Improving safety in anesthetized patients undergoing magnetic resonance imaging-Concept of time-out in the MRI suite and measures to improve adherence to time-out protocol.

BACKGROUND: The time-out protocol introduced by the Joint Commission is an important tool to prevent adverse events and improve safety in various health-care environments. However, its implementation and utilization involve human, social, behavioral as well as system issues. AIMS: The SMART aim of the current project was to increase the utilization of the time-out protocol to more than 80% from baseline of 13%, over 6-month period in all the magnetic resonance imaging (MRI) procedures performed at a tertiary care, teaching institute in South India. METHODS: The Plan, Do, Study, Act (PDSA) cycle and root cause analysis strategies were utilized in this quality improvement initiative. The time-out protocol was modified for MRI environment and put into practice to improve safety. Six months after the initiation of this safety protocol, our audit showed only a 13% compliance to the time-out protocol. A multimodal strategy was utilized by involving all the stakeholders, educational interventions, and placing reminders for following the time-out protocol, to affect change and achieve improvement in safety. RESULTS: The compliance to time-out protocol increased from 13% to 86% and the run chart showed that a special cause variation indicated by six points above the centerline at 86%. When analyzing individual components of the time-out, the greatest improvement was noted in the ferromagnetic check of the personnel involved, namely, the Anesthesiologist, radiographer, and anesthesia technician. There were no delays in the list because of adherence to the time-out protocol. CONCLUSION: Time-out protocol in an MRI suite provides a final check to the anesthesia team before the anesthetized patient is wheeled into MR gantry. Using quality improvement methodology, we increased the compliance of time-out protocol in the magnetic resonance imaging environment. Our study is an example how other institutions in India and elsewhere can adapt similar improvement strategies to enhance patient safety.

Reduction in post-operative nausea and vomiting (PONV) by preoperative risk stratification and adherence to a standardized anti emetic prophylaxis protocol in the day-care surgical population.

CONTEXT: Postoperative nausea (PON) and postoperative vomiting (POV) are the most undesirable morbidity after anaesthesia. There is paucity of data on PONV from the Indian subcontinent. AIMS: We aim to study the prevalence of PON and POV, associated risk factors and the effect of following standardized risk stratification and prophylaxis protocols in the day care patient population. SETTINGS AND DESIGN: This was a prospective cohort study at a tertiary care teaching institute. METHODS AND MATERIAL: Data from 500 patients undergoing day care surgery over a period of 12 months were analysed. We used the Apfel scoring system for evaluation of risk of post-operative nausea and vomiting (PONV) for each participant. A standard PONV prophylaxis protocol was used intra-operatively. STATISTICAL ANALYSIS USED: Data analysis was done using the Mann-Whitney U test, the Chi-square and Fisher's exact test. RESULTS: The period prevalence of post-operative nausea (PON) and post-operative vomiting (POV) was 2.04% and 2.45%, respectively, in this study. The prevalence of PONV in each risk category was lower than that predicted by the Apfel score due to utilization of a standard anti-emetic prophylactic protocol. We found younger age, previous history of nausea, previous history of vomiting, urological surgeries and alcohol consumption as significant risk factors for postoperative nausea. Longer duration of surgery, previous history of nausea, alcohol consumption and higher BMI were the significant risk factors for postoperative vomiting. CONCLUSIONS: Adherence to preoperative risk stratification and a standard anti-emetic prophylactic protocol can significantly reduce the prevalence of postoperative nausea and vomiting.

A Prospective Randomized Trial Comparing Topical Intranasal Lidocaine and Levobupivacaine in Patients Undergoing Endoscopic Binostril Transnasal Transsphenoidal Resection of Pituitary Tumors.

