Feasibility and Acceptability of a Low-Tech Simulation Using Local Resources in a Rural Community Hospital.

Simulation is an effective tool to learn or refresh skills and knowledge, but numerous barriers prevent the routine use of simulation. The purpose of this project was to assess the feasibility and acceptability of the use of a low-tech simulation kit by the hospital's personnel for overcoming those barriers. A phenomenological qualitative approach using semistructured interviews was conducted with a convenience sample of 5 Certified Registered Nurse Anesthetists (CRNAs) and a student registered nurse anesthetist at a rural community hospital. Additionally, a CRNA served as the facilitator and was interviewed. After the data were independently analyzed by 2 individuals, 6 themes emerged. A low-tech simulation was acceptable, although the sense of stress was difficult to replicate. The facilitator found that simulation preparation and execution were easier and less work than expected. A low-tech simulation kit is a viable option for increasing the frequency of simulating anesthesia emergencies and overcoming the barriers that prevent the frequent use of simulation in the clinical setting. Psychological fidelity can be enhanced through innovative methods (flip book containing screenshots of an electrocardiographic monitor, video) to overcome the limitations of a low-tech simulation.

Partial hepatic resections for metastatic neuroendocrine tumors: perioperative outcomes.

STUDY OBJECTIVE: Partial hepatic resection reduces tumor burden in patients with metastatic neuroendocrine tumors, thereby improving quality and length of life. These procedures can be challenging as well as life-threatening. Our aim was to evaluate our patients' perioperative outcomes and propose a definition for an intraoperative carcinoid crisis relevant to this surgery, given its unique surgical considerations. DESIGN: Retrospective study. SETTING: Mayo Clinic, Rochester, Minnesota. PATIENTS: One hundred sixty-nine patients undergoing partial hepatic resection for metastatic neuroendocrine tumors between 1997 and 2015 were identified retrospectively from a surgical database at Mayo Clinic Rochester. INTERVENTIONS: None. MEASUREMENTS: Intraoperative carcinoid crisis for patients undergoing hepatic resection of neuroendocrine tumors was defined. Patients' medical records were reviewed and data were abstracted describing patient and procedural characteristics and perioperative outcomes. MAIN RESULTS: There were no documented cases of carcinoid crisis (0.0%, 95% C.I. 0.0% to 2.2%). One patient developed clinical findings of an emerging carcinoid crisis, but was successfully treated with doses of octreotide and findings resolved in <10 min. Prophylactically 500 µg octreotide was given subcutaneously in 77% (130/169) of patients preoperatively. CONCLUSIONS: There were no documented cases of carcinoid crisis (0.0%, 95% C.I. 0.0% to 2.2%). Adverse events were infrequent.

Accuracy of Capillary and Arterial Whole Blood Glucose Measurements Using a Glucose Meter in Patients under General Anesthesia in the Operating Room.

BACKGROUND: The aim of this study was to evaluate the use of a glucose meter with surgical patients under general anesthesia in the operating room. METHODS: Glucose measurements were performed intraoperatively on 368 paired capillary and arterial whole blood samples using a Nova StatStrip (Nova Biomedical, USA) glucose meter and compared with 368 reference arterial whole blood glucose measurements by blood gas analyzer in 196 patients. Primary outcomes were median bias (meter minus reference), percentage of glucose meter samples meeting accuracy criteria for subcutaneous insulin dosing as defined by Parkes error grid analysis for type 1 diabetes mellitus, and accuracy criteria for intravenous insulin infusion as defined by Clinical and Laboratory Standards Institute guidelines. Time under anesthesia, patient position, diabetes status, and other variables were studied to determine whether any affected glucose meter bias. RESULTS: Median bias (interquartile range) was -4 mg/dl (-9 to 0 mg/dl), which did not differ from median arterial meter bias of -5 mg/dl (-9 to -1 mg/dl; P = 0.32). All of the capillary and arterial glucose meter values met acceptability criteria for subcutaneous insulin dosing, whereas only 89% (327 of 368) of capillary and 93% (344 of 368) arterial glucose meter values met accuracy criteria for intravenous insulin infusion. Time, patient position, and diabetes status were not associated with meter bias. CONCLUSIONS: Capillary and arterial blood glucose measured using the glucose meter are acceptable for intraoperative subcutaneous insulin dosing. Whole blood glucose on the meter did not meet accuracy guidelines established specifically for more intensive (e.g., intravenous insulin) glycemic control in the acute care environment.

