Thomas J. Caruso

Treatment of the Common Cold with Echinacea: A Structured Review

BACKGROUND Echinacea is a herbal preparation that is frequently used to treat the common cold. Spending on echinacea in the United States has risen to >300 million dollars annually. METHODS A total of 322 articles related to echinacea and colds, including 9 placebo-controlled clinical trials, were identified using the Medline and PubMed databases. Eleven features of experimental design that affect the accuracy of the measurement of features of interest, the probability of a chance relationship, bias, and blinding were used to evaluate the 9 placebo-controlled studies. The criteria were validated case definition, quantifiable hypothesis, sample-size calculation, randomized assignment, double blinding, proof of blinding, measurement of compliance, measurement of drop-out rate, analysis by intention to treat, description of the methods of analysis, and measurement of probability. Equal weight was given to each criterion, since failure to meet any one of them could potentially invalidate the findings of a clinical trial. RESULTS Of the 9 studies, 2 met all 11 criteria. The results of both studies were judged to be negative by the people who performed the studies. Of the remaining 7 studies, 6 were judged to have positive results, and 1 was judged to have negative results. The criterion most commonly not met was proof of blinding. CONCLUSIONS This structured review suggests that the possible therapeutic effectiveness of echinacea in the treatment of colds has not been established.

Treatment of Naturally Acquired Common Colds with Zinc: A Structured Review

BACKGROUND Over the past 20 years, the use of zinc as an over-the-counter alternative therapy for the common cold has vastly grown in popularity. Recent reports of potentially permanent anosmia caused by intranasal zinc therapy warrant careful analysis of the therapeutic effects of zinc. METHODS A search of the Medline database (including articles published during 1966-2006) for studies of zinc and the common cold produced 105 published reports. Fourteen were randomized, placebo-controlled studies that examined the effect of zinc lozenges, nasal sprays, or nasal gels on naturally acquired common colds. Eleven features of experimental design affecting signal quality, chance, bias, and blinding were used to evaluate the 14 placebo-controlled studies. These criteria were validated case definition, quantifiable hypothesis, sample size calculation, randomized assignment, double blinding, proof of blinding, measurement of compliance, measurement of dropout rate, analysis by intent to treat, description of methods of analysis, and measurements of probability. Equal weight was given to each criterion, because failure to meet any one could potentially invalidate the findings of a clinical trial. RESULTS Four studies met all 11 criteria. Three of these studies reported no therapeutic effect from zinc lozenge or nasal spray. One study reported positive results from zinc nasal gel. Of the remaining 10 studies, 6 reported a positive effect and 4 reported no effect. Intent-to-treat analysis was the most common criterion not met. CONCLUSIONS This structured review suggests that the therapeutic effectiveness of zinc lozenges has yet to be established. One well-designed study did report a positive effect of zinc nasal gel.

Complementary and Alternative Medicine for Pain: An Evidence-based Review

Pain is one of the most prevalent conditions for which patients seek medical attention. Additionally, the number of patients who utilize complementary and alternative medicine as a treatment of pain either in lieu of, or concurrent with, standard conventional treatments continues to grow. While research into the mechanisms, side effect profiles, and efficacies of these alternative therapies has increased in recent years, much more remains unknown and untested. Herein, we review the literature on complementary and alternative medicine for pain, with particular emphasis on evidence-based assessments pertinent to the most common alternative therapies, including acupuncture, herbal therapy, massage therapy, hypnosis, tai chi, and biofeedback.

Airway management of recovered pediatric patients with severe head and neck burns: a review.

There are approximately 10 000 pediatric burn survivors in the United States each year, many of whom will present for reconstructive surgery after severe burns in the head and neck ( 1 ). These recovered burn victims, who are beyond the acute phase of injury, often have significant scarring and contractures in the face, mouth, nares, neck, and chest, which can make airway management challenging and potentially lead to a ‘cannot intubate, cannot ventilate’ scenario ( 2 ). Although numerous cases have been presented in the literature on this topic ( 3–17 ), there are no comprehensive review articles on the unique challenges of airway management in the recovered pediatric burn patient with distorted airway anatomy. This article aims to provide a comprehensive review of airway management in such patients, focusing on challenges encountered during mask ventilation and tracheal intubation, as well as the role of surgical release of neck contractures to facilitate tracheal intubation. Lessons learned from all reported cases identified in a thorough literature search are incorporated into this review.

