Outcome of preoperative cefazolin use for infection prophylaxis in patients with self-reported penicillin allergy.

BACKGROUND: Cephalosporins are the preferred antibiotics for prophylaxis against surgical site infections. Most studies give a rate of combined IgE and non-IgE penicillin allergy yet it is recommended that cephalosporins be avoided in patients having the former but can be used in those with the latter. Some studies use penicillin allergy while others penicillin family allergy rates. The primary goal of this study was to determine the rates of IgE and non-IgE allergy as well as cross reactions to both penicillin and the penicillin family. Secondary goals were to determine the surgical services giving preoperative cefazolin and the types of self reported reactions that patients' had to penicillin prompting their allergy status. METHODS: All patients undergoing elective and emergency surgery at a University Health Sciences Centre were retrospectively studied. The hospital electronic medical record was used for data collection. RESULTS: 8.9% of our patients reported non-IgE reactions to penicillin with a cross reactivity rate of 0.9% with cefazolin. 4.0% of our patients reported IgE reactions to penicillin with a cross reactivity rate of 4.0% with cefazolin. 10.5% of our patients reported non-IgE reactions to the penicillin family with a cross reactivity rate of 0.8% with cefazolin. 4.3% of our patients reported IgE reactions to the penicillin family with a cross reactivity rate of 4.0% with cefazolin. CONCLUSIONS: Our rate of combined IgE and non-IgE reactions for both penicillin and penicillin family allergy was within the range reported in the literature. Our rate of cross reactivity between cefazolin and combined IgE and non-IgE allergy both to penicillin and the penicillin family were lower than reported in the old literature but within the range of the newer literature. We found a lower rate of allergic reaction to a cephalosporin than reported in the literature. We documented a wide range of IgE and non-IgE reactions. We also demonstrated that cefazolin is frequently the preferred antibiotics for prophylaxis against surgical site infections by many surgical services and that de-labelling patients with penicillin allergy is unnecessary.

Cancellation of elective surgery: rates, reasons and effect on patient satisfaction.

Background: The cancellation of elective surgeries is a major problem that increases wait times, exacerbates costs and can negatively affect patients, both psychologically and physically. Our objectives were to investigate the reasons for cancellations across specialties at a single centre, to compare these reasons with previous data from the same centre between 2005 and 2009 and to examine how cancellations affected patients' lives and views of the medical system in cases when the cancellations were potentially preventable. Methods: Cancellation records of all elective surgeries scheduled between June 1, 2012, and Jan. 31, 2016, at a medium-sized, tertiary care, academic centre were retrospectively reviewed. We evaluated the rates and reasons for cancellation and interviewed a subset of patients whose surgery was cancelled for a potentially preventable reason (i.e., operating room running late, bed shortage, emergency case took place of scheduled surgery). Results: Across 11 surgical specialties, 2933 of 20 881 surgeries (14.0%) were cancelled and of these, 2448 (83.5%) were for administrative or structural reasons. Compared with the data collected previously for general, gynecological and urological procedures, cancellation rates increased from 8.1% to 11.8%. Although patients reported inconvenience, they were generally satisfied with the availability and the quality of the health care they received. Conclusion: Consistent with the previous study, our data suggest that most cancellations occur because of administrative or structural processes that are potentially preventable. Targeting these processes may help to reduce cancellations for elective surgeries and thereby improve economic efficiency and patient outcomes.

