiltration for postoperative analgesia following cesarean delivery: A meta-analysis Patel, S., Halpern, S., Jadin, S., Howle, R., Carvalho, B., Sultan, P. 2018
  • Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Devereaux, P. J., Biccard, B. M., Sigamani, A., Xavier, D., Chan, M. V., Srinathan, S. K., Walsh, M., Abraham, V., Pearse, R., Wang, C. Y., Sessler, D. I., Kurz, A., Szczeklik, W., Berwanger, O., Carlos Villar, J., Malaga, G., Garg, A. X., Chow, C. K., Ackland, G., Patel, A., Borges, F., Belley-Cote, E. P., Duceppe, E., Spence, J., Tandon, V., Williams, C., Sapsford, R. J., Polanczyk, C. A., Tiboni, M., Alonso-Coello, P., Faruqui, A., Heels-Ansdell, D., Lamy, A., Whitlock, R., LeManach, Y., Roshanov, P. S., McGillion, M., Kavsak, P., McQueen, M. J., Thabane, L., Rodseth, R. N., Buse, G., Bhandari, M., Garutti, I., Jacka, M. J., Schuenemann, H. J., Lucia Cortes, O., Coriat, P., Dvirnik, N., Botto, F., Pettit, S., Jaffe, A. S., Guyatt, G. H., Writing Comm Vision Study Investig 2017; 317 (16): 1642–51

    Abstract

    Little is known about the relationship between perioperative high-sensitivity troponin T (hsTnT) measurements and 30-day mortality and myocardial injury after noncardiac surgery (MINS).To determine the association between perioperative hsTnT measurements and 30-day mortality and potential diagnostic criteria for MINS (ie, myocardial injury due to ischemia associated with 30-day mortality).Prospective cohort study of patients aged 45 years or older who underwent inpatient noncardiac surgery and had a postoperative hsTnT measurement. Starting in October 2008, participants were recruited at 23 centers in 13 countries; follow-up finished in December 2013.Patients had hsTnT measurements 6 to 12 hours after surgery and daily for 3 days; 40.4% had a preoperative hsTnT measurement.A modified Mazumdar approach (an iterative process) was used to determine if there were hsTnT thresholds associated with risk of death and had an adjusted hazard ratio (HR) of 3.0 or higher and a risk of 30-day mortality of 3% or higher. To determine potential diagnostic criteria for MINS, regression analyses ascertained if postoperative hsTnT elevations required an ischemic feature (eg, ischemic symptom or electrocardiography finding) to be associated with 30-day mortality.Among 21 842 participants, the mean age was 63.1 (SD, 10.7) years and 49.1% were female. Death within 30 days after surgery occurred in 266 patients (1.2%; 95% CI, 1.1%-1.4%). Multivariable analysis demonstrated that compared with the reference group (peak hsTnT <5 ng/L), peak postoperative hsTnT levels of 20 to less than 65 ng/L, 65 to less than 1000 ng/L, and 1000 ng/L or higher had 30-day mortality rates of 3.0% (123/4049; 95% CI, 2.6%-3.6%), 9.1% (102/1118; 95% CI, 7.6%-11.0%), and 29.6% (16/54; 95% CI, 19.1%-42.8%), with corresponding adjusted HRs of 23.63 (95% CI, 10.32-54.09), 70.34 (95% CI, 30.60-161.71), and 227.01 (95% CI, 87.35-589.92), respectively. An absolute hsTnT change of 5 ng/L or higher was associated with an increased risk of 30-day mortality (adjusted HR, 4.69; 95% CI, 3.52-6.25). An elevated postoperative hsTnT (ie, 20 to <65 ng/L with an absolute change ≥5 ng/L or hsTnT ≥65 ng/L) without an ischemic feature was associated with 30-day mortality (adjusted HR, 3.20; 95% CI, 2.37-4.32). Among the 3904 patients (17.9%; 95% CI, 17.4%-18.4%) with MINS, 3633 (93.1%; 95% CI, 92.2%-93.8%) did not experience an ischemic symptom.Among patients undergoing noncardiac surgery, peak postoperative hsTnT during the first 3 days after surgery was significantly associated with 30-day mortality. Elevated postoperative hsTnT without an ischemic feature was also associated with 30-day mortality.

    View details for DOI 10.1001/jama.2017.4360

    View details for Web of Science ID 000400014000014

    View details for PubMedID 28444280

  • Urgency of caesarean delivery, anaesthetic times and neonatal outcomes Palmer, E., Phillips, S., Harris, S., Reeve, A., Sultan, P. 2017
  • Apnoeic oxygenation during maternal cardiac arrest in a parturient with extreme obesity. International journal of obstetric anesthesia Phillips, S., Subair, S., Husain, T., Sultan, P. 2017; 29: 88–90

    View details for DOI 10.1016/j.ijoa.2016.11.003

    View details for PubMedID 28017512

  • Optimal administration of cefazolin prophylaxis for cesarean delivery. Journal of perinatology : official journal of the California Perinatal Association Duffield, A., Sultan, P., Riley, E. T., Carvalho, B. 2017; 37 (1): 16–20

    View details for PubMedID 28050017

  • Medical identification or alert jewellery: an opportunity to save lives or an unreliable hindrance? Anaesthesia Rahman, S., Walker, D., Sultan, P. 2017; 72 (9): 1139–45

    Abstract

    Medical identification jewellery can convey vital information to emergency responders, but mistakes and ambiguity may lead to misdiagnosis and morbidity. We performed a review of relevant articles retrieved from Pubmed® , Embase® and Scopus® and Google UK Inc. to investigate the commercial availability and issuance of these products. From 84 identified studies, we shortlisted 74 for review. The Google search retrieved 1,090,000 results within 0.57 s (January 2017). We explored 32 websites selling medical alert jewellery in the first five pages of these results. We found that patients themselves are currently responsible for the engraved wording on medical alert jewellery, with no mandatory physician checks. The accuracy and appropriateness of this information may thus vary. In the absence of national guidance in the UK, we suggest that there should be a list of specific indications warranting their use, a requirement for regular review of information, and clarity around the level of physician input into the engraving chosen. We discuss the potential benefits vs. risks of wearing medical alert jewellery and clarify the limitations of medical teams' responsibilities in relation to patients found to be wearing them.

    View details for DOI 10.1111/anae.13958

    View details for PubMedID 28677832

  • Ambient operating room temperature: mother, baby or surgeon? British journal of anaesthesia Sultan, P., Habib, A. S., Carvalho, B. 2017; 119 (4): 839

    View details for PubMedID 29121314

  • An analysis of anaesthetic times for caesarean delivery over a 5-year period in a London Teaching Hospital. Palmer, E., Phillips, S., Reeve, A., Harris, S., Sultan, P. 2017
  • Development of an obstetric 'Quality of Recovery' scoring tool (ObsQoR-15) Ciechanowicz, S., Chazapis, M., Sathasivam, C., Robson, E., Setty, T., Sultan, P. 2017
  • Survey of external cephalic version for breech presentation and neuraxial blockade use. Journal of clinical anesthesia Weiniger, C. F., Sultan, P., Dunn, A., Carvalho, B. 2016; 34: 616-622

    Abstract

    Neuraxial blockade may increase external cephalic version (ECV) success rates. This survey aimed to assess the frequency and characteristics of neuraxial blockade used to facilitate ECV.We surveyed Society for Obstetric Anesthesia and Perinatology members regarding ECV practice using a 15-item survey developed by 3 obstetric anesthesiologists and tested for face validity. The survey was e-mailed in January 2015 and again in February 2015 to the 1056 Society of Obstetric Anesthesiology and Perinatology members. We present descriptive statistics of responses.Our survey response rate was 322 of 1056 (30.5%).Neuraxial blockade was used for ECV always by 18 (5.6%), often by 52 (16.1%), sometimes by 98 (30.4%), rarely by 78 (24.2%), and never by 46 (14.3%) of respondents. An anesthetic sensory block target was selected by 141 (43.8%) respondents, and analgesic by 102 (31.7%) respondents. Epidural drug doses ranged widely, including sufentanil 5-25 μg; lidocaine 1% or 2% 10-20 mL, bupivacaine 0.0625% to 0.5% 6-15 mL, and ropivacaine 0.2% 20 mL. Intrathecal bupivacaine was used by 182 (56.5%) respondents; the most frequent doses were 2.5 mg used by 24 (7.5%), 7.5 mg used by 35 (10.9%), and 12 mg used by 30 (9.3%).Neuraxial blockade is not universally offered to facilitate ECV, and there is wide variability in neuraxial blockade techniques, in drugs and doses administered, and in the sensory blockade (anesthetic or analgesic) targeted. Future studies need to evaluate and remove barriers to allow for more widespread use of neuraxial blockade for pain relief and to optimize ECV success rates.

