Vanni Agnoletti

Operating room data management: improving efficiency and safety in a surgical block

BackgroundEuropean Healthcare Systems are facing a difficult period characterized by increasing costs and spending cuts due to economic problems. There is the urgent need for new tools which sustain Hospitals decision makers work. This project aimed to develop a data recording system of the surgical process of every patient within the operating theatre. The primary goal was to create a practical and easy data processing tool to give hospital managers, anesthesiologists and surgeons the information basis to increase operating theaters efficiency and patient safety.MethodsThe developed data analysis tool is embedded in an Oracle Business Intelligence Environment, which processes data to simple and understandable performance tachometers and tables. The underlying data analysis is based on scientific literature and the projects teams experience with tracked data. The system login is layered and different users have access to different data outputs depending on their professional needs. The system is divided in the tree profile types Manager, Anesthesiologist and Surgeon. Every profile includes subcategories where operators can access more detailed data analyses. The first data output screen shows general information and guides the user towards more detailed data analysis. The data recording system enabled the registration of 14.675 surgical operations performed from 2009 to 2011.ResultsRaw utilization increased from 44% in 2009 to 52% in 2011. The number of high complexity surgical procedures (≥120 minutes) has increased in certain units while decreased in others. The number of unscheduled procedures performed has been reduced (from 25% in 2009 to 14% in 2011) while maintaining the same percentage of surgical procedures. The number of overtime events decreased in 2010 (23%) and in 2011 (21%) compared to 2009 (28%) and the delays expressed in minutes are almost the same (mean 78 min). The direct link found between the complexity of surgical procedures, the number of unscheduled procedures and overtime show a positive impact of the project on OR management. Despite a consistency in the complexity of procedures (19% in 2009 and 21% in 2011), surgical groups have been successful in reducing the number of unscheduled procedures (from 25% in 2009 to 14% in 2011) and overtime (from 28% in 2009 to 21% in 2011).ConclusionsThe developed project gives healthcare managers, anesthesiologists and surgeons useful information to increase surgical theaters efficiency and patient safety. In difficult economic times is possible to develop something that is of some value to the patient and healthcare system too.

Pain relief and motor function during continuous interscalene analgesia after open shoulder surgery: A prospective, randomized, double-blind comparison between levobupivacaine 0.25%, and ropivacaine 0.25% or 0.4%

Background and objectives: To compare pain relief and motor impairment of 0.25% levobupivacaine with either an equivalent (0.25%) or equipotent (0.4%) concentration of ropivacaine for continuous interscalene block after open shoulder surgery. Methods: Seventy‐two adult patients scheduled for elective major shoulder surgery received an interscalene injection of mepivacaine 1.5% 30 mL followed by 24 h patient‐controlled interscalene analgesia (basal infusion rate: 5 mL h−1; incremental bolus: 2 mL; lockout period: 10 min; maximum boluses per hour: 4) with either 0.25% levobupivacaine (n = 24), 0.25% ropivacaine (n = 24) or 0.4% ropivacaine (n = 24). A blinded observer recorded the evolution of pain relief and recovery of motor block during the first 24 h. Motor function was assessed as the maximum pressure developed while squeezing a sphygmomanometer cuff with the blocked hand. The reduction from preoperative values was considered as an index of motor impairment. Results: No differences were reported among the three groups in the quality of postoperative analgesia. The number of incremental patient‐controlled interscalene analgesia doses, total volume of local anaesthetic infused during the 24‐h patient‐controlled interscalene analgesia, and number of rescue ketoprofen analgesia were higher in the ropivacaine 0.25% group than in the other two groups (P = 0.0005). The hand strength recovered to ≥90% of baseline values within the first 24 h of infusion in all groups, without differences among the three groups. Conclusion: When providing patient‐controlled interscalene analgesia after open shoulder surgery 0.25% levobupivacaine and 0.4% ropivacaine performed equally in terms of pain relief, motor block and number of patient‐controlled boluses required, while patients receiving 0.25% ropivacaine needed significantly more boluses and rescue analgesia to control their pain.