INTRODUCTION: Local anesthetic intranasal packing is used in transnasal surgery to reduce hemodynamic fluctuations. We hypothesized that the long acting local anesthetic levobupivacaine would provide superior hemodynamic stability and postoperative analgesia compared with lidocaine in endoscopic transnasal transsphenoidal (TNTS) surgery. MATERIALS AND METHODS: In this prospective, randomized, double-blind trial, 48 patients undergoing TNTS surgery were allocated to the 2 groups to receive preoperative intranasal packing with 15 mL of 1.5% lidocaine or 0.5% levobupivacaine each mixed with 60 mg ephedrine. Heart rate and mean arterial blood pressure were recorded immediately before induction of anesthesia, at various time points throughout surgery, and at tracheal extubation. Bleeding in the surgical field, time to extubation, and postoperative pain were also assessed. RESULTS: There was no significant difference in heart rate between the lidocaine and levobupivacaine groups at any point. Mean arterial pressure was also similar between the 2 groups during surgery, whereas at extubation blood pressure was lower in the lidocaine compared with levobupivacaine group (85±10 vs. 96±16 mm Hg; P=0.0010). There were no differences between the 2 groups in the other outcome variables. CONCLUSIONS: Preoperative intranasal packing with 1.5% lidocaine or 0.5% levobupivacaine provide similar hemodynamic stability throughout TNTS. Lidocaine packing may be more advantageous for hemodynamic stability during extubation.

Preoperative Anxiety in Adult Patients Undergoing Day Care Surgery: Prevalence and Associated Factors.

BACKGROUND: There is a paucity of data related to anxiety levels in patients undergoing day care surgery in India. METHODS: Preoperative anxiety was assessed using Amsterdam Preoperative Anxiety and Information Scale (APAIS) 1 day before surgery and on the day of surgery, and the patients were categorized as cases (APAIS score ≥13) and controls (APAIS score <13). Sociodemographic characteristics, clinical features, and fears associated with anesthesia and surgery were also noted. RESULTS: Out of the 399 patients recruited, 58.1% experienced significant preoperative anxiety. The fear of needles (P = 0.002), fear of waking up during the surgery (P < 0.001), and the patient's need of additional information regarding anesthesia and surgery (P < 0.001) were significantly associated with preoperative anxiety. CONCLUSION: A significant proportion of patients scheduled for day care surgery have preoperative anxiety. A preanesthetic workup of a patient with adequate clarification about their doubts and fears related to anesthesia and surgery is recommended to bring down the level of anxiety.

Changes in central venous oxygen saturation, lactates, and ST segment changes in a V lead ECG with changes in hemoglobin in neurosurgical patients undergoing craniotomy and tumor excision: A prospective observational study.

BACKGROUND AND AIMS: The aim of the study was to observe the trends in central venous oxygen saturation (ScvO2), lactate, and ST segment changes with change in hemoglobin in patients undergoing acute blood loss during surgery and to assess their role as blood transfusion trigger. MATERIAL AND METHODS: Seventy-seven consecutive patients undergoing craniotomy at a tertiary care institution were recruited for this study after obtaining written, informed consent. After establishing standard monitoring, anesthesia was induced with standard anesthetic protocol. Hemodynamic parameters such as heart rate, blood pressure (mean, systolic, diastolic), pulse pressure variation (PPV), and physiological parameters such as lactate, ScvO2, ST segment changes were checked at baseline, before and after blood transfusion and at the end of the procedure. STATISTICAL ANALYSIS: Comparison of the mean and standard deviation for the hemodynamic parameters was performed between the transfused and nontransfused patient groups. Pearson correlation test was done to assess the correlation between the covariates. Receiver operating characteristic (ROC) curve was constructed for the ScvO2 variable, which was used as a transfusion trigger and the cutoff value at 100% sensitivity and 75% specificity was constructed. Linear regression analysis was done between the change in hemoglobin and the change in ScvO2 and change in hemoglobin and change in the ST segment. RESULTS: There was a statistically significant positive correlation between the change in ScvO2 and change in hemoglobin during acute blood loss with a regression coefficient of 0.8 and also between change in ST segment and hemoglobin with a regression coefficient of -0.132. No significant change was observed with lactate. The ROC showed a ScvO2 cutoff of 64.5% with a 100% sensitivity and 75% specificity with area under curve of 0.896 for blood transfusion requirement. CONCLUSIONS: We conclude that ScvO2 and ST change may be considered as physiological transfusion triggers in patients requiring blood transfusion in the intraoperative period.

An audit of morbidity and mortality associated with foreign body aspiration in children from a tertiary level hospital in Northern India.

