Point-of-care platelet function testing for guided transfusion in neurosurgical management of intracranial hemorrhage: a systematic review.

Given the rising prevalence of antiplatelet therapy, rapid preoperative identification of patients with bleeding diathesis is necessary for the guidance of blood product administration. This is especially relevant in neurosurgery for intracranial hemorrhage (ICH), where indiscriminate transfusions may lead to further hemorrhagic or thromboembolic injury. Point-of-care (POC) testing of platelet function is a promising solution to this dilemma, as it has been proven effective in cardiac surgery. However, to date, POC platelet function testing in neurosurgery has not been extensively evaluated. This systematic review appraises the use of POC platelet function test (PFT) in emergency neurosurgery in terms of its impact on patient outcomes.A comprehensive search was conducted on four electronic databases (Pubmed, MEDLINE, Embase, and Cochrane) for relevant English language articles from their respective inceptions until 1 June 2022. We included all randomized controlled trials and cohort studies that met the following inclusion criteria: (i) involved adult patients undergoing neurosurgery for ICH; (ii) evaluated platelet function via POC PFT; (iii) reported a change in perioperative blood loss; and/or (iv) reported data on treatment-related adverse events and mortality. Assessment of study quality was conducted using the Newcastle Ottawa Quality Assessment Scale for Cohort Studies and Case-Control Studies, and the JBI Critical Appraisal Checklist for Case Series.The search yielded 2,835 studies, of which seven observational studies comprising 849 patients met the inclusion criteria for this review. Overall, there is evidence that the use of POC PFT to assess bleeding risk reduced bleeding events, thromboembolic adverse outcomes, and the length of hospitalization. However, there is currently insufficient evidence to suggest that using POC PFT improves blood product use, functional outcomes or mortality.

The hospital difficult airway team: experience and implications for patient care.

The difficult airway involves the complex interaction between patient factors, the clinical setting and the practitioner's skills (Apfelbaum in Anesthesiology 118(2):251-70, 2013 and Mark et al. in Anesth Analg 121(1):127-139, 2015). It can also be a result of preparedness and system failures. Our institution developed a protocol to enhance emergency airway management in settings outside of the operating theatre-the difficult airway (DA) team. The aims of this report are to perform a retrospective review to describe the patient profiles as well as our difficult airway code workflow, and to identify preliminary patterns within DAC activations over an 18-month period (September 2013 to November 2015) in a tertiary university hospital. We believe that these findings may aid institutions in establishing a difficult airway protocol or refining existing airway code workflows. Institutional board approval was granted for medical record review.

Use of GoPro point-of-view camera in intubation simulation-A randomized controlled trial.

INTRODUCTION: Teaching endotracheal intubation is uniquely challenging due to its technical, high-stakes, and highly time-sensitive nature. The GoPro is a small, lightweight, high-resolution action camera with a wide-angle field of view that can encompass both the airway as well as the procedurist's hands and positioning technique when worn with a head mount. We aimed to evaluate its effectiveness in improving intubation teaching for novice learners in a simulated setting, via a two-arm, parallel group, randomized controlled superiority trial with 1:1 allocation ratio. METHODS: We recruited Year 4 medical students at the start of their compulsory 2-week Anesthesia posting. Participants underwent a standardized intubation curriculum and a formative assessment, then randomized to receive GoPro or non-GoPro led feedback. After a span of three months, participants were re-assessed in a summative assessment by blinded accessors. Participants were also surveyed on their learning experience for a qualitative thematic perspective. The primary outcomes were successful intubation and successful first-pass intubation. RESULTS: Seventy-one participants were recruited with no dropouts, and all were included in the analysis. 36 participants received GoPro led feedback, and 35 participants received non-GoPro led feedback. All participants successfully intubated the manikin. No statistically significant differences were found between the GoPro group and the non-GoPro group at summative assessment (85.3% vs 90.0%, p = 0.572). Almost all participants surveyed found the GoPro effective for their learning (98.5%). Common themes in the qualitative analysis were: the ability for an improved assessment, greater identification of small details that would otherwise be missed, and usefulness of the unique point-of-view footage in improving understanding. CONCLUSIONS: The GoPro is a promising tool for simulation-based intubation teaching. There are considerations in its implementation to maximize the learning experience and yield from GoPro led feedback and training.

Factors predicting one-year post-surgical mortality amongst older Asian patients undergoing moderate to major non-cardiac surgery - a retrospective cohort study.

