Angela M. Bader

Simulation-based trial of surgical-crisis checklists.

BACKGROUND Operating-room crises (e.g., cardiac arrest and massive hemorrhage) are common events in large hospitals but can be rare for individual clinicians. Successful management is difficult and complex. We sought to evaluate a tool to improve adherence to evidence-based best practices during such events. METHODS Operating-room teams from three institutions (one academic medical center and two community hospitals) participated in a series of surgical-crisis scenarios in a simulated operating room. Each team was randomly assigned to manage half the scenarios with a set of crisis checklists and the remaining scenarios from memory alone. The primary outcome measure was failure to adhere to critical processes of care. Participants were also surveyed regarding their perceptions of the usefulness and clinical relevance of the checklists. RESULTS A total of 17 operating-room teams participated in 106 simulated surgical-crisis scenarios. Failure to adhere to lifesaving processes of care was less common during simulations when checklists were available (6% of steps missed when checklists were available vs. 23% when they were unavailable, P<0.001). The results were similar in a multivariate model that accounted for clustering within teams, with adjustment for institution, scenario, and learning and fatigue effects (adjusted relative risk, 0.28; 95% confidence interval, 0.18 to 0.42; P<0.001). Every team performed better when the crisis checklists were available than when they were not. A total of 97% of the participants reported that if one of these crises occurred while they were undergoing an operation, they would want the checklist used. CONCLUSIONS In a high-fidelity simulation study, checklist use was associated with significant improvement in the management of operating-room crises. These findings suggest that checklists for use during operating-room crises have the potential to improve surgical care. (Funded by the Agency for Healthcare Research and Quality.).

Adopting a surgical safety checklist could save money and improve the quality of care in U.S. hospitals

Use of the World Health Organizations Surgical Safety Checklist has been associated with a significant reduction in major postoperative complications after inpatient surgery. We hypothesized that implementing the checklist in the United States would generate cost savings for hospitals. We performed a decision analysis comparing implementation of the checklist to existing practice in U.S. hospitals. In a hospital with a baseline major complication rate after surgery of at least 3 percent, the checklist generates cost savings once it prevents at least five major complications. Using the checklist would both save money and improve the quality of care in hospitals throughout the United States.

Alternative medicine use in presurgical patients.

Background A dramatic increase in the use of complementary and alternative medicines has been observed. The use of such remedies in the presurgical population has implications for the anesthesiologist because of the potential for drug interactions, side effects, and medical liability. This study was undertaken to quantify the use of herbal remedies and vitamins in the presurgical population of a large tertiary care center. Methods A one-page questionnaire was distributed to all patients presenting for evaluation in the preoperative clinic over an 11-week period. Patients answered questions regarding use of prescription and nonprescription medications, herbal remedies, and vitamins. Results Twenty-two percent of presurgical patients reported the use of herbal remedies, and 51% used vitamins. Women and patients aged 40–60 yr were more likely to use herbal medicines. Over-the-counter medication use was strongly associated with herbal preparation use. The most commonly used compounds, from highest to lowest, included echinacea, gingko biloba, St. John’s wort, garlic, and ginseng. Conclusions Alternative medicine use is common in the preoperative period.

Perioperative Analgesia with Subarachnoid Fentanyl–Bupivacaine for Cesarean Delivery

Addition of fentanyl to bupivacaine administered for spinal anesthesia for cesarean delivery was evaluated in 56 ASA physical status 1 term parturients. Preservative-free saline was added to 0, 2.5, 5, 6.25, 12.5, 25, 37.5, or 50 micrograms fentanyl to make a 1 ml total volume, which was injected intrathecally prior to bupivacaine in a double-blind, randomized fashion. Vital signs, sensory level, motor block, pain score, and side effects were recorded every 2 min for the first 12 min and then at 15, 30, 45, and 60 min and at 30-min intervals until the patient complained of pain. At delivery maternal vein, umbilical artery, and umbilical vein blood gases were obtained. Apgar scores at 1 and 5 min were recorded. Early Neonatal Neurobehavioral Scales (ENNS) were performed on days 1 and 2. Side effects and opioid requirements were recorded for the first 24 h. All of the patients in the control group reported a pain score greater than 0 during surgery and 67% required intraoperative opioids. None of the patients who received greater than or equal to 6.25 micrograms fentanyl required intraoperative opioids. Complete analgesia (time from injection to first report of pain) lasted 33.7 +/- 30.8 min (mean +/- SD) in the control group and increased to 130 +/- 30 min (P less than 0.05) with addition of 6.25 micrograms fentanyl. Duration of effective analgesia (time from injection to first parenteral opioid) was 71.8 +/- 43.2 min in the control group and increased (P less than 0.05) to 192 +/- 74.9 min with addition of 6.25 micrograms fentanyl.(ABSTRACT TRUNCATED AT 250 WORDS)

