Torin Shear

Postoperative residual neuromuscular blockade is associated with impaired clinical recovery.

BACKGROUND:In this investigation, we sought to determine the association between objective evidence of residual neuromuscular blockade (train-of-four [TOF] ratio <0.9) and the type, incidence, and severity of subjective symptoms of muscle weakness in the postanesthesia care unit (PACU). METHODS:TOF ratios of 149 patients were quantified with acceleromyography on arrival to the PACU. Patients were stratified into 2 cohorts: a TOF <0.9 group (n = 48) or a TOF ≥0.9 (control) group (n = 101). A standardized examination determined the presence or absence of 16 symptoms and 11 signs of muscle weakness on arrival to the PACU and 20, 40, and 60 minutes after admission. RESULTS:The incidence of symptoms of muscle weakness was significantly higher in the TOF <0.9 group at all times (P < 0.001), as was the median (range) number of symptoms from PACU arrival (7 [3–6] TOF <0.9 group vs 2 [0–11] control group; difference 5, 99% confidence interval of the difference 4–6) until 60 minutes after admission (2 [0–12] TOF <0.9 group vs 0 [0–11] control group; difference 2, 99% confidence interval of the difference 1–2) (all P < 0.0001). CONCLUSION:The incidence and severity of symptoms of muscle weakness were increased in the PACU in patients with a TOF <0.9.

Residual Neuromuscular Block in the Elderly: Incidence and Clinical Implications.

Background:Elderly patients are at increased risk for anesthesia-related complications. Postoperative residual neuromuscular block (PRNB) in the elderly, defined as a train-of-four ratio less than 0.9, may exacerbate preexisting muscle weakness and respiratory dysfunction. In this investigation, the incidence of PRNB and associated adverse events were assessed in an elderly (70 to 90 yr) and younger cohort (18 to 50 yr). Methods:Data were prospectively collected on 150 younger and 150 elderly patients. Train-of-four ratios were measured on arrival to the postanesthesia care unit (PACU). After tracheal extubation, patients were examined for adverse respiratory events during transport to the PACU, for 30 min after PACU admission, and during hospital admission. Postoperative muscle weakness was quantified using a standardized examination, and PACU and hospital lengths of stay were determined. Results:The incidence of PRNB was 57.7% in elderly and 30.0% in younger patients (difference, −27.7%; 99% CI, −41.2 to −13.1%; P < 0.001). Airway obstruction, hypoxemic events, signs and symptoms of muscle weakness, postoperative pulmonary complications, and increased PACU and hospital lengths of stay were observed more frequently in the elderly (all P < 0.01). Within each cohort, most adverse events were observed in patients with PRNB. Younger patients with PRNB received larger total doses of rocuronium than did those without it (60 vs. 50 mg, P < 0.01), but there were no differences in rocuronium dose between elderly patients with PRNB and those without it (both 50 mg). Conclusion:The elderly are at increased risk for PRNB and associated adverse outcomes.

The effect of single low-dose dexamethasone on blood glucose concentrations in the perioperative period: a randomized, placebo-controlled investigation in gynecologic surgical patients.

BACKGROUND:The effect of single low-dose dexamethasone therapy on perioperative blood glucose concentrations has not been well characterized. In this investigation, we examined the effect of 2 commonly used doses of dexamethasone (4 and 8 mg at induction of anesthesia) on blood glucose concentrations during the first 24 hours after administration. METHODS:Two hundred women patients were randomized to 1 of 6 groups: Early-control (saline); Early-4 mg (4 mg dexamethasone); Early-8 mg (8 mg dexamethasone); Late-control (saline); Late-4 mg (4 mg dexamethasone); and Late-8 mg (8 mg dexamethasone). Blood glucose concentrations were measured at baseline and 1, 2, 3, and 4 hours after administration in the early groups and at baseline and 8 and 24 hours after administration in the late groups. The incidence of hyperglycemic events (the number of patients with at least 1 blood glucose concentration >180 mg/dL) was determined. RESULTS:Blood glucose concentrations increased significantly over time in all control and dexamethasone groups (from median baselines of 94 to 102 mg/dL to maximum medians ranging from 141 to 161.5 mg/dL, all P < 0.001). Blood glucose concentrations did not differ significantly between the groups receiving dexamethasone (either 4 or 8 mg) and those receiving saline at any measurement time. The incidence of hyperglycemic events did not differ in any of the early (21%–28%, P = 0.807) or late (13%–24%, P = 0.552) groups. CONCLUSIONS:Because blood glucose concentrations during the first 24 hours after administration of single low-dose dexamethasone did not differ from those observed after saline administrations, these results suggest clinicians need not avoid using dexamethasone for nausea and vomiting prophylaxis out of concerns related to hyperglycemia.