    View details for DOI 10.1016/j.jclinane.2016.05.040

    View details for PubMedID 27687460

  • Neuraxial blockade increases external cephalic version success: a well-known finding needing to be disseminated within the obstetric domain AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Sultan, P., Weiniger, C. F., Carvalho, B. 2016; 215 (5): 675–76

    View details for PubMedID 27423524

  • Amniotic fluid embolism: update and review CURRENT OPINION IN ANESTHESIOLOGY Sultan, P., Seligman, K., Carvalho, B. 2016; 29 (3): 288-296

    Abstract

    This article reviews our current understanding of amniotic fluid embolism (AFE), specifically the pathogenesis, treatment strategies, potential diagnostic tests and future therapeutic interventions for AFE.The incidence and case mortality of AFE varies widely because of heterogeneous diagnostic criteria and varying reporting mechanisms across the world. Amniotic fluid embolism is thought to be caused by abnormal activation of immunologic mechanisms following entry of fetal antigens into maternal circulation. Mast cell degranulation and complement activation may play a role in this anaphylactoid or systemic inflammatory response syndrome. Development of serum biomarkers and immune-histochemical staining techniques to aid diagnosis and develop treatments are under development and evaluation. Treatment of AFE is supportive and directed at treating cardiovascular, pulmonary, and coagulation derangements. Treatment for coagulopathy (fresh frozen plasma, cryoprecipitate/fibrinogen concentrate, and antifibrinolytics) should be initiated promptly. Recombinant factor VIIa may lead to increased mortality and should not routinely be used. C1 esterase inhibitors may be a potential therapeutic option.AFE is a devastating obstetric complication that requires early and aggressive intervention with optimal cardiopulmonary resuscitation, as well as hemorrhage and coagulopathy management. Biomarkers offer promise to aid the diagnosis of AFE, and immunomodulation may provide future therapeutic interventions to treat this lethal condition.

    View details for DOI 10.1097/ACO.0000000000000328

    View details for PubMedID 27153475

  • Inflammation and Epidural-Related Maternal Fever: Proposed Mechanisms ANESTHESIA AND ANALGESIA Sultan, P., David, A. L., Fernando, R., Ackland, G. L. 2016; 122 (5): 1546–53

    Abstract

    Intrapartum fever is associated with excessive maternal interventions as well as higher neonatal morbidity. Epidural-related maternal fever (ERMF) contributes to the development of intrapartum fever. The mechanism(s) for ERMF has remained elusive. Here, we consider how inflammatory mechanisms may be modulated by local anesthetic agents and their relevance to ERMF. We also critically reappraise the clinical data with regard to emerging concepts that explain how anesthetic drug-induced metabolic dysfunction, with or without activation of the inflammasome, might trigger the release of nonpathogenic, inflammatory molecules (danger-associated molecular patterns) likely to underlie ERMF.

    View details for PubMedID 27101499

  • A Longitudinal Study to Evaluate Pregnancy-Induced Endogenous Analgesia and Pain Modulation REGIONAL ANESTHESIA AND PAIN MEDICINE Carvalho, B., Granot, M., Sultan, P., Wilson, H., Landau, R. 2016; 41 (2): 175-180

    Abstract

    The phenomenon of pregnancy-induced analgesia has been demonstrated in animal models but less consistently in human studies. This study aimed to assess endogenous pain modulation, evaluating inhibitory and excitatory pain pathways, over the course of pregnancy and postpartum.Healthy pregnant women were approached for participation in this prospective multicenter cohort study. Conditioned pain modulation (CPM), mechanical temporal summation (mTS), and temperature that induced pain 6 out of 10 (pain-6) were assessed toward the end of each trimester of pregnancy (8-12, 18-22, and 36 weeks) and at 6 to 12 weeks postpartum. To assess how pregnancy affects CPM, mTS, and pain-6, a mixed-effects analysis of variance was performed.Thirty-three pregnant women were enrolled. Pregnancy did not significantly impact CPM (F3,39 = 0.30, P = 0.83, partial η = 0.02), and there was no significant difference between CPM scores in the third trimester compared with postpartum. The mTS scores and pain-6 ratings were also not significantly changed by pregnancy (F3,42 = 1.20, P = 0.32, partial η = 0.08; and F3,42 = 1.90, P = 0.14, partial η = 0.12, respectively).This is the first study to assess CPM and mTS changes in pregnancy and postpartum. Endogenous pain modulation evaluating both inhibitory and excitatory pain pathways did not significantly change during pregnancy or postpartum. Future studies are required to determine the magnitude and clinical significance of pregnancy-induced analgesia.

    View details for DOI 10.1097/AAP.0000000000000359

    View details for PubMedID 26866295

  • A Prospective Cohort Study Evaluating the Ability of Anticipated Pain, Perceived Analgesic Needs, and Psychological Traits to Predict Pain and Analgesic Usage following Cesarean Delivery. Anesthesiology research and practice Carvalho, B., Zheng, M., Harter, S., Sultan, P. 2016; 2016: 7948412-?

    Abstract

    Introduction. This study aimed to determine if preoperative psychological tests combined with simple pain prediction ratings could predict pain intensity and analgesic usage following cesarean delivery (CD). Methods. 50 healthy women undergoing scheduled CD with spinal anesthesia comprised the prospective study cohort. Preoperative predictors included 4 validated psychological questionnaires (Anxiety Sensitivity Index (ASI), Fear of Pain (FPQ), Pain Catastrophizing Scale, and Eysenck Personality Questionnaire) and 3 simple ratings: expected postoperative pain (0-10), anticipated analgesic threshold (0-10), and perceived analgesic needs (0-10). Postoperative outcome measures included post-CD pain (combined rest and movement) and opioid used for the 48-hour study period. Results. Bivariate correlations were significant with expected pain and opioid usage (r = 0.349), anticipated analgesic threshold and post-CD pain (r = -0.349), and perceived analgesic needs and post-CD pain (r = 0.313). Multiple linear regression analysis found that expected postoperative pain and anticipated analgesic needs contributed to post-CD pain prediction modeling (R (2) = 0.443, p < 0.0001); expected postoperative pain, ASI, and FPQ were associated with opioid usage (R (2) = 0.421, p < 0.0001). Conclusion. Preoperative psychological tests combined with simple pain prediction ratings accounted for 44% and 42% of pain and analgesic use variance, respectively. Preoperatively determined expected postoperative pain and perceived analgesic needs appear to be useful predictors for post-CD pain and analgesic requirements.

    View details for DOI 10.1155/2016/7948412

    View details for PubMedID 27143966

  • Reply. British journal of anaesthesia Sultan, P., Habib, A. S., Carvalho, B. 2016; 117 (5): 676–77

    View details for DOI 10.1093/bja/aew351

    View details for PubMedID 27799193

  • The identification of postoperative pain core outcomes used in regional anaesthesiatrials and the development of a core outcome set. Pushpanathan, E., Sultan, P. 2016
  • Molecular mechanisms of postoperative lymphopenia: MD (Res) degree Thesis Sultan, P. University College London. London. 2016

    Abstract

    Low anaerobic threshold (AT), a marker of decreased exercise capacity, is associated with poorer outcomes following surgery. In this thesis I demonstrate a relationship between low preoperative AT and preoperative lymphopenia (low lymphocyte count). I subsequently demonstrate that preoperative lymphopenia is associated with prolonged hospitalisation and increased postoperative complications in 2 surgical cohorts (n=240 and n=881). Significant metabolic (bioenergetic) and functional changes occur in lymphocytes postoperatively, which may contribute to increased morbidity and mortality. Lymphocytes demonstrate a postoperative decrease in glycolysis and oxidative phosphorylation. Altered postoperative bioenergetic function are accompanied by an increase in mitochondrial reactive oxygen species production and a reduction in lymphocyte mitochondrial membrane potential, which are associated with apoptosis or cell death. Increased apoptosis of lymphocytes following surgery is the likely mechanism for acquired lymphopenia postoperatively (reduction in lymphocyte count which occurs postoperatively). A decrease in glycolysis is accompanied by increased CD8+ lymphocyte cytokine production. Postoperative inflammasome activation as demonstrated by increased caspase-1 activity, appears to occur secondary to glucocorticoid release associated with the stress response to surgery. Caspase-1 is associated with glycolysis inhibition (decreased glycolysis postoperatively) and increased apoptosis (reduced lymphocyte count postoperatively). Increased Interleukin-1-beta expression, which is associated with activation of the inflammasome and increased cytokine production, is demonstrated following incubation of lymphocytes with glucocorticoid. I hypothesise that postoperative changes in lymphocyte function occur secondary to increased glucocorticoid levels activating the inflammasome pathway during the stress response to surgery. This thesis provides translational data introducing the concept that lymphocyte metabolic abnormalities underlie the postoperative immune phenotype.