Crisis Checklists for the Operating Room: Development and Pilot Testing

BACKGROUND Because operating room crises are rare events, failure to adhere to critical management steps is common. We sought to develop and pilot a tool to improve adherence to lifesaving measures during operating room crises. STUDY DESIGN We identified 12 of the most frequently occurring operating room crises and corresponding evidence-based metrics of essential care for each (46 total process measures). We developed checklists for each crisis based on a previously defined method, which included literature review, multidisciplinary expert consultation, and simulation. After development, 2 operating room teams (11 participants) were each exposed to 8 simulations with random assignment to checklist use or working from memory alone. Each team managed 4 simulations with a checklist available and 4 without. One of the primary outcomes measured through video review was failure to adhere to essential processes of care. Participants were surveyed for perceptions of checklist use and realism of the scenarios. RESULTS Checklist use resulted in a 6-fold reduction in failure of adherence to critical steps in management for 8 scenarios with 2 pilot teams. These results held in multivariate analysis accounting for clustering within teams and adjusting for learning or fatigue effects (11 of 46 failures without the checklist vs 2 of 46 failures with the checklist; adjusted relative risk = 0.15, 95% CI, 0.04-0.60; p = 0.007). All participants rated the overall quality of the checklists and scenarios to be higher than average or excellent. CONCLUSIONS Checklist use can improve safety and management in operating room crises. These findings warrant broader evaluation, including in clinical settings.

Clinical Effects and Maternal and Fetal Plasma Concentrations of Epidural Ropivacaine Versus Bupivacaine for Cesarean Section

Background Ropivacaine is a new amide local anesthetic structurally similar to bupivacaine and mepivacaine. Previous studies showed that ropivacaine has a similar clinical effect as bupivacaine with regard to sensory anesthesia and slightly less motor blockade than bupivacaine. Ropivacaine appears to be less cardiotoxic and arrhythmogenic than bupivacaine. The clinical and pharmacokinetic effects of 0.5% ropivacaine (5 mg/ml) versus 0.5% bupivacaine (5 mg/ml) when used epidurally for elective cesarean section were investigated. Methods Using a randomized, double-blind study design, 60 ASA physical status 1 or 2 term parturients presenting for elective cesarean section received either 0.5% bupivacaine (150 mg) or 0.5% ropivacaine (150 mg) epidurally in appropriate fractionated doses over a 10-min period. Onset, duration, and regression of sensory and motor blockade were noted until complete resolution was observed. Quality of intraoperative anesthesia and abdominal wall muscle relaxation were noted. Maternal plasma concentrations of local anesthetic were determined before anesthetic administration and 5, 10, 20, 30, and 60 min and 2, 3, 6, 8, 12, and 24 h after drug injection in 20 subjects. Umbilical cord blood was obtained at time of delivery for acid-base values and determination of the free and total plasma concentration of local anesthetic. Neonates also were examined for neurobehavioral assessments by Scanlons and Neurologic and Adaptive Capacity Scores at 2 and 24 h after delivery. Results All patients received satisfactory anesthesia for operation. The onset, duration, and regression of sensory blockade were similar for both groups. Onset of degree 1 and 2 motor blockade was faster, and duration of degree 1 motor block was longer in the group receiving bupivacaine. Hemodynamic sequelae were similar between groups. All neonates had 5-min Apgar scores of 7 or greater and normal acid-base values and neurobehavioral assessments. Pharmacokinetic analysis showed that the Cmax was similar for both drugs (1.3 plus/minus 0.09 for ropivacaine and 1.1 plus/minus 0.09 micro gram/ml for bupivacaine). The T1/2 of the terminal decline in plasma concentration was shorter for ropivacaine versus bupivacaine (5.2 plus/minus 0.60 versus 10.9 plus/minus 1.08 h, respectively; P < 0.01). The free (i.e., unbound) concentrations of ropivacaine were approximately twice those of bupivacaine in both maternal and neonatal blood at the time of delivery. The ratio of umbilical vein to maternal vein concentration of unbound drug was 0.72 for ropivacaine and 0.69 for bupivacaine. Conclusions Ropivacaine, 0.5%, epidurally provided satisfactory and similar sensory anesthesia compared to 0.5% bupivacaine for elective cesarean section. The Cmax was similar for both drugs, although the terminal half-life of ropivacaine was significantly shorter, and the blood concentrations of free ropivacaine were significantly greater than that for bupivacaine. These values were less than concentrations shown to be toxic in animals.

