Sustained Implementation of an Evidence-Based Extubation Checklist Reduced Extubation Failure in Trauma Patients.

Extubation failure remains a challenge in the perioperative setting. The aim of this intervention was to decrease the rate of perioperative extubation failure through the utilization of an extubation checklist. A five-item evidence-based extubation readiness checklist was implemented at a level I trauma center on all patients who were electively extubated in the operating room (OR). Extubation failure rates before and after implementation of the checklist were compared. Of 26,867 trauma patients extubated in the OR after the intervention, 84 cases (0.31%) failed extubation in the immediate postoperative period. A significant and sustained decrease in extubation failure rate per case performed was observed between the pre- and post-checklist period (OR, 0.33; 95% CI, 0.19, 0.56; P < 0.001). Partial (vs full) checklist completion, higher ASA physical status score, advanced age, and longer case length were independently associated with increased odds of extubation failure in the postintervention period.

Implementation of an evidence-based extubation checklist to reduce extubation failure in patients with trauma: a pilot study.

This prospective, case-controlled observational study assessed whether an evidence-based extubation checklist would increase anesthesia providers' documentation of standardized extubation criteria and reduce the occurrence of preventable extubation failures in the early postoperative period. The sample consisted of 622 ASA Physical Status I to IV patients, aged 10 to 100 years but primarily adults, who underwent elective and emergency surgeries at a university-based adult trauma teaching hospital. Before the study, all anesthesia and postanesthesia care unit staff received an in-service on adherence to an evidence-based extubation checklist, followed by implementation of the checklist for 12 weeks. Demographic data, anesthesia flow sheets, provider notes, and quality assurance records were reviewed to determine utilization of the checklist before extubation and to ascertain those patients who required reintubation. Following use of the extubation checklist, documentation of patient readiness for extubation increased from 54% to 92.5%, and extubation failures decreased from 2.5 per month to 7.2 per month. This study confirmed that extubation failure occurred less frequently when the extubation checklist was used (P = .001, Fisher exact test). Study results indicate that an extubation checklist may positively influence provider documentation of evidence-based criteria for extubation and can reduce the occurrence of preventable extubation failures.

Anesthesia-Related Malpractice Claims in Maryland 1994-2017.

This article presents data on anesthesia cases filed with the Maryland Health Claims Alternative Dispute Office between 1994 and 2017, a publicly available resource that includes all anesthesia-related claims filed in Maryland, regardless of whether they were reported to any national claims repository. Analysis of anesthesia malpractice claims offers critical information that can both decrease legal liability and improve patient outcomes for those receiving anesthesia. A total of 276 claims were filed. Variables under investigation included venue, types of surgery, legal cause of action, trends, and outcomes. Types of anesthesia-related claims included the administration of general anesthesia (59.8%), monitored anesthesia care (14.9%), pain management (10.9%), epidural/spinal anesthesia (9%), nerve blocks (2.9%), and local anesthesia infiltration (2.6%). Most cases (39.5%) involved failure to adequately monitor the patient. Inadequate perioperative care was alleged as the cause of action in 68.8% of cases. Major adverse patient outcomes were death (38.8%), brain damage (21%), and permanent nerve damage (14.9%). Understanding the events that lead to legal action can assist anesthesia providers to focus on ways to improve their practice.

Anesthetic implications of necrotizing fasciitis.

Necrotizing fasciitis, also known as necrotizing acute soft tissue injury (NASTI), commonly occurs as a consequence of group A streptococcal disease. An estimated 9,400 cases of invasive group A streptococcal disease occur annually in the United States, with 600 cases classified as NASTI. Mortality associated with NASTI is estimated at 20% to 50%. Research indicates that early diagnosis and surgical excision of necrotic tissue is the key to minimalization of morbidity and mortality associated with NASTI. Repeated surgeries typically are required in patients with NASTI, posing unusual anesthetic challenges. This article provides an overview of NASTI and includes preoperative, intraoperative, and postoperative anesthetic considerations.

Breastfeeding problems following anesthetic administration.

Research literature supports the notion that maternal comfort should be considered a priority and that mothers should receive adequate information regarding any drug prior to receiving that drug. Some studies indicate that difficulties with breastfeeding may be related to the amount of the anesthetic or analgesic that is administered to the mother. Thus, it seems wise to administer the lowest possible dose to the mother in order to minimize the amount of drug (or metabolite) exposure to the nursing infant. Infant exposure can be further reduced if breastfeeding is avoided during the times when the mother receives high doses of anesthetics and analgesics. However, because relatively small amounts of the drug are excreted into the breast milk, some mothers may opt to continue nursing after weighing the benefits of breastfeeding against the potential risk to the infant. Others may choose to "pump and dump" breast milk while they receive anesthetic or analgesic agents. Any concerns in this regard should be discussed with the anesthesia provider, preferably prior to labor or to any surgeries while breastfeeding.

Severe occupational injuries among older workers: demographic factors, time of injury, place and mechanism of injury, length of stay, and cost data.

Between 2002 and 2012, the number of individuals > 55 years of age in the workforce is projected to climb by approximately 50%. Few studies have substantiated that severe occupational injury to older workers is a significant problem. To identify the variables related to traumatic injuries of older workers, data were abstracted retrospectively from a regional trauma center database, including demographic and injury characteristics, length of hospital and intensive care unit (ICU) stay, and cost. The results showed that older workers had higher fatality rates than younger workers. As age increased, the Injury Severity Score also increased. Most injuries were the result of falls, with orthopedic injuries being the most common type of injury. Patients spent an average of 6 days in the ICU at a cost of > 4920 US dollars/day. By identifying the characteristics associated with older workers' severe occupational injuries, further research and better industry programs targeting this group can be implemented.