Calvin Thompson

Effectiveness of a novel training program for emergency medicine residents in ultrasound-guided insertion of central venous catheters.

OBJECTIVE Insertion of central venous catheters (CVCs) is an essential competency for emergency physicians. Ultrasound-guided (USG) insertion of CVCs has been shown to be safer than the traditional landmark technique. There is no clear consensus on effective methods for training physicians in USG insertion of CVCs. We developed and evaluated a novel educational training program in the USG technique for insertion of CVCs. METHODS Sixteen emergency medicine residents volunteered for a pre- and postprogram evaluation study, which was approved by our research ethics board. After their previous experience was determined, each participant was videotaped inserting a USG CVC in the right internal jugular vein on models. Participants then reviewed a Web-based instructional module and had a practical session. Participants were again videotaped inserting a USG CVC. The primary outcome was the change in score before and after the training program, using an expert-validated performance evaluation tool used to review the videotaped performances in a blinded fashion. Participants also completed a questionnaire to measure their satisfaction with the training program and any change in their perceived competence. RESULTS Participants ranged from residency year 1 to 5. Thirteen of 16 (81%) had never attempted USG insertion of a CVC. Participants reported that the models were realistic. Performance scores (12/19 to 13.2/19) and global ratings assessments (3.5/7 to 5.5/7) improved significantly (p < 0.01; the effect size, Cohen d = 1.12 before and 1.28 after) after the instruction. There was good interrater reliability between evaluators of the videotaped performances regarding performance scores (r = 0.68) and global rating scores (r = 0.75). All participants felt their confidence and technical skills were improved (p < 0.01) and all felt satisfied with the training program. CONCLUSION This brief innovative multimethod training program was effective in enhancing emergency medicine resident competence in USG insertion of CVCs.

Ultrasound-Guided Subclavian Vein Catheterization: A Systematic Review and Meta-Analysis.

Objective:Although ultrasound guidance for subclavian vein catheterization has been well described, evidence for its use has not been comprehensively appraised. Thus, we conducted a systematic review and meta-analysis to determine whether ultrasound guidance of subclavian vein catheterization reduces catheterization failures and adverse events compared to the traditional “blind” landmark method. All forms of ultrasound were included (dynamic 2D ultrasound, static 2D ultrasound, and Doppler). Data Sources:Medline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and CINAHL (from inception to September 2014). Study Selection:Randomized controlled trials of ultrasound compared to landmark technique for subclavian catheterization in adult populations were considered. Outcomes of interest included safety and failure of catheterization. Data Extraction:Adverse event data were analyzed according to Peto’s method and expressed as odd ratios and 95% CIs. Failure of catheterization was analyzed with inverse variance random effects modeling and expressed as risk ratios and 95% CI. Data Synthesis:Six hundred and one studies were reviewed and 10 met inclusion criteria (n = 2,168 participants). Six used dynamic 2D ultrasound (n = 719), one used static 2D ultrasound (n = 821), and three used Doppler-guided insertion techniques (n = 628). Overall complication rates were reduced with ultrasound use compared to the landmark group (odd ratio, 0.53; 95% CI, 0.41–0.69). Subgroup analysis demonstrated that dynamic 2D ultrasound reduced inadvertent arterial puncture, pneumothorax, and hematoma formation. No difference in failure of catheterization was noted between the ultrasound group and the landmark method (risk ratio, 0.85; 95% CI, 0.48–1.51). Subgroup analysis of dynamic 2D ultrasound demonstrated a significant decrease in failed catheterization (risk ratio, 0.24; 95% CI, 0.06–0.92). Conclusions:Ultrasound-guided subclavian catheterization reduced the frequency of adverse events compared with the landmark technique. Our findings support the use of dynamic 2D ultrasound for subclavian catheterization to reduce adverse events and failed catheterization.

