Issam Tanoubi

The electronic medical record in anesthesiology: a standard of quality healthcare and patient safety

The electronic medical record (EMR) is increasingly being used to replace the paper anesthetic record in the operating room, and it is evident that it is not far from becoming a standard of care. The literature is rich in demonstrating its acceptability and ease of use, even if a certain time for adaptation is often necessary after its implementation. Furthermore, the use of the EMR as a clinical decision support tool is expected to enhance patient care and safety, which is also increasingly being highlighted in the current literature. Indeed, in this issue of the Journal, Hincker et al. show how improvements in compliance with guidelines for repeat cefazolin administration in the perioperative period can be made by adding inexpensive nonintrusive interventions to the EMR. In their before-and-after cohort analysis, they showed that this was achieved through the use of a simple bar on the EMR monitor that displayed continuously from the start of the initial antibiotic dosing and ended 15 min before subsequent doses were indicated. Such a straightforward adjustment to the EMR management software can have a direct effect on a practitioner’s adherence to practice guidelines and could ultimately impact patient safety. Importantly, however, there are other areas in the EMR besides those related to antibiotic administration that could also be modified to improve patient safety. Preventing medical errors

Successful management of a neck hematoma following simulation training

Simulation-based education is gaining widespread acceptance in many medical specialties as an effective method to teach technical and non-technical skills. The ultimate goal of simulation is to improve health care and patient safety. Boet et al. [1] published a review on simulation-based crisis resources management (CRM) teaching, looking for evidence that it can lead to improved workplace practices and patient safety. Amongst hundreds of studies pertaining to CRM, he found only nine that were relevant, and only one that showed reduced mortality. Elaborating and putting forward studies designed to measure the impact of simulation on patient safety and outcomes is by no mean an easy task [2]. Indeed, most studies present various problems, such as biases introduced by the use of historical cohorts rather than control groups, and sample sizes based on convenience rather than power analysis. Furthermore, many significant outcomes such as mortality and major morbidity rates need to be measured over an extended period of time, which leaves room for variables other than the introduction of a simulation-based teaching program to play a confounding role [2]. These are some of the reasons why the majority of publications in simulation-based teaching are focusing mostly if not exclusively on measuring participants’ satisfaction and performance in a simulated environment. At the Universite de Montreal, we developed surgical high-fidelity simulation-based CRM scenarios focusing on teamwork. The specific simulation based training on CRM, which includes this airway management scenario, is given only once a year, in the beginning of their second year of residency. This highly appreciated training [3] place surgical residents in rare and urgent situations, but within a safe simulated environment. One of these scenarios focuses on the management of neck hematoma after thyroidectomy. It teaches a step-by-step approach that emphasizes, amongst other things, the need for bedside evacuation in the setting of significant and life-threatening airway obstruction (figure 1). The purpose of this case report is to describe how a postgraduate year 3 (PGY 3) surgical residents used and credited the training acquired during a simulation-based CRM scenario for positively influencing a patients outcome.

High-fidelity simulation of transcutaneous cardiac pacing: characteristics and limitations of available high-fidelity simulators, and description of an alternative two-mannequin model.

Introduction Transcutaneous cardiac pacing (TCP) is a potentially lifesaving technique that is part of the recommended treatment for symptomatic bradycardia. Transcutaneous cardiac pacing however is used uncommonly, and its successful application is not straightforward. Simulation could, therefore, play an important role in the teaching and assessment of TCP competence. However, even the highest-fidelity mannequins available on the market have important shortcomings, which limit the potential of simulation. Methods Six criteria defining clinical competency in TCP were established and used as a starting point in the creation of an improved TCP simulator. The goal was a model that could be used to assess experienced clinicians, an objective that justifies the additional effort required by the increased fidelity. Results The proposed 2-mannequin model (TMM) combines a highly modified Human Patient Simulator with a SimMan 3G, the latter being used solely to provide the electrocardiography (ECG) tracing. The TMM improves the potential of simulation to assess experienced clinicians (1) by reproducing key features of TCP, like using the same multifunctional pacing electrodes used clinically, allowing dual ECG monitoring, and responding with upper body twitching when stimulated, but equally importantly (2) by reproducing key pitfalls of the technique, like allowing pacing electrode misplacement and reproducing false signs of ventricular capture, commonly, but erroneously, used clinically to establish that effective pacing has been achieved (like body twitching, electrical artifact on the ECG, and electrical capture without ventricular capture). Conclusions The proposed TMM uses a novel combination of 2 high-fidelity mannequins to improve TCP simulation until upgraded mannequins become commercially available.

