Ngozi Imasogie

What is the minimum training required for successful cricothyroidotomy?: a study in mannequins.

Background A correctly performed cricothyroidotomy may be lifesaving in a cannot-ventilate, cannot-intubate situation. However, many practicing anesthesiologists do not have experience with cricothyroidotomy. The purpose of this study was to determine the minimum training required to perform cricothyroidotomy in 40 s or less in mannequins. Methods After informed consent, participants were shown a demonstration video and asked to perform 10 consecutive cricothyroidotomy procedures on a mannequin using a preassembled percutaneous dilational cricothyroidotomy set. Each attempt was timed from skin palpation to lung insufflation. Cricothyroidotomy was considered successful if it was performed in 40 s or less, and the cricothyroidotomy time was considered to have plateaued when there were no significant reductions in cricothyroidotomy times in three consecutive attempts. Results One hundred two anesthesiologists participated in the study. There was a significant reduction of cricothyroidotomy times over the 10 attempts (P < 0.0001) and between three consecutive attempts until the fourth attempt (P < 0.03). The cricothyroidotomy times plateaued by the fourth attempt, while the success rate plateaued at the fifth attempt (94, 96, 96, and 96% at the fourth, fifth, sixth, and seventh attempts, respectively). Conclusion Practice on mannequins leads to reductions in cricothyroidotomy times and improvement in success rates. By the fifth attempt, 96% of participants were able to successfully perform the cricothyroidotomy in 40 s or less. While clinical correlates are not known, the authors recommend that providers of emergency airway management be trained on mannequins for at least five attempts or until their cricothyroidotomy time is 40 s or less. The most appropriate retraining intervals have yet to be determined for optimal cricothyroidotomy skill retention.

Elimination of routine testing in patients undergoing cataract surgery allows substantial savings in laboratory costs. A brief report

PurposeTo evaluate the possible cost savings when routine preoperative testing is discontinued in ambulatory cataract surgery patients.MethodsA policy was introduced at our hospital to stop routine testing in ambulatory cataract patients. Consecutive patients’ medical records were analyzed in a four-month period pre-and a fourmonth period post-discontinuation of routine laboratory tests. Ambulatory cataract surgery is performed under topical (and sometimes retrobulbar block) anesthesia with iv sedation. Co-morbidities, perioperative events, frequency and cost of tests ordered were compared for the two groups. Average costs per patient preand post-discontinuation of routine tests, and total possible cost savings were calculated.ResultsOne thousand two hundred and thirty-one patients were studied; 636 had routine laboratory tests and 595 had no routine laboratory tests. The ratios of gender, co-morbidities and perioperative events were similar in the two groups. There was a significant reduction in the number of tests ordered after the new policy was introduced, from 5.8 tests per patient to 0.4 tests per patient. The cost of tests per patient was reduced from Can

Effect of return hospital visits on economics of ambulatory surgery.

39.67 to

Risk factors for prolonged stay after ambulatory surgery: economic considerations.

4.01.ConclusionIn ambulatory cataract surgery, over 90% savings in laboratory costs is possible after elimination of routine tests.RésuméObjectifÉvaluer l’économie possible si on supprime l’examen de routine préopératoire chez les patients qui subissent une opération ambulatoire de la cataracte.MéthodeII a été décidé à notre hôpital de ne plus procéder aux tests de laboratoire de routine chez les patients ambulatoires opérés pour une cataracte. Les dossiers médicaux des patients qui se sont successivement présentés pendant les quatre mois qui ont précédé l’arrêt de ces examens, et pendant les quatre mois qui ont suivi cet arrêt, ont été analysés. L’opération ambulatoire de la cataracte se fait sous anesthésie topique, et parfois sous bloc rétrobulbaire, avec une sédation iv. La comorbidité, les incidents périopératoires, la fréquence et le coût des tests demandés dans les deux groupes ont été comparés. Le coût moyen par patient avant et après l’arrêt des tests de routine et l’économie totale possible ont été calculés.RésultatsLétude a porté sur I 231 patients dont 636 ont eu des tests de laboratoire et 595 n’ont pas eu d’examen de routine. Les deux groupes avaient des caractéristiques similaires quant au sexe des patients, à la comorbidité et aux incidents périopératoires notés. II y a eu une réduction significative du nombre de tests demandés, passant de 5,8 à 0,4 par patient après l’introduction de la nouvelle politique. Le coût des tests est passé de 39,67