  • Reducing spinal hypotension during caesarean delivery with glycopyrrolate: A meta-analysis PAtel, S., Habib, A., Sodha, S., Carvalho, B., Sultan, P. 2016
  • Regulation of leukocyte caspase-1 activity by bupivacaine in labour Gutierrez Del Arroyo, A., Patel, S., Crean, A., Sanchez, J., David, A., Fernando, R., Sultan, P., Ackland, G. 2016
  • Metabolic dysfunction in lymphocytes promotes postoperative morbidity CLINICAL SCIENCE Edwards, M. R., Sultan, P., del Arroyo, A., Whittle, J., Karmali, S. N., Moonesinghe, S., Haddad, F. S., Mythen, M. G., Singer, M., Ackland, G. L. 2015; 129 (5): 423–37

    Abstract

    Perioperative lymphopenia has been linked with an increased risk of postoperative infectious complications, but the mechanisms remain unclear. We tested the hypothesis that bioenergetic dysfunction is an important mechanism underlying lymphopenia, impaired functionality and infectious complications. In two cohorts of patients (61-82 years old) undergoing orthopaedic joint replacement (n=417 and 328, respectively), we confirmed prospectively that preoperative lymphopenia (≤1.3 x 10(9)·l(-1); <20% white cell count; prevalence 15-18%) was associated with infectious complications (relative risk 1.5 (95% confidence interval 1.1-2.0); P=0.008) and prolonged hospital stay. Lymphocyte respirometry, mitochondrial bioenergetics and function were assessed (n=93 patients). Postoperative lymphocytes showed a median 43% fall (range: 26-65%; P=0.029; n=13 patients) in spare respiratory capacity, the extra capacity available to produce energy in response to stress. This was accompanied by reduced glycolytic capacity. A similar hypometabolic phenotype was observed in lymphocytes sampled preoperatively from chronically lymphopenic patients (n=21). This hypometabolic phenotype was associated with functional lymphocyte impairment including reduced T-cell proliferation, lower intracellular cytokine production and excess apoptosis induced by a range of common stressors. Glucocorticoids, which are ubiquitously elevated for a prolonged period postoperatively, generated increased levels of mitochondrial reactive oxygen species, activated caspase-1 and mature interleukin (IL)-1β in human lymphocytes, suggesting inflammasome activation. mRNA transcription of the NLRP1 inflammasome was increased in lymphocytes postoperatively. Genetic ablation of the murine NLRP3 inflammasome failed to prevent glucocorticoid-induced lymphocyte apoptosis and caspase-1 activity, but increased NLRP1 protein expression. Our findings suggest that the hypometabolic phenotype observed in chronically lymphopenic patients and/or acquired postoperatively increases the risk of postoperative infection through glucocorticoid activation of caspase-1 via the NLRP1 inflammasome.

    View details for PubMedID 25891048

  • Pharmacokinetics of Prophylactic Cefazolin in Parturients Undergoing Cesarean Delivery (vol 58, pg 3504, 2014) ANTIMICROBIAL AGENTS AND CHEMOTHERAPY Elkomy, M. H., Sultan, P., Drover, D. R., Epshtein, E., Galinkin, J. L., Carvalho, B. 2015; 59 (6): 3694

    View details for PubMedID 25977453

  • Perioperative considerations of the patient with malaria CANADIAN JOURNAL OF ANESTHESIA-JOURNAL CANADIEN D ANESTHESIE Soltanifar, D., Carvalho, B., Sultan, P. 2015; 62 (3): 304-318

    Abstract

    Malaria is a life-threatening infectious disease caused by the Plasmodium parasite. Increased global travel has resulted in an escalation in the number of imported cases seen in developed countries. Patients with malaria may present for surgery in both endemic and non-endemic countries. This article reviews the perioperative considerations when managing patients with malaria.A literature review of anesthesia, perioperative care, and malaria-related articles was performed using the MEDLINE(®), EMBASE™, and Web of Science databases to identify relevant articles published in English during 1945-2014. Of the 303 articles matching the search criteria, 265 were excluded based on title and abstract. Eleven of the remaining 38 articles were relevant to anesthesia/perioperative care, and 27 articles were identified as having direct relevance to critical care medicine.The majority of imported malaria cases are caused by the falciparum species, which is associated with the greatest degree of morbidity and mortality. Various organ systems may be impacted as a consequence of changes in the structure and function of parasitized erythrocytes. Preoperative assessment should focus on establishing the species of malaria, the severity of disease, assessing the degree of end-organ impairment, and initiating treatment of malaria prior to surgery. Intravenous artesunate is the treatment of choice for severe falciparum malaria. Quinine is a second-line agent but has a narrow therapeutic index and particularly hazardous side effects. Intraoperatively, attention should focus on fluid management, dynamics of cerebral blood flow, and avoidance of hypoglycemia. Postoperative care of severe cases should ideally take place in a critical care unit as there may be ongoing requirements for multi-organ support, including renal replacement therapy, ventilation, and/or inotropic support. The safety of neuraxial anesthesia has not been well studied in the setting of malaria.Malaria remains one of the most devastating infectious diseases worldwide. Multiple organ systems can be impacted as a consequence of changes in structure and function of parasitized erythrocytes. Safe perioperative management requires a sound knowledge of all these potential system effects.

    View details for DOI 10.1007/s12630-014-0286-7

    View details for Web of Science ID 000349912900010

    View details for PubMedID 25471683

  • Ondansetron pharmacokinetics in pregnant women and neonates: towards a new treatment for neonatal abstinence syndrome. Clinical pharmacology & therapeutics Elkomy, M., Sultan, P., Carvalho, B., Peltz, G., Wu, M., Clavijo, C., Galinkin, J., Drover, D. 2015; 97 (2): 167-176

    Abstract

    Ondansetron is the drug of choice to prevent nausea in women undergoing cesarean surgery and can be used to prevent neonatal abstinence syndrome (NAS). The pharmacokinetics of ondansetron have not been characterized in pregnant women or in newborns. A nonlinear mixed-effects modeling approach was used to analyze plasma samples obtained from 20 nonpregnant and 40 pregnant women following a single administration of 4 or 8 mg ondansetron, from umbilical cord blood at delivery, and from neonates after birth. The analysis indicates that: ondansetron disposition is not affected by pregnancy (P > 0.05), but influenced by dose (P < 0.05), and is characterized by rapid transplacental transfer and longer elimination half-life in neonates compared to their mother. A dosing regimen for prevention of NAS was designed based on the model. The regimen involves IV administration of 4 mg to the mothers shortly before cord clamping, or oral administration of 0.07 mg/kg (or equivalently 0.04 mg/kg IV) to neonates.

    View details for DOI 10.1002/cpt.5

    View details for PubMedID 25670522

    View details for PubMedCentralID PMC4325425

  • Survey of Accepted Practice following Failed Intubation for Emergency Caesarean Delivery. Anesthesiology research and practice Soltanifar, D., Bogod, D., Harrison, S., Carvalho, B., Sultan, P. 2015; 2015: 192315-?