Standardized ICU to OR handoff increases communication without delaying surgery

Purpose No studies have examined preoperative handoffs from the intensive care unit (ICU) to OR. Given the risk of patient harm, the authors developed a standardized ICU to OR handoff using a previously published handoff model. The purpose of this paper is to determine whether a standardized ICU to OR handoff process would increase the number of team handoffs and improve patient transport readiness. Design/methodology/approach The intervention consisted of designing a multidisciplinary, face-to-face handoff between sending ICU providers and receiving anesthesiologist and OR nurse, verbally presented in the I-PASS format. Anticipatory calls from the OR nurse to the ICU nurse were made to prepare the patient for transport. Data collected included frequency of handoff, patient transport readiness, turnover time between OR cases, and anesthesia provider satisfaction. Findings In total, 57 audits were completed. The frequency of handoffs increased from 25 to 86 percent ( p<0.0001) and the frequency of patient readiness increased from 61 to 97 percent ( p=0.001). There were no changes in timeliness of first start cases and no significant change in turnover times between cases. Anesthesia provider satisfaction scores increased significantly. Practical implications A standardized, team based ICU to OR handoff increased the frequency of face-to-face handoffs, patient readiness and anesthesia provider satisfaction within increasing turnover between cases. Originality/value Although studies have identified the transition of patients from the ICU to the OR as a period of increased harm, the development of a preoperative ICU to OR handoff had not been described. This intervention may be used in other institutions to design ICU to OR transitions of care.

Implementation of a Standardized Postanesthesia Care Handoff Increases Information Transfer Without Increasing Handoff Duration

BACKGROUND In the transition of a patient from the operating room (OR) to the postanesthesia care unit (PACU), it was hypothesized that (1) standardizing the members of sending and receiving teams and (2) requiring a structured handoff process would increase the overall amount of patient information transferred in the OR-to-PACU handoff process. METHODS A prospective cohort study was conducted at a 311-bed freestanding academic pediatric hospital in Northern California. The intervention, which was conducted in February-March 2013, consisted of (1) requiring the sending team to include a surgeon, an anesthesiologist, and a circulating nurse, and the receiving team to include the PACU nurse; (2) standardizing the content of the handoff on the basis of literature-guided recommendations; and (3) presenting the handoff verbally in the I-PASS format. Data included amount of patient information transferred, duration of handoff, provider presence, and nurse satisfaction. RESULTS Forty-one audits during the preimplementation phase and 45 audits during the postimplementation phase were analyzed. Overall information transfer scores increased significantly from a mean score of 49% to 83% (p < .0001). Twenty-two PACU nurse satisfaction surveys were completed after the preimplementation phase and 14 surveys were completed in the postimplementation phase. Paired mean total satisfaction scores increased from 36 to 44 (p =. 004). The duration of the handoffs trended downward from 4.1 min to 3.5 min (p = 0.10). CONCLUSION A standardized, team-based approach to OR-to-PACU handoffs increased the quantity of patient information transferred, increased PACU nurse satisfaction, and did not increase the handoff duration.

Cervical erector spinae plane block catheter using a thoracic approach: an alternative to brachial plexus blockade for forequarter amputation

To the Editor, We read with interest the recent report outlining the utilization of an erector spinae plane block (ESPB) for chronic shoulder pain. The reporting of clinical outcomes and the identification of contrast spread to the cervical spine nerve roots with an ESPB inspired us to use one in managing a patient who required analgesia of the brachial plexus and anterior thoracic distribution. An 81-yr-old female (consenting to this report) with congestive heart failure and a history of breast cancer presented with a painful recurrent radiation-induced sarcoma of the left proximal humerus. The patient initially decided to forego further treatment because of anticipated debilitating pain and instead to seek an end-oflife care. After discussion with the surgical team, the patient elected to undergo forequarter amputation intended to optimize palliative pain control, but also had a reasonable possibility for a cure. In the preoperative area, we placed a left ultrasound-guided ESPB catheter (Flexblock, Arrow, Teleflex , Morrisville, NC, USA) using an in-plane approach at the T5 transverse process. After saline hydrodissection of the fascial plane deep to the erector spinae muscle, the catheter was threaded 10 cm past the cephalad-oriented needle tip into the space. We injected 10 mL 0.5% ropivacaine through the catheter with complete relief of her shoulder pain 30 min prior to the induction of general anesthesia. Her complex five-hour surgery included removal of the left arm, scapula and clavicle. During the procedure, the catheter tip could be palpated by the surgeon at approximately the C5 and C6 level. Intraoperatively, the patient received ketamine 20 mg, methadone 5 mg, and fentanyl 250 lg. At the end of surgery, the patient was extubated and transferred to the intensive care unit. She reported a pain score of 0 and the ESPB catheter was started with a continuous ropivacaine infusion 0.2% at 5 mL hr with a 5-mL demand every 30 min. On postoperative day (POD) 1, she was in good spirits and tolerated a full diet without any pain. She was transferred later that day to an acute care bed, started on oral oxycodone 5 mg (only as needed), and continued her ESPB catheter infusion. In the first 48 hr, the patient only received bolused ESPB local anesthetic for breakthrough pain and did not require any oxycodone. On POD 3, the infusion was then switched to an automatic 5 mL bolus every hour with a further 5 mL demand bolus every 30 min for breakthrough pain as well as a regularly scheduled oxycodone 5 mg dose every eight hours. On POD 4, the ESPB catheter was removed and the patient’s pain remained well controlled with oxycodone. The patient was discharged on POD 5. During a follow-up visit a month later, she stated that she has been feeling ‘‘optimistic’’ and had well-controlled pain using only acetaminophen and gabapentin. She has had no evidence of local recurrence or metastasis. This novel description of a cervical ESPB catheter being advanced into a cervical location from the thoracic region supports the utilization of ESPB as an alternative to the brachial plexus catheter for complex upper extremity procedures. This case also illustrates the impact of a regional analgesia-based regimen as an important B. C. H. Tsui, MD, MSc (&) T. J. Caruso, MD J. L. Horn, MD Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, CA, USA e-mail: bantsui@stanford.edu

