Steven H. Rose

Epidemiologic features of humeral fractures.

Five hundred sixty-four Rochester, Minnesota, residents had a total of 586 humeral fractures during the period from 1965 to 1974. Of these, 47% involved the proximal humerus, and 20% the humeral shaft, and 33% the distal humerus. The incidence of humeral fractures associated with severe trauma was relatively higher among children and young adults, and distal humeral fractures predominated. Among the elderly, however, proximal humeral fractures associated with moderate trauma were most common and were responsible for the excess humeral fracture incidence rates among women and the dramatic increase in rates with age for both sexes. Rochester incidence rates for all three humeral fracture sites were substantially greater than those previously reported from the United Kingdom, although the proximal humeral fracture incidence was very similar to that in Malmo, Sweden. The Rochester rates appear to be the best available for use in determining the costs and benefits of efforts to prevent these and other aging or osteoporosis-related fractures in the United States.

Preoperative antiplatelet therapy does not increase the risk of spinal hematoma associated with regional anesthesia

One thousand orthopedic procedures in 924 patients given spinal or epidural anesthesia were prospectively studied to determine the risk of hemorrhagic complications associated with regional anesthesia.A history of excessive bruising or bleeding was elicited in 115 (12%) patients. Preoperative antiplatelet medications were taken by 386 (39%) patients. Aspirin was the most frequently reported antiplatelet drug and was taken by 193 patients. Subcutaneous heparin was administered to 22 patients before surgery on the operative day. One patient of 774 tested had a preoperative platelet count less than 100,000/mm.3 In addition, 26 of 171 preoperative prothrombin times and 10 of 115 preoperative activated partial thromboplastin times were longer than normal. Only 31 preoperative bleeding times were performed; five were prolonged. There were no documented spinal hematomas (major hemorrhagic complications). Blood was noted during needle or catheter placement (minor hemorrhagic complication) in 223 (22%) patients, including 73 patients with frank blood in the needle or catheter. Preoperative antiplatelet therapy did not increase the incidence of minor hemorrhagic complications. However, female gender, increased age, a history of excessive bruising/bleeding, surgery to the hip, continuous catheter anesthetic technique, large needle gauge, multiple needle passes, and moderate or difficult needle placement were all significant risk factors. The lack of correlation between antiplatelet medications and bloody needle or catheter placement (producing clinically insignificant collections of blood in the spinal canal or epidural space) is strong evidence that preoperative antiplatelet therapy is not a significant risk factor for the development of neurologic dysfunction from spinal hematoma in patients who undergo spinal or epidural anesthesia while receiving these medications. (Anesth Analg 1995;80:303-9)

A systems approach for implementing practice-based learning and improvement and systems-based practice in graduate medical education

The Accreditation Council for Graduate Medical Education (ACGME) initiated its Outcome Project to better prepare physicians-in-training to practice in the rapidly changing medical environment and mandated assessment of competency in six outcomes, including Practice-Based Learning and Improvement (PBLI) and Systems-Based Practice (SBP). Before the initiation of the Outcome Project, these competencies were not an explicit element of most graduate medical education training programs. Since 1999, directors of ACGME-accredited programs nationwide have been challenged to teach and assess these competencies. The authors describe an institution-wide curriculum intended to facilitate the teaching and assessment of PBLI and SBP competencies in the 115 ACGME-accredited residency and fellowship programs (serving 1,327 trainees) sponsored by Mayo School of Graduate Medical Education. Strategies to establish the curriculum in 2005 included development of a Quality Improvement (QI) curriculum Web site, one-on-one consultations with program directors, a three-hour program director workshop, and didactic sessions for residents and fellows on core topics. An interim program director self-assessment survey revealed a 13% increase in perceived ability to measure competency in SBP, no change in their perceived ability to measure competence in PBLI, a 15% increase in their ability to provide written documentation of competence in PBLI, and a 35% increase in their ability to provide written documentation of competence in SBP between 2005 and 2007. Nearly 70% of the programs had trainees participating in QI projects. Further research is needed to evaluate the cost-effectiveness of such a program and to measure its impact on learner knowledge, skills, and attitudes and, ultimately, on patient outcomes.

