Eric Wittkugel

Impact of a nurse practitioner-assisted preoperative assessment program on quality

Background : The anesthesia manpower shortage in the last few years in the US has limited many hospital pediatric surgical services. We sought to meet an increasing surgical caseload, while providing safe, timely and patient‐centered care by instituting a nurse practitioner‐assisted preoperative evaluation (NPAPE) program. The strategic goal of this program was to shift anesthesiologists from the preanesthesia clinic to the operating room (OR), while maintaining the quality of preoperative care. Our study sought to evaluate the quality of the NPAPE program.

Pediatric preoperative evaluation--a new paradigm.

Preoperative assessment and preparation of infants, children, and adolescents is foundational to successful anesthetic outcome. For the past 15 years, an ever-increasing number of patients, even those with complex conditions, are not admitted to the hospital before surgical or diagnostic procedures that require anesthesia care. Therefore, preanesthetic assessment must be performed on an outpatient basis. It is crucial to proactively identify patients who have special anesthetic needs and are at higher perioperative risk. This chapter discusses current and future models for preoperative evaluation and preparation of pediatric patients. The traditional model for preoperative evaluation of outpatients has been to evaluate all patients before the day of the procedure in an anesthesia preoperative clinic (APC). The APC consists of anesthesiologists performing preoperative history and physical examination, reviewing medical history and laboratory studies, ordering any necessary additional studies and consultations as well as discussing the anesthetic plan with the patient and family. Although this model provides the opportunity to evaluate most patients in person, it presents challenges for the anesthesiologist and the family. Because many pediatric patients are healthy and their preoperative evaluation is brief, they can easily be evaluated on the day of surgery and do not need a separate preoperative visit. Therefore, valuable manpower resources are spent on evaluating children in an APC who do not have any special anesthetic concerns. Families are increasingly busy and may find it difficult or impossible to come for an anesthesia preoperative visit, especially if they live far from the medical center. An alternative APC model selectively schedules preanesthetic evaluations several days before the procedure for certain patients, whereas preanesthetic evaluations are performed on themajority of patients on the day of the procedure immediately before beginning the case. Healthy patients can be effectively evaluated and prepared for anesthesia on the day of surgery. Patients with medically complicated conditions or presenting for major operations are identified in advance and evaluated days

Interventions designed using quality improvement methods reduce the incidence of serious airway events and airway cardiac arrests during pediatric anesthesia

Although serious complications during pediatric anesthesia are less common than they were 20 years ago, serious airway events continue to occur. Based on Quality Improvement (QI) data from our institution, a QI project was designed to reduce the incidence of serious airway events and airway cardiac arrests.

Development of a nurse‐assisted preanesthesia evaluation program for pediatric outpatient anesthesia

Historically, anesthesiologists have conducted preanesthesia evaluation, but more recently, nurse practitioners (NPs) are increasingly assisting with the preanesthesia evaluation of children. In the current economic environment for healthcare, strategies to provide superior outcomes and exceptional patient experience at the lowest possible cost are constantly being explored. We examined whether well trained nurses, working alongside NPs, could safely and effectively assist in preanesthesia evaluation. The aim of this quality improvement project was to implement a new model for preanesthesia evaluation for healthy outpatient pediatric patients: nurse‐assisted preanesthesia evaluation (NAPE).

A comparison of inhalational inductions for children in the operating room vs the induction room.

Background:  There has been debate about the use of an induction room (IR) compared with an operating room (OR) for inhalational induction in children. The quality of the anesthesia induction between these two physical environments has not been studied previously. We sought to compare child distress, OR utilization and efficiency, and parental satisfaction and safety, between an IR and an OR.

Motor blockade of abdominal muscles following a TAP block presenting as an abdominal bulge

