Lebron Cooper

Surgery under extreme conditions in the aftermath of the 2010 haiti earthquake: The importance of regional anesthesia

The 12 January 2010 earthquake that struck Port-au-Prince, Haiti caused >200,000 deaths, thousands of injuries requiring immediate surgical interventions, and 1.5 million internally displaced survivors. The earthquake destroyed or disabled most medical facilities in the city, seriously hampering the ability to deliver immediate life- and limb-saving surgical care. A Project Medishare/University of Miami Miller School of Medicine trauma team deployed to Haiti from Miami within 24 hours of the earthquake. The team began work at a pre-existing tent facility in the United Nations (UN) compound based at the airport, where they encountered 225 critically injured patients. However, non-sterile conditions, no means to administer oxygen, the lack of surgical equipment and supplies, and no anesthetics precluded the immediate delivery of general anesthesia. Despite these limitations, resuscitative care was administered, and during the first 72 hours following the event, some amputations were performed with local anesthesia. Because of these austere conditions, an anesthesiologist, experienced and equipped to administer regional block anesthesia, was dispatched three days later to perform anesthesia for limb amputations, debridements, and wound care using single shot block anesthesia until a better equipped tent facility was established. After four weeks, the relief effort evolved into a 250-bed, multi-specialty trauma/intensive care center staffed with >200 medical, nursing, and administrative staff. Within that timeframe, the facility and its staff completed 1,000 surgeries, including spine and pediatric neurological procedures, without major complications. This experience suggests that when local emergency medical resources are completely destroyed or seriously disabled, a surgical team staffed and equipped to provide regional nerve block anesthesia and acute pain management can be dispatched rapidly to serve as a bridge to more advanced field surgical and intensive care, which takes longer to deploy and set up.

Medication errors in anesthesia: a review.

Medication errors in anesthesia practice have long afflicted our specialty. Over the span of the last 60 years, from the earliest reports of misadventures to current reports of medication errors during anesthesia practice, the rate of human error during the conduct of anesthesia does not seem to be improving. This review highlights the limited studies published on anesthesia medication errors, summarizes the national and international initiatives to reduce errors, addresses the challenges associated with data collection and reporting of errors, and reiterates previously published strategies for reduction or prevention of medication errors. With the advent of innovative technologies, a continued focus on patient safety and recognition of the challenges associated with reporting, opportunities exist to decrease human error during anesthesia practice.

Review article: The evolving role of information technology in perioperative patient safety

