Manuel C. Vallejo

The use of cognitive aid checklist leading to successful treatment of malignant hyperthermia in an infant undergoing cranioplasty.

To the Editor In citing the well-known and very successful landing of flight 1549 on the Hudson River, Goldhaber-Fiebert and Howard1 raise some important issues regarding the use of cognitive aids and checklists in time-sensitive crisis scenarios. An alternative perspective, however, is that the “dual engine restart” checklist proved a distraction (the aircraft was too low and the engines irreparably damaged), and the reason for the successful outcome was the pilot’s training, experience, and safety awareness—an example no less valuable to anesthesiologists. The success of the Hudson River landing was more consistent with Klein’s recognitionprimed decision-making model mentioned later in the article; a process that “...allows difficult decisions in less than ideal circumstances.”2 In this instance, the Captain had very quickly assessed altitude, engine performance, airspeed, and landing opportunities—perhaps the only checklist benefit was to prevent or shorten the “startle” effect.3 Emergency manuals or cognitive aids can help improve performance4 but concerns remain. An incorrect diagnosis can lead to the wrong checklist being used, and a disproportionate sense of urgency can result in fixation error. It is also reasonable to predict that specific checklists will not be a perfect fit for every clinical context and may actually distract from task prioritizing. Interestingly on flight 1549, the directive to seal doors and hatches for water landings was on a different checklist and not completed.a To the Editor The journal recently published several articles on implementing emergency manuals and the use of perioperative cognitive aids during emergencies to help translate best practices for patient care during acute events.1–3 We describe a real life example of the benefits resulting from introduction of one such cognitive aid, The Emergency Manual4,5 into each anesthesia workstation. Informed consent from the parents to publish this report was obtained. Approximately 1 hour after inhalational induction in a 4-month-old boy undergoing cranioplasty, acute unexplained increases in heart rate (180/min), end-tidal carbon dioxide (62 mm·Hg), and patient temperature from 34°C to 38°C occurred over 5 minutes These physiologic changes were quickly noted as suspicious for malignant hyperthermia (MH), and the now readily available The Emergency Manual was referenced and utilized as a cognitive aid in quickly treating the patient. Dantrolene 2.5 mg/ kg IV was administered, and the Malignant Hyperthermia Association of the United States hotline was concurrently contacted for assistance. Cooling measures were instituted, and blood samples were sent for arterial blood gases, lactate, and coagulation profile. The patient’s heart rate and end-tidal carbon dioxide began to return toward normal after dantrolene administration. Twenty-four hours later, his trachea was extubated, and he was discharged from the pediatric intensive care unit on postoperative day 3. Management of MH requires early diagnosis, rapid intervention, and smooth coordination of operating room personnel at the direction of the anesthesiologist to safeguard a favorable outcome. The MH section of The Emergency Manual assisted us in implementing the necessary steps to immediately manage the patient in this critical situation. This avoids the need for personnel to be dependent only on memory for management6 and is much more effective in completing each of the steps in the least time possible. In our case, this occurred within the first 5 minutes of diagnosis. It was also clear to us that availability of The Emergency Manual assisted other operating room staff to work as a team during the management of this crisis. As the information was read aloud, a clear understanding of the management sequence including distribution of the workload and effective communication were established. The prompt diagnosis and rapid team intervention prevented a potentially fatal outcome. This case illustrates the clinical advantage of using cognitive aids in the operating room, which has been proposed in simulation scenarios described by Marshall.1 This report was previously presented, in part, at the Malignant Hyperthermia Association of the U.S. conference in November, 2013. DOI: 10.1213/ANE.0000000000000156 The Use of Cognitive Aid Checklist Leading to Successful Treatment of Malignant Hyperthermia in an Infant Undergoing Cranioplasty LETTERS TO THE EDITOR E

An open-label randomized controlled clinical trial for comparison of continuous phenylephrine versus norepinephrine infusion in prevention of spinal hypotension during cesarean delivery

BACKGROUND During spinal anesthesia for cesarean delivery phenylephrine is the vasopressor of choice but can cause bradycardia. Norepinephrine has both β- and α-adrenergic activity suitable for maintaining blood pressure with less bradycardia. We hypothesized that norepinephrine would be superior to phenylephrine, requiring fewer rescue bolus interventions to maintain blood pressure. METHODS Eighty-five parturients having spinal anesthesia for elective cesarean delivery were randomized to Group P (phenylephrine 0.1μg/kg/min) or Group N (norepinephrine 0.05μg/kg/min) fixed-rate infusions. Rescue bolus interventions of phenylephrine 100μg for hypotension, or ephedrine 5mg for bradycardia with hypotension, were given as required to maintain systolic blood pressure. Maternal hemodynamic variables were measured non-invasively. RESULTS There was no difference between groups in the proportion of patients who required rescue vasopressor boluses (Group P: 65.8% [n=25] vs. Group N: 48.8% [n=21], P=0.12). The proportion of patients who received ⩾1 bolus of phenylephrine was similar between groups (Group P: 52.6% [n=20] vs. Group N: 46.5% [n=20], P=0.58). However, more patients received ⩾1 bolus of ephedrine in the phenylephrine group (Group P: 23.7% [n=9] vs. Group N: 2.3% [n=1], P<0.01). The incidence of emesis was greater in the phenylephrine group (Group P: 26.3% vs. Group P: 16.3%, P<0.001). Hemodynamic parameters including heart rate, the incidence of bradycardia, blood pressure, cardiac output, cardiac index, stroke volume, and systemic vascular resistance and neonatal outcome were similar between groups (all P<0.05). CONCLUSION Norepinephrine fixed-rate infusion has efficacy for preventing hypotension and can be considered as an alternative to phenylephrine.