laryngoscopy provided a better laryngeal view than did the standard midline approach, and authors suggest the left molar approach when intubation was difficult. We prefer the left molar approach of laryngoscopy as the primary alternative when the conventional midline approach fails since 2007 (2). We also use the left molar approach of laryngoscopy in cases of difficult intubation in pediatric and adult patients in our anesthesia clinic. We want to draw attention to two points about the article by Mahmoud et al. (1). Firstly, in the section of ‘Introduction’, the author mentioned that ‘Difficult airway management in uncorrected cleft palate patients has been studied by many authors (1–16)’. However, our patients consisted of only adult patients with the unexpected difficulty of laryngoscopy without cleft palate. Secondly, in the section of ‘Discussion’, the author mentioned the disadvantages of the left molar approach to laryngoscopy citing our article (2) and said that these results support the superiority of the author’s novel technique. We suggest that the left molar approach can be attempted, while preparations for alternate airway management are completed. Left molar approach of laryngoscopy is a safe and easy method and does not necessitate any extra equipment such as a hard gum shield. Because of this reason, we think that the left molar approach of laryngoscopy is a safe and preferable method also in pediatric patients with uncorrected cleft palate. Additionally, we emphasize that left molar approach of laryngoscopy may be useful and provide better Cormack and Lehane scoring of glottic view in case of difficulty in conventional midline laryngoscopy with the use of hard gum shield in uncorrected cleft palate pediatric patients.

Quality in pediatric ambulatory anesthesia: its recognition, measurement, and improvement.

1. Review the current literature surrounding quality of pediatric anesthesia in the ambulatory setting. 2. Describe the essential components of quality care as defined by the Institute of Medicine (IOM). 3. Discuss how each component is measured and quantified at our outpatient surgery center. 4. Explore the role of the quality director in using effective, data-driven tools, and strategies for improving quality and outcomes.

Anesthesia for Epidermolysis Bullosa

Epidermolysis Bullosa (EB) is a heterogeneous group of mechanobullous disorders of the skin. EB is caused by 1 of 13 genes responsible for mechanical adhesion between the epidermis and the dermis. EB can have far-reaching effects, involving multiple organ systems in addition to the skin. Although more than 20 phenotypes have been identified, there are three major types of EB: epidermolysis bullosa simplex; junctional epidermolysis bullosa; and recessive dystrophic epidermolysis bullosa. While they all have cutaneous features in common, the systemic manifestations vary. Depending on the type and severity of the disease, anesthesia in these patients can be challenging. A comprehensive and multi-disciplinary plan is necessary to ensure safe and effective perioperative anesthetic care. From transferring the patient to the operating room table, to placing patient monitors, to vascular access, to airway management, each step requires meticulous attention to detail. While airway management can present a significant risk in the perioperative setting, with careful preoperative evaluation and a thoughtful approach, it can be performed safely. Understanding the different types, pathophysiology, and anesthetic considerations EB patients enables better long-term outcomes for these patients who require repeated gastrointestinal, dermatologic, and airway interventions throughout their lives.

