Raymond Borkowski

Operating room fires: optimizing safety.

Background: This prospective study was undertaken to determine the safest means of supplemental oxygen delivery for patients undergoing facial cosmetic surgery under conscious sedation. Two common methods of oxygen delivery were used in 20 patients: (1) a nasal cannula and (2) a red rubber nasopharyngeal tube through which the cut ends of the nasal cannula were passed into the posterior pharynx. Methods: The project was carried out in two parts. In part one, each subject was placed supine and oxygen supplementation at 3 liters/minute was applied through the nasal cannula. The oxygen concentration at 24 different set locations around the patient’s face was analyzed using the random access mass spectrometer unit, starting at the right and left alar rim and then at 2-cm intervals laterally, superiorly, and inferiorly. The procedure in part one was repeated with oxygen being delivered by passing the cut cannula end through a red rubber nasopharyngeal tube into the posterior pharynx. Results: Statistical analysis has showed that in all sites at or above the nasal area, the difference between the nasal cannula and red rubber nasopharyngeal tube is significantly greater than 0, indicating that higher concentrations are observed with the nasal cannula than with the red rubber nasopharyngeal tube (p = 0.004). Conclusion: The authors’ study demonstrates a significant reduction in oxygen concentration, to levels consistent with ambient air, even at points extremely close to the oxygen source, when the nasopharyngeal tube system was used.

Does general anesthesia increase the diagnostic yield of endoscopic ultrasound-guided fine needle aspiration of pancreatic masses?

Background:Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of the pancreas has become the preferred method for tissue diagnosis for pancreatic solid masses. The yield of EUS-FNA in this setting is influenced by multiple factors. We hypothesized that general anesthesia (GA) may improve EUS-FNA yield by improving patient cooperation and stillness during the procedure. Our objective was to assess the association between the sedation method employed and the diagnostic yield of EUS-FNA. Methods:A retrospective cohort study was conducted involving consecutive patients who received EUS-FNA for diagnosis of a solid pancreatic mass at the Cleveland Clinic (Cleveland, OH) gastrointestinal endoscopy units from 2007 to 2009. We compared the diagnostic yield of EUS-FNA between patients receiving GA provided by an anesthesiologist (GA group) and patients receiving conscious sedation (CS) provided by a qualified registered nurse (CS group). Results:Of 371 patients, a cytological diagnosis was obtained in 73/88 patients (83%) in the GA group and 206/283 patients (73%) in the CS group. Anesthesiologist-delivered GA was associated with an increased odds of having a successful diagnosis as compared with CS (adjusted odds ratio [95% CI]: 2.56 [1.27–5.17], P = 0.01). However, the incidence of complication during or after the procedure was not different between the groups (P > 0.99). Conclusions:Anesthesiologist-delivered GA was associated with a significantly higher diagnostic yield of EUS-FNA. GA should be considered a preferred sedation method for EUS-FNA of a solid pancreatic mass.

Prevention of postoperative surgical site infections.

Before Joseph Lister introduced the principles of antisepsis in the late 1860s, postoperative wound infections were a major cause of sepsis and death. However, despite antiseptic techniques, surgical site infections (SSI) remain problematic. Currently SSIs are the third most frequently reported nosocomial infection and account for 14% to 16% of those documented in hospitalized patients. Among surgical patients, SSIs are the most common nosocomial infection, with 77% of patient deaths reported to be related to the infection. Also, the frequency of SSIs can be correlated with the type of surgery performed. In patients undergoing clean extra-abdominal operations, the occurrence of a SSI is 2% to 5%. However, this frequency is increased up to 20% in patients undergoing intra-abdominal procedures. Complications related to SSIs have been associated with increased patient readmission rates, length of hospital stay (LOHS), overall costs, and mortality. Importantly, patients with SSI are twice as likely to die as patients having the same procedure who so not develop a SSI. In addition, patients with SSIs have been shown to spend 60% more time in the intensive care unit (ICU) and are 5 times more likely to be readmitted to the hospital after initial discharge. SSIs have been shown

On-line resources for the Pain Medicine physician.

BACKGROUND AND OBJECTIVES The Internet is increasingly an important resource for both the Pain Medicine physician and the patient. Considerable high-quality information exists within numerous government, university, professional association, and private sites. Large documents, such as patient care guidelines, can be readily retrieved on-line. Search capabilities within websites improve the efficiency of information retrieval. Clinicians may communicate about complex patient management issues via a list-serve, which delivers entire discussions to their E-mail accounts. These multiple resources offer an enriched environment for patient care, education, and research in pain management.

Office-Based Anesthesia for the Urologist

This article describes office-based surgery and office-based anesthesia (OBA), including the safe setup of OBA and safety concerns regarding OBA. Also discussed are the preoperative selection and workup of a patient undergoing OBA, anesthetic options, the prevention and treatment of postoperative nausea, vomiting, and pain, and planning for safe discharge.

Difficulties in anesthetizing a 106-yr-old patient for total hip replacement

To the Editor: We present details of the difficult anesthetic management of a 106-yr-old patient scheduled for hip replacement surgery. A 106-yr-old, 54 kg female with severe osteoarthritis of the right hip was scheduled to undergo total hip replacement. Multiple attempts to achieve dural puncture for spinal anesthesia were unsuccessful due to severe vertebral column deformity. General anesthesia was induced with etomidate 6 mg, fentanyl 50 µg, and tracheal intubation was facilitated with 100 mg of succinylcholine. The patient was returned to the supine position at the conclusion of the surgery. After positioning, the oxygen saturation dropped to 90%. The desaturation persisted despite 100% oxygen. Lung auscultation revealed no breathing sounds on the left. The endotracheal tube (ETT) was noted to be taped in the same position as after induction, but because the patient was edentulous with loose soft tissue around the mouth, the ETT with the lips had entered the oral cavity, resulting in a right main stem intubation. The ETT was pulled back and the oxygen saturation returned to normal. The patient was extubated and was transported to the postanesthesia care unit, discharged to the regular nursing floor on postoperative day (POD) three and to the rehabilitation centre on POD four. This patient presented numerous technical difficul