Carotid arterial cannulation: removing the risk with ultrasound?

leading nationalorganizations (National Institute for Clinical Excellence[UK], Agency for Healthcare Research and Quality [USA])to recommend US guided internal jugular CVC insertion.We describe an intraoperative carotid artery punctureduring attempted internal jugular venous cannulation,which occurred despite the use of US.A 34-year-old male with chronic renal failure had aCVC placed for perioperative monitoring during renaltransplantation. The right jugular approach was used withUS guidance oriented in the transverse view. A puncture ofthe carotid artery by the 18G needle was identified by colorand pulsatility. The needle was withdrawn and pressureapplied. The next attempt, also with US, resulted in apuncture of a vessel that was identified as a vein because ofthe dark non-pulsatile blood aspirated through the needle.Next, a multi-lumen 7 Fr catheter was inserted, and arterialcannulation was identified by connecting the catheter to apressure transducer. The catheter was withdrawn andpressure applied. A non-pulsatile hematoma developed,and further attempts at CVC were abandoned. Due to thehematoma, the patient required brief postoperative venti-lation. A postoperative Doppler exam of the carotid arterywas normal.The use of an US technique does not remove all riskinherent with CVC insertion. Methods are not standardized,and we believe many practitioners use the US techniqueonly to locate and puncture the internal jugular vein, andthen they discontinue using the method.

Limitations of preoperative dobutamine stress echocardiography in identifying severe left main coronary artery stenosis: a report of two cases and a brief review

PurposeUsing case illustrations, to elucidate factors which increase the likelihood of false negative preoperative dobutamine stress echocardiography (DSE) studies in patients with severe left main coronary artery stenosis, and to provide criteria which must be met in order to ensure the accurate interpretation of these tests.Clinical features and sourceTwo patients presented for elective abdominal aortic aneurysm repair within a one-month period of time. Both patients had DSE as part of their preoperative assessment, which were interpreted as normal. Nevertheless, both suffered major coronary events in the perioperative period, and both proved to have severe left main coronary artery stenosis on postoperative angiography. A narrative review is presented based on a selection of the current literature, and local experience with the technique. Some pitfalls in the interpretation of these tests are presented, along with modalities to increase their sensitivity and specificity.ConclusionDSE is an important and useful modality in the preoperative cardiac evaluation of patients who are unable to exercise. However the reliable interpretation of the test depends on an understanding of the limitations of the procedure.RésuméObjectifÉlucider, à l’aide d’observation de cas, les facteurs qui augmentent la possibilité de résultats faux négatifs à l’échocardiographie d’effort préopératoire avec dobutamine (EED) chez des patients qui présentent une grave sténose du tronc de l’artère coronaire gauche, et fournir les critères à satisfaire pour produire une interprétation exacte de ces tests.Éléments cliniques et sourceAu cours d’un mois, deux patients ont été admis pour la réparation réglée d’un anévrysme de l’aorte abdominale. Les deux patients ont été évalués entre autres par un examen EED qui s’est révélé normal. Néanmoins, les deux avaient été victimes d’ennuis coronariens majeurs pendant la période périopératoire et présentaient une grave sténose du tronc de l’artère coronaire gauche à l’angiographie postopératoire. Nous avons préparé une revue descriptive provenant d’un choix documentaire actuel et d’une expérience locale avec la technique. Nous présentons certaines embûches rencontrées lors de l’interprétation des tests ainsi que les modalités pour accroître leur sensibilité et leur spécificité.ConclusionL’EED est une modalité d’évaluation cardiaque préopératoire, importante et utile chez les patients qui ne peuvent faire d’exercice. Toutefois, l’interprétation fable du test dépend des connaissances de ses limites.