Airway management after failure to intubate by direct laryngoscopy: outcomes in a large teaching hospital

PurposeThe purpose of this single-centre database review was to establish the incidence of failure to intubate by direct laryngoscopy, to measure morbidity and mortality associated with this event, and to examine the use and efficacy of alternative airway devices.MethodsDifficult intubation via direct laryngoscopy at Mayo Clinic Rochester is recorded in an electronic database using a functional classification: 0 = no difficulty; 1 = mild to moderate difficulty; and 2 = severe difficulty often requiring a change in intubation technique. Using this database, the total number of intubations was determined for a selected review period and the incidence of failure to intubate by direct laryngoscopy was established. Abstraction of chart data allowed for determination of associated morbidity and mortality, success of alternative airway devices, and case cancellation rate.ResultsDuring the period from August 1, 2001 through December 31, 2002, 37,482 patients underwent general anesthesia with attempted direct laryngoscopy. One hundred sixty-one patients (0.43%) could not be intubated by direct laryngoscopy alone. Morbidity associated with difficult intubation included soft tissue/ dental damage (n = 8), intraoperative cardiac arrest (n = 1), and possible aspiration (n = 1). Three patients required intensive care unit admission. There was no associated mortality. The most commonly used alternative airway device was the flexible fibreoptic scope. Five case cancellations resulted from failure to intubate with alternative devices.ConclusionThe rate of unexpected failure to intubate by direct laryngoscopy is essentially unchanged from earlier studies. While morbidity was low, continued education and early use of alternative difficult airway devices may further limit complications associated with this event.RésuméObjectifÉtablir, par une revue de la base de données d’un seul centre, la fréquence des échecs à intuber par laryngoscopie directe, mesurer la morbidité et la mortalité associées et vérifier l’usage et l’efficacité d’autres instruments d’intubation.MéthodeLes cas d’intubation difficile par laryngoscopie directe à la clinique Mayo de Rochester ont été notés dans une base de données électronique selon une classification fonctionnelle : 0 = aucune difficulté 1 = difficulté légère à modérée et 2 = difficulté sévère exigeant souvent le recours à d’autres techniques d’intubation. Le nombre total d’intubations a été déterminé pour une période de révision choisie et la fréquence des échecs à intuber par laryngoscopie directe a été établie. Un résumé analytique des données a permis de déterminer la morbidité et la mortalité associées, le succès des autres techniques et le taux d’annulation.RésultatsDu premier août 2001 au 31 décembre 2002, 37 482 patients ont eu une anesthésie générale et subi une laryngoscopie directe. Cent soixante et un patients (0,43 %) n’ont pu être intubés par laryngoscopie directe seulement. La morbidité associée à l’intubation difficile comprenait une lésion des tissus mous/des dents (n = 8), un arrêt cardiaque peropératoire (n = 1) et une aspiration possible (n = 1). Trois patients ont dû être admis à l’unité des soins intensifs. Il n’y a pas eu de mortalité associée. L’instrument de remplacement le plus souvent utilisé a été le fibroscope flexible. Cinq annulations ont résulté de l’échec à intuber avec d’autres instruments.ConclusionLe taux imprévu d’échec à intuber par laryngoscopie directe est essentiellement le même depuis les études antérieures. La morbidité est faible, mais une formation continue et un usage précoce d’autres instruments réduiraient davantage les complications qui y sont associées.

Prone position: visceral hypoperfusion and rhabdomyolysis.

T he prone position is often used for operations involving the spine (1) and posterior fossa (21, and for certain urologic and lower gastrointestinal procedures (3). This position provides excellent surgical access and, with proper positioning, a decrease in extradural vein and cerebrospinal fluid pressures (1). The main complications associated with the prone position include: ocular and auricular injuries, musculoskeletal injuries, venous air embolism, compression of limb neurovascular bundles, ischemia of the skin at pressure points, and excessive joint flexion and extension (2). Additional rare complications have also been reported (4-7). However, the overall complication rate is low (6,8). We report two cases with rare complications of the prone position.