Period Prevalence of Ketamine-Propofol Admixture "Ketofol" in the Operating Room among Anesthesia Providers at an Academic Medical Center.

BACKGROUND: The primary aim of this study was to determine the period prevalence of the single-syringe ketamine-propofol admixture used for sedation and induction among anesthesia providers during a 5-year period before and after educational sessions addressing barriers to its use. Secondary aims were to determine barriers to its use and address the most prevalent concerns through educational sessions. MATERIAL AND METHODS: Surveys were administered to certified and student registered nurse anesthetists, anesthesia residents, and anesthesiologists at Mayo Clinic Rochester, MN before and after educational sessions addressing common barriers. Identified barriers were addressed by oral and/or electronic presentations with identical content. RESULTS: Pre-education period prevalence for sedation was 110 (43%) and 64 (25%) for induction. Identified barriers were uncertainty of benefit in 62 respondents (23%), mixed controlled substance disposal in 48 (18%), regulatory/institutional policies in 20 (7%), and compatibility in 9 (3%). Post-education period prevalence for sedation was 102 (44%), and induction 63 (27%). No concerns were noted in 72% of the post-education group verses 42% in the pre-education group (p<0.01). No concerns were reported in 51% of the electronic only education group verses 64% in the oral education group (p<0.01). CONCLUSIONS: The period prevalence of "ketofol" was greater for sedation than induction. The period prevalence following education showed a slight increase in both sedation and induction use. There was a significant reduction in barriers following education, with oral presentations being more effective than electronic only. Period prevalence was increasing following education; however, allowing more time may have shown a significant practice change.

Lambert-Eaton myasthenic syndrome during anesthesia: a report of 37 patients.

STUDY OBJECTIVE: Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune disorder of the neuromuscular junction that manifests with muscle weakness, autonomic and bulbar dysfunction, and increased sensitivity to neuromuscular blocking drugs. The objective of this study is to review perioperative outcomes on a series of patients with LEMS. DESIGN: The medical records of surgical patients with LEMS from January 1, 1990, to December 31, 2012, were retrospectively reviewed. SETTING: Major academic hospital. PATIENTS: Surgical patients with LEMS. MEASUREMENTS AND MAIN RESULTS: Thirty-seven patients underwent 60 surgeries, with most performed to diagnose or treat lung malignancy (n = 31; 51.7%). Equal number of patients had LEMS associated with small cell lung cancer (n = 16; 43.2%) or an autoimmune process (n = 16; 43.2%), with the remainder having various malignancies. Neuromuscular blocking drug medications were used in 23 (38.3%) of cases, including 8 patients who were not treated for LEMS symptoms. Four patients (11%) had respiratory complications. Interestingly, 3 patients were either undiagnosed or not treated for LEMS at the time of perioperative complication, and developed weakness after use of neuromuscular blocking drugs. CONCLUSION: Patients with LEMS have increased sensitivity to neuromuscular blocking drugs. The risk for the development of prolonged muscle weakness or postoperative respiratory failure after being exposed to neuromuscular blocking drugs is increased in patients with undiagnosed or untreated LEMS.

Does low-dose droperidol increase the risk of polymorphic ventricular tachycardia or death in the surgical patient?

BACKGROUND: The Food and Drug Administration issued a black box warning regarding the use of droperidol and the potential for torsade de pointes. METHODS: The primary objective of this retrospective study was to determine if low-dose (0.625 mg) droperidol administration was associated with episodes of torsade de pointes in the general surgical population during the 3-yr period following the reinstitution of droperidol to our institutional formulary. RESULTS: The authors identified 20,122 surgical patients who received 35,536 doses of droperidol. These patients were cross-matched with an electrocardiogram database and an adverse outcome database. The charts of 858 patients were reviewed, including patients with documentation of prolonged QTc (>440 ms) from March 2007 to February 2011, polymorphic ventricular tachycardia (VT) within 48 h of receiving droperidol, or death within 7 days of receiving droperidol. Twelve surgical patients had VT (n = 4) or death (n = 8) documented within 48 h of droperidol administration. No patients developed polymorphic VT or death due to droperidol administration (n = 0). The eight patients that died were on palliative care. The four patients with documented VT had previous cardiac conditions: two had pre-existing implantable cardiac defibrillators, three had episodes of VT before receiving droperidol, and another had pre-existing hypertrophic obstructive cardiomyopathy. The authors found 523 patients with a documented QTc >440 ms before receiving droperidol. No patients developed VT or death as a direct result of droperidol administration. CONCLUSIONS: Our evidence suggests that low-dose droperidol does not increase the incidence of polymorphic VT or death when used to treat postoperative nausea and vomiting in the surgical population.

