Evaluation of the Temple Touch Pro, a Novel Noninvasive Core-Temperature Monitoring System.

BACKGROUND: The Temple Touch Pro (TTP) is a novel system that estimates core temperature from skin over the temporal artery. We tested the hypothesis that this noninvasive system estimates core temperature to an accuracy within 0.5°C. METHODS: Core temperature was continuously monitored in 50 adult and pediatric surgical patients by positioning the sensor patch of a TTP over one temporal artery. The sensor consists of a thermistor array near the skin surface, another set of thermistors above an insulator, and a second insulator between the upper unit and the environment. The sensor measures skin temperature and heat flux, from which the monitor unit estimates core temperature from a proprietary algorithm. Reference core temperature was measured from the esophagus or nasopharynx. We conducted agreement analysis between the TTP and the reference core temperature measurements using the 95% Bland-Altman limits of agreement for repeated measurement data. The proportion of all differences that were within 0.5°C and repeat measures concordance correlation coefficient (CCC) were estimated as well. RESULTS: TTP and the reference core temperature measurements agreed well in both adults and pediatric patients. Bland-Altman plots showed no evidence of systematic bias or variability over the temperature from 35.2°C to 37.8°C. The estimated 95% lower and upper limits of agreement were -0.57°C (95% confidence interval [CI], -0.76 to -0.41) and 0.57°C (95% CI, 0.44 to 0.71), indicating good agreement between the 2 methods. Ninety-four percentage (95% CI, 87% to 99%) of the TTP temperatures were within 0.5°C of the reference temperature. Good agreement was also supported by an estimated repeated measures CCC of 0.82 (95% CI, 0.66 to 0.91). The TTP core temperature measurements also agreed well with nasopharyngeal reference temperatures. CONCLUSIONS: The noninvasive TTP system is sufficiently accurate and reliable for routine intraoperative core temperature monitoring.

Oxygen Reserve Index: A Novel Noninvasive Measure of Oxygen Reserve--A Pilot Study.

BACKGROUND: Pulse oximetry provides no indication of downward trends in PaO2 until saturation begins to decrease. The Oxygen Reserve Index (ORI) is a novel pulse oximeter-based nondimensional index that ranges from 1 to 0 as PaO2 decreases from about 200 to 80 mmHg and is measured by optically detecting changes in SvO2 after SaO2 saturates to the maximum. The authors tested the hypothesis that the ORI provides a clinically important warning of impending desaturation in pediatric patients during induction of anesthesia. METHODS: After preoxygenation, anesthesia induction, and tracheal intubation, the anesthesia circuit was disconnected and oxygen saturation was allowed to decrease to 90% before ventilation recommenced. The ORI and SpO2 values were recorded from a Masimo Pulse Co-Oximeter Sensor at the beginning of apnea, beginning and end of intubation, beginning and end of the ORI alarm, and 2 min after reoxygenation. RESULTS: Data from 25 healthy children, aged 7.6 ± 4.6 yr, were included in the analysis. During apnea, the ORI slowly and progressively decreased over a mean of 5.9 ± 3.1 min from 0.73 ± 0.16 at the beginning of apnea to 0.37 ± 0.11. SpO2 remained 100% throughout this initial period. Concurrently with alarm activation, the ORI began to decrease rapidly, and in median of 31.5 s (interquartile range, 19 to 34.3 s), saturation decreased to 98%. CONCLUSIONS: In this pilot study, the ORI detected impending desaturation in median of 31.5 s (interquartile range, 19-34.3 s) before noticeable changes in SpO2 occurred. This represents a clinically important warning time, which might give clinicians time for corrective actions.

Morbidity and mortality after major pulmonary resections in patients with locally advanced stage IIIA non-small cell lung carcinoma who underwent induction therapy.