“Winding down” guidelines for anesthesiologists: The Ottawa Hospital plan

In a previous Journal article by Baxter et al., we described the effects of aging on anesthesiologists and suggested strategies to deal with such issues towards the end of one’s career. It was hoped that this would increase awareness and provoke discussion, both locally and at higher levels. Subsequently there has been a ‘‘panel discussion session’’ at the 2015 annual meeting of the Canadian Anesthesiologists’ Society, an article in the 2016 Canadian Medical Protective Association newsletter, and most recently by the President of the Royal College of Anesthetists in the College Bulletin earlier this year. An example of a template for discussion was initially described in the Baxter et al article, and your readers may be interested to learn how we have now applied it here at The Ottawa Hospital. The Anesthesiology Department Human Resources Committee was tasked with producing a policy document on phased retirement framework guidelines, a draft of which was circulated to all department members. The vast majority of respondents agreed with it. For those who did not, their concerns were addressed, the document was modified where appropriate, and more detailed explanations were given where necessary. After it was presented at a recent department meeting, with some further minor modifications made, the final document (Appendix) was approved after a department-wide vote. In brief, variability in the aging process was acknowledged when making these ‘‘guidelines’’, with various changes in practice activities to be at least considered at various age prompts (e.g., consider stopping ‘‘overnight on-call’’ at age 60 yr, no further high acuity cases at age 65 yr, retirement from main operating room practice at age 70 yr). Simulation training is recommended to enhance the ability to recognize and deal with crises in the operating room for OR anesthesiologists every five years and annually at age 60 yr. Other departments may have differing perspectives on this issue, but clearly it needs to be addressed as the anesthesiology staff ages. We encourage the topic to be discussed locally. This document is another example of how it is possible to address this difficult issue.

Early Discharge after Laparoscopic Hysterectomy: a Prospective Study

OBJECTIVE To evaluate the feasibility of same-day discharge after laparoscopic hysterectomy without excluding patients with complex surgical pathology and medical comorbidities. These factors are often considered potential barriers to early discharge, and the literature is lacking prospective trials addressing the feasibility of same-day discharge after laparoscopic hysterectomy in this patient population. METHODS All women undergoing laparoscopic hysterectomy by a member of the minimally invasive gynaecology team at The Ottawa Hospital, a tertiary academic referral centre, from May 2013 to February 2015 were eligible to participate regardless of patient comorbidities or surgical complexity. Strict perioperative protocols are presented. Factors associated with decreased success of same-day discharge and baseline and postoperative quality of life surveys were analyzed. RESULTS Fifty-three patients were included. Overall success of same day discharge was 83.0%. Average age and BMI were 44.4 years and 29.8 kg/m2, respectively. Thirty-four patients (63.0%) had at least one prior abdominal surgery. Those who had their surgery as first case of the day had a 91.7% same-day discharge rate versus 64.7% if they did not (relative risk = 1.4 [range 1.0-2.0]; P = 0.02). Ninety-eight percent of participants would recommend same-day discharge. Clinically significant improvement in quality of life from baseline was observed in 5 of 8 of the Short Form 36 domains at 6 months. CONCLUSION Same-day discharge from hospital is reasonable and well accepted for patients undergoing laparoscopic hysterectomy, even with complex surgical pathology. The implementation of a successful same-day discharge program would mean greater efficiency, economic benefits, and improved access to surgical care for women.

Long-term patient outcomes from the first year of a robotic surgery program using multi-surgeon implementation

INTRODUCTION There is concern that surgical quality initially declines during the learning phase of robotic surgery. At our institution, we used a multi-surgeon programmatic approach to the introduction of robotic surgery. The purpose of this study was to evaluate outcomes of patients treated during the first year of our program. METHODS This is a historical cohort of all radical prostatectomy patients during a one-year period. Baseline, perioperative, and long-term followup data were prospectively and retrospectively collected. Treatment failure was a composite of any postoperative radiation, androgen-deprivation, or prostate-specific antigen (PSA) ≥0.2. RESULTS During the study period, 225 radical prostatectomy procedures were performed (104 robotic and 121 open). Baseline characteristics were similar between groups (p>0.05). All patients were continent and 74% were potent prior to surgery. Mean estimated blood loss (280 cc vs. 760 cc; p<0.001) and blood transfusion (0% vs. 8.3%; p=0.002) was lower in the robotic cohort. Non-transfusion complications were similar between groups (13% vs. 12%; p=0.7). Mean hospital stay was shorter in the robotic cohort (1.4 vs. 2.5 days). There was no difference in overall positive margin rate (38% vs. 43%; p=0.4) or treatment failure at a median followup of 3.5 years (p=0.4). Robotically treated patients were more often continent (89% vs. 77%; p=0.02) and potent (48% vs. 32%; p=0.02). CONCLUSIONS Using an inclusive multi-surgeon approach, robotic pros-tatectomy was introduced safely at a Canadian academic institution.

