Jeanette R. Bauchat

Acquisition of critical intraoperative event management skills in novice anesthesiology residents by using high-fidelity simulation-based training.

Background:Early acquisition of critical competencies by novice anesthesiology residents is essential for patient safety, but traditional training methods may be insufficient. The purpose of this study was to determine the effectiveness of high-fidelity simulation training of novice residents in the initial management of critical intraoperative events. Methods:Twenty-one novice residents participated in this 6-week study. Three hypoxemia and three hypotension scenarios were developed and corresponding checklists were validated. Residents were tested in all scenarios at baseline (0 weeks) and divided into two groups, using a randomized crossover study design. Group 1 received simulation-based training in hypoxemic events, whereas Group 2 was trained in hypotensive events. After intermediate (3 weeks) testing in all scenarios, the groups switched to receive training in the other critical event. Final testing occurred at 6 weeks. Raters blinded to subject identity, group assignment, and test date scored videotaped performances by using checklists. The primary outcome measure was composite scores for hypoxemia and hypotension scenarios, which were compared within and between groups. Results:Baseline performance between groups was similar. At the intermediate evaluation, the mean hypoxemia score was higher in Group 1 compared with Group 2 (65.5% vs. 52.4%, 95% CI of difference 6.3–19.9, P < 0.003). Conversely, Group 2 had a higher mean hypotension score (67.4% vs. 45.5%, 95% CI of difference 14.6–29.2, P < 0.003). At Week 6, the scores between groups did not differ. Conclusions:Event-specific, simulation-based training resulted in superior performance in scenarios compared with traditional training and simulation-based training in an alternate event.

A randomized controlled trial of the effect of combined spinal-epidural analgesia on the success of external cephalic version for breech presentation

BACKGROUND Improving the success of external cephalic version (ECV) for breech presentation may help avoid some cesarean deliveries. The results of randomized trials comparing the success of ECV with neuraxial analgesia compared to control are inconsistent. We hypothesized that combined spinal-epidural (CSE) analgesia would increase the success of ECV when compared with systemic opioid analgesia. METHODS Parturients with singleton breech presentation (n=96) were randomized to receive CSE analgesia with bupivacaine 2.5mg and fentanyl 15 microg (CSE group) or intravenous fentanyl 50 microg (SYS group) before ECV attempt. The primary outcome was ECV success. RESULTS The success rate of ECV was 47% with CSE and 31% in the SYS group (P=0.14). Subsequent vaginal delivery was 36% for CSE and 25% for SYS (P=0.27). Median [IQR] visual analog pain scores (0-100mm scale) were lower with CSE (3 [0-12]) compared to SYS analgesia (36 [16 to 54]) (P<0.005) and patient satisfaction (0-10 scale) was higher (CSE 10 [9 to 10] versus SYS 7 [4 to 9]) (P<0.005). There were no differences in fetal heart rate patterns, but median time to return to fetal heart rate reactivity after analgesia was shorter with CSE (13 [IQR 9-21] min) compared to the SYS group (39 [IQR 23-51] min) (P=0.02). CONCLUSIONS There was no difference in the rate of successful ECV or vaginal delivery with CSE compared to intravenous fentanyl analgesia. Pain scores were lower and satisfaction higher with CSE analgesia, and median time to fetal heart rate reactivity was shorter in the CSE group.

Low-dose ketamine with multimodal postcesarean delivery analgesia: a randomized controlled trial.