BACKGROUND: The optimal treatment for patients with locally advanced stage IIIA non-small cell lung carcinoma (NSCLC) remains controversial, but induction therapy is increasingly used. The aim of this study was to evaluate mortality, morbidity, hospital stay and frequency of postoperative complications in stage IIIA NSCLC patients that underwent major pulmonary resections after neoadjuvant chemotherapy or chemoradiation. METHODS: We conducted a retrospective analysis of all patients who underwent major pulmonary resections after induction therapy for locally advanced NSCLC from October 2009 to February 2014. Forty-one patients were included in the study. RESULTS: Complete resection was achieved in 40 patients (97.5%). A complete pathologic response was seen in 10 patients (24.4%). Mean hospital stay was 17.7 days (ranged 5-129 days). Early (in-hospital) mortality occurred in 2.4% (one patient after bilobectomy), late (six months) mortality in 4.9% (two patients after right pneumonectomy and bilobectomy), and overall morbidity in 58.5% (24 patients). Postoperative complications included: bronchopleural fistula (BPF) with empyema - three patients, empyema without BPF - five patients, air leak - eight patients, atrial fibrillation - eight patients, pneumonia - eight patients, and lobar atelectasis - four patients. CONCLUSION: Following neoadjuvant therapy for stage IIIA NSCLC, pneumonectomy can be performed with low early and late mortality (0% and 5.8%, respectively), bilobectomy is a high risk operation (16.7% early and 16.7% late mortality); and lobectomy a low risk operation (0% early and late mortality). The need for major pulmonary resections should not be a reason to exclude patients from a potentially curative procedure if it can be performed with acceptable morbidity and mortality rates at an experienced medical centre.

Effect of Surgical Safety checklist implementation on the occurrence of postoperative complications in orthopedic patients.

BACKGROUND: Surgical adverse events are errors that emerge during perioperative patient care. The World Health Organization recently published "Guidelines for Safe Surgery." OBJECTIVES: To estimate the effect of implementation of a safety checklist in an orthopedic surgical department. METHODS: We conducted a single-center cross-sectional study to compare the incidence of complications prior to and following implementation of the Guidelines for Safe Surgery checklist. The medical records of all consecutive adult patients admitted to the orthopedics department at Wolfson Medical Center during the period 1 July 2008 to 1 January 2009 (control group) and from 1 January 2009 to 1 July 2009 (study group) were reviewed. The occurrences of all complications were compared between the two groups. RESULTS: The records of 760 patients (380 in each group) hospitalized during this 12 month period were analyzed. Postoperative fever occurred in 5.3% versus 10.6% of patients with and without the checklist respectively (P = 0.008). Significantly more patients received only postoperative prophylactic antibiotics rather than both pre-and postoperative antibiotic treatment prior to implementation of the checklist (3.2% versus 0%, P = 0.004). In addition, a statistically non-significant 34% decrease in the rate of surgical wound infection was also detected in the checklist group. In a logistic regression model of postoperative fever, the checklist emerged as a significant independent predictor of this outcome: odds ratio 0.53, 95% confidence interval 0.29-0.96, P = 0.037. CONCLUSION: A significant reduction in postoperative fever after the implementation of the surgical safety checklist occurred. It is possible that the improved usage of preoperative prophylactic antibiotics may explain the reduction in postoperative fever.

Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises: results from the Israeli Board of Anesthesiologists.

BACKGROUND: Cardiac arrest in the parturient is often fatal, but appropriate resuscitation in this special situation may save the lives of the mother and/or unborn baby. Concern has arisen as to application of recommended techniques for resuscitation in the obstetric patient. The Israel Board of Anesthesiology has incorporated simulation assessment into accreditation examinations. The candidates represent a unique national cohort in which we were able to assess competence in the simulated scenario of cardiorespiratory arrest in the parturient. METHODS A simulated scenario of preeclampsia with magnesium toxicity leading to cardiac arrest in a pregnant patient was performed by 25 senior anesthesiology residents. A unique two-stage simulation examination consisting of high fidelity simulation followed immediately by oral debriefing was conducted. The assessment was scored using a predetermined checklist of key actions and answers to clarifying questions. Simulation performance was compared to debriefing performance. RESULTS During the board examination, resuscitation not specific to the pregnant patient was performed well (commencing chest compressions, bag-mask ventilation, cardiac defibrillation); however actions specific to the parturient were performed poorly. Left uterine displacement, cricoid pressure during bag-mask ventilation, and instructing preparations to be made for perimortem cesarean delivery within 5 minutes were performed by 68%, 48%, and 40% of candidates respectively (lower 99% confidence limit 42%, 25%, and 19%, respectively). Cricoid pressure during bag-mask ventilation was performed by 48% (25%) but described in debriefing by 80% of candidates (53%) (P = 0.08), and time setting for perimortem cesarean delivery was performed by 40% (29%) but described by 80% (53%) (P = 0.05) of examinees. CONCLUSIONS Senior anesthesiology residents have poor knowledge of resuscitation of the pregnant patient. The results suggest 2-stage simulation including an oral component may reveal disparities in knowledge not assessed by simulation alone, but definitive conclusions require further study.