Quality improvement methods toreduce adverse events in anesthesia

Result: A total number of 72 male patients of acute coronary syndrome were studied, S.T.E.M.I (ST-elevation myocardial infarction) was diagnosed in 11 (15.277%) patients, non-S.T.E.M.I in 26 (36.111%) while 35 (48.611%) patients were having unstable angina. Hypertension was documented in 49 (68.055%), smoking in 40 (55.555%) patients, diabetes in 27 (37.5%) and a family history of CAD was recorded in 29 (40.277%) patients.47 (65.277%) patients were active physically.Hypertension, smoking and dyslipidemia were the most frequent combinations observed in 27(37.5%) subjects while diabetes and hypertension was in 21(29%) patients.A serious complications during anesthesia are less common today than in the past, serious airway events, especially in pediatric anesthesia, continue to occur and lead to patient morbidity, escalation of care and unplanned hospital admission. Quality improvement methodology evaluates existing processes, identifies parts of the process which are faulty and proposes changes which are believed to result in improvement. Proposed changes are then evaluated using small tests of change and Plan-Do-Study-Act (PDSA) cycles to be sure that they actually result in improvement and do not have unintended negative effects. Quality improvement measures and analyzes data so that quality and safety failures are traced back to their underlying causes. Based on data, clinical processes can then be changed to prevent future failures and adverse outcomes. While outcome data is widely considered to be the ultimate measure of quality, the processes and the environment in which health care is delivered are also fundamental to high quality, safe care. We identified system factors related to the clinical practice of anesthesia in our pediatric hospital which contributed to serious airway events and cardiac arrests in the operating room. In conjunction with anesthesia providers, we designed and tested interventions to reduce these adverse events. Simple process changes were put in place whichled to a greater standardization of our clinical practice. Over the 2 1⁄2 year period of the improvement project, the incidence of serious airway events and airway related cardiac arrests were reduced by 44% and 59% respectively, compared to the previous two years. Quality improvement enables any organization to continuously assess its performance and use the information to drive change and improvement, however challenging.Introduction: Pregnancy is associated with major changes in the thyroid function.The thyroid function is very closely related to the reproductive performance in women. Hypothyroidism is one of the most common endocrinopathyseen during pregnancy. Approximately 5% of allpregnancies are affected by hypothyroidism. Majority of such cases have subclinical hypothyroidism, which is defined by an elevated serum serum thyroid stimulating hormone (TSH) concentration ≥3.00 mU/L and a serum free thyroxine (FT4) in the normal range, i.e., between 0.80 to 1.90 ng/dl.Hypothyroidism has been associated with pregnancy complications such as preeclampsia, preterm labor, low birth weight, placental abruption, recurrent abortions, perinatal death and congenital hypothyroidism in the newborn. There has been a lot of debate on the impact of subclinical hypothyroidism and pregnancy outcome. Therefore, we did this large scale, multi-institutional prospective study to evaluate the consequences of subclinical hypothyroidism on pregnancy outcome.Methods: A three phase study, phase (1) (pre-intervention phase) was a retrospective cohort study of the frequency of potential DDIs in 500 prescriptions of patients in the surgical ICU using Lexi-Interact interaction database. Phase (2) (intervention phase) involved the implementation of DDIs reducing measures. Phase 3 (post-intervention phase) was a prospective study of the frequency of potential DDIs in the 500 prescription collected after intervention phase (phase 2).Case: Pediatric surgery planned gastrostomy for a 7 year old boy with muscle-eye-brain syndrome. The patients was agitated and it was observed that muscular tonus increased, head was in hyperextension and contracture developed in elbow and wrists. Patients was on liresal for spasticity and the cause of gastrostomy opening was the difficulty in swallowing owing to hyperextension of the head. ECG, pulse oximeter and non-invasiveblood pressure was used in standard monitorization in addition to placement of heat probe. Patients was sedated with sevoflurane induction and venous access was made with 22G canula. 2.5 mg/kg propofol induction was made and subsequently 2.5 no LMA was placed. In anesthesia maintenance, sevoflurane 2%, N2O 60% mixture was used. No increase was seen in body temperature and etCO2 (end tidal carbondioxide). No intraoperative problems was experienced and patients wasawakened without any problems and transferred to clinic. Discussion : (POMGnT1) genes are implicated for muscle-brain-eye (MBE) disease.In MEB disease, congenital muscular distrophy, eye anomalies (myopia, glaucoma, retinal hypoplasia),brain malformation (type 2 lysenecephalia, hypoplasia in brain stem, and cerebellum, and high cretainene kinase values occur. In patients, who are hypotonic at birth, spasticity develops in time. In diagnosis, clinical and MRI findings are used. In the literature, four cases have been reported in whom CK levels increase excessively after the administration of succynilcolin under general anesthesia, but the relation between malignant hyperthermia and MEB syndrome is still far from clear.Introduction: Odontogenic cysts are commonly seen pathological lesions in the jaw bones. Odontogenic cysts may be inflammatory or developmental regarding their origin. Pathogenesis differs due to the types of the odontogenic cysts and recurrence may be observed. Including periapical lesions, the roles of oral bacteria on periodontal infections were stated, however a study conducting the identification of the bacteria was not found before. Along with this, viruses such as human cytomegalovirus and Epstein Barr virus were observed on the inflammatory cells present in the periodontal lesions. However the role of the virus presence in the odontogenic cysts’ ethiopathology was not stated. The main purpose of this study is to evaluate the role of the Human Cytomegalovirus (HCMV) and the Epstein–Barr (EBV) viruses in the pathogenesis of the radicular cysts’ (RCs) and odontogenickeratocysts’ (OKCs) fluids.Background & Objective: The parabrachial nucleus is a critical link in the transmission of short latency nociceptive information to midbrain neurons. GABA(A) receptors have bidirectional roles in controlling nociception and are abundant in the parabrachial region. We examined the effects of bilateral intra parabrachial microinjection of different doses of the GABA(A) receptoragonist, muscimol, and the GABA(A) receptor antagonist, bicuculline, on pain modulation using a chronic pain test.