    Abstract

    Background. There is no consensus on the optimum management of failed tracheal intubation in emergency cesarean delivery performed for fetal compromise. The decision making process on whether to wake the patient or continue anesthesia with a supraglottic airway device is an underexplored area. This survey explores perceptions and experiences of obstetric anesthetists managing failed intubation. Methods. Anesthetists attending the Group of Obstetric Anaesthetists London (GOAL) Meeting in April 2014 were surveyed. Results. Ninety-three percent of anesthetists surveyed would not always wake the patient in the event of failed intubation for emergency cesarean delivery performed for fetal compromise. The median (interquartile range) of perceived acceptability of continuing anesthesia with a well-fitting supraglottic airway device, assessed using a visual analogue scale (0-100; 0 completely unacceptable; 100 completely acceptable), was 90 [22.5]. Preoperative patient consent regarding the use of a supraglottic airway device for surgery in the event of failed intubation would affect the decision making of 40% of anaesthetists surveyed. Conclusion. These results demonstrate that a significant body of anesthetists with a subspecialty interest in obstetric anesthesia in the UK would not always wake up the patient and would continue with anesthesia and surgery with a supraglottic airway device in this setting.

    View details for DOI 10.1155/2015/192315

    View details for PubMedID 25821464

  • Keep calm and carry on? A survey of accepted practice following failed intubation for emergency caesarean delivery. Soltanifar, D., Harrison, S., Bogod, D., Carvalho, B., Sultan, P. 2015
  • Spinal anaesthesia for emergency caesarean delivery in a parturient with falciparum malaria. International journal of obstetric anesthesia Soltanifar, D., Jacobs, M., Jones, T., McGlennan, A., Sultan, P. 2015; 24 (1): 91

    View details for DOI 10.1016/j.ijoa.2014.07.003

    View details for PubMedID 25433574

  • Randomized controlled trial of vagal modulation by sham feeding in elective non-gastrointestinal (orthopaedic) surgery. British journal of anaesthesia Karmali, S., Jenkins, N., Sciusco, A., John, J., Haddad, F., Ackland, G. L. 2015; 115 (5): 727–35

    Abstract

    Enhanced recovery, in part, aims to reduce postoperative gastrointestinal dysfunction (PGID). Acquired - or established- vagal dysfunction may contribute to PGID, even for surgery not involving the gastrointestinal tract. However, direct evidence for this is lacking. We hypothesized that chewing gum reduces morbidity (including PGID) by preserving efferent vagal neural activity postoperatively after elective orthopaedic surgery.In a two-centre randomized controlled trial (n=106), we explored whether patients randomized to prescribed chewing gum for five days postoperatively sustained less morbidity (primary outcome, defined by the Postoperative Morbidity Survey), PGID and faster time to become morbidity free (secondary outcomes). In a subset of patients (n=38), cardiac parasympathetic activity was measured by serial Holter monitoring and assessed using time and frequency domain analyses.Between September 2011 and April 2014, 106 patients were randomized to chewing gum or control. The primary clinical outcome did not differ between groups, with similar morbidity occurring between patients randomized to control (26/30) and chewing gum (21/28; absolute risk reduction (ARR):13% (95%C I:- 6-32); P=0.26). However, chewing gum reduced PGID (ARR:20% (95% CI: 1-38); P=0.049). Chewing gum reduced time to become morbidity-free (relative risk (RR): 1.62 (95% CI: 1.02-2.58); P=0.04) and was associated with a higher proportion of parasympathetic activity contributing to heart rate variability (11% (95% CI: 1-20); P=0.03).Chewing gum did not alter overall morbidity, but reduced PGID. These data show for the first time that prescription of sham feeding preserves vagal activity in surgery not directly involving the gastrointestinal tract.ISRCTN20301599.

    View details for DOI 10.1093/bja/aev283

    View details for PubMedID 26323293

  • Maternal fever and epidural insertion: An OAA approved survey Liu, Y., Patel, S., Mon, W., Fernando, R., Columb, M., Sultan, P. 2015
  • Effect of intrathecal morphine dose for caesarean delivery on maternal and neonatal outcomes: A metaanalysis Sultan, P., Halpern, S., Pushpanathan, E., Carvalho, B. 2015
  • Effect of active warming for elective caesarean delivery on maternal and neonatal outcomes: A meta-analysis Sultan, P., Habib, A., Cho, Y., Carvalho, B. 2015
  • Pharmacokinetics of Prophylactic Cefazolin in Parturients Undergoing Cesarean Delivery ANTIMICROBIAL AGENTS AND CHEMOTHERAPY Elkomy, M. H., Sultan, P., Drover, D. R., Epshtein, E., Galinkin, J. L., Carvalho, B. 2014; 58 (6): 3504-3513

    Abstract

    The objectives of this work were (i) to characterize the pharmacokinetics of cefazolin in pregnant women undergoing elective cesarean delivery and in their neonates; (ii) to assess cefazolin transplacental transmission; (iii) to evaluate the dosing and timing of preoperative, prophylactic administration of cefazolin to pregnant women; and (iv) to investigate the impact of maternal dosing on therapeutic duration and exposure in newborns. Twenty women received 1 g of cefazolin preoperatively. Plasma concentrations of total cefazolin were analyzed from maternal blood samples taken before, during, and after delivery; umbilical cord blood samples obtained at delivery; and neonatal blood samples collected 24 h after birth. The distribution volume of cefazolin was 9.44 liters/h. The values for pre- and postdelivery clearance were 7.18 and 4.12 liters/h, respectively. Computer simulations revealed that the probability of maintaining free cefazolin concentrations in plasma above 8 mg/liter during scheduled caesarean surgery was <50% in the cord blood when cefazolin was administered in doses of <2 g or when it was administered <1 h before delivery. Therapeutic concentrations of cefazolin persisted in neonates >5 h after birth. Cefazolin clearance increases during pregnancy, and larger doses are recommended for surgical prophylaxis in pregnant women to obtain the same antibacterial effect as in nonpregnant patients. Cefazolin has a longer half-life in neonates than in adults. Maternal administration of up to 2 g of cefazolin is effective and produces exposure within clinically approved limits in neonates.

    View details for DOI 10.1128/AAC.02613-13

    View details for Web of Science ID 000338776900064

  • Pharmacokinetics of prophylactic cefazolin in parturients undergoing cesarean delivery. Antimicrobial agents and chemotherapy Elkomy, M. H., Sultan, P., Drover, D. R., Epshtein, E., Galinkin, J. L., Carvalho, B. 2014; 58 (6): 3504-3513

    Abstract

    The objectives of this work were (i) to characterize the pharmacokinetics of cefazolin in pregnant women undergoing elective cesarean delivery and in their neonates; (ii) to assess cefazolin transplacental transmission; (iii) to evaluate the dosing and timing of preoperative, prophylactic administration of cefazolin to pregnant women; and (iv) to investigate the impact of maternal dosing on therapeutic duration and exposure in newborns. Twenty women received 1 g of cefazolin preoperatively. Plasma concentrations of total cefazolin were analyzed from maternal blood samples taken before, during, and after delivery; umbilical cord blood samples obtained at delivery; and neonatal blood samples collected 24 h after birth. The distribution volume of cefazolin was 9.44 liters/h. The values for pre- and postdelivery clearance were 7.18 and 4.12 liters/h, respectively. Computer simulations revealed that the probability of maintaining free cefazolin concentrations in plasma above 8 mg/liter during scheduled caesarean surgery was <50% in the cord blood when cefazolin was administered in doses of <2 g or when it was administered <1 h before delivery. Therapeutic concentrations of cefazolin persisted in neonates >5 h after birth. Cefazolin clearance increases during pregnancy, and larger doses are recommended for surgical prophylaxis in pregnant women to obtain the same antibacterial effect as in nonpregnant patients. Cefazolin has a longer half-life in neonates than in adults. Maternal administration of up to 2 g of cefazolin is effective and produces exposure within clinically approved limits in neonates.