Comparison of bupivacaine- and ropivacaine-induced conduction blockade in the isolated rabbit vagus nerve

Ropivacaine (LEA-103) is a new amino-amide local anesthetic agent the chemical structure and anesthetic properties of which are similar to bupivacaine. Preliminary studies in animals indicate that the CNS toxicities of ropivacaine and bupivacaine are similar, but that ropivacaine may have less arrhythmogenic effects than bupivacaine. The current study was designed to compare the in vitro potency, onset and recovery from block of ropivacaine and bupivacaine using an isolated rabbit vagus nerve model. The effect of varying concentrations of ropivacaine and bupivacaine on the compound action potential of A and C nerve fibers was assessed to determine whether motor and sensory fibers have different sensitivities to the two agents. The results showed that the depressant effect of bupivacaine was 16% greater than that of ropivacaine on motor fibers, but only 3% greater on sensory fibers. An analysis of variance indicated that this was a statistically significant difference (P=0.028). Thus, at the concentrations tested, ropivacaine appears to produce relatively less blockade of motor fibers than does bupivacaine but with similar sensory blockade. The onset of this difference became significant as early as five minutes after the drug exposure was begun. No significant differences in recovery times were observed.

Anesthesia for the Obstetric Patient with Multiple Sclerosis

Data on all obstetric patients delivering at the Brigham and Womens Hospital during the years 1982 through 1987 were collected. The anesthetic techniques used, the type and amount of anesthetic agents administered, and the postpartum relapse rate of multiple sclerosis patients were compared. Women who received epidural anesthesia for vaginal delivery did not have a significantly higher incidence of relapse than those who received local infiltration. However, all of the women who experienced postpartum relapses had received concentrations of bupivacaine greater than 0.25%. This finding may suggest that a higher concentration of drug over a longer period of time may adversely influence the relapse rate.

The effects of varying volumes of crystalloid administration before cesarean delivery on maternal hemodynamics and colloid osmotic pressure.

The value of intravenous crystalloid administration in preventing spinal-induced hypotension in the parturient has recently been questioned. Also, the association between increasing crystalloid volume and decreasing postpartum colloid osmotic pressure (COP) raises concern regarding the risk of maternal and fetal pulmonary edema. To study the dose-response effect of varying amounts of crystalloid volume prior to spinal anesthesia, we measured maternal hemodynamic variables and maternal and fetal COP in three groups of healthy parturients receiving spinal anesthesia for elective cesarean delivery. Fifty-five parturients were randomized in a double-blind fashion to receive one of 10, 20, or 30 mL/kg of crystalloid volumes prior to induction of spinal anesthesia. Measurements included mean arterial blood pressure (MAP), cardiac index (CI), and systemic vascular resistance index (SVRI) recorded using noninvasive thoracic impedance monitoring until delivery. Maternal and neonatal COP were measured. All groups showed declines in MAP and SVRI from baseline at 5 min after spinal anesthesia, but the amount of decline did not differ among groups. Total ephedrine and additional intravenous (IV) fluid administered did not differ among groups. The 20- and 30- mL/kg groups showed a larger decline in maternal COP than the 10-mL/kg group; no differences in neonatal COP were seen with varying preload. We conclude that increasing the amount of IV crystalloid administered to 30 mL/kg in the healthy parturient does not significantly alter maternal hemodynamics or ephedrine requirements after spinal anesthesia and has no apparent benefit. (Anesth Analg 1996;83:299-303)

Percent Body Fat and Prediction of Surgical Site Infection

BACKGROUND Obesity is a risk factor for surgical site infection (SSI) after elective surgery. Body mass index (BMI) is commonly used to define obesity (BMI >or=30 kg/m(2)), but percent body fat (%BF) (obesity is >25%BF [men]; >31%BF [women]) might better predict SSI risk because BMI might not reflect body composition. STUDY DESIGN This prospective study included 591 elective surgical patients 18 to 64 years of age from September 2008 through February 2009. Height and weight were measured for BMI. %BF was calculated by bioelectrical impedance analysis. Preoperative, operative, and 30-day postoperative data were captured through interviews and chart review. Our primary, predetermined outcomes measurement was SSI as defined by the Center for Disease Control and Prevention. RESULTS Mean %BF and BMI were 34+/-10 and 29+/-8, respectively. Four-hundred and nine (69%) patients were obese by %BF; 225 (38%) were obese by BMI. SSI developed in 71 (12%) patients. With BMI defining obesity, SSI incidence was 12.3% in nonobese and 11.6% in obese patients (p = 0.8); Using %BF, SSI occurred in 5.0% of nonobese and 15.2% of obese patients (p < 0.001). In univariate analyses, significant predictors of SSI were %BF (p = 0.005), obesity by %BF (p < 0.001), smoking (p = 0.002), National Nosocomial Infections Surveillance score (p < 0.001), postoperative hyperglycemia (p = 0.03), and anemia (p = 0.02). In multivariable analysis, obese patients by %BF had a 5-fold higher risk for SSI than nonobese patients (odds ratio = 5.3; 95% CI, 1.2-23.1; p = 0.03). Linear regression was used to show that there is a positive, nonlinear relationship between %BF and BMI. CONCLUSIONS Obesity, defined by %BF, is associated with a 5-fold increased SSI risk. This risk increases as %BF increases. %BF is a more sensitive and precise measurement of SSI risk than BMI. Additional studies are required to better understand this relationship.