Airway management practices in adult intensive care units in Israel: a national survey.

Timely and adequate management of normal and compromised airway is a crucial task facing medical teams taking care of patients in intensive care units. We investigated the airway management practices in the Israeli intensive care units (ICUs). A postal survey was sent to the 20 main ICUs in Israel. We investigated which medical specialty (ICU, anesthesiology or ENT) is involved with airway management in the ICUs and summarized the availability of airway equipment and medication necessary for endotracheal intubation, the use of dedicated airway management algorithms, the approaches to specific airway scenarios and education in airway management. The response rate was 70 % (14 out of the 20 units). Intubation with normal airway is performed mainly by ICU doctors (86 %). A difficult airway is most frequently cared for by anesthesiologists (79 %), while impossible intubation/mask ventilation is mainly managed by anesthesiologists and ENT surgeons (50-79 %). Airways in C-spine injury are mainly managed by anesthesiologists (70 %). Surgical airway is mainly performed by ENT surgeons (79 %). The ASA difficult airway algorithm is used in 71 % of the units. Fiberoptic intubation is used significantly more often than other methods in two scenarios: 78 % of the difficult airways and 64 % of the C-spine injuries (p < 0.0001). Only 43 % of the units reported holding quality assurance meetings. 69 % of the units' heads are satisfied with their airway management policies. Equipment and medications necessary for airway management are available in most of the units. Difficult airways in ICUs are mainly managed by anesthesiologists and ENT surgeons. Few ICUs have quality assurance meetings.

Identifying and managing technical faults in the anesthesia machine: lessons learned from the Israeli Board of Anesthesiologists.

BACKGROUND: The potential for catastrophe resulting from anesthetic equipment failure and the failure of training programs to adequately prepare residents to detect and manage equipment failure prompted the Israel Board of Anesthesiologists to include simulation-based testing in the Objective Structured Clinical Evaluation component of the Israeli Board Examination in Anesthesiology. METHODS: We used simulation-based scenarios to measure the performance of residents while (a) checking the anesthesia machine before the first morning case, (b) checking the anesthesia machine between cases, (c) managing an oxygen pipeline failure, and (d) managing an expiratory valve failure. RESULTS: During board examination, 3 of 28 examinees failed to correctly check at least 70% of the items on the anesthesia machine checkout list before the first morning case and 3 of 30 failed to correctly check 70% of the items between cases. Although all examinees recognized inadequate oxygen cylinder pressure and a malfunctioning valve, 1 of 31 examinees failed to open the O(2) cylinder, 6 of 31 did not disconnect the anesthesia machine from the central oxygen supply, 14 of 31 could not explain how to minimize the use of oxygen, 2 of 30 failed to find the faulty valve, and 15 of 30 could not give the correct differential diagnosis. CONCLUSIONS: During simulation-based board examination most senior anesthesia residents became aware of equipment failures but many failed to correctly diagnosis and manage the failure.

Objective Structured Clinical Examination-based assessment of regional anesthesia skills: the Israeli National Board Examination in Anesthesiology experience.