Étude de cas : Anesthésie locorégionale sciatique et fémorale bilatérale chez un polytraumatisé@@@Case report: Bilateral femoral and sciatic regional anesthesia in a polytraumatized. patient

RésuméObjectif: Nous présentons un cas d’anesthésie locorégionale bilatérale des deux membres inférieurs comme anesthésie principale, en mettant en relief les mesures d’atténuation de la toxicité liée aux doses importantes d’anesthésiques locaux nécessaires.Éléments cliniques: Une femme de 32 ans, obèse (index de masse corporelle=30,4 kg·m−2), présentait des fractures bimalléolaires aux deux membres inférieurs nécessitant des ostéosynthèses urgentes. À cause de fractures au niveau de la face, de l’odontoïde et du bassin ainsi que de l’obésité et de l’estomac plein, nous avons priorisé l’indication de blocs bilatéraux des membres inférieurs. Des blocs fémoral et sciatique des deux membres inférieurs ont été réalisés avec un mélange de ropivacaïne et de mépivacaïne, en laissant un intervalle de 210 min entre chaque membre. Des dosages sanguins des anesthésiques locaux utilisés ont été faits 80 min après les blocs du premier membre et 45 min après les blocs du second. Les niveaux plasmatiques de ropivacaïne et de mépivacaïne étaient inférieurs aux seuils de toxicité habituels. La patiente n’a présenté aucun signe de toxicité et la chirurgie a été complétée sans complication.Conclusion: La pratique d’une anesthésie locorégionale bilatérale exige parfois des doses élevées d’anesthésiques locaux s’approchant des seuils de toxicité. Ce cas montre qu’en tenantAbstractPurpose: To present a case requiring regional anesthesia for both lower limbs, and to highlight the considerations to avoid potential local anesthetic toxicity, as a result of high cumulative doses of local anesthetic in this setting.Clinical Features: A 32-yr-old, obese (body mass index=30.4 kg·m−2) woman required urgent, open reduction of bilateral ankle fractures. She also had facial, odontoid and pelvic fractures, and, in view of full stomach considerations, the anesthetic plan was to use regional anesthesia. Bilateral femoral and sciatic nerve blocks were performed, using a combination of ropivacaine and mepivacaine, with a 210-min interval between limbs. Blood samples were drawn 80 and 45 min after the first and second blocks, respectively, to measure plasma con centrations of the local anesthetics. Ropivacaine and mepivacaine concentrations were below reported toxic levels, and the patient underwent surgery successfully, without any symptoms suggestive of local anesthetic toxicity.Conclusions: Regional anesthetic techniques for the lower limb may require local anesthetic doses approaching toxic levels, especially when bilateral blocks are required. This case indicates that by considering the pharmacokinetic and pharmacodynamic characteristics of each agent, and by timing the blocks properly to minimize peak plasma concentrations, the potential for local anesthetic toxicity can be reduced.PURPOSE To present a case requiring regional anesthesia for both lower limbs, and to highlight the considerations to avoid potential local anesthetic toxicity, as a result of high cumulative doses of local anesthetic in this setting. CLINICAL FEATURES A 32-yr-old, obese (body mass index = 30.4 kg.m(-2)) woman required urgent, open reduction of bilateral ankle fractures. She also had facial, odontoid and pelvic fractures, and, in view of full stomach considerations, the anesthetic plan was to use regional anesthesia. Bilateral femoral and sciatic nerve blocks were performed, using a combination of ropivacaine and mepivacaine, with a 210-min interval between limbs. Blood samples were drawn 80 and 45 min after the first and second blocks, respectively, to measure plasma concentrations of the local anesthetics. Ropivacaine and mepivacaine concentrations were below reported toxic levels, and the patient underwent surgery successfully, without any symptoms suggestive of local anesthetic toxicity. CONCLUSIONS Regional anesthetic techniques for the lower limb may require local anesthetic doses approaching toxic levels, especially when bilateral blocks are required. This case indicates that by considering the pharmacokinetic and pharmacodynamic characteristics of each agent, and by timing the blocks properly to minimize peak plasma concentrations, the potential for local anesthetic toxicity can be reduced.