BACKGROUND: While short-term perioperative outcomes have been well studied in Western surgical populations, the aim of this study is to look at the one-year perioperative mortality and its associated factors in an Asian surgical population after non-cardiac surgery. METHODS: A retrospective cohort study of 2163 patients aged above 45 undergoing non-cardiac surgery in a university-affiliated tertiary hospital from January to July 2015 was performed. Relevant demographic, clinical and surgical data were analysed to elicit their relationship to mortality at one year after surgery. A univariate analysis was first performed to identify significant variables with p-values ≤ 0.2, which were then analysed using Firth multiple logistic regression to calculate the adjusted odds ratio. RESULTS: The one-year mortality in our surgical population was 5.9%. The significant factors that increased one-year mortality include smoking (adjusted OR 2.17 (1.02-4.45), p = 0.044), anaemia (adjusted OR 1.32 (1.16-1.47), p < 0.001, for every 1 g/dL drop in haemoglobin level), lower BMI (adjusted OR 0.93 (0.87-0.98), p = 0.005, for every 1 point increase in BMI), Malay and Indian ethnicity (adjusted OR 2.68 (1.53-4.65), p = 0.001), peripheral vascular disease (adjusted OR 4.21 (1.62-10.38), p = 0.004), advanced age (adjusted OR 1.04 (1.01-1.06), p = 0.004, for every one year increase in age), emergency surgery (adjusted OR 2.26 (1.29-3.15), p = 0.005) and malignancy (adjusted OR 3.20 (1.85-5.52), p < 0.001). CONCLUSIONS: Our study shows that modifiable risk factors such as malnutrition, anaemia and smoking which affect short term mortality extend beyond the immediate perioperative period into longer term outcomes. Identification and optimization of this subset of patients are therefore vital. Further similar large studies should be done to develop a risk scoring system for post-operative long-term outcomes. This would aid clinicians in risk stratification, counselling and surgical planning, which will help in patients' decision making and care planning.

Anaesthesia considerations and techniques for Pressurised IntraPeritoneal Aerosol Chemotherapy (PIPAC).

Pressurised IntraPeritoneal Aerosol Chemotherapy (PIPAC) is a novel surgical technique to administer aerosolized chemotherapy into the abdominal cavity as treatment for peritoneal metastasis from various cancers. As the surgery is unique and there are concerns about occupational hazards, specific anaesthetic setup and techniques are required. Notably, our institution's experience with PIPAC has enlightened us that anaesthesia requirements during PIPAC are generally uncomplicated and that the majority of the patients undergoing PIPAC do not require invasive monitoring, advanced intra or postoperative analgesia like epidurals or PCA. The need for postoperative intensive unit care is also not required in routine PIPAC cases. We describe the anaesthetic considerations involved and the detailed preparation of staff, space, anaesthetic equipment and drugs to facilitate the appropriate modifications for anaesthesia monitoring and maintenance for an elective set up as well as our standard operating procedure for an emergency situation should it arise.

How the personalities of medical students at the National University of Singapore differ from those of the local non-medical undergraduate population: a cross-sectional study.

INTRODUCTION: Integrity and willingness to contribute to society are desired traits of medical students beyond academic excellence. We investigated the personality traits of medical students at the National University of Singapore (NUS), who were about to become doctors. Personality traits were compared with a peer population of local university students. METHODS: This study was conducted between October 2013 and December 2014. Year 4 medical students were administered the Revised NEO (Neuroticism-Extraversion-Openness) Personality Inventory (NEO PI-R), a 240-item Likert scale personality test. Test data was analysed by an institutional psychologist and compared to a separate sample of 377 non-medical students who were peers at the same university taking psychology as a module. Data was collated and analysed. RESULTS: 65 Year 4 medical students completed the NEO PI-R personality test. The personalities of Year 4 medical students at NUS differed from their peers in all domains except for openness. NUS medical students generally had less neuroticism, and were more extroverted, agreeable and conscientious than their peers. CONCLUSION: Personality testing of NUS Year 4 medical students showed many of the desired traits of a doctor when compared to their peers at the same university.

End-task versus in-task feedback to increase procedural learning retention during spinal anaesthesia training of novices.

Communication of feedback during teaching of practical procedures is a fine balance of structure and timing. We investigate if continuous in-task (IT) or end-task feedback (ET) is more effective in teaching spinal anaesthesia to medical students. End-task feedback was hypothesized to improve both short-term and long-term procedural learning retention as experiential learning promotes active learning after encountering errors during practice. Upon exposure to a 5-min instructional video, students randomized to IT or ET feedbacks were trained using a spinal simulator mannequin. A blinded expert tested the students using a spinal anaesthesia checklist in the short term (immediate) and long-term (average 4 months). Sixty-five students completed the training and testing. There were no differences in demographics of age or gender within IT or ET distributions. Both short-term and long-term learning retention of spinal anaesthesia ET feedback proved to be better (P < 0.01) than IT feedback. The time taken for ET students was shorter at long-term testing. End-task feedback improves both short-term and long-term procedural learning retention.

Inadvertent spinal injection of ondansetron.

Cesarean sections under spinal anesthesia are now a daily occurrence in most tertiary hospitals. We report the first published case of inadvertent spinal injection of ondansetron without any neurological sequelae in a patient undergoing elective Cesarean section under spinal anesthesia. She did not experience any permanent neurological sequelae, and also did not exhibit any central neuraxial opioid side effects-nausea, vomiting or pruritus. Vigilance is essential to reduce the risk of wrong route delivery of drugs, especially when presented in very similar-looking 2 mL ampules as in our institution.