    View details for DOI 10.1128/AAC.02613-13

    View details for PubMedID 24733461

  • In response. Anesthesia and analgesia Macario, A., Carvalho, B., Tan, J. M., Sultan, P., El-Sayed, Y. Y. 2014; 118 (4): 884-885

    View details for DOI 10.1213/ANE.0000000000000114

    View details for PubMedID 24651247

  • Cardiopulmonary Exercise Capacity and Preoperative Markers of Inflammation MEDIATORS OF INFLAMMATION Sultan, P., Edwards, M. R., del Arroyo, A., Cain, D., Sneyd, J., Struthers, R., Minto, G., Ackland, G. L. 2014: 727451

    Abstract

    Explanatory mechanisms for the association between poor exercise capacity and infections following surgery are underexplored. We hypothesized that aerobic fitness-assessed by cardiopulmonary exercise testing (CPET)-would be associated with circulating inflammatory markers, as quantified by the neutrophil-lymphocyte ratio (NLR) and monocyte subsets. The association between cardiopulmonary reserve and inflammation was tested by multivariable regression analysis with covariates including anaerobic threshold (AT) and malignancy. In a first cohort of 240 colorectal patients, AT was identified as the sole factor associated with higher NLR (P = 0.03) and absolute and relative lymphopenia (P = 0.01). Preoperative leukocyte subsets and monocyte CD14(+) expression (downregulated by endotoxin and indicative of chronic inflammation) were also assessed in two further cohorts of age-matched elective gastrointestinal and orthopaedic surgical patients. Monocyte CD14(+) expression was lower in gastrointestinal patients (n = 43) compared to age-matched orthopaedic patients (n = 31). The circulating CD14(+)CD16(-) monocyte subset was reduced in patients with low cardiopulmonary reserve. Poor exercise capacity in patients without a diagnosis of heart failure is independently associated with markers of inflammation. These observations suggest that preoperative inflammation associated with impaired cardiorespiratory performance may contribute to the pathophysiology of postoperative outcome.

    View details for PubMedID 25061264

    View details for PubMedCentralID PMC4098894

  • Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology Botto, F., Alonso-Coello, P., Chan, M. T., Villar, J. C., Xavier, D., Srinathan, S., Guyatt, G., Cruz, P., Graham, M., Wang, C. Y., Berwanger, O., Pearse, R. M., Biccard, B. M., Abraham, V., Malaga, G., Hillis, G. S., Rodseth, R. N., Cook, D., Polanczyk, C. A., Szczeklik, W., Sessler, D. I., Sheth, T., Ackland, G. L., Leuwer, M., Garg, A. X., Lemanach, Y., Pettit, S., Heels-Ansdell, D., Luratibuse, G., Walsh, M., Sapsford, R., Schünemann, H. J., Kurz, A., Thomas, S., Mrkobrada, M., Thabane, L., Gerstein, H., Paniagua, P., Nagele, P., Raina, P., Yusuf, S., Devereaux, P. J., Devereaux, P. J., Sessler, D. I., Walsh, M., Guyatt, G., McQueen, M. J., Bhandari, M., Cook, D., Bosch, J., Buckley, N., Yusuf, S., Chow, C. K., Hillis, G. S., Halliwell, R., Li, S., Lee, V. W., Mooney, J., Polanczyk, C. A., Furtado, M. V., Berwanger, O., Suzumura, E., Santucci, E., Leite, K., Santo, J. o., Jardim, C. A., Cavalcanti, A. B., Guimaraes, H. P., Jacka, M. J., Graham, M., McAlister, F., McMurtry, S., Townsend, D., Pannu, N., Bagshaw, S., Bessissow, A., Bhandari, M., Duceppe, E., Eikelboom, J., Ganame, J., Hankinson, J., Hill, S., Jolly, S., Lamy, A., Ling, E., Magloire, P., Pare, G., Reddy, D., Szalay, D., Tittley, J., Weitz, J., Whitlock, R., Darvish-Kazim, S., Debeer, J., Kavsak, P., Kearon, C., Mizera, R., O'Donnell, M., McQueen, M., Pinthus, J., Ribas, S., Simunovic, M., Tandon, V., Vanhelder, T., Winemaker, M., Gerstein, H., McDonald, S., O'Bryne, P., Patel, A., Paul, J., Punthakee, Z., Raymer, K., Salehian, O., Spencer, F., Walter, S., Worster, A., Adili, A., Clase, C., Cook, D., Crowther, M., Douketis, J., Gangji, A., Jackson, P., Lim, W., Lovrics, P., Mazzadi, S., Orovan, W., Rudkowski, J., Soth, M., Tiboni, M., Acedillo, R., Garg, A., Hildebrand, A., Lam, N., Macneil, D., Mrkobrada, M., Roshanov, P. S., Srinathan, S. K., Ramsey, C., John, P. S., Thorlacius, L., Siddiqui, F. S., Grocott, H. P., McKay, A., Lee, T. W., Amadeo, R., Funk, D., McDonald, H., Zacharias, J., Villar, J. C., Cortés, O. L., Chaparro, M. S., Vásquez, S., Castañeda, A., Ferreira, S., Coriat, P., Monneret, D., Goarin, J. P., Esteve, C. I., Royer, C., Daas, G., Chan, M. T., Choi, G. Y., Gin, T., Lit, L. C., Xavier, D., Sigamani, A., Faruqui, A., Dhanpal, R., Almeida, S., Cherian, J., Furruqh, S., Abraham, V., Afzal, L., George, P., Mala, S., Schünemann, H., Muti, P., Vizza, E., Wang, C. Y., Ong, G. S., Mansor, M., Tan, A. S., Shariffuddin, I. I., Vasanthan, V., Hashim, N. H., Undok, A. W., Ki, U., Lai, H. Y., Ahmad, W. A., Razack, A. H., Malaga, G., Valderrama-Victoria, V., Loza-Herrera, J. D., De Los Angeles Lazo, M., Rotta-Rotta, A., Szczeklik, W., Sokolowska, B., Musial, J., Gorka, J., Iwaszczuk, P., Kozka, M., Chwala, M., Raczek, M., Mrowiecki, T., Kaczmarek, B., Biccard, B., Cassimjee, H., Gopalan, D., Kisten, T., Mugabi, A., Naidoo, P., Naidoo, R., Rodseth, R., Skinner, D., Torborg, A., Paniagua, P., Urrutia, G., Maestre, M. L., Santaló, M., Gonzalez, R., Font, A., Martínez, C., Pelaez, X., De Antonio, M., Villamor, J. M., García, J. A., Ferré, M. J., Popova, E., Alonso-Coello, P., Garutti, I., Cruz, P., Fernández, C., Palencia, M., Díaz, S., Del Castillo, T., Varela, A., de Miguel, A., Muñoz, M., Piñeiro, P., Cusati, G., Del Barrio, M., Membrillo, M. J., Orozco, D., Reyes, F., Sapsford, R. J., Barth, J., Scott, J., Hall, A., Howell, S., Lobley, M., Woods, J., Howard, S., Fletcher, J., Dewhirst, N., Williams, C., Rushton, A., Welters, I., Leuwer, M., Pearse, R., Ackland, G., Khan, A., Niebrzegowska, E., Benton, S., Wragg, A., Archbold, A., Smith, A., McAlees, E., Ramballi, C., Macdonald, N., Januszewska, M., Stephens, R., Reyes, A., Paredes, L. G., Sultan, P., Cain, D., Whittle, J., Del Arroyo, A. G., Sessler, D. I., Kurz, A., Sun, Z., Finnegan, P. S., Egan, C., Honar, H., Shahinyan, A., Panjasawatwong, K., Fu, A. Y., Wang, S., Reineks, E., Nagele, P., Blood, J., Kalin, M., Gibson, D., Wildes, T. 2014; 120 (3): 564–78

    Abstract

    Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study's four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS.In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated "abnormal" laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria.An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors' diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96-5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6-41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom.Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

    View details for DOI 10.1097/ALN.0000000000000113

    View details for PubMedID 24534856

  • Caesarean delivery in a parturient with type III hereditary angioedema. International journal of obstetric anesthesia Soltanifar, D., Afzal, S., Harrison, S., Sultan, P. 2014; 23 (4): 398–99

    View details for DOI 10.1016/j.ijoa.2014.05.010

    View details for PubMedID 25201314

  • Pharmacokinetics of ondansetron in non-pregnant and pregnant women International Journal of Obstetric Anesthesia Sultan, P., Elkomy, M., Peltz, G., Clavijo, C., Wu, M., Galinkin, J., Drover, D., Carvalho, B. 2014
  • Combined-spinal-epidural for cesarean delivery In a parturient with heriditary angioedema type III Soltanifar, D., Afzal, S., Harrison, S., Sultan, P. 2014
  • Obstetric ICU admissions: An audit of a London teaching hospital Patel, S., Ward, S., Sultan, P. 2014
  • Abstracts of the AAGBI Annual Congress, 17-19 September 2014, Harrogate, UK. Anaesthesia 2014; 69 Suppl 4: 11–88

