Melanie Jaeger

Spinal Needle Navigation by Tracked Ultrasound Snapshots

Purpose: Ultrasound (US) guidance in facet joint injections has been reported previously as an alternative to imaging modalities with ionizing radiation. However, this technique has not been adopted in the clinical routine, due to difficulties in the visualization of the target joint in US and simultaneous manipulation of the needle. Methods: We propose a technique to increase targeting accuracy and efficiency in facet joint injections. This is achieved by electromagnetically tracking the positions of the US transducer and the needle, and recording tracked US snapshots (TUSS). The needle is navigated using the acquired US snapshots. Results: In cadaveric lamb model, the success rate of facet joint injections by five orthopedic surgery residents significantly increased from 44.4% (p <; 0.05) with freehand US guidance to 93.3% with TUSS guidance. Needle insertion time significantly decreased from 47.9 ± 34.2 s to 36.1 ± 28.7 s (mean ± SD). In a synthetic human spine model, a success rate of 96.7% was achieved with TUSS. The targeting accuracy of the presented system in a gel phantom was 1.03 ± 0.48 mm (mean ± SD). Conclusion: Needle guidance with TUSS improves the success rate and time efficiency in spinal facet joint injections. This technique readily translates also to other spinal needle placement applications.

Perioperative on-site haemoglobin determination: as accurate as laboratory values?

PurposeThis study assessed the accuracy of photometer based haemoglobin (Hb) determination technology (HemoCue®) when used by different anaesthetists in situations of rapidly changing Hb values during anaesthesia.Methods(Part 1) In the laboratory, repeated measurements were done on 16 split samples of blood using both the Hematology Analyzer (CELLDYN 3500 System™, Abbot Laboratories, San Jose, California) and the photometer. (Part 2) Twelve patients had blood samples drawn from an arterial line for simultaneous Hb determination in the hospital laboratory and by the photometer. At the same time, capillary samples were taken from the patient’s earlobe for Hb determination by the photometer. All sample collection and photometer measurements were done by the same operator. (Part 3) The Part 2 protocol was then repeated with different anaesthetists performing both the sampling and the photometer measurements. Statistical comparison was by ANOVA and a twotailed paired ttest.Results(Part 1) Samples determined by the photometer and the laboratory were highly correlated (r2 = 1.0, P < 0.001). The average error of each method was similar (< 4%). (Part 2) Using a 2-tailed paired ttest, the photometer arterial measurements were not different from the laboratory measurements, however the photometer capillary measurements were consistently ≈8% higher (P = 0.003). (Part 3) When multiple operators performed the sampling there were no differences on arterial or capillary samples (r2 = 0.942, r2 = 0.851 respectively), although the variance was greater.ConclusionsThe HemoCue® haemoglobinometer has sufficient accuracy to support treatment decisions regarding blood transfusions.RésuméObjectifÉvaluer la précision du titrage de l’hémoglobine (Hb) par la méthode photométrique (HémoCue®) lorsque différents anesthésistes l’utilisent pendant l’anesthésie dans des situations où la concentration de l’hémoglobine change rapidement.Méthodes(1e partie) En laboratoire, des mesures répétées ont été effectuées sur des échantillons de sang divisés en 16 fractions en utilisant à la fois l’Hemotology Analyzer (CELLDYN 3500 System, laboratoires Abbott, San Jose, Californie) et le photomètre. (2e partie) Des échantillons de sang provenant d’une canule artérielle ont été prélevés chez douze patients pour le titrage de l’hémoglobine par le laboratoire de l’hôpital et le photomètre. Le recueil de tous les échantillons et les mesures photométriques étaient réalisés par la même personne. (3e partie) Le protocole de la 2e partie a alors été répété par différents anesthésistes qui effectuaient à la fois les prélèvements et les mesures photométriques. La comparaison statistique a été établie par ANOVA et le test t pour groupes appariés.Résultats(1e partie) Les échantillons analysés par photométrie et laboratoire avaient un haut degré de corrélation (r2 = 1,0, P < 0,001). L’erreur moyenne de chaque méthode était identique (< 4%). (2e partie) Avec le test t apparié, les mesures du sang artériel par photométrie ne différaient pas des mesures du laboratoire; cependant, les mesures du sang capillaire par photométrie étaient invariablement plus élevées de 8% (P = 0,003). (3e partie) Quand plusieurs personnes effectuaient l’échantillonnage, il n’y a avait pas de différence entre les échantillons artériels ou capillaires (respectivement r2 = 0,92, r2 = 0,8510) bien que la variance ait été plus grande.ConclusionL’hémoglobinomètre HemoCue® est suffisamment précis pour justifier lu pertinence des transfusions sanguines.