Contexte: L'annulation des chirurgies électives est un problème majeur qui allonge les temps d'attente, fait gonfler les coûts et peut affecter négativement les patients, tant psychologiquement que physiquement. Nos objectifs étaient de découvrir les raisons des annulations dans les diverses spécialités d'un seul centre, afin de comparer ces raisons à des données antérieures du même centre recueillies entre 2005 et 2009 et d'examiner en quoi les annulations affectent la vie des patients et leur perception du système médical dans les cas où les annulations auraient pu être évitées. Méthodes: Les dossiers d'annulation de toutes les chirurgies électives entre le 1er juin 2012 et le 31 janvier 2016 dans un centre hospitalier universitaire de soins tertiaires de taille moyenne ont été analysés de manière rétrospective. Nous avons évalué les taux d'annulation et les motifs, et interrogé un groupe de patients dont la chirurgie a été annulée pour des raisons potentiellement évitables (p. ex., retards au bloc opératoire, manque de lits, priorisation de cas plus urgents). Résultats: Entre les 11 spécialités chirurgicales, 2933 des 20 881 chirurgies (14,0 %) ont été annulées et parmi elles, 2448 (83,5 %) pour des raisons administratives ou structurelles. Comparativement aux données précédemment recueillies pour les interventions générales, gynécologiques et urologiques, les taux d'annulation ont augmenté de 8,1 % à 11,8 %. Même si les patients ont déploré des inconvénients, ils se sont généralement déclarés satisfaits de la qualité des soins reçus et de leur accessibilité. Conclusion: Comme lors de l'étude précédente, nos données suggèrent que les causes les plus fréquentes d'annulation sont liées à des marches à suivre administratives ou structurelles qui sont potentiellement évitables. Cibler ces marches à suivre pourrait contribuer à réduire le nombre d'annulations de chirurgies électives et améliorer de ce fait l'efficience économique et les résultats chez les patients.

Predicting operative bleeding in elective pediatric surgeries using the Pediatric Bleeding Questionnaire (PBQ).

To test the Pediatric Bleeding Questionnaire's (PBQ) utility for predicting excessive bleeding during elective surgery, we retrospectively evaluated 60 pediatric patients who had been preoperatively investigated for von Willebrand disease. Of 58 patients with bleeding scores (BS) ≤2 (within normal range), 1 hemorrhaged during surgery. Two had a BS of >2 (positive BS); however, neither bled excessively during surgery. The resulting sensitivity, specificity, positive predictive values, and negative predictive values of the PBQ are 0%, 97%, 0%, and 98%, respectively. On the basis of this small sample, we cannot recommend the PBQ for screening in this setting.

Early intraoperative blood collection does not affect complete blood counts, von Willebrand factor or factor VIII levels in normal children.

BACKGROUND: Obtaining blood from children for research studies can be difficult, particularly for controls. One solution is to obtain samples during elective surgery; however, consideration must be given to the potential effects of the timing of phlebotomy. OBSERVATIONS: Ten children were recruited and phlebotomy was carried out during a preoperative clinic visit and intraoperatively immediately after the induction of anesthesia but before the start of surgery. CBCs, VWF, and FVIII levels were measured at both time points and no significant differences were seen. CONCLUSIONS: This negative result may be beneficial to pediatric research by suggesting that early intraoperative blood collection for controls does not affect the results.

[Knowledge retention after focused cardiac ultrasound training: a prospective cohort pilot study]. / Retenção do conhecimento após treinamento de ultrassonografia cardíaca focada: estudo­piloto prospectivo de coorte.

BACKGROUND AND OBJECTIVES: Focused Cardiac Ultrasound (FoCUS) has proven instrumental in guiding anesthesiologists' clinical decision-making process. Training residents to perform and interpret FoCUS is both feasible and effective. However, the degree of knowledge retention after FoCUS training remains a subject of debate. We sought to provide a description of our 4-week FoCUS curriculum, and to assess the knowledge retention among anesthesia residents at 6 months after FoCUS rotation. METHODS: A prospective analysis involving eleven senior anesthesia residents was carried out. At end of FoCUS Rotation (EOR) participants completed a questionnaire (evaluating the number of scans completed and residents' self-rated knowledge and comfort level with FoCUS), and a multiple-choice FoCUS exam comprised of written- and video-based questions. Six months later, participants completed a follow-up questionnaire and a similar exam. Self-rated knowledge and exam scores were compared at EOR and after 6 months. Spearman correlations were conducted to test the relationship between number of scans completed and exam scores, perceived knowledge and exam scores, and number of scans and perceived knowledge. RESULTS: Mean exam scores (out of 50) were 44.1 at EOR and 43 at the 6-month follow-up. Residents had significantly higher perceived knowledge (out of 10) at EOR (8.0) than at the 6-month follow-up (5.5), p=0.003. At the EOR, all trainees felt comfortable using FoCUS, and at 6 months 10/11 still felt comfortable. All the trainees had used FoCUS in their clinical practice after EOR, and the most cited reason for not using FoCUS more frequently was the lack of perceived clinical need. A strong and statistically significant (rho=0.804, p=0.005) correlation between number of scans completed during the FoCUS rotation and 6-month follow-up perceived knowledge was observed. CONCLUSION: Four weeks of intensive FoCUS training results in adequate knowledge acquisition and 6-month knowledge retention.