    View details for DOI 10.1111/anae.12866

    View details for PubMedID 25219491

  • Platelet Counts and Coagulation Tests Prior to Neuraxial Anesthesia in Patients With Preeclampsia A Retrospective Analysis CLINICAL AND APPLIED THROMBOSIS-HEMOSTASIS Sultan, P., Butwick, A. 2013; 19 (5): 529-534

    Abstract

    This retrospective, descriptive study aimed to assess hematologic testing practices in 100 patients with preeclampsia undergoing neuraxial blockade (NB). Prior to NB, platelet (PLT) count was performed in 61 (98%) of 62 women in labor and in 37 (97%) of 38 women undergoing cesarean delivery (CD). No patients had a pre-NB PLT count <70 × 10(9)/L. Pre-NB tests for prothrombin time (PT) and activated partial thromboplastin time (APTT) were less common and varied among laboring patients (15 [24%] of 62) and patients prior to CD (18 [47%] of 38). Prior to NB, PT and APTT values were within normal limits in all patients. The time intervals between laboratory testing and NB ranged from <2 to >12 hours. The lack of consistency in pre-NB coagulation testing and the variable time intervals between laboratory tests and NB may be due to a lack of consensus among anesthesiologists for determining "safe" hemostatic conditions for NB placement in patients with preeclampsia.

    View details for DOI 10.1177/1076029612441860

    View details for PubMedID 22531481

  • Brief report: a cost analysis of neuraxial anesthesia to facilitate external cephalic version for breech fetal presentation. Anesthesia and analgesia Carvalho, B., Tan, J. M., Macario, A., El-Sayed, Y. Y., Sultan, P. 2013; 117 (1): 155-159

    Abstract

    BACKGROUND:In this study, we sought to determine whether neuraxial anesthesia to facilitate external cephalic version (ECV) increased delivery costs for breech fetal presentation.METHODS:Using a computer cost model, which considers possible outcomes and probability uncertainties at the same time, we estimated total expected delivery costs for breech presentation managed by a trial of ECV with and without neuraxial anesthesia.RESULTS:From published studies, the average probability of successful ECV with neuraxial anesthesia was 60% (with individual studies ranging from 44% to 87%) compared with 38% (with individual studies ranging from 31% to 58%) without neuraxial anesthesia. The mean expected total delivery costs, including the cost of attempting/performing ECV with anesthesia, equaled $8931 (2.5th-97.5th percentile prediction interval $8541-$9252). The cost was $9207 (2.5th-97.5th percentile prediction interval $8896-$9419) if ECV was attempted/performed without anesthesia. The expected mean incremental difference between the total cost of delivery that includes ECV with anesthesia and ECV without anesthesia was $-276 (2.5th-97.5th percentile prediction interval $-720 to $112).CONCLUSION:The total cost of delivery in women with breech presentation may be decreased (up to $720) or increased (up to $112) if ECV is attempted/performed with neuraxial anesthesia compared with ECV without neuraxial anesthesia. Increased ECV success with neuraxial anesthesia and the subsequent reduction in breech cesarean delivery rate offset the costs of providing anesthesia to facilitate ECV.

    View details for DOI 10.1213/ANE.0b013e31828e5bc7

    View details for PubMedID 23592608

  • Experiences and challenges in achieving sustainable quality improvement in two UK hospitals BRITISH JOURNAL OF HOSPITAL MEDICINE Fernandez-Caballero, S., Becic, D., Bouras, I., Walker, D., Sultan, P. 2013; 74 (7): 403–7

    View details for PubMedID 24159644

  • A Cost Analysis of Neuraxial Anesthesia to Facilitate External Cephalic Version for Breech Fetal Presentation ANESTHESIA AND ANALGESIA Carvalho, B., Tan, J. M., Macario, A., El-Sayed, Y. Y., Sultan, P. 2013; 117 (1): 155-159

    Abstract

    BACKGROUND:In this study, we sought to determine whether neuraxial anesthesia to facilitate external cephalic version (ECV) increased delivery costs for breech fetal presentation.METHODS:Using a computer cost model, which considers possible outcomes and probability uncertainties at the same time, we estimated total expected delivery costs for breech presentation managed by a trial of ECV with and without neuraxial anesthesia.RESULTS:From published studies, the average probability of successful ECV with neuraxial anesthesia was 60% (with individual studies ranging from 44% to 87%) compared with 38% (with individual studies ranging from 31% to 58%) without neuraxial anesthesia. The mean expected total delivery costs, including the cost of attempting/performing ECV with anesthesia, equaled $8931 (2.5th-97.5th percentile prediction interval $8541-$9252). The cost was $9207 (2.5th-97.5th percentile prediction interval $8896-$9419) if ECV was attempted/performed without anesthesia. The expected mean incremental difference between the total cost of delivery that includes ECV with anesthesia and ECV without anesthesia was $-276 (2.5th-97.5th percentile prediction interval $-720 to $112).CONCLUSION:The total cost of delivery in women with breech presentation may be decreased (up to $720) or increased (up to $112) if ECV is attempted/performed with neuraxial anesthesia compared with ECV without neuraxial anesthesia. Increased ECV success with neuraxial anesthesia and the subsequent reduction in breech cesarean delivery rate offset the costs of providing anesthesia to facilitate ECV.

    View details for DOI 10.1213/ANE.0b013e31828e5bc7

    View details for Web of Science ID 000326512300025

  • Provision of critical care services for the obstetric population. Best practice & research. Clinical obstetrics & gynaecology Sultan, P., Arulkumaran, N., Rhodes, A. 2013; 27 (6): 803–9

    Abstract

    Management of the peripartum patient is a challenging aspect of critical care that requires consideration of both the physiological changes associated with pregnancy as well as the well-being of the foetus. In the UK, for every maternal death, approximately 118 near-miss events or severe acute maternal morbidities (SAMMs) occur. While a dedicated anaesthetic cover is usually provided on larger labour wards in the UK and US, a close communication with intensive care and other medical specialties must still be maintained. Medical outreach teams and early warning scores may help facilitate the early identification of clinical deterioration and prompt treatment. Ultimately level of care is allocated according to the clinical need, not the location, which may be a designated room, a normal labour room or a recovery area. Specialist obstetric units that provide high-dependency care facilities show lower rates of maternal transfer to critical care units and improved continuity of care before and after labour. The benefits of obstetric high-dependency units (HDUs) are likely to be determined by a number of logistic aspects of the hospital organisation, including hospital size and available resources. There remains a striking contrast in the burden of maternal mortality and morbidity and intensive care unit (ICU) resources between high- and low-income countries. The countries with the highest maternal mortality rates have the lowest number of ICU beds per capita. In under-resourced countries, patients admitted to ICUs tend to have higher illness severity scores, suggesting delayed admission to the ICU. The appropriate training of midwives is essential for successful HDUs located within labour wards.

    View details for DOI 10.1016/j.bpobgyn.2013.07.005

    View details for PubMedID 23972289

  • Continuous spinal anesthesia for Cesarean hysterectomy and massive hemorrhage in a parturient with placenta increta CANADIAN JOURNAL OF ANESTHESIA-JOURNAL CANADIEN D ANESTHESIE Sultan, P., Hilton, G., Butwick, A., Carvalho, B. 2012; 59 (5): 473-477

    Abstract

    We present anesthetic management using a continuous spinal anesthesia (CSA) technique in a patient with placenta increta who underwent elective Cesarean hysterectomy with massive postpartum hemorrhage.A 34-yr-old parturient (G3P2) was scheduled for Cesarean delivery and possible hysterectomy at 35(+3) weeks due to suspected placenta accreta. Her body mass index was 21 kg·m(-2) and she had a reassuring airway. Inadvertent dural puncture occurred during combined spinal-epidural (CSE) placement, and a decision was made to thread the epidural catheter and utilize a CSA technique. Following delivery of a healthy infant, morbid adherence of the placenta to the myometrium was confirmed, and a supracervical hysterectomy was performed. Eight litres of blood loss occurred postpartum requiring resuscitation with crystalloid 3,800 mL, colloid 1,500 mL, red blood cells 16 units, fresh frozen plasma 16 units, platelets 4 units, and cryoprecipitate 1 unit. The patient developed pulmonary edema requiring conversion to general anesthesia. The patient's cardiovascular status was stable throughout surgery, and her lungs were mechanically ventilated for 18 hr postoperatively in the intensive care unit. The intrathecal catheter was removed 24 hr after placement. She developed no adverse neurological sequelae and reported no postdural puncture headache. The pathology report confirmed placenta increta.A CSA technique may be a viable option in the event of inadvertent dural puncture during planned CSE or epidural placement in patients with a reassuring airway undergoing Cesarean delivery. Although a catheter-based neuraxial technique is appropriate for Cesarean hysterectomy for abnormal placentation, conversion to general anesthesia may be required in the event of massive perioperative hemorrhage and fluid resuscitation.