PurposeThe adoption of new technologies in medicine is frequently met with both enthusiasm and resistance. The universal adoption of health information technology (IT) and anesthesia information management systems (AIMS) remains low despite the potential benefits. Electronic medical records, and hence AIMS, are at the intersection of patient safety. This article highlights advantages and barriers to adoption and implementation of IT in general and AIMS in particular, with a focus on clinical decision support systems (CDSS) and computerized physician order entry (CPOE) as hallmarks that may lead to improvement in patient safety and quality in the perioperative setting.Principal findingsThe advantages of health IT and AIMS include improved legibility of documentation; the ability to integrate new scientific evidence into practice; enhanced management and exchange of complex health information; the ability to standardize order sets, incorporate computerized physician order entry, and provide clinical decision support; and the ability to capture data for management, research, and quality monitoring and reporting. While not foolproof, AIMS have been shown to improve safety, quality, and patient outcomes. Barriers to the adoption of health IT and AIMS include costs, lack of truly interoperable AIMS components in health-system IT solutions, and lack of clinician involvement in implementation, planning, design, and installation of many IT or AIMS products.ConclusionsHealth IT and AIMS are at the intersection of patient safety and technology. Anesthesiologists are perfectly positioned to be the physician leaders of adoption, design, implementation, and integration, not only for AIMS but also for health-system IT solutions in general.RésuméObjectifL’adoption de nouvelles technologies en médecine suscite souvent à la fois enthousiasme et résistance. L’adoption universelle de l’informatique pour les soins de santé et des systèmes de gestion de l’information en anesthésie (AIMS) demeure peu répandue malgré leurs avantages potentiels. Les dossiers médicaux électroniques, et donc les AIMS, sont au cœur de la sécurité des patients. Cet article souligne les avantages et les barrières à l’adoption et à la mise en œuvre de l’informatique en général et des AIMS en particulier, en se concentrant sur les systèmes de soutien à la décision clinique (CDSS) et à l’entrée informatisée des ordonnances du médecin (CPOE) en tant que percées qui pourraient entraîner des améliorations au niveau de la sécurité des patients et de la qualité dans le contexte périopératoire.Constatations principalesLes avantages de l’informatique dans les soins de santé et des AIMS comprennent une lisibilité améliorée de la documentation; la capacité d’intégrer de nouvelles données probantes scientifiques à la pratique; une meilleure gestion et un échange amélioré des informations de santé complexes; la capacité de normaliser des ensembles de modèles d’ordonnance, d’incorporer la saisie informatisée d’ordonnances de médecins, ainsi que de fournir un soutien à la décision clinique; et la capacité à saisir des données pour l’administration, la recherche, le suivi de la qualité et les rapports de qualité. Bien que les systèmes AIMS ne soient pas à toute épreuve, il a été démontré qu’ils amélioraient la sécurité, la qualité et les pronostics des patients. Parmi les barrières à l’adoption de l’informatique dans les soins de santé et des systèmes AIMS, citons les coûts, l’absence de composantes d’AIMS véritablement intégrables dans les solutions informatiques des systèmes de santé, et le manque d’engagement des médecins dans la mise en œuvre, la planification, la conception et l’installation de nombreux produits informatiques et d’AIMS.ConclusionL’informatique dans les soins de santé et les systèmes AIMS se situent à l’intersection de la sécurité des patients et de la technologie. Les anesthésiologistes sont dans une situation idéale pour devenir les médecins chefs de file de l’adoption, de la conception, de la mise en œuvre et de l’intégration – non seulement des systèmes AIMS, mais également des solutions informatiques pour les systèmes de santé en général.

A randomized, controlled trial on dexmedetomidine for providing adequate sedation and hemodynamic control for awake, diagnostic transesophageal echocardiography

OBJECTIVE Transesophageal echocardiography (TEE) has become established as a sensitive and accurate diagnostic method for the rapid assessment of myocardial function. It was theorized that dexmedetomidine (Precedex; Hospira, Inc, Lake Forest, IL) might prove to be useful for sedating patients while undergoing TEE. DESIGN A prospective, randomized trial was designed comparing dexmedetomidine versus standard therapy (eg, midazolam and opioids) for sedation. SETTING This trial was performed in a tertiary care, single-institution university hospital. PARTICIPANTS Males and females, American Society of Anesthesiologists I to IV, ages 18 to 65 years, requiring diagnostic TEE. Patients were excluded if pregnant, if they had taken benzodiazepines or opioids within 24 hours, or if they were deemed to be too unstable to receive any kind of sedation. INTERVENTIONS Patients were randomized to standard therapy or dexmedetomidine infusion groups. Sedation was assessed at 6 time points. Pulse oximetry, electrocardiogram, heart rate, noninvasive blood pressure, and respiratory rate were monitored. Additional variables measured were the amount of each drug given, the time of the TEE procedure, and the time to recovery. MEASUREMENTS AND MAIN RESULTS A survey about the quality of sedation, the level of comfort, and whether or not they would accept this type of sedation again was administered after recovery from sedation. Demographic data and patient questionnaire responses were reported as means and standard errors or percents and were analyzed with the t test and chi-square test. Twenty-two patients were enrolled. Hemodynamics were statistically different between the two groups at several time points. Both systolic and diastolic blood pressures (BP) were elevated in the standard therapy group, whereas the dexmedetomidine group had a lower BP. Heart rate was elevated significantly in the standard therapy group compared with the dexmedetomidine group. There was no statistical or clinical difference between the groups in terms of oxygenation or respiratory rate. CONCLUSIONS The authors concluded that dexmedetomidine appears equivalent in achieving adequate levels of sedation without increasing the rate of respiratory depression or decreasing oxygen saturation compared with standard therapy, and it may be better in achieving desired hemodynamic results.