A valid and reliable assessment tool for remote simulation-based ultrasound-guided regional anesthesia.

Background and Objectives The purpose of this study was to establish construct and concurrent validity and interrater reliability of an assessment tool for ultrasound-guided regional anesthesia (UGRA) performance on a high-fidelity simulation model. Methods Twenty participants were evaluated using a Checklist and Global Rating Scale designed for assessing any UGRA block. The participants performed an ultrasound-guided supraclavicular brachial plexus block on both a patient and a simulator. Evaluations were completed in-person by an expert and remotely by a blinded expert using video recordings. Using previous number of blocks performed as an indication of expertise, participants were divided into Novice (n = 8) and Experienced (n = 12) groups. Construct validity was assessed through the tool’s reliable on-site and remote discrimination of Novice and Experienced anesthetists. Concurrent validity was established by comparisons of patient versus simulator scoring. Finally, interrater reliability was determined by comparing the scores of on-site and off-site evaluators. Results The Global Rating Scale was able to differentiate Novice from Experienced anesthetists both by on-site and remote assessment on a patient and simulation model. The Checklist was unable to discern the 2 groups on a simulation model remotely and was marginally significant with on-site scoring. Conclusions This is the first study to demonstrate the validity and reliability of a Global Rating Scale assessment tool for use in UGRA simulation training. Although the checklist may require further refinement, the Global Rating Scale can be used for remote and on-site assessment of UGRA skills.

Brief review: Adoption of electronic medical records to enhance acute pain management

AbstractPurpose The purpose of this paper is to examine physician barriers to adopting electronic medical records (EMRs) as well as anesthesiologists’ experiences with the EMRs used by the acute pain management service at two tertiary care centres in Canada.SourceWe first review the recent literature to determine if physician barriers to adoption are changing given the exponential growth of information technology and the evolving healthcare environment. We next report on institutional experience from two academic health sciences centres regarding the challenges they encountered over the past ten years in developing and implementing an electronic medical record system for acute pain management.Principal findingsThe key identified barriers to adoption of EMRs are financial, technological, and time constraints. These barriers are identical to those reported in a systematic review performed prior to 2009 and remain significant factors challenging implementation. These challenges were encountered during our institution’s process of adopting EMRs specific to acute pain management. In addition, our findings emphasize the importance of physician participation in the development and implementation stages of EMRs in order to incorporate their feedback and ensure the EMR system is in keeping with their workflow.ConclusionsUse of EMRs will inevitably become the standard of care; however, many barriers persist to impede their implementation and adoption. These challenges to implementation can be facilitated by a corporate strategy for change that acknowledges the barriers and provides the resources for implementation. Adoption will facilitate benefits in communication, patient management, research, and improved patient safety.RésuméObjectifL’objectif de cet article est d’examiner les réticences des médecins à l’adoption du dossier médical informatisé (DMI) ainsi que l’expérience des anesthésiologistes avec les DMI utilisés au service de prise en charge de la douleur aiguë de deux centres tertiaires canadiens.SourceNous passons tout d’abord en revue la littérature récente afin de déterminer si les réticences des médecins à l’adoption évoluent étant donné la croissance exponentielle des technologies de l’information et l’évolution de l’environnement des soins de santé. Par la suite, nous rapportons l’expérience institutionnelle de deux centres universitaires des sciences de la santé et les défis qu’ils ont rencontrés au cours des dix dernières années en matière de mise au point et de mise en œuvre d’un système de dossier médical informatisé pour la prise en charge de la douleur aiguë.Constatations principalesLes principaux obstacles à l’adoption du DMI que nous avons identifiés sont liés à des contraintes financières, technologiques et de temps. Ces obstacles sont identiques à ceux rapportés dans une revue méthodique réalisée avant 2009 et demeurent d’importants facteurs rendant difficiles la mise en œuvre d’un tel système. Nous avons rencontré ces difficultés pendant le processus d’adoption de DMI spécifiques à la prise en charge de la douleur aiguë dans notre institution. En outre, nos résultats soulignent l’importance de la participation des médecins dans les étapes de mise au point et de mise en œuvre du DMI afin d’intégrer leurs commentaires et de garantir que le système de DMI s’intègre dans leur flux de travail.ConclusionL’utilisation du DMI deviendra inévitablement la norme de soins; toutefois, de nombreux obstacles persistent et freinent sa mise en œuvre et son adoption. Ces défis à la mise en œuvre peuvent être résolus en utilisant une stratégie institutionnelle de changement qui tient compte de ces obstacles et fournit les ressources nécessaires à la mise en œuvre. En adoptant le DMI, la communication, la prise en charge des patients, la recherche et la sécurité des patients seront toutes améliorées.