    View details for DOI 10.1007/s12630-012-9681-0

    View details for PubMedID 22395824

  • Spinal anaesthesia for caesarean delivery in a parturient with babesiosis and Lyme disease ANAESTHESIA Sultan, P., Green, C., Riley, E., Carvalho, B. 2012; 67 (2): 180-183

    Abstract

    We present a case of a parturient with babesiosis and Lyme disease who was scheduled for elective caesarean section. The caesarean section was performed under spinal anaesthesia, and the patient had a coronary artery dissection 4 days postoperatively. Neuraxial anaesthesia and possible mechanisms for the coronary artery dissection in a patient with babesiosis and Lyme disease are discussed.

    View details for DOI 10.1111/j.1365-2044.2011.06941.x

    View details for Web of Science ID 000299158200012

    View details for PubMedID 22251109

  • Preoperative muscle weakness as defined by handgrip strength and postoperative outcomes: a systematic review BMC ANESTHESIOLOGY Sultan, P., Hamilton, M. A., Ackland, G. L. 2012; 12: 1

    Abstract

    Reduced muscle strength- commonly characterized by decreased handgrip strength compared to population norms- is associated with numerous untoward outcomes. Preoperative handgrip strength is a potentially attractive real-time, non-invasive, cheap and easy-to-perform "bedside" assessment tool. Using systematic review procedure, we investigated whether preoperative handgrip strength was associated with postoperative outcomes in adults undergoing surgery.PRISMA and MOOSE consensus guidelines for reporting systematic reviews were followed. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Clinical Trials (1980-2010) were systematically searched by two independent reviewers. The selection criteria were limited to include studies of preoperative handgrip strength in human adults undergoing non-emergency, cardiac and non-cardiac surgery. Study procedural quality was analysed using the Newcastle-Ottawa Quality Assessment score. The outcomes assessed were postoperative morbidity, mortality and hospital stay.Nineteen clinical studies (17 prospective; 4 in urgent surgery) comprising 2194 patients were identified between1980-2010. Impaired handgrip strength and postoperative morbidity were defined inconsistently between studies. Only 2 studies explicitly ensured investigators collecting postoperative outcomes data were blinded to preoperative handgrip strength test results. The heterogeneity of study design used and the diversity of surgical procedures precluded formal meta-analysis. Despite the moderate quality of these observational studies, lower handgrip strength was associated with increased morbidity (n = 10 studies), mortality (n = 2/5 studies) and length of hospital stay (n = 3/7 studies).Impaired preoperative handgrip strength may be associated with poorer postoperative outcomes, but further work exploring its predictive power is warranted using prospectively acquired, objectively defined measures of postoperative morbidity.

    View details for PubMedID 22251661

  • Ultra-low compared to higher concentration epidural local anesthetic solutions in labor: A meta-analysis. Murphy, C., Sultan, P., Halpern, S., Carvalho, B. 2012
  • Performance on a probabilistic inference task in healthy subjects receiving ketamine compared with patients with schizophrenia. Journal of psychopharmacology (Oxford, England) Evans, S., Almahdi, B., Sultan, P., Sohanpal, I., Brandner, B., Collier, T., Shergill, S. S., Cregg, R., Averbeck, B. B. 2012; 26 (9): 1211–17

    Abstract

    Evidence suggests that some aspects of schizophrenia can be induced in healthy volunteers through acute administration of the non-competitive NMDA-receptor antagonist, ketamine. In probabilistic inference tasks, patients with schizophrenia have been shown to 'jump to conclusions' (JTC) when asked to make a decision. We aimed to test whether healthy participants receiving ketamine would adopt a JTC response pattern resembling that of patients. The paradigmatic task used to investigate JTC has been the 'urn' task, where participants are shown a sequence of beads drawn from one of two 'urns', each containing coloured beads in different proportions. Participants make a decision when they think they know the urn from which beads are being drawn. We compared performance on the urn task between controls receiving acute ketamine or placebo with that of patients with schizophrenia and another group of controls matched to the patient group. Patients were shown to exhibit a JTC response pattern relative to their matched controls, whereas JTC was not evident in controls receiving ketamine relative to placebo. Ketamine does not appear to promote JTC in healthy controls, suggesting that ketamine does not affect probabilistic inferences.

    View details for DOI 10.1177/0269881111435252

    View details for PubMedID 22389244

    View details for PubMedCentralID PMC3546628

  • Should endotracheal cuff pressure be routinely measured during elective surgery? British journal of hospital medicine (London, England : 2005) Ramadan, M., Pushpanathan, E., Sultan, P. 2012; 73 (9): 538

    View details for PubMedID 23124413

  • Comparison of ultra-low and higher-concentration epidural local anaesthetic solutions in labour: A metaanalysis Sultan, P., Murphy, C., Halpern, S., Carvalho, B. 2012
  • Endotracheal tube cuff pressure monitoring: a review of the evidence. Journal of perioperative practice Sultan, P., Carvalho, B., Rose, B. O., Cregg, R. 2011; 21 (11): 379-386

    Abstract

    Tracheal intubation constitutes a routine part of anaesthetic practice both in the operating theatre as well as in the care of critically ill patients. The procedure is estimated to be performed 13-20 million times annually in the United States alone. There has been a recent renewal of interest in the morbidity associated with endotracheal tube cuff overinflation, particularly regarding the rationale and requirement for endotracheal tube cuff monitoring intra-operatively.

    View details for PubMedID 22165491

  • Neuraxial blockade for external cephalic version: a systematic review INTERNATIONAL JOURNAL OF OBSTETRIC ANESTHESIA Sultan, P., Carvalho, B. 2011; 20 (4): 299-306

    Abstract

    The desire to decrease the number of cesarean deliveries has renewed interest in external cephalic version. The rationale for using neuraxial blockade to facilitate external cephalic version is to provide abdominal muscular relaxation and reduce patient discomfort during the procedure, so permitting successful repositioning of the fetus to a cephalic presentation. This review systematically examined the current evidence to determine the safety and efficacy of neuraxial anesthesia or analgesia when used for external cephalic version.A systematic literature review of studies that examined success rates of external cephalic version with neuraxial anesthesia was performed. Published articles written in English between 1945 and 2010 were identified using the Medline, Cochrane, EMBASE and Web of Sciences databases.Six, randomized controlled studies were identified. Neuraxial blockade significantly improved the success rate in four of these six studies. A further six non-randomized studies were identified, of which four studies with control groups found that neuraxial blockade increased the success rate of external cephalic version. Despite over 850 patients being included in the 12 studies reviewed, placental abruption was reported in only one patient with a neuraxial block, compared with two in the control groups. The incidence of non-reassuring fetal heart rate requiring cesarean delivery in the anesthesia groups was 0.44% (95% CI 0.15-1.32).Neuraxial blockade improved the likelihood of success during external cephalic version, although the dosing regimen that provides optimal conditions for successful version is unclear. Anesthetic rather than analgesic doses of local anesthetics may improve success. The findings suggest that neuraxial blockade does not compromise maternal or fetal safety during external cephalic version.