Extracranial contamination in the INVOS 5100C versus the FORE-SIGHT ELITE cerebral oximeter: a prospective observational crossover study in volunteers

PurposePrevious studies have found that most cerebral oximeters are subject to inaccuracies secondary to extracranial contamination of the cerebral oximetric signals. We hypothesized that the more advanced second-generation FORE-SIGHT ELITE cerebral oximeter would be significantly less affected by extracranial tissue hypoxemia than the more widely used first-generation INVOS™ 5100C monitor.MethodsTwenty healthy volunteers aged 18-45 yr had the INVOS and FORE-SIGHT probes placed on their forehead in a random sequence while in the supine position. A pneumatic head cuff was then placed around each volunteer’s head just below both the oximeter and a concomitantly placed scalp forehead pulse oximeter probe. The subjects’ scalp cerebral oxygen saturation (SctO2) values were measured and compared using the two different devices in sequence, both before and after scalp tissue ischemia was induced by the pneumatic cuff.ResultsExtracranial ischemia resulted in a significant reduction in SctO2 values from baseline in both devices. The INVOS 5100C recorded a median [interquartile range] decrease in SctO2 from baseline at five minutes of 15.1% [12.6 - 17.6], while that recorded by the FORESIGHT ELITE device was 8.6% [4.0 -12.3] at five minutes (median difference, 7.9%; 99% confidence interval, 1.9 to 16.5; P = 0.002).ConclusionUpdated technological algorithms employed in the FORE-SIGHT ELITE cerebral oximeter may be responsible for less extracranial contamination than was observed in the previous-generation INVOS 5100C device. The impact that this extracranial contamination may have on the clinical use of these devices remains to be determined.RésuméObjectifSelon les études réalisées par le passé, la plupart des oxymètres cérébraux sont sujets à des inexactitudes suite à une contamination extracrânienne des signaux d’oxymétrie cérébrale. Nous avons émis l’hypothèse que l’oxymètre cérébral FORE-SIGHT ELITE, l’oxymètre cérébral de deuxième génération le plus innovant à ce jour, serait significativement moins affecté par l’hypoxémie des tissus extracrâniens que le moniteur de première génération INVOS™ 5100C, plus répandu.MéthodeLes sondes des appareils INVOS et FORE-SIGHT ont été placées selon une séquence aléatoire sur le front de vingt volontaires sains âgés de 18 à 45 ans en position allongée sur le dos. On a ensuite placé un bandeau gonflable autour de la tête de chaque participant, juste au-dessous de l’oxymètre, et placé une sonde d’oxymètre de pouls simultanément sur le front. La saturation en oxygène cérébral sur le scalp (SctO2) des participants a été mesurée et comparée à l’aide des deux appareils en séquence, avant et après provocation d’une ischémie des tissus du scalp par le bandeau gonflable.RésultatsL’ischémie extracrânienne a entraîné une réduction significative des valeurs de SctO2 comparativement aux valeurs de base obtenues avec les deux appareils. L’oxymètre INVOS 5100C a enregistré une réduction moyenne [écart interquartile] de la SctO2 à cinq minutes de 15,1 % [12,6 – 17,6], alors que le FORE-SIGHT ELITE a enregistré une réduction de 8,6 % [4,0 −12,3] à cinq minutes comparativement aux valeurs de base (différence médiane, 7,9 %; intervalle de confiance 99 %, 1,9 à 16,5; P = 0,002).ConclusionLes algorithmes technologiques plus récents employés par l’oxymètre cérébral FORE-SIGHT ELITE pourraient expliquer la contamination extracrânienne moindre observée avec cet appareil comparativement à celle observée avec le dispositif de première génération évalué ici, l’INVOS 5100C. L’impact de cette contamination extracrânienne sur l’utilisation clinique de ces dispositifs doit encore être déterminé.