A Prospective, Randomized Evaluation of the Effects of Epidural Needle Rotation on the Distribution of Epidural Block

We evaluated the effects of turning the tip of the Tuohy needle 45° toward the operative side before threading the epidural catheter (45°-rotation group, n = 24) as compared to a conventional insertion technique with the tip of the Tuohy needle oriented at 90° cephalad (control group, n = 24) on the distribution of 10 mL of 0.75% ropivacaine with 10 μg sufentanil in 48 patients undergoing total hip replacement. The catheter was introduced 3 to 4 cm beyond the tip of the Tuohy needle. A blinded observer recorded sensory and motor blocks on both sides, quality of analgesia, and volumes of local anesthetic used during the first 48 h of patient-controlled epidural analgesia. Readiness to surgery required 21 ± 6 min in the control group and 17 ± 7 min in the 45°-rotation group (P > 0.50). The maximum sensory level reached on the operative side was T10 (T10-7) in the control group and T9 (T10-6) in the 45°-rotation group (P > 0.50); whereas the maximum sensory level reached on the nonoperative side was T10 (T12-9) in the control group and L3 (L5-T12) in the 45°-rotation group (P = 0.0005). Complete motor blockade of the operative limb was achieved earlier in the 45°-rotation than in the control group, and motor block of the nonoperative side was more intense in patients in the control group. Two-segment regression of sensory level on the surgical side was similar in the two groups, but occurred earlier on the nonoperative side in the 45°-rotation group (94 ± 70 min) than in the control group (178 ± 40 min) (P = 0.0005). Postoperative analgesia was similar in the 2 groups, but the 45°-rotation group consumed less local anesthetic (242 ± 35 mL) than the control group (297 ± 60 mL) (P = 0.0005). We conclude that the rotation of the Tuohy introducer needle 45° toward the operative side before threading the epidural catheter provides a preferential distribution of sensory and motor block toward the operative side, reducing the volume of local anesthetic solution required to maintain postoperative analgesia.

Splenic trauma: WSES classification and guidelines for adult and pediatric patients

Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.

The role of open abdomen in non-trauma patient: WSES Consensus Paper

The open abdomen (OA) is defined as intentional decision to leave the fascial edges of the abdomen un-approximated after laparotomy (laparostomy). The abdominal contents are potentially exposed and therefore must be protected with a temporary coverage, which is referred to as temporal abdominal closure (TAC). OA use remains widely debated with many specific details deserving detailed assessment and clarification. To date, in patients with intra-abdominal emergencies, the OA has not been formally endorsed for routine utilization; although, utilization is seemingly increasing. Therefore, the World Society of Emergency Surgery (WSES), Abdominal Compartment Society (WSACS) and the Donegal Research Academy united a worldwide group of experts in an international consensus conference to review and thereafter propose the basis for evidence-directed utilization of OA management in non-trauma emergency surgery and critically ill patients. In addition to utilization recommendations, questions with insufficient evidence urgently requiring future study were identified.

Use of the Bonfils Intubation Fiberscope in Patients with Limited Mouth Opening

Airway management of patients with very limited mouth opening remains a challenge for the anaesthetist. We describe the use of the Bonfils Intubation Fiberscope for awake intubation in two patients with a very limited mouth opening. In the first case, a 60-year-old 80 kg female, scheduled for a right modified radical mastectomy for infiltrating ductal carcinoma (15 mm mouth opening, a short thick neck, limited neck extension, and a Mallampati class 4 airway), the Bonfils was advanced via the retromolar technique. In the second patient, a 34-year-old male, scheduled for a surgical tracheotomy for right tonsillar cancer, due to a neoplastic infiltration of the right temporomandibular joint (7 mm mouth opening and limited neck movement), the Bonfils was advanced using the midline approach. The Bonfils is a reusable, rigid, straight fiberoptic device with a curved tip, is 5 mm in diameter, and has several advantages: it is quick and easy to use, more cost effective than a flexible fiberscope, and is safe in expert hands, thanks to its smaller diameter. Our conclusion is that awake BIF intubation is a reliable, atraumatic, and well-tolerated procedure to secure a safe airway in patients with a limited mouth opening.

The Airtraq laryngoscope for emergency tracheal intubation without interruption of chest compression

The 2005 American Heart Association Cardiopulmonary Resuscitation (CPR) Guidelines emphasize minimizing the interruption of chest compression to maximize coronary and cerebral perfusion pressure. In an emergency situation, airway management is often performed by a less experienced physician, in sub-optimal conditions. Introduction of video laryngoscopes might have benefits in these situations. The Airtraq enables inexperienced operators to obtain an optimal view for tracheal intubation without requiring the alignment of the oral, pharyngeal, and tracheal axes, and it reduces the time to secure the airway and the incidence of failed tracheal intubation by novice laryngoscopists. The authors report a case of a 61-year-old man presented to their Medical Emergency Team for inhospital cardiac arrest in radiology suite