Increasing operating room efficiency through electronic medical record analysis.

We used electronic medical record (EMR) analysis to determine errors in operating room (OR) time utilisation. Over a two year period EMR data of 44,503 surgical procedures was analysed for OR duration, on-time, first case, and add-on time performance, within 19 surgical specialties. Maximal OR time utilisation at our institution could have saved over 302,620 min or 5,044 hours of OR efficiency over a two year period. Most specialties (78.95%) had inaccurately scheduled procedure times and therefore used the OR more than their scheduled allotment time. Significant differences occurred between the mean scheduled surgical durations (101.38 ± 87.11 min) and actual durations (108.18 ± 102.27 min; P<0.001). Significant differences also occurred between the mean scheduled add-on durations (111.4 ± 75.5 min) and the actual add-on scheduled durations (118.6 ± 90.1 minutes; P<0.001). EMR quality improvement analysis can be used to determine scheduling error and bias, in order to improve efficiency and increase OR time utilisation.

Standardizing Maternity Care Data to Improve Coordination of Care

The amount of data generated by health information technology systems is staggering, and using those data to make meaningful care decisions that improve patient outcomes is difficult. The purpose of this article is to describe the Maternal Health Information Initiative, a multidisciplinary group of maternity care stakeholders charged with standardizing maternity care data. Complementary strategies that practicing clinicians can use to support this initiative and improve the usability of maternity care data are provided.

Perioperative risk factors for postoperative respiratory failure

The study aimed to identify the risk factors for respiratory failure after surgery. Postoperative respiratory failure (PRF) was defined as prolonged intubation after surgery or reintubation after unsuccessful extubation. We conducted a retrospective analysis of the following risk factors: age, obesity as reflected by body mass index (BMI), gender, patient admitted to hospital (in-patient status) vs. outpatient surgery, smoking, hypertension, chronic obstructive pulmonary disease (COPD), diabetes, abnormal liver function, anaemia, respiratory infection, physical condition as reflected by ASA class, case type (elective or emergency), anaesthesia type, and surgical duration. The incidence of PRF was found to be 2.4%. Independent risk factors were older age, inpatient status, hypertension, COPD, elective procedure, surgical duration >2 hours, and ASA class ≥3. The study concludes that PRF results in significant postoperative complications. Minimising these risks is essential in improving PRF and subsequently surgical outcomes.

An online web-based assessment tool to monitor graduate medical trainee professionalism and supervision

Medical education is tasked to ensure a humanistic training environment where trainees are taught to manifest professionalism and effacement of self-interest to meet the needs of their patients.1-3 Graduate and undergraduate medical education communities are searching for tools to assess professionalism, supervision, and mistreatment. The creation of timely and readily available assessment tools to monitor these events and trigger interventions is of much interest to medical educators. We describe our use of an institutional online reporting tool or “button” to document and track professionalism, supervision and mistreatment across multiple specialty training programs with the purpose of determining the underlying reasons for tool activations, and to enhance our understanding of how this assessment tool can improve graduate medical trainee professionalism and mistreatment.

Ultrasound and the Pregnant Patient

Ultrasound is widely used in all medical specialties. There are multiple reasons for the increased use of ultrasound including its ease of use, point-of-care determination, and rapid confirmation of clinical diagnoses. Ultrasound is a valuable tool that can assist in the diagnosis and treatment of obstetric patients for both obstetric and non-obstetric conditions. In this review, we will describe the common applications for point-of-care ultrasound in the perioperative period including intravenous placement and guidance for vascular access, head and neck evaluation (airway exam, difficult airway), lung and chest evaluation (pleural effusions, pneumonia), echocardiography (transthoracic echocardiography and transesophageal echocardiography), evaluation of gastric contents, postoperative pain management (transversus abdominis plane block) and regional anesthesia, neuraxial (spinal and epidural conduction), bladder volume estimation, and trauma evaluation (focused assessment with sonography in trauma) exam for detection of intraperitoneal fluid and hemorrhage.

SOAP Delivers: Options for Labor Pain.

To the Editor The article by Morey et al. 1 illustrates the fact that anesthesiologists are effectively being turned into glorified technicians and clerks, one step at a time. As an example, it is a New York State law requirement that a fluid warmer is to be used and documented while administering blood products to patients. However, it seems counterintuitive that the physician anesthesiologist administering the blood product should divert his or her attention from the hemorrhaging patient to document the serial number of the blood/fluid warmer used. Very soon, we will have to record the lot number and expiration date of every single vial of medication we use, the lot number of the laryngoscope and the endotracheal tube, etc. While we are busy with clerical tasks that have never been shown to improve outcomes, how can we be fully vigilant and provide the best patient care? Regarding the example given by the authors, the rules on saline bags should be supported by evidence: is bacterial growth detectable 1 hour after a sterile saline bag is spiked with a sterile set? If yes, let us try to determine what is the safe time interval, how we can decrease bacterial contamination, and why so few patients connected to an arterial blood pressure monitoring set develop an infection. If not, this bureaucratic rule, probably created with good intentions, should be purely and simply scrapped, because it is both impractical and actually dangerous if enforced in the setting of a busy trauma center requiring a functional operating room at all times. SOAP Delivers: Options for Labor Pain