Advanced Monitoring Is Associated with Fewer Alarm Events During Planned Moderate Procedure-Related Sedation: A 2-Part Pilot Trial.

BACKGROUND: Diagnostic and interventional procedures are often facilitated by moderate procedure-related sedation. Many studies support the overall safety of this sedation; however, adverse cardiovascular and respiratory events are reported in up to 70% of these procedures, more frequently in very young, very old, or sicker patients. Monitoring with pulse oximetry may underreport hypoventilation during sedation, particularly if supplemental oxygen is provided. Capnometry may result in false alarms during sedation when patients mouth breathe or displace sampling devices. Advanced monitor use during sedation may allow event detection before complications develop. This 2-part pilot study used advanced monitors during planned moderate sedation to (1) determine incidences of desaturation, low respiratory rate, and deeper than intended sedation alarm events; and (2) determine whether advanced monitor use is associated with fewer alarm events. METHODS: Adult patients undergoing scheduled gastroenterology or interventional radiology procedures with planned moderate sedation given by dedicated sedation nurses under the direction of procedural physicians (procedural sedation team) were monitored per standard protocols (electrocardiography blood pressure, pulse oximetry, and capnometry) and advanced monitors (acoustic respiratory monitoring and processed electroencephalograpy). Data were collected to computers for analysis. Advanced monitor parameters were not visible to teams in part 1 (standard) but were visible to teams in part 2 (advanced). Alarm events were defined as desaturation-SpO2 ≤92%; respiratory depression, acoustic respiratory rate ≤8 breaths per minute, and deeper than intended sedation, indicated by processed electroencephalograpy. The number of alarm events was compared. RESULTS: Of 100 patients enrolled, 10 were excluded for data collection computer malfunction or consent withdrawal. Data were analyzed from 90 patients (44 standard and 46 advanced). Advanced had fewer total alarms than standard (Wilcoxon-Mann-Whitney = 2.073, P = 0.038; Wilcoxon-Mann-Whitney odds, 1.67; 95% confidence interval [CI], 1.04-2.88). Similar numbers of standard and advanced had ≥1 alarm event (Wald difference, -10.2%; 95% CI, -26.4% to 7.0%; P = 0.237). Fewer advanced patients had ≥1 respiratory depression event (Wald difference, -22.1%; 95% CI, -40.9% to -2.4%; P = 0.036) or ≥1 desaturation event (Wald difference, -24.2%; 95% CI, -42.8% to -3.6%; P = 0.021); but there was no significant difference in deeper than intended sedation events (Wald difference, -1.38%; 95% CI, -20.21% to 17.49%; P = 0.887). CONCLUSIONS: Use of advanced monitoring parameters during planned moderate sedation was associated with fewer alarm events, patients experiencing desaturation, and patients experiencing respiratory depression alarm events. This pilot study suggests that further study into the safety and outcome impacts of advanced monitoring during procedure-related sedation is warranted.

Transfusion Ethics in a Pediatric Jehovah's Witness Trauma Patient: Simulation Case.

INTRODUCTION: Current ethical practice allows for adult patients with decision-making capacity to refuse blood transfusion, even at the cost of high morbidity or mortality. However, for an adult patient who is of the Jehovah's Witness faith, an unwanted blood transfusion confers a psychospiritual cost to the patient and a financial cost to health care entities. The ethical boundaries are increasingly ambiguous with minors who are members of the Jehovah's Witness faith. This simulation experience intends to identify and address knowledge gaps in the care of minors in an emergent setting using a biomedical ethics framework. METHODS: This scenario provides an immersive simulation experience involving a 12-year-old Jehovah's Witness patient requiring emergent laparotomy for splenic hemorrhage. Patient interview (via simulation manikin with instructor voice) and care handoff take place in an operating room setting. The learner ascertains the patient's and family's refusal of blood products. Induction of general anesthesia results in profound patient hypotension secondary to acute blood-loss anemia. Pulseless electrical activity results if packed red blood cells are not administered. Ethical principles require the learner to impose an unwanted lifesaving therapy on a minor patient over the objections of family members. Secondly, the anesthesia provider must advocate for transfusion on these ethical grounds against a well-meaning but ultimately misguided surgeon who opposes transfusion. An included learner evaluation form based on ACGME core competencies facilitates postsimulation debriefing. RESULTS: Participants were primarily anesthesia residents and fellows. Anecdotally, the residents said that it "felt good to be an attending" and that the simulation helped them appreciate how important conflict resolution skills are in the OR setting. Additionally, faculty appreciated the ability to assess the development of crucial assertiveness skills, with the option of remediating incorrect behavior during the debriefing. DISCUSSION: This simulation experience provides experience in the emergent medical management of a pediatric trauma patient while also incorporating specific ethical consent issues unique to pediatric and trauma patient populations. Furthermore, this experience develops professionalism skills and practice in assertive patient advocacy.

Continuous Noninvasive Hemodynamic Monitoring in an Infant With Tetra-Amelia.

Tetra-amelia syndrome is a congenital disorder associated with near or complete absence of all 4 limbs. Noninvasive hemodynamic monitoring may be difficult or impossible in such patients. We describe the use of a finger cuff blood pressure system for continuous noninvasive blood pressure monitoring in an infant with near-complete tetra-amelia undergoing laparoscopic gastrostomy tube placement. This case suggests the potential use of such a blood pressure monitoring system for other patients with comparable deformities.

Comparison of web-based and face-to-face interviews for application to an anesthesiology training program: a pilot study.

OBJECTIVE: This study compared admission rates to a United States anesthesiology residency program for applicants completing face-to-face versus web-based interviews during the admissions process. We also explored factors driving applicants to select each interview type. METHODS: The 211 applicants invited to interview for admission to our anesthesiology residency program during the 2014-2015 application cycle were participants in this pilot observational study. Of these, 141 applicants selected face-to-face interviews, 53 applicants selected web-based interviews, and 17 applicants declined to interview. Data regarding applicants' reasons for selecting a particular interview type were gathered using an anonymous online survey after interview completion. Residency program admission rates and survey answers were compared between applicants completing face-to-face versus web-based interviews. RESULTS: One hundred twenty-seven (75.1%) applicants completed face-to-face and 42 (24.9%) completed web-based interviews. The admission rate to our residency program was not significantly different between applicants completing face-to-face versus web-based interviews. One hundred eleven applicants completed post-interview surveys. The most common reasons for selecting web-based interviews were conflict of interview dates between programs, travel concerns, or financial limitations. Applicants selected face-to-face interviews due to a desire to interact with current residents, or geographic proximity to the residency program. CONCLUSIONS: These results suggest that completion of web-based interviews is a viable alternative to completion of face-to-face interviews, and that choice of interview type does not affect the rate of applicant admission to the residency program. Web-based interviews may be of particular interest to applicants applying to a large number of programs, or with financial limitations.