BACKGROUND: There is paucity of data regarding the morbidity and mortality of rigid bronchoscopy in children for foreign body (FB) retrieval from India. The aim was to audit data regarding anaesthetic management of rigid bronchoscopy in children and associated morbidity and mortality. MATERIALS AND METHODS: Hospital records of all patients below 18 years of age undergoing rigid bronchoscopy for suspected FB aspiration (FBA) between January 1, 2002 and December 31, 2011 were audited to assess their demographic profile, anaesthetic management, complications, and postoperative outcomes. The children were divided into early and late diagnosis groups depending on whether they presented to the hospital within 24 hours of FBA, or later. RESULTS: One hundred and forty children, predominantly male (75%), with an average age of 1-year and 8 months, presented to our hospital for rigid bronchoscopy during the study period. Majority of children presented in the late diagnosis group (59.29% vs. 40.71%). The penetration syndrome was observed in 22% of patients. Majority of patients aspirated an organic FB (organic: Inorganic FB = 3:1), with peanuts being the most common (49.28%). A significantly higher number of children presented with cough (P = 0.0001) and history of choking (P = 0.0022) in the early diagnosis group and crepitations (P = 0.0011) in the late diagnosis group. Major complications included cardiac arrest (2.1%), pneumothorax (0.7%), and laryngeal oedema (9.3%). The average duration of hospitalization in our series was 3.08 ± 0.7 days. CONCLUSIONS: Foreign body aspiration causes considerable morbidity, especially when diagnosis is delayed.

Stridor in children: Is airway always the cause?

Stridor in children is usually, but not always caused by airway pathology. The anesthesiologists should have a sound knowledge of the neurological associations of stridor and its management. In such cases, prompt treatment of the neurological pathology usually resolves the stridor and may prevent unnecessary airway evaluation and intervention in the child.

Anesthetic considerations in a preterm: Extremely low birth weight neonate posted for exploratory laparotomy.

Preterm neonates present unique challenges to the anesthesiologist due to their immature physiology and anatomy. Many preterm neonates are critically ill and can develop necrotizing enterocolitis, respiratory distress syndrome, intra ventricular hemorrhage, and heart failure or retinopathy of prematurity. Anesthesiologists play a vital role in the management of preterm neonates requiring surgical interventions, by integrating their knowledge of the developmental physiology and pharmacology. The successful conduct of anesthesia in premature neonates requires an understanding of the basic principles of neonatal care.

Submental intubation for airway management of patients with complex caniomaxillofacial injuries: Our experience.

CONTEXT: There is paucity of data regarding the role of submental intubation (SI) in the airway management of patients with craniomaxillofacial trauma from India. AIMS: To study the characteristics of patients presenting with craniomaxillofacial injuries requiring submental intubation, the duration of SI procedure and complications of this technique. SETTINGS AND DESIGN: Tertiary level, teaching institute, retrospective, observational study. MATERIALS AND METHODS: Forty patients requiring submental intubation between June, 2007 and December, 2009. The primary outcome measure was the time required for submental intubation defined as starting from the completion of the orotracheal intubation to the fixation of the submental tube. The secondary outcome measures included characteristics of patients with craniomaxillofacial injuries, intraoperative and postoperative complications of the SI technique. STATISTICAL ANALYSIS USED: Data are presented as mean± standard deviation and frequency and percentages, where relevant. RESULTS: Most of the patients were young (average age = 35.15 ± 12.02 years), males (75%) and sustained craniomaxillofacial injuries due to road traffic accidents (85%). The 40 patients included in this audit had 56 injuries recorded at the time of admission including, orthopedic injuries in 65% and head injuries in 55% of patients. The mean time required for completion of SI was 8.90 min. The complications observed included, intraoperative tube migration, development of extra oral fistula, and sialocele, in one patient each. CONCLUSIONS: Submental intubation is a simple, safe, quick, and relatively harmless alternative to tracheostomy for securing the airway in selected patients with craniofacial trauma. Familiarity with the submental intubation technique will help the anesthesiologist to avoid tracheostomy in selected patients with craniofacial trauma who do not require long-term mechanical ventilation.

Tetany: A diagnostic dilemma.

Tetany is a disorder of increased neuronal excitability usually associated with hypocalcemia. We report a patient with typical tetanic cramps and carpopedal spasm in the postoperative period, despite normal serum concentrations of calcium, which responded to intravenous infusion of calcium.