Probable gas embolism during operative hysteroscopy caused by products of combustion

CAN à 4,01

Ultrsound guided axillary brachial plexus block: single vs triple injection

par patient.ConclusionEn chirurgie ambulatoire de la cataracte, on peut économiser au-delà de 90 % du coût de laboratoire en éliminant les examens de laboratoire de routine.

What Is the Minimum Training Required for Successful Cricothyroidotomy (CT)?: [2002][A-1329]

This review examines the effect of unanticipated admission, return hospital visits and readmission on the economics of ambulatory surgery. The overall rate of unanticipated admission was approximately 1% and the overall rate of readmission to hospital was approximately 1%. Ambulatory surgery allows total cost savings of 20-50% when compared with inpatient surgery. If 98% of ambulatory surgery patients experience uneventful recovery, the decrease in cost savings caused by unanticipated admission and return hospital visit is very small. Modifications of anesthesia and surgical technique can help to further reduce the incidence of unanticipated admission or readmission to hospital.

What Is the Minimum Training Required for Successful Cricothyroidotomy

The risk factors that prolong length of stay of ambulatory patients can be classified as preoperative, intraoperative, and postoperative. Preoperative factors include the type of surgery, ear, nose and throat and strabismus surgery, old age and pre-existing congestive heart failure. Intraoperative factors include increasing length of surgery, and general anesthesia, while postoperative factors include postoperative nausea and vomiting, excessive pain and adverse cardiovascular events. The factors that anesthesiologists can address to reduce length of stay are postoperative nausea and vomiting and excessive pain. Multimodal management of postoperative nausea and vomiting and pain can minimize adverse events and thereby reduce length of stay in the postanesthetic care unit, but will not necessarily lead to a reduction in staffing levels. As personnel costs contribute the majority of postanesthetic care unit costs, more than 95%, direct financial savings may not be possible from eliminating adverse events alone. Optimizing the use of the postanesthetic care unit and reducing total hours in the unit with higher operating room turnover may lead to indirect financial benefits.

Frequency and implications of ambulatory surgery without a patient escort.