Does training with human patient simulation translate to improved patient safety and outcome

Purpose of review In this review, we evaluate several articles in an attempt to qualify the effect of human patient simulation in anaesthesia on patient outcome. The recognition of medical error as a significant cause of patient morbidity and mortality has sparked an increased focus on improving healthcare quality and patient safety. Simulation in anaesthesia is a potential tool to help achieve this goal by allowing anaesthesia providers to learn, practice and perfect their craft without a potential harm to patients. It has gained growing traction in the field and is recently a required element in the American Board of Anesthesiologys Maintenance of Certification in Anesthesia programme. Recent findings Very few studies have evaluated the effect of simulation on patient outcome. To date, one study has demonstrated improved individual clinical performance in anaesthesia after simulation training. Research suggests that simulation-based team training can reduce patient mortality and improve the quality of care as measured by surgical quality improvement measures. Simulation may improve healthcare systems by serving as a tool to detect latent error and drive process improvement. Summary Despite the adoption of simulation, further study is needed to better qualify its effect on patient safety and outcome.

Intraoperative Methadone for the Prevention of Postoperative Pain: A Randomized, Double-blinded Clinical Trial in Cardiac Surgical Patients.

Background: The intensity of pain after cardiac surgery is often underestimated, and inadequate pain control may be associated with poorer quality of recovery. The aim of this investigation was to examine the effect of intraoperative methadone on postoperative analgesic requirements, pain scores, patient satisfaction, and clinical recovery. Methods: Patients undergoing cardiac surgery with cardiopulmonary bypass (n = 156) were randomized to receive methadone (0.3 mg/kg) or fentanyl (12 &mgr;g/kg) intraoperatively. Postoperative analgesic requirements were recorded. Patients were assessed for pain at rest and with coughing 15 min and 2, 4, 8, 12, 24, 48, and 72 h after tracheal extubation. Patients were also evaluated for level of sedation, nausea, vomiting, itching, hypoventilation, and hypoxia at these times. Results: Postoperative morphine requirements during the first 24 h were reduced from a median of 10 mg in the fentanyl group to 6 mg in the methadone group (median difference [99% CI], −4 [−8 to −2] mg; P < 0.001). Reductions in pain scores with coughing were observed during the first 24 h after extubation; the level of pain with coughing at 12 h was reduced from a median of 6 in the fentanyl group to 4 in the methadone group (−2 [−3 to −1]; P < 0.001). Improvements in patient-perceived quality of pain management were described in the methadone group. The incidence of opioid-related adverse events was not increased in patients administered methadone. Conclusions: Intraoperative methadone administration resulted in reduced postoperative morphine requirements, improved pain scores, and enhanced patient-perceived quality of pain management.

Neostigmine Administration after Spontaneous Recovery to a Train-of-Four Ratio of 0.9 to 1.0: A Randomized Controlled Trial of the Effect on Neuromuscular and Clinical Recovery

Background: When a muscle relaxant is administered to facilitate intubation, the benefits of anticholinesterase reversal must be balanced with potential risks. The aim of this double-blinded, randomized noninferiority trial was to evaluate the effect of neostigmine administration on neuromuscular function when given to patients after spontaneous recovery to a train-of-four ratio of 0.9 or greater. Methods: A total of 120 patients presenting for surgery requiring intubation were given a small dose of rocuronium. At the conclusion of surgery, 90 patients achieving a train-of-four ratio of 0.9 or greater were randomized to receive either neostigmine 40 &mgr;g/kg or saline (control). Train-of-four ratios were measured from the time of reversal until postanesthesia care unit admission. Patients were monitored for postextubation adverse respiratory events and assessed for muscle strength. Results: Ninety patients achieved a train-of-four ratio of 0.9 or greater at the time of reversal. Mean train-of-four ratios in the control and neostigmine groups before reversal (1.02 vs. 1.03), 5 min postreversal (1.05 vs. 1.07), and at postanesthesia care unit admission (1.06 vs. 1.08) did not differ. The mean difference and corresponding 95% CI of the latter were −0.018 and −0.046 to 0.010. The incidences of postoperative hypoxemic events and episodes of airway obstruction were similar for the groups. The number of patients with postoperative signs and symptoms of muscle weakness did not differ between groups (except for double vision: 13 in the control group and 2 in the neostigmine group; P = 0.001). Conclusions: Administration of neostigmine at neuromuscular recovery was not associated with clinical evidence of anticholinesterase-induced muscle weakness.