Simulation techniques are increasingly being used in anesthesia training programs and to a lesser extent in evaluation of residents. We describe 7 years of experience with Objective Structured Clinical Examination-based regional anesthesia assessment in the Israeli National Board Examinations in Anesthesiology. We believe this is the first use of such mock scenarios for the assessment of regional anesthesia for the important purpose of national accreditation. During the study period, 308 candidates were examined in 1 of 8 different blocks. The total pass rate was 83%(257 of 308), ranging from 73% to 91%. The interrater correlation for total, critical, and global scores were 0.84, 0.88, and 0.75, respectively. Technological and cost constraints preclude actual assessment of regional anesthesia. However, testing formats that more closely reflect clinical practice are potentially valuable adjuncts to traditional examinations.

Perioperative metabolic alkalemia is more frequent than metabolic acidemia in major elective abdominal surgery.

OBJECTIVE: To investigate the incidence, type and etiology of perioperative metabolic disturbances associated with major abdominal surgery. We hypothesized that metabolic alkalemia is more frequent than metabolic acidemia. METHODS: This was a prospective, observational study, performed in a university-affiliated hospital. 98 consecutive patients undergoing major abdominal surgery were included in the study. Patients were observed by serial vital signs and laboratory measurements during the preoperative, intraoperative, PACU and the first three postoperative day periods. Central venous pressure, systolic pressure variation, fluid input, urine output, temper- ature, electrolytes, and acid-base variables were recorded. The primary endpoint of the study was the incidence of metabolic alkalemia or acidemia. Metabolic alkalemia was defined as pH >7.45 and BE >+3. Metabolic acidemia was defined as pH <7.35 and BE <-3. Continuous variables were described as mean ± standard deviation. Distributions of continuous variables was assessed for normalty using the Kolmogorov-Smirnov test (cut off at P = 0.01). The frequency of metabolic acidemia or alkalemia was compared across time points using Cochran's Q test and between time points using the binomial distribution. RESULTS: Metabolic acidemia occurred only intraoperatively and in the PACU. Subjects with metabolic acidemia were older, (74 ± 9 yr. vs. 66 ± 12, P = 0.01). Intraoperative body temperature was inversely associated with PACU lactate (P = 0.035). Blood loss >500 mL was more frequent in acidemic patients (42% vs. 19%, P = 0.033). More patients with hyperphosphatemia had acidemia than subjects without hyperphosphatemia (39% vs. 17%, P = 0.019). Metabolic alkalemia occurred more frequently than metabolic acidemia (49% vs. 23%, P < 0.0001) and was correlated with hypochloremia. The incidence of metabolic alkalemia decreased from baseline to intraoperative and PACU periods (13% vs. 3%, P = 0.003) and increased from the PACU to the three postoperative days (3% vs. 45%, P = 0.007). CONCLUSIONS: Metabolic alkalemia occurred more frequently than metabolic acidemia and occurred mainly preoperatively and postoperatively, while acidemia occurred mainly during surgery and in the PACU.

Organizational prerequisites for anesthesia outside the operating room.

PURPOSE OF REVIEW: The purpose of this review is to define the responsibility and designation of anesthesia personnel to nonoperating room location anesthesia and their education in this regard. The review will also define the safety standards, guidelines, physical environment, equipment, accreditation, the quality of care and patient and procedural selection. RECENT FINDINGS: Anesthesia outside the operating room continues to be a challenging field. With the advances in surgical and anesthetic technology, there is an increasing need for research in the area of office-based anesthetic techniques and for improvement in terms of adherence to safety standards in aiming to decrease morbidity and mortality and increase patient satisfaction. SUMMARY: Complications of anesthesia outside the operating room still persist even in American Society of Anesthesiologists (ASA) status I patients and in accredited facilities with board-certified physicians. The department of anesthesiology taking care of the in-hospital office-based facility has the responsibility to define safe practice standards according to the ASA guidelines regarding education, documentation, guidelines preparation, equipment, standards monitoring, collaboration with other facilities, backup for the personnel in case of emergencies and prolongation of observation of a complicated patient in the postanesthesia care unit. Office-based facilities outside the hospital should comply with all federal, state, local laws and regulations. Such precautions will enhance safety, efficiency and reliability of office-based anesthesia inside and outside the hospital.