PurposeGas embolism is a rare but well documented entity during operative hysteroscopy, with an incidence of 10–50%. Catastrophic outcomes occur at a rate of three in 17,000 procedures. The purpose of this report is to present a non-fatal case of gas embolism probably caused by the gaseous products of combustion.Clinical featuresA 50-yr-old woman with a history of menorrhagia was scheduled for hysteroscopy and endometrial ablation and polypectomy. Fifteen minutes into the procedure, with the patient in lithotomy position, 20° head down tilt, and breathing spontaneously, a sudden oxygen desaturation occurred from 97% to 87%. The patient’s end-tidal carbon dioxide dropped from 46 mmHg to 27 mmHg. The patient’s breathing pattern remained normal, respiratory rate remained 11–12 breaths·min−1 but amplitude of the reservoir bag movement was increased. Cardiovascular variables remained stable. She responded rapidly to 100% oxygen and made an uneventful recovery. Having ruled out other possible causes, we concluded gas embolism was responsible for the fall in oxygen saturation and end-tidal CO2.ConclusionWith all the precautions in place to minimize the likelihood of fluid overload and ambient air embolism occurring, we surmised that products of combustion were the cause of the gas embolism. During endometrial ablation, gaseous products of combustion, mainly carbon dioxide, accumulate. The gases may then contribute to the rise in uterine pressure that occurs as irrigation fluid enters the uterus and this rise in pressure in turn encourages passage of gas into the open venous sinuses.RésuméObjectifL’embolie gazeuse est un état pathologique rare, mais bien documentée, survenant pendant l’hystéroscopie peropératoire selon une incidence de 10– 50%. Des conséquences catastrophiques surviennent dans trois interventions sur 17 000. Nous avons voulu présenter un cas d’embolie gazeuse non mortelle causée probablement par des produits de combustion gazeux.Éléments cliniquesUne femme de 50 ans présentant des antécédents de ménorragie devait subir une hystéroscopie et l’ablation de l’endomètre ainsi qu’une polypectomie. Quinze minutes après le début de l’opération, la patiente en position de lithotomie, avec inclinaison de 20° et tête vers le bas, respirait spontanément quand est survenue une soudaine désaturation en oxygène qui est passé de 97% à 87%. Le gaz carbonique télé-expiratoire du patient a chuté de 46 mmHg à 27 mmHg. Le type de respiration est demeuré normal, le rythme respiratoire était de 11–12 respirations·min−1, mais l’amplitude du mouvement du sac-réservoir a augmenté. Les variables cardiovasculaires étaient stables. La patiente a réagi rapidement à l’administration de 100% d’oxygène et s’est bien rétablie. Après avoir exclu d’autres causes possibles, nous avons conclu qu’une embolie gazeuse avait causé la chute de saturation en oxygène et le CO2 télé-expiratoire.ConclusionConsidérant toutes les précautions mises en place pour minimiser la probabilité d’une surcharge liquide et d’une embolie à l’air ambiant, nous avons supposé que les produits de combustion étaient la cause de l’embolie gazeuse. Pendant l’ablation de l’endomètre, des produits de combustion gazeux, surtout du gaz carbonique, s’accumulent. Les gaz peuvent ainsi contribuer à l’élévation de la pression utérine qui survient au moment où le liquide d’irrigation pénètre dans l’utérus. Cette hausse de pression favorise le passage de gaz dans les sinus veineux.

The effect of combined use of naloxone and tramacet on postoperative analgesia in elderly patients undergoing joint replacement surgery: a prospective feasibility study

Ultrasound-guided axillary brachial plexus block: single versus triple injection. Introduction: Axillary brachial plexus block is a common anesthetic technique for distal upper extremity surgery. A recent meta-analysis has shown that multiple injections are more effective than single injection. (1) Ultrasound guidance has become popular for performance of brachial plexus blocks and is associated with excellent anesthesia (2). In this prospective, randomized, double blind clinical trial we compared the effects of a single injection versus triple injection on the onset time and quality of sensory and motor block using ultrasound in patients having axillary block for surgery. Methods: Following Research Ethics Board approval and written informed consent,88 adult patients undergoing upper limb surgery were randomized to one of two groups: group A received 30mls of local anesthetic posterior to the artery, at the 6 o’clock position and group B received 10mls of local anesthetic, at the 11 o’clock, 4 o’clock and 6 o’clock positions corresponding to the locations of the median, ulna and radial nerves respectively.All blocks were done using 0.5% ropivacaine with epinephrine 1:400,000. In all patients, the musculocutaneous nerve was blocked separately with 10mls of local anesthetic . Total procedure time and time to complete motor and sensory block was noted by a blind observer. Patients with incomplete blocks at 30 minutes were supplemented and this was noted. Results: Demographics were similar between groups. (Table 1). The time to perform the block was 3 minutes faster in group A (p = 0.015, t-test). There was no difference in the time to ready for surgery (40.0 min in group A vs. 44.2 min in group B). Both techniques were associated with high success rates (88.1% in group A vs. 89.1% in group B). Data were analysed with SAS 9.1 software. Conclusion: In summary, when using ultrasound guidance for axillary brachial plexus block, single injection posterior to the artery (at the 6 o’clock position) is performed faster than triple injection with no difference in subsequent sensory and motor block quality.