Peri-operative allogeneic blood transfusion and outcomes after radical cystectomy: a population-based study

IntroductionTo describe factors associated with peri-operative blood transfusion (PBT) at radical cystectomy (RC) for patients with bladder cancer and evaluate its association on both early and late outcomes.MethodsElectronic records of treatment and surgical pathology reports were linked to the population-based Ontario Cancer Registry to identify all patients who underwent RC between 2000 and 2008. Modified Poisson regression model was used to determine the factors associated with PBT. A Cox-proportional hazards regression model was used to explore the association between PBT and overall (OS) and cancer-specific (CSS) survival.ResultsAmong 2593 patients identified, 62% received an allogeneic red blood cell transfusion. The frequency of PBT decreased over the study period (from 68 to 54%, p < 0.001). Factors associated with PBT included age, sex, greater co-morbidity, stage, and surgeon volume. PBT was associated with inferior outcomes, including median length of stay (11 vs. 9 days, p < 0.001), 90-day re-admission rate (38 vs. 29%, p < 0.001), and mortality (11 vs. 4%, p < 0.001). OS and CSS at 5 years were lower among patients with PBT on multivariate analysis (OS HR 1.33, 95% CI 1.20–1.48; CSS HR 1.39, 95% CI 1.23–1.56).ConclusionsAlthough rates are decreasing, these data suggest a very high utilization rate of PBT at time of RC in routine clinical practice. PBT is associated with substantially worse early outcomes and long-term survival. This association persists despite adjustment for disease-, patient-, and provider-related factors, suggesting that PBT is an important indicator of surgical care of RC.

Intra-operative inferior vena cava syndrome in a patient with autosomal dominant polycystic kidney disease

The renal and hepatic cysts characteristic of autosomal dominant polycystic kidney disease can exert a mass effect on surrounding structures. If this involves the inferior vena cava (IVC), patients usually present with signs and symptoms characteristic of congestive heart failure. However, the absence of these signs or symptoms does not exclude a potentially hemodynamically significant IVC syndrome. This case report describes a patient with no pre-operative evidence of congestive heart failure or IVC compression, who subsequently experienced intra-operative hypotension and hypoxemia due to an IVC syndrome.

Development and Evaluation of an Epidural Analgesia Workshop for Senior Nursing Students

BACKGROUND Most prelicensure nursing students receive little to no training in providing care for patients who receive epidural analgesia, despite exposure in clinical settings and the potential for devastating adverse effects. To develop and pilot an epidural workshop for senior nursing students using standardized patients (SPs), and to evaluate feasibility and learner outcomes. METHOD A 4-hour epidural workshop consisted of a large group lecture and demonstration, small-group practice scenarios, and individual learner evaluation with SPs. Learning outcomes were evaluated using a performance checklist and critical thinking rubric, and pre- and posttests. RESULTS Participants scored well on the performance-based evaluation (mean score of 86% items performed correctly) and rated the workshop highly. However, learners and instructors made several recommendations for improving the learning module for future sessions. CONCLUSION This pilot project demonstrated that an epidural analgesia workshop using SPs is feasible and results in positive learning outcomes and high satisfaction with senior nursing students. [J Nurs Educ. 2018;57(6):359-365.].

Longitudinal assessment of procedural skills.

Longitudinal assessment of procedural skills Lindsey Patterson, Eleni Katsoulas, Amber Hastings, Anthony Sanfilippo & Melanie Jaeger To cite this article: Lindsey Patterson, Eleni Katsoulas, Amber Hastings, Anthony Sanfilippo & Melanie Jaeger (2016) Longitudinal assessment of procedural skills, Medical Teacher, 38:9, 961-961, DOI: 10.1080/0142159X.2016.1210784 To link to this article: http://dx.doi.org/10.1080/0142159X.2016.1210784