Recommendations for effective documentation in regional anesthesia: an expert panel Delphi consensus project.

BACKGROUND AND OBJECTIVES: Documentation is important for quality improvement, education, and research. There is currently a lack of recommendations regarding key aspects of documentation in regional anesthesia. The aim of this study was to establish recommendations for documentation in regional anesthesia. METHODS: Following the formation of the executive committee and a directed literature review, a long list of potential documentation components was created. A modified Delphi process was then employed to achieve consensus amongst a group of international experts in regional anesthesia. This consisted of 2 rounds of anonymous electronic voting and a final virtual round table discussion with live polling on items not yet excluded or accepted from previous rounds. Progression or exclusion of potential components through the rounds was based on the achievement of strong consensus. Strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement. RESULTS: Seventy-seven collaborators participated in both rounds 1 and 2, while 50 collaborators took part in round 3. In total, experts voted on 83 items and achieved a strong consensus on 51 items, weak consensus on 3 and rejected 29. CONCLUSION: By means of a modified Delphi process, we have established expert consensus on documentation in regional anesthesia.

How to Realize the Benefits of Point-of-Care Testing at the General Practice: A Comparison of Four High-Income Countries.

BACKGROUND: In some countries, such as the Netherlands and Norway, point-of-care testing (POCT) is more widely implemented in general practice compared to countries such as England and Australia. To comprehend what is necessary to realize the benefits of POCT, regarding its integration in primary care, it would be beneficial to have an overview of the structure of healthcare operations and the transactions between stakeholders (also referred to as value networks). The aim of this paper is to identify the current value networks in place applying to POCT implementation at general practices in England, Australia, Norway and the Netherlands and to compare these networks in terms of seven previously published factors that support the successful implementation, sustainability and scale-up of innovations. METHODS: The value networks were described based on formal guidelines and standards published by the respective governments, organizational bodies and affiliates. The value network of each country was validated by at least two relevant stakeholders from the respective country. RESULTS: The analysis revealed that the biggest challenge for countries with low POCT uptake was the lack of effective communication between the several organizations involved with POCT as well as the high workload for general practitioners (GPs) aiming to implement POCT. It is observed that countries with a single national authority responsible for POCT have a better uptake as they can govern the task of POCT roll-out and management and reduce the workload for GPs by assisting with set-up, quality control, training and support. CONCLUSION: Setting up a single national authority may be an effective step towards realizing the full benefits of POCT. Although it is possible for day-to-day operations to fall under the responsibility of the GP, this is only feasible if support and guidance are readily available to ensure that the workload associated with POCT is limited and as low as possible.

Emergency Front-of-Neck Airway Rescue Via the Cricothyroid Membrane: A High-Resolution Computed Tomography Study of Airway Anatomy in Adults.

BACKGROUND: Emergency front-of-neck airway rescue is recommended in a can't intubate, can't oxygenate clinical scenario. Cannula cricothyroidotomy has been reported as having a high failure rate. Our primary aim was to estimate the angle of the trachea in relation to the horizontal axis in a simulated emergency front-of-neck airway rescue position. Our secondary aims were to estimate the optimal cannula angle of approach and evaluate the anatomical relationship of the cricothyroid membrane (CTM) to adjacent structures. We also assessed whether the CTM lies above or below the neck midpoint, a point equidistant from the suprasternal notch (SSN), and the chin surface landmarks. All measurements were compared between the male and female subjects. METHODS: Subjects having elective computed tomography of their thorax were consented to have extension of the computed tomography to include their neck. A preliminary radiation dose and risk assessment deemed the additional radiation to be of very low risk (level IIa). Subjects were positioned supinely on the computed tomography table. Standard neck extension was achieved by placing a pillow under the scapulae and a rolled towel under the neck to simulate emergency front-of-neck airway rescue positioning. RESULTS: Fifty-two subjects were included in this study: 31 men and 21 women. The mean angle of the trachea in relation to the horizontal axis was 25.5° (95% confidence interval [CI], 21.8-29.1) in men and 14.0° (95% CI, 11.5-16.5) in women. The mean minimum angles required for hypothetical cannula cricothyroidotomy for men and women were 55.2° (95% CI, 51.8-58.7) and 50.5° (95% CI, 45.4-55.6), respectively. The CTM was located lower in the neck in men compared to women. The CTM was located below the neck midpoint in 30 of 30 (100%) male subjects and 11 of 20 (55%) female subjects (P < .001). CONCLUSIONS: The trachea angulates posteriorly in a simulated emergency front-of-neck airway rescue position in supine subjects and to a greater degree in men compared to women (P < .001). The minimum angle required for hypothetical cannula cricothyroidotomy was >45° in the majority (75%) of subjects studied. A steeper cannula angle of approach may be more reliable and warrants further clinical study. If airway anatomy is indistinct and performing a vertical scalpel cricothyroidotomy, consideration should be given to performing this incision lower in the neck in men compared to women.

Demonstrating the influence of HTA: INAHTA member stories of HTA impact.