The open abdomen in trauma and non-trauma patients: WSES guidelines

Damage control resuscitation may lead to postoperative intra-abdominal hypertension or abdominal compartment syndrome. These conditions may result in a vicious, self-perpetuating cycle leading to severe physiologic derangements and multiorgan failure unless interrupted by abdominal (surgical or other) decompression. Further, in some clinical situations, the abdomen cannot be closed due to the visceral edema, the inability to control the compelling source of infection or the necessity to re-explore (as a “planned second-look” laparotomy) or complete previously initiated damage control procedures or in cases of abdominal wall disruption. The open abdomen in trauma and non-trauma patients has been proposed to be effective in preventing or treating deranged physiology in patients with severe injuries or critical illness when no other perceived options exist. Its use, however, remains controversial as it is resource consuming and represents a non-anatomic situation with the potential for severe adverse effects. Its use, therefore, should only be considered in patients who would most benefit from it. Abdominal fascia-to-fascia closure should be done as soon as the patient can physiologically tolerate it. All precautions to minimize complications should be implemented.

Failure of Double-Lumen Tube Positioning in a Patient With Lingual Tonsil Hypertrophy

A 59-year-old man (weight, 93 kg; height, 172 cm) was scheduled for left video-assisted thoracoscopy. The preoperative airway assessment revealed a Mallampati grade 2, an interdental distance of 5 cm, a wide mouth and limited cervical spine movement. After preoxygenation, general anesthesia was induced with intravenous fentanyl (2 g/kg), propofol (2 mg/ kg), and succinylcholine (0.8 mg/kg). The direct laryngoscopy with a Macintosh 3 blade revealed a Cormack/Lehane (C/L) grade 4 view; no glottic structures were visible at all. A second attempt was performed using the GlideScope videolaryngoscope, and the best view of the larynx achieved was C/L grade 3; direct vision of the tongue revealed a lingual tonsil hypertrophy. Ventilation and oxygenation with a bag and mask continued to be effective, and anesthesia was continued with a mixture of sevoflurane 2% and oxygen 100%. The previous sniffing position was changed, the patient was placed in simple head extension, and a further attempt with the GlideScope was tried (C/L grade 3). A blind technique of tracheal intubation failed, and the right tonsil began bleeding, probably because of direct contact with the blade and the endotracheal tube. A size 5 supraglottic airway i-gel device (Intersurgical Ltd, Berkshire, UK) was inserted without further drugs, and spontaneous ventilation was achieved. Afterwards, fiberoptic endotracheal intubation through the supraglottic device was attempted unsuccessfully. The anesthesia was stopped, and consciousness returned. The fiberoptic view showed an anterior and small glottis perpendicular to the axis of the trachea with a small space between the glottis and arytenoids. The airway was secured by awake nasal fiberoptic intubation under topical anesthesia, and surgery took place as scheduled without any problem for the patient; one-lung ventilation was achieved using a Cohen endobronchial blocker, and tonsillar bleeding stopped before the end of surgery. The supraglottic airway i-gel device permitted us to achieve spontaneous ventilation by maintaining airway patency and preventing collapse of laryngeal structures; this device was also

Real-time view of anesthetic solution spread during an ultrasound-guided thoracic paravertebral block

Background: Thoracic paravertebral block is a technique for perioperative analgesia in patients undergoing thoracic, chest wall, or breast surgery, or for pain management with rib fractures, which can be performed with or without ultrasound guidance. The ultrasound guidance technique can be used to identify the thoracic paravertebral space, guide needle placement, monitor the spread of local anesthetic (LA) solution, and reduce complications such as pleural puncture and pneumothorax. The possibility of assessing anesthetic spread in real time using ultrasound guidance during paravertebral block offers numerous advantages, including the immediate and accurate identification of the extent of nervous block, with a consequent reduction of LA dose. The real-time visualization of spread may be used to achieve good anesthetic cover by administering the block at a single level, thus reducing complications normally associated with the technique. Case summary: This case report describes the use of ultrasound-guided thoracic paravertebral block, at thoracic (T) 4 and 5 levels, in a patient undergoing breast surgery for perioperative analgesia. The authors were able to witness cranial diffusion of LA at T3-T4 in real time, and measure the increase in space between the costotransverse ligament and pleura, as an indication of anesthetic spread, at T2-T3 and T6-T7 levels. Conclusions: This is the first known case in the literature of direct viewing of LA diffusion in a paravertebral space other than the one in which the block is administered and may open important scenarios for the improvement of anesthesia technique.