A Patient Safety Curriculum for Graduate Medical Education: Results From a Needs Assessment of Educators and Patient Safety Experts

Graduate medical education (GME) has traditionally focused on the diagnosis and management of disease with little attention devoted to patient safety and systems thinking. In this article, we describe the results of a needs assessment conducted to develop a patient safety curriculum for GME. Eight program directors, 10 patient safety experts, and 9 experts in education technology were interviewed for this project. A total of 21 patient safety topics were identified in the categories of cultural, cognitive, and technical content and included communications and handoffs, sentinel event reporting and management, calling for help when in doubt, hand hygiene, universal protocol, fatigue, and the culture of safety and transparency. Objective structured clinical examinations and experiential learning (including simulation) were viewed as the most effective methods for teaching and assessing competence in patient safety. The results of this study provide a framework for the development of patient safety curricula in GME.

A historical perspective on use of the laryngoscope as a tool in anesthesiology

EACH year, one of the first skills anesthesia residents must master is direct visualization of the vocal cords to safely and successfully intubate the trachea of surgical patients. Debates have raged in teaching centers about the superiority of one laryngoscope over another or the merits of a straight versus a curved blade. However, this yearly debate is a phenomenon of the twentieth century, as anesthesiologists sought better tools to facilitate patient care. Physician interest in visualizing the vocal cords can be traced to at least the mid-1700s. However, controversy remains as to who deserves historical credit for the development of the laryngoscope. An appreciation of the contributions of several innovative scientists involved with the development of the laryngoscope over more than 250 yr may be of greater importance. Although the laryngoscope was initially a tool developed solely for the otolaryngologist, advances in anesthesia during the early 20th century made the addition of the laryngoscope and development of the skills to use it successfully essential to the anesthesiologist. The introduction of the laryngoscope into the practice of clinical anesthesia is best described by considering these advances in the “surgeon” and “anesthesiologist” periods.

Sacral tumor resection: the effect of surgical staging on patient outcomes, resource management, and hospital cost.

Study Design. Single-institution retrospective study. Objective. To assess the effect surgical staging (i.e., sequencing) has on clinical and economic outcomes for patients undergoing sacropelvic tumor resection requiring lumbopelvic stabilization. Summary of Background Data. Sacral corpectomy with lumbopelvic stabilization is an extensive surgical procedure that can be performed in either a single episode or multiple episodes of care on different days. The impact of varied sequencing of surgical episodes of care on patient, resource, and financial outcomes is unknown. Methods. This single-center retrospective case series identified all cases of sacropelvic tumor resection requiring lumbopelvic stabilization over an 8-year period. We assessed and compared clinical and economic outcomes for patients whose anterior exposure and posterior resection were separated into two distinct surgical episodes of care (staged) versus patients whose anterior exposure and posterior resection occurred in a single encounter (nonstaged procedures). Primary endpoints included procedural outcomes (operative and after-hours surgical time), resuscitative requirements, adverse perioperative events, mortality, and direct medical costs (hospital and physician) associated with the surgical episodes of interest. Results. From January 1, 2000, to July 15, 2008, a total of 25 patients were identified. Eight patients had their procedure staged. Surgical staging was associated with a significant increase in intensive care unit free days (P = 0.03), ventilator free days (P < 0.01), and reduced morbidity (P < 0.01). Surgical staging significantly reduced postoperative red blood cell (P = 0.03), and after-hours red blood cell (P < 0.01) and component requirements (P = 0.04). Mean total inpatient costs were

Publication misrepresentation among anesthesiology residency applicants.

89,132 lower for patients undergoing the staged procedure (95% confidence interval of mean cost difference = −

Doxacurium chloride for neuromuscular blockade before tracheal intubation and surgery during nitrous oxide-oxygen-narcotic enflurane anesthesia

178,899 to −