    View details for DOI 10.1016/j.ijoa.2011.07.001

    View details for Web of Science ID 000297087100006

    View details for PubMedID 21925869

  • Crossing the pond: applying to train in the USA. British journal of hospital medicine Qadan, M., Kastenberg, Z., Carvalho, B., Sultan, P. 2011; 72 (4): M50-2

    View details for PubMedID 21537230

  • The postoperative anaesthetic review. Journal of perioperative practice Sultan, P., Jigajinni, S., McGlennan, A., Butwick, A. 2011; 21 (4): 135-139

    Abstract

    An anaesthetic preoperative assessment for all patients is the standard of care in UK hospitals. The Royal College of Anaesthetists (RCoA) 2009 guidelines state that a postoperative visit, within 24 hours following surgery, is recommended for patients only in certain circumstances. This article critiques these guidelines and explores factors which must be taken into consideration when deciding whether or not anaesthetists should routinely visit their patients after they leave the recovery area. We discuss the physiological rationale for performing a postoperative anaesthetic visit; the identification of post-operative morbidity including provision of adequate post-operative analgesia; patient benefits; limitations of performing postoperative review, and the implications that expanding anaesthetists' responsibilities as perioperative physicians has had upon anaesthetic training and service provision. Finally, this article offers an alternative model for deciding when to perform a post-anaesthetic visit.

    View details for PubMedID 21560554

  • Neuraxial Morphine and Respiratory Depression Finding the Right Balance DRUGS Sultan, P., Gutierrez, M. C., Carvalho, B. 2011; 71 (14): 1807-1819

    Abstract

    Morphine is a drug commonly administered via the epidural or intrathecal route, and is regarded by many as the 'gold-standard' single-dose neuraxial opioid due to its postoperative analgesic efficacy and prolonged duration of action. However, respiratory depression is a recognized side effect of neuraxial morphine administered in the perioperative setting. We conducted an extensive review of articles published since 1945 that examine respiratory depression or failure associated with perioperative intrathecal or epidural morphine use. Respiratory depression was previously thought to result from the interaction of opioid in the cerebrospinal fluid with ventral medullary opioid receptors. More recently, the preBötzinger complex located in the medulla has been identified as the site responsible for the decrease in respiratory rate following systemic administration of opioids. Neurons in the preBötzinger complex expressing neurokinin-1 receptors are selectively inhibited by opioids, and therefore are the mediators of opioid-induced respiratory depression. Epidural, intrathecal and plasma pharmacokinetics of opioids are complex, vary between neuraxial compartments, and can even differ within the epidural space itself depending upon level of insertion. Caution should be exercised when prescribing systemic opioids (intravenous or oral) in addition to neuraxial morphine as this can compound the potential for early or delayed respiratory depression. There is a wide range of incidences for respiratory depression following neuraxial morphine in a perioperative setting. Disparity of definitions used for the diagnosis of respiratory depression in the literature precludes identification of the exact incidence of this rare event. The optimal neuraxial opioid dose is a balance between the conflicting demands of providing optimal analgesia while minimizing dose-related adverse effects. Dose-response studies show that neuraxial morphine appears to have an analgesic efficacy 'ceiling'. The optimal 'single-shot' intrathecal dose appears to be 0.075-0.15 mg and the ideal 'single-shot' epidural morphine dose is 2.5-3.75 mg. Analgesic efficacy studies have not been adequately powered to show differences in the incidence of clinically significant respiratory depression. Opioid antagonists such as naloxone to prevent or treat opioid-induced respiratory depression have a number of limitations. Researchers have recently focused on non-opioid drugs such as serotonin receptor agonists. Early evidence suggests that ampakine (α-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid [AMPA]) receptor modulators may be effective at reducing opioid-induced respiratory depression while maintaining analgesia. Sodium/proton exchanger type 3 (NHE3) inhibitors, which act centrally on respiratory pathways, also warrant further study.

    View details for PubMedID 21942973

  • A practical guide to undertaking out of programme experience in the United States of America. British journal of hospital medicine Sultan, P., Qadan, M., Pushpanathan, E., Carvalho, B. 2010; 71 (10): M158-9

    View details for PubMedID 20944517

  • What makes a good anaesthetist? Sultan, P., Gilbert, E., Burdett, E., Clarke, S. LIPPINCOTT WILLIAMS & WILKINS. 2010: 229–30
  • Via the lungs or the veins? British journal of hospital medicine (London, England : 2005) John, S., Jigajinni, S., Pushpanathan, E., Sultan, P. 2010; 71 (11): 658

    View details for DOI 10.12968/hmed.2010.71.11.79666

    View details for PubMedID 21063267

  • Intermittent positive pressure ventilation: endotracheal tube vs laryngeal mask airway? British journal of hospital medicine (London, England : 2005) Jigajinni, S., Sultan, P. 2010; 71 (5): 297

    View details for DOI 10.12968/hmed.2010.71.5.47924

    View details for PubMedID 20448504

  • The intensive care unit handover: the most stressful part of the shift. British journal of hospital medicine (London, England : 2005) Jigajinni, S., Sultan, P. 2010; 71 (2): M25–7

    View details for DOI 10.12968/hmed.2010.71.Sup2.46506

    View details for PubMedID 20220710

  • Anaesthesia for the bleeding tonsil. British journal of hospital medicine (London, England : 2005) Pushpanathan, E., Sultan, N., Sultan, P. 2010; 71 (2): 117

    View details for DOI 10.12968/hmed.2010.71.2.46497

    View details for PubMedID 20220706

  • Not just a patient that snores. Obstructive sleep apnoea: the perioperative concerns through the eye of the anaesthetist. Journal of perioperative practice Jigajinni, S., Sultan, P., Radhakrishnan, D. 2009; 19 (11): 395–99

    Abstract

    Obstructive sleep apnoea (OSA) has life threatening perioperative cardiorespiratory implications. As patients present to hospital for incidental surgery unaware of their condition, perioperative practitioners need a thorough knowledge of OSA to allow optimisation before theatre. Elective cases should be delayed for investigation and treatment if OSA is suspected. In theatre cardiorespiratory problems should be managed by a senior anaesthetist and a perioperative team alert to the risk of post-operative hypoxia.

    View details for DOI 10.1177/175045890901901104

    View details for PubMedID 20041627

  • Regional anaesthesia for caesarean section: a choice of three techniques. British journal of hospital medicine (London, England : 2005) Campbell, J., Sultan, P. 2009; 70 (10): 605

    Abstract

    Over the last 20 years, there has been a large increase in the proportion of caesarean sections (Brown and Russell, 1995) which are performed under regional rather than general anaesthesia. A bilateral sensory block from the T4 dermatome (nipple level) to the sacral nerve roots (perineum) is necessary.

    View details for DOI 10.12968/hmed.2009.70.10.44637

    View details for PubMedID 19966715

  • Is there a role for thiopentone in modern anaesthetic practice? British journal of hospital medicine (London, England : 2005) Sultan, P., Campbell, J. 2008; 69 (9): 541

    View details for DOI 10.12968/hmed.2008.69.9.31058

    View details for PubMedID 18819313

  • Is cricoid pressure needed during rapid sequence induction? British journal of hospital medicine (London, England : 2005) Sultan, P. 2008; 69 (3): 177

    View details for DOI 10.12968/hmed.2008.69.3.28763

    View details for PubMedID 18422234

  • Anaesthetic rooms: luxury or necessity? British journal of hospital medicine (London, England : 2005) Sultan, P. 2008; 69 (2): 116

    View details for DOI 10.12968/hmed.2008.69.2.28365

    View details for PubMedID 18386748

  • Contamination of anaesthetic machines with pathogenic organisms. Anaesthesia Baillie, J. K., Sultan, P., Graveling, E., Forrest, C., Lafong, C. 2007; 62 (12): 1257–61

    Abstract

    Hospital-acquired infections are commonly resistant to antibiotics and cause substantial morbidity and mortality in susceptible populations. Although there is no direct contact between the anaesthetic machine's controls and the patient, there is considerable potential for colonising organisms to be carried between the anaesthetic machine and the patient on the anaesthetist's hands. We performed two cross-sectional studies of bacterial contamination on anaesthetic machines before and after a simple intervention. Without warning, during theatre sessions, bacterial cultures were obtained from anaesthetic equipment. A new departmental policy of cleaning anaesthetic equipment with detergent wipes between cases was then introduced. Six weeks later, again without warning, a further set of cultures was taken. There was significant reduction in the proportion of cultures containing pathogenic bacteria (from 14/78 cultures (18%; 95% CI 9.4-26.5%) before the intervention to 5/77 cultures (6%; 95% CI 1.0-12%) after the intervention (p = 0.03)). The intervention was quick, easy and enthusiastically taken up by the majority of staff. We conclude that cleaning of anaesthetic equipment between cases should become routine practice.

    View details for DOI 10.1111/j.1365-2044.2007.05261.x

    View details for PubMedID 17991263