A quality improvement initiative to optimize dosing of surgical antimicrobial prophylaxis

The risk of surgical site infections is reduced with appropriate timing and dosing of preoperative antimicrobials. Based on evolving national guidelines, we increased the preoperative dose of cefazolin from 25 to 30 mg·kg−1. This quality improvement project describes an improvement initiative to develop standard work processes to ensure appropriate dosing.

Bedside Entertainment and Relaxation Theater: size and novelty does matter when using video distraction for perioperative pediatric anxiety

1 Tait AR, Malviya S. Anesthesia for the child with an upper respiratory tract infection: still a dilemma? Anesth Analg 2005; 100: 59– 65. 2 Miller GG. Waiting for an operation: parents’ perspectives. Can J Surg 2004; 47: 179–181. 3 Tait AR, Voepel-Lewis T, Munro HM et al. Cancellation of pediatric outpatient surgery: economic and emotional implications for patients and their families. J Clin Anesth 1997; 9: 213–219. 4 Gould E. Millions of Working People Don’t Get Paid Time Off for Holidays or Vacation. Economic Policy Institute, 2015. Available at: http://www.epi.org/publication/millions-ofworking-people-dont-get-paid-time-off-forholidays-or-vacation/. Accessed 23 February, 2017.

Interactive video game built for mask induction in pediatric patients

To the Editor, Induction of anesthesia is a stressful event for many pediatric patients. Preoperative distress has been correlated with postoperative agitation, negative behaviors, and increased postoperative pain. We recently introduced the ‘‘Sevo the Dragon’’ video game as a non-pharmacologic audiovisual intervention technique to reduce anxiety during induction. Consent to describe the case utilizing this technique was obtained from the patient’s mother. A six-year-old girl with a history of renal failure secondary to renal osteodystrophy and kidney transplant presented for a transplanted kidney biopsy. The patient had required physical restraint during a prior inhalational induction. On presentation for the biopsy, she appeared anxious, clutching her mother and communicating only through her. We discussed various anxiolytic options with the patient and her mother, including oral medications, video tablets, video projection through the Bedside Entertainment and Relaxation Theatre (BERT), and an interactive video game built on the BERT platform. The patient elected to try the interactive video game titled ‘‘Sevo the Dragon’’. In the holding area, we set up a plastic screen (24 9 36 inches) at the foot of the child’s bed and displayed the game from a projector (Spro2, ZTE, USA) mounted on the bed’s head rail. The patient selected a character from the three dragon options – red, blue, green, each with a different hat. She then chose from three food choices for the dragon to cook by breathing fire – birthday cake, tacos, pizza. The perioperative team controlled these choices through the mounted touchscreen projector. The game began in the preoperative area and then traveled with the patient to the operating room without interruption. The patient’s mother helped hold the anesthesia mask to the patient’s face facilitating anesthesia induction (Figure). The patient was engaged by the anesthesiologist who prompted her to breathe deeply to trigger the dragon to breathe fire. After the biopsy, the patient, parents, and medical staff reported high satisfaction with the compliant induction in contrast to her previously stormy experience. This case illustrates successful application of an interactive video game on the BERT platform. Although audiovisual distraction for inhalational induction in pediatric cases has been described, most interactive video game systems are televisionor tablet-based, with which children are generally familiar. In contrast, the use of BERT’s large theatrical screen is supported by studies that detailed an association between the large size of the images and patients’ emotional engagement with them. Other studies have shown the importance of novel vs familiar stimuli in capturing a patient’s attention. In our case, both mother and patient were completely engrossed throughout the process. The mother later thanked the team, saying that the induction was ‘‘so cool.’’ The other unique feature of the game is that it not only distracts the child, it promotes cooperation with mask induction by encouraging deep breathing. By normalizing the breathing experience at induction via incorporating it into the game play, the patient displays a greater willingness to participate in the inhalational induction. A similar concept, the ‘‘ blow up the balloon’’ method, has been employed for many years. The major drawbacks of the ‘‘balloon’’ technique are that it is difficult to keep the S. Rodriguez, MD J. H. Tsui (&) S. Y. Jiang, BA T. J. Caruso, MD Department of Anesthesiology, Perioperative, and Pain Medicine, Lucile Packard Children’s Hospital Stanford, Stanford University School of Medicine, Palo Alto, CA, USA e-mail: jeremy.tsui@yahoo.com