Tobacco intervention attitudes and practices among certified registered nurse anesthetists.

BACKGROUND: The period before surgery represents an opportunity for perioperative nurses, including certified registered nurse anesthetists (CRNAs), to address the tobacco use of their patients. OBJECTIVE: To assess the current practices and attitudes of CRNAs toward tobacco interventions. METHODS: A survey assessing current attitudes, practices and beliefs, and respondent demographics was mailed to 1,000 practicing CRNAs randomly selected from the membership of the American Association of Nurse Anesthetists, with one follow-up reminder. Summary statistics of survey responses were prepared. RESULTS: The response rate was 44% (N = 439). Almost all respondents (92%) reported routinely asking their patients if they smoke cigarettes, and the majority felt that it was their responsibility to advise their patients to quit smoking. However, most do not routinely do so. Identified barriers to intervention included a lack of time to intervene and a lack of training. Interest in learning more about tobacco interventions was high, with strong majorities willing to take an extra 5 minutes preoperatively to intervene and to refer patients to other intervention services. DISCUSSION: These results can inform efforts to promote tobacco use interventions in surgical patients by CRNAs. Increasing the frequency and effectiveness of tobacco use interventions provided by CRNAs would benefit not only immediate perioperative outcomes, but also the long-term health of surgical patients who take advantage of the surgical episode to initiate long-term tobacco abstinence.

Risk factors for laryngospasm in children during general anesthesia.

BACKGROUND: Laryngospasm is a common and often serious adverse respiratory event encountered during anesthetic care of children. We examined, in a case control design, the risk factors for laryngospasm in children. MATERIAL AND METHODS: The records of 130 children identified as having experienced laryngospasm under general anesthesia were examined. Cases were identified from those prospectively entered into the Mayo Clinic performance improvement database between January 1, 1996 and December 31, 2005. Potential demographic, patient, surgical and anesthetic related risk factors were determined in a 1 : 2 case-control study. RESULTS: No individual demographic factors were found to be significantly associated with risk for laryngospasm. However, multivariate analysis demonstrated significant associations between laryngospasm and intercurrent upper respiratory infection (OR 2.03 P = 0.022) and the presence of an airway anomaly (OR = 3.35, P = 0.030). Among those experiencing laryngospasm during maintenance or emergence, the use of a laryngeal mask airway was strongly associated even when adjusted for the presence of upper respiratory infection and airway anomaly (P = 0.019). Ten patients experienced postoperatively one or more complications whereas only three complications were observed among controls (P = 0.008). No child required cardiopulmonary resuscitation and there were no deaths in either study cohort. CONCLUSIONS: In our pediatric population, the risk of laryngospasm was increased in children with upper respiratory tract infection or an airway anomaly. The use of laryngeal mask airway was found to be associated with laryngospasm even when adjusted for the presence of upper respiratory tract infection and airway anomaly.

Disseminated intravascular coagulation after craniotomy.

Disseminated intravascular coagulation (DIC) is reported in neurosurgical patients; however, the incidence of DIC after craniotomy procedures is unknown. Using a surgical database, we identified 3164 patients who underwent primary craniotomy at Mayo Clinic Rochester between January 1, 2000 and December 31, 2004. Potential cases of DIC in this population were identified using 3 search triggers, patients: (1) in whom the diagnosis of DIC was noted on their hospital discharge summary, (2) who received red blood cell-free blood products, or (3) in whom a blood fibrinogen or d-dimer concentration was assessed. Using criteria based on laboratory values, we estimated the incidence of DIC developing within 72 hours of primary craniotomy to be between 13 and 44 per 10,000 patients. Despite a low incidence of DIC, the associated mortality rate was 43% to 75%. Traumatic head injury was a significant risk factor for the development of DIC [odds ratio of trauma was in the range of 16 (95% confidence interval (CI)=5.3-49) to 29 (CI=4.0-204)]. Autologous salvaged blood was administered intraoperatively to 44 patients, and 1 of these developed DIC. Although this small sample of patients receiving salvaged blood requires caution in interpreting the results, the risk of DIC seemed to be greater with salvaged blood than without [odds ratio 24 (CI=2.5-237)]. In children, 2 of 3 patients who developed DIC had congenital malformations of the brain. Findings from this study suggest that DIC is rare after craniotomy, but is often associated with mortality.

Does low-dose droperidol administration increase the risk of drug-induced QT prolongation and torsade de pointes in the general surgical population?

BACKGROUND: The US Food and Drug Administration issued a black box warning regarding the use of droperidol and the potential for torsade de pointes (TdP). METHODS: The primary objective of this retrospective study was to determine whether low-dose droperidol administration increased the incidence of TdP in the general surgical population during a 3-yr time period before and after the Food and Drug Administration black box warning. A random sample of 150 surgical patients during each time interval was selected to estimate the droperidol use for each time period. RESULTS: During the time period before the black box warning (July 1, 1998 to June 30, 2001), 2,321/139,932 patients (1.66%) had QT prolongation, TdP, or death within 48 h after surgery. We could identify no patients who clearly developed TdP before the black box warning. There was one patient for whom the cause of death could not positively be ruled out as due to TdP. In the time period after the black box warning (July 1, 2002 to June 30, 2005), 2,207 patients (1.46%) had documented QT prolongation, TdP, or death within 48 h after surgery, including only two cases (<0.1%) of TdP. The incidence of droperidol exposure was approximately 12% (exact 95% confidence interval, 7.3-18.3%) before the black box warning and 0% after placement of the black box warning on droperidol. Therefore, we estimate that approximately 16,791 patients (95% confidence interval, 10,173-25,607) were exposed to droperidol, none of whom experienced documented TdP. CONCLUSIONS: This indicates that the Food and Drug Administration black box warning for low dose droperidol is excessive and unnecessary.

Predictors of mortality following symptomatic pulmonary embolism in patients undergoing noncardiac surgery.

PURPOSE: To determine 30-day mortality and predictors of mortality following perioperative pulmonary embolism (PE). METHODS: We searched both the Mayo Clinic electronic medical records and Autopsy Registry, between January 1, 1998 and December 31, 2001, for patients who developed PE within 30 days after noncardiac surgery performed under general or neuraxial anesthesia. Medical records of all identified patients were reviewed using standardized data collection forms. The association between risk factors for PE and 30-day post-PE mortality was assessed using t tests, exact binomial tests, and logistic regression. RESULTS: We identified 158 patients with probable or definite perioperative PE. The overall 30-day mortality from the day of PE was 25.3%, i.e., 40 patients died. Hypotension requiring treatment, need for mechanical ventilation, and intensive care unit admission were the prominent univariate predictors of 30-day mortality (all P

Anesthetic care of the trauma patient: development of a Web-based resource.

Adequate preparation by anesthesia providers promotes quality care and decreases the likelihood of morbidity and mortality. Unfortunately, many trauma cases occur after hours when support resources are less readily available. At a large midwest academic medical center, it was determined that a website on the institution's Intranet relating to anesthetic care of trauma patients would be a readily accessible, user-friendly resource for improved care. In recent years, media tools such as computers have become increasingly popular and accessible as effective learning tools. A comprehensive literature search was completed on anesthetic care of trauma patients and on adult and Web-based learning principles. Information was gathered from textbooks, research journals, existing web links on the institution's intranet, and staff at the medical center. Assistance was obtained from the institution's Internet/website Development Department for creation of the website. The information was placed on the institution's Intranet. The web page contains 17 subject categories, including initial considerations, common trauma drugs, circulation and fluid resuscitation, management of pregnant trauma patients, and intraoperative death. It is our goal that the systematic developmental process described in this article may provide a model for other institutions wanting to develop websites.

A prospective study on anesthesia machine fault identification.

BACKGROUND: Although few studies have been performed recently, several have suggested that some practitioners are not well able to detect preset anesthesia machine faults. METHODS: We performed a prospective study to determine whether there is a correlation between duration of anesthesia practice and the ability to detect anesthesia machine faults. Our hypothesis was that more anesthesia practice would increase the ability to detect anesthesia machine faults. This study was performed during a nationally attended anesthesia meeting held at a large academic medical center, where 87 anesthesia providers were observed performing anesthesia machine checkouts. The participants were asked to individually check out an anesthesia machine with an unspecified number of preset faults. The primary outcome measures were the written listing of faults detected during an anesthesia machine checkout. RESULTS: Of the five faults preset into the test machine, participants with 0-2 yr experience detected a mean of 3.7 faults, participants with 2-7 yr experience detected a mean of 3.6 faults, and participants with more than 7 yr experience detected a mean of 2.3 faults (P < 0.001). CONCLUSIONS: Our prospective study demonstrated that anesthesia machine checkout continues to be a problem.

Update for nurse anesthetists--anesthetic considerations for patients with amyloidosis.

Amyloidosis is a rare disease process that results in the deposition of insoluble, fibrous amyloid proteins in extracellular spaces and tissues. Amyloid fibrils can be deposited locally or may involve every organ system of the body. Advancements in the treatment for amyloidosis allow longer survival, and patients are being seen in our operating rooms for diagnostic, interventional, and curative purposes. Amyloidosis has numerous implications for anesthesia providers due to the possibility of systemic involvement. This course describes 2 cases of amyloidosis and discusses the types of amyloidosis and their anesthetic implications.

Changing incidence, type, and natural history of conduction defects after coronary artery bypass grafting.

BACKGROUND: Cardiac conduction defects occur after cardiac surgery. We hypothesized that population aging and increased use of beta-blockers would increase the incidence of new conduction defects after coronary surgery. METHODS: We examined the medical records of 800 coronary artery bypass grafting (CABG) patients (400 from 1991 and 400 from 2001). Exclusion criteria included the following: preexisting conduction defect, permanent pacemaker, and perioperative atrial fibrillation, leaving 303 and 269 patients, respectively, included in the two study years. The incidence, type, and persistence of new conduction defects were determined from the preoperative, postoperative, and the predischarge electrocardiogram. Multivariate analysis identified predictors of new defects. RESULTS: Study populations were well-matched. There was a marked decrease in the incidence of new postoperative conduction defects from 1991 (19%) to 2001 (6%). There was also a change in the most frequently occurring block, from a right-bundle-branch-block in 1991 (10%) to first-degree atrioventricular block (3%) in 2001. Finally, conduction defects in 1991 were more transient. While 19% of 1991 patients showed a conduction defect early postoperatively, only 9% were persistent. In 2001, the incidence of conduction defects at discharge (7%), was equivalent to that early postoperatively (6%). Predictors of new conduction defects included year of operation, age, intraaortic balloon counterpulsation, number of vessels bypassed, and crystalloid cardioplegia. CONCLUSIONS: Our results were the opposite of those predicted. Our report identifies a changing incidence, type, and natural history of conduction defects after CABG. Our comparison demonstrated a decrease in the incidence of new conduction defects, as well as a qualitative change in the defects identified. Multivariate analysis provided predictors of new conduction defects after CABG.

Childhood airway manifestations of lymphangioma: a case report.

Lymphangioma is a congenital malformation of the lymphatic system, often involving areas of the head and neck. The involved structures may include enlarged tongue and lips, swelling of the floor of the mouth, and direct involvement of the upper respiratory tract. The definitive treatment for lymphangioma is surgery, often during the first years of life. Despite surgical removal, lymphangioma may persist. Anesthetic concerns include bleeding, difficulty visualizing the airway, extrinsic and intrinsic pressure on the airway causing distortion, and enlarged upper respiratory structures, including the lips, tongue, and epiglottis. This is a case report of a 9-year-old patient with lymphangioma who had impacted teeth and a suspected odontogenic cyst. There seems to be little information on the optimal anesthetic management for this age group. The challenges with airway management, including bleeding, laryngospasm, and a difficult intubation, are outlined. Awareness of potential airway involvement and possible complications is necessary to provide a safe anesthetic to a patient with lymphangioma. A review of the literature, airway management techniques, and current airway equipment will be discussed.