BACKGROUND Ketamine at subanesthetic doses has analgesic properties that have been shown to reduce postoperative pain and morphine consumption. We hypothesized that intravenous ketamine 10mg administered during spinal anesthesia for cesarean delivery, in addition to intrathecal morphine and intravenous ketorolac, would decrease the incidence of breakthrough pain and need for supplemental postoperative analgesia. METHODS Using a randomized double-blind placebo-controlled design, healthy women scheduled for cesarean delivery receiving hyperbaric spinal bupivacaine, fentanyl and morphine were randomized to intravenous ketamine 10mg or saline following delivery. Postoperative analgesia included scheduled ketorolac and acetaminophen/hydrocodone tablets as needed for breakthrough pain. The primary outcome was the incidence of breakthrough pain in the first 24h. Secondary outcomes included the number of acetaminophen/hydrocodone tablets administered and numeric rating scale for pain (0-10). RESULTS Group characteristics did not differ. There was no difference in the incidence of breakthrough pain (ketamine 75% VS. saline 74%, P=0.86). There was no difference in 24-h or 72-h use of supplemental acetaminophen/hydrocodone tablets between groups. Pain scores in the first 24h were similar, but lower in the ketamine compared to the saline group 2weeks postpartum (difference -0.6, 95% CI -1.1 to -0.9). CONCLUSIONS We found no additional postoperative analgesic benefit of low-dose ketamine during cesarean delivery in patients who received intrathecal morphine and intravenous ketorolac. Subjects who received ketamine reported lower pain scores 2weeks postpartum.

Detection of Intimate Partner Violence in a General Medicine Practice

In this study, an assessment phase is undertaken to determine intimate partner violence (IPV) prevalence. An anonymous survey is followed by a chart review documenting identification of IPV. Two methods are attempted to increase assessment/documentation of IPV: a physician educational intervention and a nursing routine inquiry intervention in one quadrant of the practice. The IPV physician educational intervention includes didactic sessions, an IPV counselor, and resource information. The routine inquiry intervention involves nurses screening female patients for IPV at check-in. IPV is found to be prevalent in a general medicine clinic. An enhanced educational intervention does not increase IPV documentation. A routine inquiry intervention significantly increases documentation of lifetime IPV but does not impact current IPV identification.

Labor Analgesia Consumption and Time to Neuraxial Catheter Placement in Women with a History of Surgical Correction for Scoliosis: A Case-Matched Study.

BACKGROUND: Neuraxial analgesic techniques are the most effective form of labor analgesia. Small studies (9–21 patients), conducted 10 to 20 years ago, demonstrated successful neuraxial labor analgesia in only 50% to 66% of patients with surgical correction for scoliosis. Newer surgical techniques for scoliosis correction make the epidural space more accessible, but postsurgical changes may still alter the efficacy of neuraxial labor analgesia. The purpose of this prospective case-matched study was to compare hourly bupivacaine consumption and time to placement of neuraxial technique in laboring women with spinal instrumentation compared with women without previous back surgery. METHODS: All women with previous spinal instrumentation surgery for scoliosis correction who requested neuraxial labor analgesia at Prentice Women’s Hospital during the study period were approached. Control subjects were matched for anesthesiologist level of experience. The primary outcomes were bupivacaine consumption per hour of labor analgesia and time to placement of the neuraxial technique. Secondary outcomes included supplemental analgesia requirements and neuraxial analgesia failures and complications. RESULTS: Data from 41 women with surgical correction for scoliosis and 41 control subjects requesting neuraxial labor analgesia were analyzed. Obstetric and demographic characteristics of study participants were not different between groups. Median (interquartile range) hourly bupivacaine consumption was 15.2 mg/h (12.5–18.7) in the spinal instrumentation group and 14.2 mg/h (11.8–16.0) in the control group; the difference in medians was 1 mg/h (95% confidence interval [CI], −1.3 to 3.0; P = 0.38). The total bupivacaine consumption, number of manual reboluses, and number of subjects requiring greater bupivacaine concentrations did not differ between groups. Neuraxial analgesia failure occurred in 5 (12%) of women in the spinal instrumentation group but in none of the control patients (difference [95% CI], 12% [−0.3% to 25%]; P = 0.06). The mean time required to complete the neuraxial technique was 41% (95% CI, 7%–108%; P = 0.01) longer in the spinal instrumentation group than in the control group. The spinal instrumentation group also required a greater number of needle redirections, attempted interspaces, and need to switch to a more experienced provider than matched controls. CONCLUSIONS: The findings of this investigation suggest that previous surgery for scoliosis repair does not affect neuraxial labor analgesia consumption, but performance of the neuraxial technique is more difficult. Our findings suggest that neuraxial labor analgesia should be offered to parturients with previous surgery for scoliosis repair although informed consent should include a discussion of the possibility of technical difficulties and surgical anesthesia failure.