Periarticular Morphine-Induced Sphincter of Oddi Spasm Causing Severe Pain and Bradycardia in an Awake Patient Under Spinal Anesthesia: An Important Diagnostic Consideration.

Sphincter of Oddi spasm from opioids has been documented, presenting as severe epigastric pain and potentially overlooked in a differential diagnosis. We present a case of sphincter of Oddi spasm from periarticular morphine in a patient under spinal anesthesia, causing severe distress and treated effectively with glucagon. It is important for anesthesiologists using opioids to consider it as a cause of perioperative pain and be familiar with treatment as it may be refractory by conventional use of opioids for pain relief. It is also important to consider the systemic effects of periarticular absorption, as evident by our case.

Knowledge retention after focused cardiac ultrasound training: a prospective cohort pilot study / Retenção do conhecimento após treinamento de ultrassonografia cardíaca focada: estudo-piloto prospectivo de coorte

Abstract Background and objectives: Focused Cardiac Ultrasound (FoCUS) has proven instrumental in guiding anesthesiologists' clinical decision-making process. Training residents to perform and interpret FoCUS is both feasible and effective. However, the degree of knowledge retention after FoCUS training remains a subject of debate. We sought to provide a description of our 4-week FoCUS curriculum, and to assess the knowledge retention among anesthesia residents at 6 months after FoCUS rotation. Methods: A prospective analysis involving eleven senior anesthesia residents was carried out. At end of FoCUS Rotation (EOR) participants completed a questionnaire (evaluating the number of scans completed and residents' self-rated knowledge and comfort level with FoCUS), and a multiple-choice FoCUS exam comprised of written- and video-based questions. Six months later, participants completed a follow-up questionnaire and a similar exam. Self-rated knowledge and exam scores were compared at EOR and after 6 months. Spearman correlations were conducted to test the relationship between number of scans completed and exam scores, perceived knowledge and exam scores, and number of scans and perceived knowledge. Results: Mean exam scores (out of 50) were 44.1 at EOR and 43 at the 6-month follow-up. Residents had significantly higher perceived knowledge (out of 10) at EOR (8.0) than at the 6-month follow-up (5.5), p = 0.003. At the EOR, all trainees felt comfortable using FoCUS, and at 6 months 10/11 still felt comfortable. All the trainees had used FoCUS in their clinical practice after EOR, and the most cited reason for not using FoCUS more frequently was the lack of perceived clinical need. A strong and statistically significant (rho = 0.804, p = 0.005) correlation between number of scans completed during the FoCUS rotation and 6-month follow-up perceived knowledge was observed. Conclusion: Four weeks of intensive FoCUS training results in adequate knowledge acquisition and 6-month knowledge retention.