Early postoperative seizures after vocal fold surgery attributed to shigellosis.

A 44-year-old previously healthy woman underwent surgery of the vocal folds and developed early postoperative seizures caused by an unusual aetiology. Clinical assessment and laboratory results revealed that the patient suffered from an acute-onset shigellosis infection which was thought to be the cause of her early postoperative seizures. The shigellosis infection was treated with azithromycin which resulted in rapid clinical improvement, and the seizures were successfully managed with benzodiazepines, sodium valproate and levetiracetam. To our knowledge, this is the first reported case of shigellosis-induced seizures in an adult in the peri-operative period. Early detection of the aetiology of seizures is crucial to ensure appropriate management and a safe patient outcome.

A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age.

OBJECTIVE: To present a concise history of tracheostomy and tracheal intubation for the approximately forty centuries from their earliest description around 2000 BC until the middle of the twentieth century, at which time a proliferation of advances marked the beginning of the modern era of anesthesiology. DATA SOURCES: Review of the literature. CONCLUSIONS: The colorful and checkered past of tracheostomy and tracheal intubation informs contemporary understanding of these procedures. Often, the decision whether to perform a life-saving tracheostomy or tracheal intubation has been as important as the technical ability to perform it. The dawn of modern airway management owes its existence to the historical development of increasingly effective airway devices and to regular contributions of research into the pathophysiology of the upper airway.

Monitored anaesthesia care in the elderly: guidelines and recommendations.

As the number of elderly patients undergoing surgery continues to rise, it is important to consider anaesthetic options that minimize physiological stress in these patients. Monitored anaesthesia care (MAC), or sedation and monitoring during surgery, is an attractive option for certain common procedures. However, those administering MAC must consider the normal decline in functional reserve in patients aged >70 years. This includes loss of normal compensation for the stress of hypovolaemia, decreased peripheral vascular resistance, altered mental status and reduced response to hypoxia and hypercarbia associated with the perioperative and sedated state in this population. In addition, vigilance is necessary to identify co-morbid states, which increase in incidence with age and often present atypically. Elderly patients have increased sensitivity to all sedatives and opioids (doubled by age 80 years, quadrupled by age 90 years with benzodiazepines). As a result of changes in body composition, as well as senescence of renal and hepatic function, the time to onset and offset of even short-acting sedatives will be prolonged. There is also extreme variability in the response to sedatives among these patients. Anaesthetic dosing should be in smaller increments in the elderly, boluses reduced by half and infusions reduced by as much as two-thirds. Caution must be exercised through full monitoring of intra-operative and postoperative mental status, oxygenation and perfusion states. Pain is best treated using smaller doses in a multimodal regimen, the aim being to reduce adverse effects while ensuring adequate pain relief. In this way, a huge range of procedures can be safely performed in our aging population with expectations for a full and early return to baseline functional status.

Listening to music during anesthesia does not reduce the sevoflurane concentration needed to maintain a constant bispectral index.

BACKGROUND: Music reduces stress responses in awake subjects. However, there remains controversy about the role of music or therapeutic suggestions during general anesthesia and postoperative recovery. We thus tested the hypothesis that intraoperative exposure to soothing music reduces the end-tidal concentration of sevoflurane (ETSevo) necessary to maintain bispectral index (BIS) near 50 during laparoscopic surgery. METHODS: Forty patients, aged 40-60 yrs, ASA I and II, undergoing laparoscopic hernias or cholecystectomy under general anesthesia were studied. All patients were connected to a BIS monitor. Anesthesia was induced with fentanyl 2 microg/kg, sevoflurane in oxygen, rocuronium (0.6 mg/kg), and maintained with sevoflurane in oxygen and 50% nitrous oxide, with an infusion of fentanyl (1 microg x kg(-1) x h(-1)). Sevoflurane was titrated to maintain BIS near 50 throughout the procedure. Patients were randomly assigned to either listen to music or not. RESULTS: The ETSevo necessary to maintain a BIS near 50 was virtually identical in patients who listened to music (1.29 +/- 0.33%) and those who did not (1.27 +/- 0.33%, P = 0.84). Patients who listened to music reported slightly less pain, but the difference was not statistically significant. Mean arterial blood pressure was slightly higher in patients who listened to music (101 +/- 11 mm Hg) than in those who did not (94 +/- 10 mm Hg, P = 0.040). CONCLUSIONS: The end-tidal concentration of sevoflurane required to maintain BIS near 50 during laparoscopic cholecystectomy was virtually identical in patients exposed to music or not. Although previous work suggests that music reduces preoperative stress and may be useful during sedation, our results do not support the use of music during surgery.