Prior lumbar discectomy surgery does not alter the efficacy of neuraxial labor analgesia.

BACKGROUND:Lumbar discectomy surgery is a common neurosurgical procedure. Neuraxial labor analgesia may be less effective in parturients with a history of discectomy surgery because of postsurgical scarring and anatomical distortion. In this prospective observational case-controlled study, we compared bupivacaine consumption per hour of labor analgesia as an indirect measure of labor analgesic effectiveness between women with prior discectomy surgery and those who did not have back surgery. METHODS:All women with prior discectomy surgery who requested neuraxial labor analgesia at a high-volume, single university-affiliated womens hospital during the study period were approached. Control subjects were matched for anesthesiologist skill level. The primary outcome was bupivacaine consumption per hour of labor analgesia. Characteristics associated with the epidural catheter placement including the number of interspaces attempted, time to placement, and number of epidural catheters replaced for inadequate analgesia were recorded. Subject characteristics, labor outcomes, and analgesia outcomes were analyzed using the Wilcoxon ranked sum or Fisher exact test. Epidural placement data were analyzed using the Wilcoxon signed rank, McNemars, or sign test. RESULTS:Data were analyzed for 42 women in the discectomy group and 42 women in the control group. Bupivacaine consumption per hour of labor analgesia was not different between groups (median [interquartile range, IQR]: discectomy 12.7 mg/h [11.0 to 15.3] and control 13.2 mg/h [11.3 to 15.7]; difference in medians [95% confidence interval, CI]: −0.55 mg/h [−1.33 to 1.39]; P = 0.43). The interval from initiation of neuraxial analgesia and delivery and mode of delivery did not differ between groups. The median difference (95% CI) in the time to place the epidural catheter between the discectomy and control subjects was 0 minute (−1 to 2.5); P = 0.38. More than 1 interspace was attempted in 17% discectomy in comparison with 2% of the control subjects—difference (95% CI) 15% (2–26); P = 0.03. The neuraxial technique and estimated level of catheter placement did not differ. Completion of the procedure by a more senior anesthesiologist occurred in 3 discectomy subjects and 2 control subjects (P = 1.0). No epidural catheters were replaced. CONCLUSIONS:There was no difference in hourly bupivacaine consumption in parturients with prior lumbar discectomy surgery undergoing neuraxial labor analgesia in comparison with controls. Time to placement of the epidural catheter was not different either, but more interspaces were attempted in the discectomy group. Our findings suggest that standard clinical neuraxial analgesic methods are effective in women with discectomy surgery.

Evidence-Based Anesthesia for Major Gynecologic Surgery

Studies on enhanced recovery after gynecological surgery are limited but seem to report outcome benefits similar to those reported after colorectal surgery. Regional anesthesia is recommended in enhanced recovery protocols. Effective regional anesthetic techniques in gynecologic surgery include spinal anesthesia, epidural analgesia, transversus abdominis plane blocks, local anesthetic wound infusions and intraperitoneal instillation catheters. Non-opioid analgesics including pregabalin, gabapentin, NSAIDs, COX-2 inhibitors, and paracetamol reduce opioid consumption after surgery. This population is at high risk for PONV, thus, a multimodal anti-emetic strategy must be employed, including strategies to reduce the baseline risk of PONV in conjunction with combination antiemetic therapy.