The addition of adrenaline to thoracic epidural meperidine does not improve analgesia following thoracotomy

PurposePatient-controlled epidural analgesia (PCEA) with meperidine provides effective analgesia following thoracotomy. Accumulation of normeperidine, a meperidine metabolite with neuroexcitatory effects, has led to recommendations to limit the use of meperidine postoperatively. The purpose of this study was to determine if the addition of adrenaline to PCEA meperidine decreased meperidine consumption, reduced serum normeperidine levels, and improved analgesia following thoracotomy.MethodsFollowing Research Ethics approval consenting patients were randomly assigned to PCEA with either meperidine (2 mg·mL-1) + adrenaline (2 μg·mL-1) or meperidine alone (2 mg·mL-1). All patients received a standardized anesthetic and similar perioperative care. Visual analogue pain scores (at rest and with activity), quality of recovery (QoR) scores, and side effects were documented six, 24, and 48 hr postoperatively. Serum levels of meperidine and normeperidine were measured at the same time points.ResultsForty-six patients completed the study protocol. Meperidine consumption (mean ± SD) was similar in the meperidine + adrenaline and the meperidine groups (601 ± 211 mg vs 580 ±211 mg over 48 hr, respectively; P = 0.744). Serum meperidine levels were similar at all study time points. Serum normeperidine was not detected in any sample. Pain scores, QoR scores, and adverse events were comparable in both study groups.ConclusionThe addition of adrenaline did not influence PCEA meperidine consumption, analgesia outcomes, or QoR. Normeperidine did not accumulate in patients of either study group during the 48-hr study period. Meperidine for patient-controlled epidural analgesia, with or without adrenaline, provides effective post-thoracotomy analgesia in selected patients.RésuméObjectifL’analgésie péridurale contrôlée par le patient (APCP) avec de la mépéridine offre une analgésie efficace après une thoracotomie. L’accumulation de normépéridine, un métabolite de la mépéridine aux effets neuroexcitateurs, a engendré des recommandations dans le but de limiter l’utilisation de mépéridine dans le contexte postopératoire. L’objectifde cette étude était de déterminer si l’adjonction d’adrénaline à la mépéridine APCP réduit la consommation de mépéridine, abaisse les niveaux sériques de normépéridine, et améliore l’analgésie après une thoracotomie.MéthodeAvec l’assentiment du comité d’éthique de la recherche, les patients consentants ont été randomisés à une APCP avec soit de la mépéridine (2 mg·mL-1) + adrénaline (2 μg·mL-1), soit de la mépéridine seule (2 mg·mL-1). Tous les patients ont reçu un anesthésique standardisé et des soins périopératoires similaires. Les scores de douleur visuels analogues (au repos et à l’effort), les scores de la qualité de la récupération (QoR), et les effets secondaires ont été enregistrés à six, 24 et 48 h postopératoires. Les niveaux sériques de mépéridine et de normépéridine ont été mesurés aux mêmes temps.RésultatsQuarante-six patients ont terminé le protocole d’étude. La consommation de mépéridine (moyenne ± déviation standard (SD)) était similaire dans les groupes mépéridine + adrénaline et mépéridine seule (601 ± 211 mgvs 580 ±211 mg sur 48 h, respectivement; P = 0,744). Les niveaux sériques de mépéridine étaient similaires à tous les points temporels de l’étude. Aucune normépéridine sérique n’a été détectée dans les échantillons. Les scores de douleur, les scores QoR et les événements indésirables étaient comparables dans les deux groupes à l’étude.ConclusionL’ajout d’adrénaline n’a pas influencé la consommation de mépéridine APCP, l’analgésie, ou la QoR. La normépéridine ne s’est accumulée chez les patients déaucun des deux groupes durant la période d’étude de 48 h. La mépéridine pour l’analgésie péridurale contrôlée par le patient, avec ou sans adrénaline, offre une analgésie efficace après une thoracotomie chez certains patients.