A prospective, randomized comparison of cobra perilaryngeal airway and laryngeal mask airway unique in pediatric patients.

BACKGROUND: The Cobra Perilaryngeal Airway (PLA) provides better sealing pressure than the Laryngeal Mask Airway Unique (LMAU) during positive-pressure ventilation in adults. We compared the performance of the CobraPLA and LMAU in infants and children. METHODS: Two-hundred pediatric patients were randomly assigned to a CobraPLA or an Laryngeal Mask Airway (LMA). We measured airway sealing at cuff inflation pressures of 40 and 60 cm H2O; ease and time of insertion; device stability; efficacy of ventilation; number of insertion attempts; incidence of postoperative sore throat, dysphonia, laryngospasm, bronchospasm, and gastric gas insufflation. Steady-state end-tidal(CO2) was measured at the head of the CobraPLA and at the "Y-piece" piece of the anesthetic circuit. For the major outcomes, the airway groups were subdivided post hoc into small and large CobraPLA and small and large LMA subgroups. Results are presented as means +/- sds; P < 0.05 was considered statistically significant. RESULTS: Airway sealing pressure with the cuff inflated to 60 cm H2O in the large CobraPLA subgroup (22 +/- 7 cm H2O) was significantly more than that of the small CobraPLA subgroup (18 +/- 5 cm H2O) and large LMA subgroup (16 +/- 5 cm H2O; P < 0.001). The CobraPLA was more stable than the LMA (same anatomic fit score before and after surgery) and produced less gastric insufflation. Head CobraPLA end-tidal(CO2) values were 6.4 +/- 6 mm Hg more than those of the Y piece of the circle circuit. CONCLUSIONS: The CobraPLA airway performed as well as the LMAU during anesthesia in pediatric patients for a large range of outcomes and was superior for some.

CobraPLA Insertion by anesthetists and non-anesthetists wearing unconventional protective gear: a prospective study in humans.

BACKGROUND: The threat of a mass casualty unconventional attack has challenged the medical community to devise means for providing rapid and reliable emergent airway control under chaotic conditions by inexperienced medical personnel dressed in self protective gear. Since endotracheal intubation may not be feasible under those conditions, other extraglottic devices should be considered. We assessed the performance of anesthesia and non-anesthesia residents in inserting the CobraPLA, a supraglottic airway device, on consecutive anesthetized patients, to assess its potential use under simulated conditions. MATERIAL/METHODS: Anesthesia and non-anesthesia residents wearing either surgical scrubs or complete anti-chemical gear inserted the CobraPLA in anesthetized patients. If post-trial positive pressure ventilation via the CobraPLA was unsuccessful, an LMA or endotracheal tube was inserted in its stead. RESULTS: It took anesthesia residents 57+/-23 sec and 43+/-13 sec (P<0.05) to place the CobraPLA while wearing anti-chemical gear and surgical scrubs, respectively. Non-anesthesia residents wearing anti-chemical gear performed worse than anesthetists in their first insertion (73+/-9 sec, P<0.05), but after the brief training period they performed as well as their colleagues anesthetists (58+/-10 sec, P=NS). Post-trial, twenty-one CobraPLA (42%) leaked, preventing adequate positive-pressure ventilation: 13 devices (26% of the total) required replacements. CONCLUSIONS: Anti-chemical protective gear slowed the insertion of the CobraPLA by anesthetists, and more so by other residents inexperienced in airway management. In 26% of the cases CobraPLA was inadequate for positive pressure ventilation.