Neuraxial morphine and oral herpes reactivation in the obstetric population

Neuraxial morphine administration is a common strategy for providing postcesarean delivery analgesia. Morphine delivered via this route increases the risk of herpes labialis (oral herpes) reactivation, a disease common in women of childbearing age. A primary concern is risk of transmission to the neonate from maternal reactivation. The benefits to the mother of this form of analgesia outweigh the risk of neonatal herpes acquired postpartum from maternal recurrence because serious neonatal morbidity from recurrent herpes has not been described.

Transcutaneous Carbon Dioxide Measurements in Women Receiving Intrathecal Morphine for Cesarean Delivery: A Prospective Observational Study

BACKGROUND: Neuraxial morphine is the most commonly used analgesic technique after cesarean delivery. The incidence of respiratory depression is reported to be very low (0%–1.2%) in this patient population as measured by pulse oximetry and respiratory rates. However, hypercapnia may be a more sensitive measure of respiratory depression. In the current study, the incidence of hypercapnia events (transcutaneous CO2 [TcCO2] >50 mm Hg) for ≥2-minute duration was evaluated using the Topological Oscillation Search with Kinematical Analysis monitor in women who received intrathecal morphine for postcesarean delivery analgesia. METHODS: Healthy women (>37 weeks of gestation) scheduled for a cesarean delivery with spinal anesthesia with intrathecal morphine were recruited. Baseline STOP-BANG sleep apnea questionnaire and TcCO2 readings were obtained. Spinal anesthesia was initiated with 12 mg hyperbaric bupivacaine, 15 µg fentanyl, and 150 µg morphine. The Topological Oscillation Search with Kinematical Analysis monitor was reapplied in the postanesthesia care unit and TcCO2 measurements obtained for up to 24 hours. Supplemental opioid administration and adverse respiratory events were recorded. The primary outcome was the incidence of hypercapnia events, defined as a TcCO2 reading >50 mm Hg for ≥2 minutes in the first 24 hours after delivery. RESULTS: Of the 120 women who were recruited, 108 completed the study. Thirty-five women (32%; 99.15% confidence interval, 21%–45%) reached the primary outcome of a sustained hypercapnia event. The median time (interquartile range [IQR]) from intrathecal morphine administration to the hypercapnia event was 300 (124–691) minutes. The median (IQR) number of events was 3 (1–6) and longest duration of an event was 25.6 (8.4–98.7) minutes. Baseline median (IQR) TcCO2 measurements were 35 (30–0) mm Hg and postoperatively, median (IQR) TcCO2 measurements were 40 (36–43) mm Hg, a difference of 5 mm Hg (99.15% confidence interval of the difference 2–8 mm Hg, P < .001). The incidence of hypercapnia events was 5.4% in women with a baseline TcCO2 value ⩽31 mm Hg, 22.5% with a baseline TcCO2 between 32 and 38 mm Hg, and 77.4% with a baseline TcCO2 >38 mm Hg (P < .001). CONCLUSIONS: Hypercapnia events (>50 mm Hg for ≥2-minute duration) occurred frequently in women receiving 150 &mgr;g intrathecal morphine for postcesarean analgesia. Higher baseline TcCO2 readings were observed in women who had hypercapnia events.

Using simulation to study speaking up and team performance

May 2013 • Volume 116 • Number 5 www.anesthesia-analgesia.org 1183 Using Simulation to Study Speaking Up and Team Performance to a different threshold, but our general conclusion is that length of ICU stay remains a factor to take into consideration before using succinylcholine for critically ill patients. We performed a clinical not a pharmacologic study2 and found it impossible to precisely measure the peak potassium concentration. The resulting bias however should be an observed lower peak concentration and thus an underestimated ΔK and underestimated correlation between ΔK and length of ICU stay. In some cases, ΔK was surprisingly negative, independent of ΔpH, but these data are actual clinical observations with the usual assay and interspecimen variability. Finally, some points are superimposed in the scatter plot, and all 153 results were analyzed. In conclusion, we continue to consider that the length of ICU stay is an additional risk factor for hyperkalemia after administration of succinylcholine in critically ill patients.