A matter of life or limb? A review of traumatic injury patterns and anesthesia techniques for disaster relief after major earthquakes

BACKGROUND:All modalities of anesthetic care, including conscious sedation, general, and regional anesthesia, have been used to manage earthquake survivors who require urgent surgical intervention during the acute phase of medical relief. Consequently, we felt that a review of epidemiologic data from major earthquakes in the context of urgent intraoperative management was warranted to optimize anesthesia disaster preparedness for future medical relief operations. The primary outcome measure of this study was to identify the predominant preoperative injury pattern (anatomic location and pathology) of survivors presenting for surgical care immediately after major earthquakes during the acute phase of medical relief (0–15 days after disaster). The injury pattern is of significant relevance because it closely relates to the anesthetic techniques available for patient management. We discuss our findings in the context of evidence-based strategies for anesthetic management during the acute phase of medical relief after major earthquakes and the associated obstacles of devastated medical infrastructure. METHODS:To identify reports on acute medical care in the aftermath of natural disasters, a query was conducted using MEDLINE/PubMed, Embase, CINAHL, as well as an online search engine (Google Scholar). The search terms were “disaster” and “earthquake” in combination with “injury,” “trauma,” “surgery,” “anesthesia,” and “wounds.” Our investigation focused only on studies of acute traumatic injury that specified surgical intervention among survivors in the acute phase of medical relief. RESULTS:A total of 31 articles reporting on 15 major earthquakes (between 1980 and 2010) and the treatment of more than 33,410 patients met our specific inclusion criteria. The mean incidence of traumatic limb injury per major earthquake was 68.0%. The global incidence of traumatic limb injury was 54.3% (18,144/33,410 patients). The pooled estimate of the proportion of limb injuries was calculated to be 67.95%, with a 95% confidence interval of 62.32% to 73.58%. CONCLUSIONS:Based on this analysis, early disaster surgical intervention will focus on surviving patients with limb injury. All anesthetic techniques have been safely used for medical relief. While regional anesthesia may be an intuitive choice based on these findings, in the context of collapsed medical infrastructure, provider experience may dictate the available anesthetic techniques for earthquake survivors requiring urgent surgery.

Outpatient regional anesthesia for upper extremity surgery update (2005 to present) distal to shoulder.

Multiple different approaches to the brachial plexus are available for the regional anesthesiologist to provide successful anesthesia and analgesia for ambulatory surgery of the upper extremity. Although supraclavicular and infraclavicular blocks are faster to perform than axillary blocks, the operator needs to keep in mind that blocks performed around the clavicle carry the risk for specific side effects and complications, no matter whether ultrasound or nerve stimulation is the chosen modality for neurolocation. Owing to the ambulatory nature of the planned surgical intervention, even significant side effects may not become clinically symptomatic until the patient is discharged from the facility. For example, due to pneumothorax risks, axillary or mid-humeral blocks remain the most logical approaches for ambulatory surgical procedures at and below the elbow, while reserving infra-clavicularor supraclavicular approaches for surgery from the proximal humerus to above the elbow. Smaller interventions such as carpal tunnel release or trigger finger release can be performed under elbow, wrist, or digital blocks. The regional anesthesiologist should strive to develop a tailored plan for each individual case to provide the most effective and safest nerve block technique for their patients.