Resumo Justificativa e objetivos: A ultrassonografia cardíaca no local de atendimento (USCLA) provou ser importante para orientar o processo de tomada de decisão clínica dos anestesiologistas. Treinar os residentes para fazer e interpretar uma USCLA é viável e eficaz. No entanto, o grau de retenção do conhecimento após o treinamento permanece um assunto de debate. Procuramos fornecer uma descrição do currículo de quatro semanas do treinamento de USCLA e avaliar a retenção do conhecimento entre os residentes de anestesia seis meses após a rotação em USCLA. Métodos: Uma análise prospectiva foi realizada com 11 residentes seniores de anestesia. Ao final da rotação em USCLA, os participantes preencheram um questionário (avaliando o número de exames ultrassonográficos concluídos, o conhecimento adquirido e o nível de conforto dos residentes com a USCLA) e fizeram um exame de múltipla escolha para USCLA, composto por perguntas escritas e baseadas em vídeo. Seis meses depois, os participantes preencheram um questionário de acompanhamento e um exame similar. A autoavaliação do conhecimento e os escores do exame foram comparados no final da rotação e após seis meses. Correlações de Spearman foram usadas para testar a relação entre o número de exames concluídos e os escores dos exames, o conhecimento percebido, os escores dos exames, o número de exames e o conhecimento percebido. Resultados: Os escores médios dos exames (50) foram: 44,1 no final da rotação e 43 após seis meses. Os residentes tiveram conhecimento percebido significativamente maior (10) no final da rotação (8,0) que após seis meses (5,5), p = 0,003. No final da rotação, todos os residentes se sentiram confortáveis usando o aparelho de USCLA e, aos seis meses, 10/11 ainda se sentiam confortáveis. Todos os residentes haviam usado o USCLA em sua prática clínica após o final da rotação e a razão mais citada para não usar o USCLA com mais frequência foi a falta de necessidade clínica percebida. Uma correlação forte e estatisticamente significativa (rho = 0,804, p = 0,005) foi observada entre o número de exames realizados durante a rotação em USCLA e o conhecimento percebido em seis meses de seguimento. Conclusão: Quatro semanas de treinamento intensivo de USCLA resultaram em aquisição e retenção adequadas do conhecimento por seis meses.

How well are prebooked surgical step-down units utilized?

STUDY OBJECTIVE: To evaluate the utilization of the surgical step-down unit (SSDU) by a sample of patients who were preoperatively booked for admission to the unit, and to identify those patient characteristics and perioperative variables that are associated with an intervention in the unit. DESIGN: Retrospective chart review. SETTING: Canadian tertiary-care facility. MEASUREMENTS: Data from 133 elective surgery patients with prebooked SSDU beds were recorded, including comorbidities, Surgical Risk Scale (SRS), Surgical Apgar Score (SAS), and number and nature of interventions and events occurring in the SSDU. MAIN RESULTS: Of the 133 patients scheduled for SSDU admission, 60 (45.1%) were actually admitted and the other 73 (54.9%) were admitted directly to the surgical ward or else discharged. Of the patients admitted to the SSDU, 48.3% had an intervention during their stay. In logistic regression, the SRS was a significant predictor (P < 0.001) of SSDU use, while the SAS was a significant predictor (P = 0.034) of the need for an intervention or the likelihood of an event while in the SSDU. CONCLUSIONS: Less than half of patients identified were actually admitted to the SSDU postoperatively; of those, less than half required an intervention. The Surgical Apgar Score, a score based on intraoperative factors, predicted the need for an intervention during SSDU admission. Consideration should be given to the development of a predictive score that emphasizes intraoperative factors and early postoperative factors to optimize allocation of this scarce resource.

A demand-based assessment of the Canadian anesthesia workforce - 2002 through 2007.

PURPOSE: The number of anesthesia providers required by the Canadian health care system remains controversial. Questions persist regarding both the adequacy of the current supply and what the future demand will be. The purpose of this study was to quantify the number and adequacy of anesthesia providers in 2002, and predict the same for the year 2007. METHODS: All licensed health care facilities potentially employing anesthetic services were identified. On February 1(st), 2002 a questionnaire was mailed to each institution. On April 1(st), a second mailing was sent to non-responders. Those facilities that did not respond to either mailing were contacted by telephone. RESULTS: Responses were obtained from 831 of 891 (93%) health care facilities. Four hundred and twenty-six of the facilities employed anesthetic services. There were 1,610 operating rooms (ORs) in use daily, and 2,134 full-time equivalent (FTE) anesthesia providers were available to the institutions surveyed. Respondents identified an immediate need for 228 additional FTEs. Hospitals with less than five ORs or five FTEs reported higher vacancy rates than hospitals with greater than five ORs or five FTEs (P < 0.0001). Ontario (n = 85) and Quebec (n = 69) had the largest absolute deficits of FTEs and significantly greater odds of vacancies than western provinces (Ontario OR = 1.84, Quebec OR = 2.50). The projected need for 2007 was an additional 560 FTEs. CONCLUSION: This is the first study to survey a national census of "consumers" of anesthetic services: Canadian health care facilities. The results indicate substantial current and worsening future shortages of anesthesia providers in Canada.