Increasing compliance with the World Health Organization Surgical Safety Checklist—a regional health system's experience

BACKGROUND In 2009, NorthShore University HealthSystem adapted the World Health Organization Surgical Safety Checklist (SSC) at each of its 4 hospitals. Despite evidence that SSC reduces intraoperative mistakes and increase patient safety, compliance was found to be low with the paper form. In November 2013, NorthShore integrated the SSC into the electronic health record (EHR). The aim was to increase communication between operating room (OR) personnel and to encourage best practices during the natural workflow of surgeons, anesthesiologists, and nurses. The purpose of this study was to examine the impact of an electronic SSC on compliance and patient safety. METHODS An anonymous OR observer selected cases at random and evaluated the compliance rate before the rollout of the electronic SSC. In June 2014, an electronic audit was performed to assess the compliance rate. Random OR observations were also performed throughout the summer in 2014. Perioperative risk events, such as consent issues, incorrect counts, wrong site, and wrong procedure were compared before and after the electronic SSC rollout. A perception survey was also administered to NorthShore OR personnel. RESULTS Compliance increased from 48% (n = 167) to 92% (n = 1,037; P < .001) after the SSC was integrated into the electronic health record. Surgeons (91% vs 97%; P < .001), anesthesiologists (89% vs 100%; P < .001), and nurses (55% vs 93%; P < .001) demonstrated an increase in compliance. A comparison between risk events in the pre- and post-rollout period showed a 32% decrease (P < .01). Hospital-wide indicators including length of stay and 30-day readmissions were lower. In a survey to assess the OR personnels perceptions of the new checklist, 76% of surgeons, 86% of anesthesiologists, and 88% of nurses believed the electronic SSC will have a positive impact on patient safety. CONCLUSIONS The World Health Organization SSC is a validated tool to increase patient safety and reduce intraoperative complications. The electronic SSC has demonstrated an increased compliance rate, a reduced number of risk events, and most OR personnel believe it will have a positive impact on patient safety.

Procedural Timeout Compliance Is Improved With Real-Time Clinical Decision Support.

Purpose The goal of this study was to assess compliance with a presurgical safety checklist before and after the institution of a surgical flight board displaying a surgical safety checklist with embedded real-time clinical decision support (CDS). We hypothesized that the institution of a surgical flight board with embedded real-time data support would improve compliance with the presurgical safety checklist. Methods In this prospective, observational trial, surgeon-led procedural timeout compliance for 300 procedures was studied. In phase I (PI), procedural timeouts were performed using a simple paper checklist. In phase II (PII), an electronic surgical flight board with an embedded safety checklist was installed in each operating room, but the timeout procedure consisted of the same paper process as in PI. In phase III (PIII), the flight board safety checklist was used. Ten procedures each from 10 surgeons were evaluated in each phase. Compliance was scored on a 12-point scale with each point representing a different item on the checklist. Results Timeout compliance in PI ranged from 4.5 to 8.6 and 8.75 to 12 in PIII. All 10 surgeons demonstrated statistically improved compliance from PI to PIII. Compliance was significantly improved in 8 of 12 safety check items. Decreased compliance was not seen with any checklist item. Of the items with CDS, compliance with procedure consent and special safety precautions improved from PI to PIII, as did compliance with display of essential imaging, critical events or concerns, and number of procedures (i.e., >1 surgeon performing procedures). Conclusions Using the electronic medical record with real-time CDS improves compliance with presurgical safety checklists.

Clinical Effectiveness and Safety of Intraoperative Methadone in Patients Undergoing Posterior Spinal Fusion Surgery: A Randomized, Double-blinded, Controlled Trial

Background: Patients undergoing spinal fusion surgery often experience severe pain during the first three postoperative days. The aim of this parallel-group randomized trial was to assess the effect of the long-duration opioid methadone on postoperative analgesic requirements, pain scores, and patient satisfaction after complex spine surgery. Methods: One hundred twenty patients were randomized to receive either methadone 0.2 mg/kg at the start of surgery or hydromorphone 2 mg at surgical closure. Anesthetic care was standardized, and clinicians were blinded to group assignment. The primary outcome was intravenous hydromorphone consumption on postoperative day 1. Pain scores and satisfaction with pain management were measured at postanesthesia care unit admission, 1 and 2 h postadmission, and on the mornings and afternoons of postoperative days 1 to 3. Results: One hundred fifteen patients were included in the analysis. Median hydromorphone use was reduced in the methadone group not only on postoperative day 1 (4.56 vs. 9.90 mg) but also on postoperative days 2 (0.60 vs. 3.15 mg) and 3 (0 vs. 0.4 mg; all P< 0.001). Pain scores at rest, with movement, and with coughing were less in the methadone group at 21 of 27 assessments (all P = 0.001 to < 0.0001). Overall satisfaction with pain management was higher in the methadone group than in the hydromorphone group until the morning of postoperative day 3 (all P = 0.001 to < 0.0001). Conclusions: Intraoperative methadone administration reduced postoperative opioid requirements, decreased pain scores, and improved patient satisfaction with pain management.