Comparison of intrathecal bupivacaine-fentanyl and bupivacaine-butorphanol mixtures for lower limb orthopedic procedures.

CONTEXT: Intrathecal use of butorphanol is less explored in human subjects. AIMS: To compare the safety and efficacy of anesthesia and analgesia of intrathecal bupivacaine-butorphanol mixture with intrathecal bupivacaine-fentanyl mixture. SETTINGS AND DESIGN: Tertiary level, teaching hospital. Prospective, randomized, double-blind study. MATERIALS AND METHODS: Eighty patients aged above 18 years, of ASA physical status 1 or 2, undergoing lower limb orthopedic surgeries were randomly allocated to two groups of 40 patients each. Patients in group A and group B received intrathecal 2.5 ml of hyperbaric bupivacaine (0.5%), with 25 µg of fentanyl and 25 µg of butorphanol, respectively. STATISTICAL ANALYSIS USED: Fisher's exact test and Chi square tests. RESULTS: The times required for onset of sensory and motor blockade were comparable among the two groups. Significantly slower block regression to S2 level was observed in the group receiving intrathecal butorphanol as compared to intrathecal fentanyl (P=0.0230). A higher number of patients in group A requested for rescue analgesia during the postoperative period than in group B (9 versus 2; P=0.0238). The average times to first request for rescue analgesia were 308.6±14.9 minutes and 365.9±12.3 minutes in group A and B, respectively (P=0.0254). CONCLUSIONS: Both 25 µg fentanyl and 25 µg butorphanol given intrathecally along with 12.5 mg of hyperbaric bupivacaine provide effective anesthesia for lower limb surgeries. Intrathecal bupivacaine-butorphanol mixture provides longer duration of sensory blockade and superior analgesia than intrathecal fentanyl-bupivacaine mixture.

Antibiotic prescription patterns at admission into a tertiary level intensive care unit in Northern India.

CONTEXT: An audit of antibiotic prescribing patterns is an important indicator of the quality and standard of clinical practice. AIMS: To study the (1) antibiotic prescription and consumption patterns at admission into the intensive care unit (ICU); (2) average costs of antibiotics prescribed; and (3) correlation of antibiotic usage and the costs incurred with age, severity of illness, and diagnosis. SETTINGS AND DESIGN: A 13-bedded tertiary level ICU. A prospective, observational audit. MATERIALS AND METHODS: Two hundred consecutive prescriptions on patients admitted to the ICU from August to October, 2008, were audited. The total number of drugs and antibiotics, the class, dose, route, and cost of antibiotics were noted and the Defined Daily Dose/100 bed-days (DDD/100 bed-days) of the 10 most frequently prescribed antibiotics were calculated. STATISTICAL ANALYSIS USED: Univariate analysis was performed using Epi Info software (version 8.0). RESULTS: A total of 1246 drugs and 418 antibiotics were prescribed in the 200 patients studied, that is, an average of 6.23 (± SD 2.73) drugs/prescription and 2.09 (± SD 1.27) antibiotics/prescription. Antibiotics were prescribed on 190 patients (95%) at admission. There was a significant correlation between the number of patients prescribed three or more antibiotics and mortality rates (53% nonsurvivors vs. 33.5% survivors (P = 0.015). The average cost of the antibiotics was Rupees 1995.08 (± SD 2099.99) per patient and antibiotics expenditure accounted for 73.2% of the total drug costs. CONCLUSIONS: Antibiotics are commonly prescribed to most ICU patients at admission and contribute significantly to the total drug costs. Antibiotic restriction policies and a multidisciplinary effort to reduce usage are urgently required.

Fatal airway obstruction following arterial trauma during internal jugular venous cannulation.

Central venous cannulations are commonly performed in the intensive care unit. However, these may be associated with severe mechanical or bleeding complications. Here, we describe a patient who died following severe and rapid airway obstruction secondary to an arterial trauma during internal jugular vein cannulation. This case report highlights the importance of prompt recognition of arterial trauma so that it can be repaired surgically instead of sheath removal. The prompt diagnosis of an impending airway obstruction and obtaining early airway access cannot be overemphasized. Finally, we discuss the risk factors associated with this complication and what we could have possibly done to prevent this outcome.