Trauma, systemic inflammatory response syndrome, dietary supplements, illicit steroid use and a questionable malignant hyperthermia reaction.

BACKGROUND: Malignant hyperthermia (MH) is a pharmacogenetic disorder of skeletal muscle calcium regulation associated primarily, but not exclusively, with mutations in the skeletal muscle ryanodine receptor. Associated environmental factors, however, may also be important for expression of the syndrome. METHODS AND RESULTS: A 24-yr-old trauma patient developed a fulminant MH crisis after a 3 minute exposure to sevoflurane. A thorough evaluation of underlying co-morbidities revealed a number of environmental factors that could have altered skeletal muscle calcium regulation, and may have potentially influenced the effects of volatile inhaled anesthetics. Since MH is a syndrome characterized by abnormal skeletal muscle calcium regulation, other factors that alter calcium homeostasis may exacerbate the impact of inhaled MH-triggering drugs. CONCLUSIONS: While a thorough history of MH episodes in a proband and family is emphasized as part of a complete preanesthetic evaluation, obtaining a history of other environmental entities that may alter calcium regulation may be equally important to knowing the family history.

Perioperative Corneal Abrasions After Nonocular Surgery: A Systematic Review.

PURPOSE: To perform a systematic review of the international literature evaluating the risk factors, preventative steps, and treatments for perioperative corneal injuries for nonocular surgery. METHODS: PubMed, Embase, and Evidence-Based Medicine Reviews databases were searched on April 13, 2018. Two hundred four articles were identified with 16 meeting the inclusion criteria. All studies were evaluated for quality and level of evidence. Two types of studies were included. The first were primary epidemiological studies that looked at the rates of perioperative corneal injuries after nonocular surgery and the second were trials that either studied preventative steps or treatments. RESULTS: A statistical analysis was completed to reveal trends in perioperative corneal abrasions. Rates ranged from 0.01% to 59% with a cumulative rate of 0.64% (95% confidence interval 0.36%-1.35%). Primary risk factors were identified as longer procedures, general anesthesia, and advanced age. The most commonly associated ocular injuries were found to include chemical injury, conjunctivitis, blurred vision, and conjunctival congestion. Treatment strategies for corneal abrasion in the literature recommended erythromycin ointment and ample ocular lubrication for the fastest recovery. Education interventions alone, as studied in 2 of the 16 articles, demonstrated a significant decrease in the rate of corneal abrasions. CONCLUSIONS: Standardized ocular protection, reporting, and education initiatives were found to maximally decrease rates of perioperative corneal abrasions after nonocular surgery. However, no gold standard currently exists for intraoperative ocular protection. More research needs to be conducted on specific prevention strategies and content of educational initiatives in hopes of standard development across facilities nationwide.

LAST Double Check - A Comprehensive Pre-Regional Checklist for the Busy Institution.

INTRODUCTION: Wrong site peripheral nerve blocks are included in the National Quality Forum and Joint Commission's category of "never event." Multiple attempts have been made by various groups in an effort to eliminate these events. Prior attempts to eliminate these never events include the Regional Block Preprocedural Checklist provided by the American Society of Regional Anesthesia (ASRA) taskforce. Following a series of errors involving anticoagulation prior to regional anesthesia, our department saw a need for a more comprehensive checklist. MATERIALS AND METHODS: An expert panel developed the LAST Double Check Checklist with the aim of identifying and eliminating errors associated with regional anesthesia delivery. This checklist was implemented over the course of two 30 d trial periods. Feedback was collected and any delays associated with implementation were recorded. RESULTS: There were no reported procedures performed on patients taking anticoagulation or reported case delays during the two 30 d trials. A total of 350 regional anesthetics were performed during both trials. During the first week of implementation, a patient was identified as having received enoxaparin, despite the electronic medical record showing the medication as held. The planned regional anesthetic was not performed given increased risk of bleeding. Feedback collected during the trial periods was incorporated into the final draft and implementation of the LAST Double Check for use in all locations where regional anesthesia is performed. There have been no post-implementation events reported (11-mo period, greater than 1,000 regional anesthetics performed). CONCLUSION: The LAST Double Check is a more comprehensive checklist with the aim of preventing errors associated with wrong site blocks, anticoagulation administration, and care team coordination. This checklist covers areas of the patient history that are routinely reviewed prior to regional anesthesia administration and did not contribute to delay in arrival to the operating room.

Introducing a Novel Applicant Ranking Tool to Predict Future Resident Performance: A Pilot Study.

The purposes of this study are to (1) introduce our novel Applicant Ranking Tool that aligns with the Accreditation Council for Graduate Medical Education competencies and (2) share our preliminary results comparing applicant rank to current performance. After a thorough literature review and multiple roundtable discussions, an Applicant Ranking Tool was created. Feasibility, satisfaction, and critiques were discussed via open feedback session. Inter-rater reliability was assessed using weighted kappa statistic (κ) and Kendall coefficient of concordance (W). Fisher's exact tests evaluated the ability of the tool to stratify performance into the top or bottom half of their class. Internal medicine and anesthesiology residents served as the pilot cohorts. The tool was considered user-friendly for both data input and analysis. Inter-rater reliability was strongest with intradisciplinary evaluation (W = 0.8-0.975). Resident performance was successfully stratified into those functioning in the upper vs. lower half of their class within the Clinical Anesthesia-3 grouping (p = 0.008). This novel Applicant Ranking Tool lends support for the use of both cognitive and noncognitive traits in predicting resident performance. While the ability of this instrument to accurately predict future resident performance will take years to answer, this pilot study suggests the instrument is worthy of ongoing investigation.

Milestone-specific, Observed data points for evaluating levels of performance (MODEL) assessment strategy for anesthesiology residency programs.

BACKGROUND: Anesthesiology residency programs will be expected to have Milestones-based evaluation systems in place by July 2014 as part of the Next Accreditation System. METHODS: The San Antonio Uniformed Services Health Education Consortium (SAUSHEC) anesthesiology residency program developed and implemented a Milestones-based feedback and evaluation system a year ahead of schedule. It has been named the Milestone-specific, Observed Data points for Evaluating Levels of performance (MODEL) assessment strategy. RESULTS: The "MODEL Menu" and the "MODEL Blueprint" are tools that other anesthesiology residency programs can use in developing their own Milestones-based feedback and evaluation systems prior to ACGME-required implementation. Data from our early experience with the streamlined MODEL blueprint assessment strategy showed substantially improved faculty compliance with reporting requirements. CONCLUSIONS: The MODEL assessment strategy provides programs with a workable assessment method for residents, and important Milestones data points to programs for ACGME reporting.