Prevention of hospital-acquired pressure ulcers in the operating room and beyond: A successful monitoring and intervention strategy program

The incidence of pressure ulcers in the United States has increased over the past several years, with a 78.9% increase in hospital stays from 1993 to 2006 that resulted in a cost of

Postoperative Complications after Thoracic Surgery in the Morbidly Obese Patient

11.0 billion in additional health care costs. Development of pressure ulcers results in increased length of stays by 7 to 10 days, and these patients are 3 times more likely to be discharged to long-term care facilities. Mortality is more than twice the rate for patients who develop pressure ulcers than those who do not. Patients who develop pressure ulcers during hospitalization tend to be older with a mean age of 71.9. Comorbidities that contribute to the risk of development include urinary or fecal incontinence, nutritional deficiencies, diabetes, and dementia. In October 2008, Centers for Medicare and Medicaid Services discontinued reimbursement for stage 3 and 4 hospital-acquired pressure ulcers (HAPUs), leaving hospitals to absorb the additional health care costs related to treatment. HAPUs have become indicators of quality of care in hospitals; therefore, it is assumed other care is substandard when the incidence of pressure ulcer

Should automated information management systems be leased

Little has been recently published about specific postoperative complications following thoracic surgery in the morbidly obese patient. Greater numbers of patients who are obese, morbidly obese, or supermorbidly obese are undergoing surgical procedures. Postoperative complications after thoracic surgery in these patients that can lead to increased morbidity and mortality, prolonged hospital stay, and increased cost of care are considered. Complications include difficulties with mask ventilation and securing the airway, obstructive sleep apnea with risk of oversedation, pulmonary complications related to reduced total lung capacity, reduced functional residual capacity, and reduced vital capacity, risks of aspiration pneumonitis and ventilator-associated pneumonia, cardiomyopathies, and atrial fibrillation, inadequate diabetes management, positioning injuries, increased risk of venous thrombosis, and pulmonary embolism. The type of thoracic surgical procedure may also pose other problems to consider during the postoperative period. Obese patients undergoing thoracic surgery pose a challenge to those caring for them. Those working with these patients must understand how to recognize, prevent, and manage these postoperative complications.

Preface: Patient safety: A noble enterprise

To the Editor: Anesthesia information management systems (AIMS) improve staff scheduling, medical decision-making support, and quality improvement monitoring [1]. Information management systems facilitate benchmarking and monitoring of quality and performance improvement, and they are an essential component of the data-driven quality improvement process [2]. Decisions to upgrade existing information systems, or even switching to a new provider, are often delayed due to the high costs associated with the process. As the importance of achieving and maintaining competitive advantage using AIMS are weighed against the high capital expenditure of a purchase, leasing software and hardware may be amore convenient, flexible, and attractive option to operating room medical directors and health system administrators. Leasing, as opposed to borrowing or buying, has several advantages, including increased tax shields, reduced restrictive covenants, and lower transaction costs [3]. Leases may beless costly than purchases, allowing for conservation of working capital while preserving the credit and debt capacity of the organization. Reduced risk of obsolescence and concern for capital equipment disposal at the end of the assets life are additional benefits of leasing. Leases are classified as operating or capital. Operating lease agreements may offer advantages to the hospital (lessee) regarding the AIMS. Typically, operating leases are written for a shorter period than the expected life of the asset, and the hospital may have the right to cancel the lease before the expiration of the agreement. In addition, the information management company (lessor) provides for maintenance of the AIMS. In contrast, capital leases cannot be cancelled before the end of the agreement. According to these agreements, if cancellation were allowed, the information management company would not recover the full cost of the AIMS, as rental payments are based on the full price of the asset minus its residual value. Although uncertainty may exist as to a standard way of evaluating the lease versus purchase decision, comparing the cost streams on the basis of the present value of cash flows is a simple method [4]. The benefit of leasing is determined by comparing the net present value (NPV) of purchasing to the NPV of leasing, known as the net advantage of leasing (NAL). Leases should be analyzed as projects according to their NPV, known as the NAL [3]. The NAL is the most popular method for analyzing a lease, representing the total monetary saving resulting from leasing an asset. For an asset to be leased, the NPV of the lease must be positive and greater than the NPV of owning the asset. Calculations should include estimates of three main variables, namely depreciation, maintenance costs, and the average life expectancy of the AIMS. Detailed tax implications of leases are beyond the scope of this analysis. The present value (PV) of annual cash flows is calculated using the formula: