Factors associated with increased risk of postoperative blood transfusion in patients undergoing total hip arthroplasty at an Irish University Hospital.

INTRODUCTION: Approximately 7000 total hip arthroplasty (THA) surgeries occur in Ireland each year. A number of preoperative factors have been identified that increase the risk of postoperative blood transfusion after THA, including anaemia. The ability to identify patients at risk may allow preoperative management strategies to reduce blood transfusions. Data from Irish orthopaedic patients is currently lacking. AIM: To investigate if preoperative anaemia and other factors are associated with postoperative blood transfusions in patients who undergo THA. METHODS: A retrospective cohort study of all patients who underwent THA in 2019 in SIVUH, Cork, using medical chart review. RESULTS: In total, 350 charts met the inclusion criteria, with 291 charts reviewed. 8.9% of the patients who underwent THA had preoperative anaemia. Among these, 19.2% had a postoperative blood transfusion, compared to 1.5% of patients who were not anaemic preoperatively. The odds of receiving a blood transfusion was 15.5 times greater in the preoperative anaemia group compared to the non-anaemic group. Increasing age and higher ASA scores were associated with preoperative anaemia and postoperative blood transfusions. Length of stay was increased by 2.2 days (p < 0.00016) if blood transfusion was required. CONCLUSION: Preoperative anaemia was common in an Irish orthopaedic population undergoing THA. Preoperative anaemia predisposes patients to the greatest increased risk of postoperative blood transfusions. The other factors associated with the need for postoperative transfusion were ASA grade 3 or more and age greater than 65 years. Patients who received postoperative blood transfusions had a significantly increased length of hospital stay.

Recommendations for effective documentation in regional anesthesia: an expert panel Delphi consensus project.

BACKGROUND AND OBJECTIVES: Documentation is important for quality improvement, education, and research. There is currently a lack of recommendations regarding key aspects of documentation in regional anesthesia. The aim of this study was to establish recommendations for documentation in regional anesthesia. METHODS: Following the formation of the executive committee and a directed literature review, a long list of potential documentation components was created. A modified Delphi process was then employed to achieve consensus amongst a group of international experts in regional anesthesia. This consisted of 2 rounds of anonymous electronic voting and a final virtual round table discussion with live polling on items not yet excluded or accepted from previous rounds. Progression or exclusion of potential components through the rounds was based on the achievement of strong consensus. Strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement. RESULTS: Seventy-seven collaborators participated in both rounds 1 and 2, while 50 collaborators took part in round 3. In total, experts voted on 83 items and achieved a strong consensus on 51 items, weak consensus on 3 and rejected 29. CONCLUSION: By means of a modified Delphi process, we have established expert consensus on documentation in regional anesthesia.

Failure Rates for Endotracheal Tube Placement Using Videolaryngoscopy in Patients with a Difficult Airway.

Airway management has undergone dramatic transformation since the development of videolaryngoscopy (VL). VL improves glottic views when compared to direct laryngoscopy (DL). The image obtained is from a camera at the tip of the curved blade, and the view is not direct line of sight. Placement of the endotracheal tube (ETT) may therefore require the ETT to be manipulated in multiple planes to match the curvature of the VL blade. This placement of the ETT "around the corner" may be difficult without additional airway aids. The aim of this retrospective observational study was to determine whether endotracheal placement during VL in patients with a difficult airway required the use of an additional airway aid (bougie or fiberoptic scope). Difficult airway was defined as a Cormack and Lehane (C&L) grade 3 or 4 view obtained using DL prior to VL use. Data from 165 patients was included in the study. Simple ETT placement without an additional airway device was achieved in only 20.6% of cases (n = 34). The remaining 131 patients required a bougie or fiberscope to assist intubation. ETT placement was not possible with the bougie in 33 patients. These 33 patients were successfully intubated using a fiberscope-assisted VL (FAV) technique. VL improved C&L grade 3 views by at least one grade in 99.1% of cases, and grade 4 view to a grade 1 or 2 in 96.3% of cases. VL improves glottic view in patients with a difficult airway; but in nearly 80% of patients, a bougie or fiberscope is required to properly place the ETT. Practitioners should be aware that improved glottic views with VL may not translate into simple ETT placement, and additional airway aids need to be readily available.

A description of the spread of injectate after psoas compartment block using magnetic resonance imaging.

BACKGROUND AND OBJECTIVES: Magnetic resonance imaging (MRI) provides for excellent visualization of spread of solution after peripheral nerve block. The aim of this observational study was to utilize MRI to describe the distribution of injectate (gadopentetate dimeglumine) administered for continuous psoas compartment block (PCB) performed by use of two approaches (Capdevila and modified Winnie) and to describe the spread of injectate to the lumbar plexus. METHODS: Four volunteers were enrolled in a prospective crossover study. Each volunteer underwent PCB with catheter placement performed by use of Capdevila's approach followed 1 week later by PCB, with catheter placement performed by use of a modified Winnie approach. MRI of injectate distribution was performed after each PCB. RESULTS: The catheter was unable to be inserted in 1 volunteer undergoing Winnie's approach; therefore, 7 sets of MR images were analyzed. In 6 of 7 cases (4 Capdevila and 2 Winnie) spread was primarily within the psoas muscle. Contrast surrounded the L2-3 lumbar branch of the femoral nerve at L4 and cleaved the fascial plane within the psoas muscle and spread cephalad to reach the lumbar nerve roots. In 1 case (Winnie approach) contrast spread between the psoas and quadratus lumborum muscles. Contrast surrounded the femoral and obturator nerves where they lie outside the psoas muscle at L5. CONCLUSION: The most common pattern of injectate spread seen on MRI with both approaches to PCB was spread within the body of the psoas muscle around the lumbar branches (L2-4), with cephalad spread to the lumbar nerve roots. One catheter resulted in injectate between the psoas and quadratus lumborum muscles.

Local production of skeletal traction pins to improve access to skeletal traction.

Femoral fractures represent a substantial orthopaedic injury. In the developed world, closed reduction and locked intramedullary nailing is recognized as the optimal treatment. In the less developed world, the use of skeletal traction remains limited by cost and availability of traction pins, which are obtained from orthopaedic companies in the UK or Indian subcontinent. This study aimed to establish whether traction pins may be manufactured locally in resource-limited countries from cut down stainless steel rods. The overall costs for traction pins were obtained from five UK, Indian subcontinent-based companies and metal fabrication shops in Africa. Strict design specifications were provided. The mean price for 100 Steinmann pins was$428 in the Indian subcontinent,$96 in Malawi,$105 in Kenya and$244 in Tanzania. Our results indicate that Steinmann pins may be manufactured locally in resource-limited countries at a significantly cheaper price, which may increase the access to skeletal traction.

Effect of Endotracheal Tube Size on Vocal Outcomes After Thyroidectomy: A Randomized Clinical Trial.

IMPORTANCE: The optimum size of endotracheal tube (ETT) for general anesthesia remains unresolved. Choice of ETT size may be of particular relevance to thyroid surgery because of the increased risk of laryngeal trauma and concerns regarding postoperative vocal outcomes. OBJECTIVE: To test our hypothesis that intubation with a smaller ETT would lead to reduced postoperative vocal impairment and associated reduced laryngoscopic evidence of laryngeal trauma compared with intubation with a standard-size ETT. DESIGN, SETTING, AND PARTICIPANTS: This double-blind randomized clinical trial studied patients 18 years and older undergoing elective thyroidectomy at an academic teaching hospital from October 15, 2012, through June 13, 2013. INTERVENTIONS: Patients were randomized to group 1 (standard-size ETT, 8.0 mm for men and 7.5 mm for women; n = 24) or group 2 (small ETT, 7.0 mm for men and 6.5 mm for women; n = 25). Patients were assessed preoperatively and at 24 hours and 3 weeks postoperatively. MAIN OUTCOMES AND MEASURES: Fiberoptic videolaryngoscopy with modified scoring system, voice assessment using the GRBAS (grade, roughness, breathiness, asthenia, strain) rating scale, vocal self-assessment using the 30-item Voice Handicap Index, and subjective pain score. RESULTS: At 24 hours, no significant differences were found between patients in groups 1 and 2 in change in GRBAS scores, change in laryngoscopic score (1.71 vs 1.76, P = .90), or postoperative pain score (3.3 vs 3.2, P = .91). At 3 weeks, no significant differences were found in changes in the 30-item Voice Handicap Index score (-2.2 vs -1.3, P = .74), GRBAS scores, or laryngoscopic score (0.25 vs 0.16, P = .67). CONCLUSIONS AND RELEVANCE: We did not find evidence that smaller ETT size for thyroidectomy has any significant effect on postoperative vocal outcomes, incidence of laryngeal trauma as assessed by laryngoscopy, or pain scores. However, because of the small sample size, our study may have been underpowered to detect small differences. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02136459.

Prothrombin complex concentrate for rapid reversal of warfarin anticoagulation to allow neuraxial blockade.

The development of Prothrombin Complex Concentrates (PCCs) has led to better outcomes in patients receiving emergency reversal of warfarin. However, most published data describes the use of PCCs in the setting of major bleeding or emergent major surgery, with little information on neuraxial blockade. We describe a case of rapid warfarin reversal using PCC and subsequent surgery under spinal anaesthesia in an 87-year-old lady, for whom general anaesthesia was deemed high risk. Her international normalised ratio (INR) on the morning of surgery was 1.8, precluding neuraxial blockade; however, it was felt that given, the need for imminent surgery, immediate reversal of the warfarin was indicated. We administered a single dose of 23 units/kg PCC and 5 mg vitamin K. Her INR 1 hour following PCC was 1.2, and spinal anesthetic was administered. The patient then underwent excision of melanoma deposits from her leg and groin dissection. There were no complications, the patient recovered satisfactorily, and there were no thrombotic or hemorrhagic events at 30 days postoperatively. This case study demonstrates a novel use of PCCs; in certain patients, PCCs may be safely used for immediate reversal of warfarin to allow for neuraxial blockade, safer anaesthesia, and better outcomes.

Intravenous but not perineural clonidine prolongs postoperative analgesia after psoas compartment block with 0.5% levobupivacaine for hip fracture surgery.

We evaluated the systemic and local effects of clonidine as an analgesic adjunct to psoas compartment block (PCB) with levobupivacaine. In a randomized, prospective, double-blind trial, 36 patients requiring hip fracture surgery received PCB and general anesthesia. Patients were randomized into three groups. Each patient received PCB with 0.4 mL/kg of levobupivacaine 0.5%. The control group (group L) received IV saline, the systemic clonidine group (group IC) received IV clonidine 1 mug/kg, and the peripheral clonidine group (group C) received IV saline and PCB with clonidine 1 microg/kg. The interval from time of completion of block injection to first supplementary analgesic administration was longer in group IC compared with group L (mean +/- sd, 13.4 +/- 6.1 versus 7.3 +/- 3.6 h; P = 0.03). There was no difference between group C and group L (10.3 +/- 5.9 versus 7.3 +/- 3.6 h; P > 0.05). The groups were similar in terms of 24 h cumulative morphine and acetaminophen consumption. There were no significant differences among groups regarding postoperative adverse effects (bradycardia, hypotension, sedation, and nausea). We conclude that IV but not perineural clonidine (1 microg/kg) prolongs analgesia after PCB without increasing the incidence of adverse effects.

In with the new, out with the old? Comparison of two approaches for psoas compartment block.

We compared the approaches of Winnie and Capdevila for psoas compartment block (PCB) performed by a single operator in terms of contralateral spread, lumbar plexus blockade, and postoperative analgesic efficacy. Sixty patients underwent PCB (0.4 mL/kg levobupivacaine 0.5%) and subsequent spinal anesthesia for primary joint arthroplasty (hip or knee) in a prospective, double-blind study. Patients were randomly allocated to undergo PCB by using the Capdevila (group C; n = 30) or a modified Winnie (group W; n = 30) approach. Contralateral spread and lumbar plexus blockade were assessed 15, 30, and 45 min after PCB. Contralateral spread (bilateral from T4 to S5) and femoral and lateral cutaneous nerve block were evaluated by sensory testing, and obturator motor block was assessed. Bilateral anesthesia occurred in 10 patients in group C and 12 patients in group W (P = 0.8). Blockade of the femoral, lateral cutaneous, and obturator nerves was 90%, 93%, and 80%, respectively, for group C and 93%, 97%, and 90%, respectively, for group W (P > 0.05). No differences were found in PCB procedure time, pain scores, 24-h morphine consumption, or time to first morphine analgesia.