A central function of health technology assessment (HTA) agencies is the production of HTA reports to support evidence-informed policy and decision making. HTA agencies are interested in understanding the mechanisms of HTA impact, which can be understood as the influence or impact of HTA report findings on decision making at various levels of the health system. The members of the International Network of Agencies for HTA (INAHTA) meet at their annual Congress where impact story sharing is one important activity. This paper summarizes four stories of HTA impact that were finalists for the David Hailey Award for Best Impact Story.The methods to measure impact include: document review; claims analysis and review of reimbursement status; citation analysis; qualitative evaluation of stakeholders' views; and review of media response. HTA agency staff also observed changes in government activities and priorities based on the HTA. Impact assessment can provide information to improve the HTA process, for example, the value of patient and clinician engagement in the HTA process to better define the assessment question and literature reviews in a more holistic and balanced way.HTA reports produced by publicly funded HTA agencies are valued by health systems around the globe as they support decision making regarding the appropriate use, pricing, reimbursement, and disinvestment of health technologies. HTAs can also have a positive impact on information sharing between different levels of government and across stakeholder groups. These stories show how HTA can have a significant impact, irrespective of the health system and health technology being assessed.

Accuracy of pediatric cricothyroid membrane identification by digital palpation and implications for emergency front of neck access.

BACKGROUND: Emergency front of neck access in a "can't intubate can't oxygenate" scenario in pediatrics is rare. Ideally airway rescue would involve the presence of an ear, nose, and throat surgeon. If unavailable however, responsibility lies with the anesthesiologist and accurate identification of anterior neck structures is essential for success. AIM: We assessed anesthesiologists' accuracy in identification of the pediatric cricothyroid membrane by digital palpation in three predefined age groups (37 weeks to <1 year old, 1-8 years old, and 9-16 years old) and whether accuracy improved with repetition. We also investigated a novel hypothetical vertical skin incision strategy to successfully expose the cricothyroid membrane. METHODS: We asked anesthesiologists to identify the location of the cricothyroid membrane of anesthetized children in the extended neck position. Accuracy was defined as a mark made within the margins of the cricothyroid membrane using ultrasound as a reference standard. The position of the cricothyroid membrane relative to the neck midpoint, between the suprasternal notch and mentum, was defined for each child. Using this neck midpoint, we determined the hypothetical vertical skin incision lengths required to successfully expose the cricothyroid membrane ("midpoint incision"). RESULTS: Ninety-seven patients were included in this study. There were 14, 58, and 25 patients recruited across the three predefined groups. Accurate anesthesiologist identification of the location of the cricothyroid membrane occurred in 29.4%, 28.6%, and 38.2% of attempts, respectively. The majority of inaccurate assessments (64.1%) were below the cricothyroid membrane. There was no improvement in accuracy with repetition. Hypothetical "midpoint incision" lengths of 20, 30, and 35 mm were required. CONCLUSION: Significant anesthesiologist inaccuracy exists in locating the cricothyroid membrane in children of all ages. This has implications for the technical approach to emergency front of neck access and how we teach the management of "can't intubate can't oxygenate" in pediatric practice.

Accuracy of ultrasound in measurement of the pediatric cricothyroid membrane.

BACKGROUND: Emergency front of neck airway is a recommended airway rescue strategy in children over 1 year old. Surgical tracheostomy is advocated as the first-line technique, but in the absence of an ear, nose and throat surgeon cricothyroidotomy or tracheostomy is proposed. Recent research shows that clinical identification of the cricothyroid membrane is frequently inaccurate in older children and adults and has prompted investigation of ultrasound as a potential clinical tool for emergency front of neck airway. Advance knowledge of the dimensions of the pediatric cricothyroid membrane may assist clinicians in determining the feasibility of emergency front of neck airway, optimum technique, and equipment. AIMS: The aim of this study was to assess the accuracy of ultrasound-assisted pediatric cricothyroid membrane localization and dimension measurement using magnetic resonance imaging as the reference standard. METHODS: After structured training, two pediatric anesthesiology trainees used ultrasound to identify and measure the dimensions of the cricothyroid membrane in pediatric patients undergoing elective magnetic resonance imaging of the head and neck under general anesthesia. A pediatric radiologist reviewed the corresponding magnetic resonance imaging scans and measured the height of the cricothyroid membrane. The accuracy of the cricothyroid membrane height as measured by ultrasound was compared to that measured by magnetic resonance imaging. RESULTS: Twenty-two patients were included in the study. The cricothyroid membrane was accurately identified by ultrasound in all cases. The correlation coefficient for cricothyroid membrane height measured by ultrasound and that measured by magnetic resonance imaging was 0.98 (95% C.I 0.95-0.99, P < 0.0001). The bias was -0.16 mm and the precision was 0.19 mm. All differences were within the a priori limits of agreement. The 95% limits of agreement were -0.54 to 0.22 mm. CONCLUSION: Ultrasound can be used to accurately identify and measure cricothyroid membrane height in pediatric patients. This approach could have clinical and research utility.

Increased expression and co-localization of ACE, angiotensin II AT(1) receptors and inducible nitric oxide synthase in atherosclerotic human coronary arteries.

Using immunohistochemistry and quantitative in vitro autoradiography, the present study was undertaken to examine whether co-expression of pro-atherosclerotic factors, ACE, the AT(1) receptor, and iNOS, is increased in early and advanced atherosclerotic lesions of human coronary arteries. In normal coronary arteries, ACE and eNOS were strongly co-expressed in endothelial cells (ECs), whereas the AT(1) receptor was expressed in medial smooth muscle cells (SMCs). By contrast, iNOS was not expressed in ECs and SMCs. In early atherosclerotic lesions and atheromatous plaques, ACE, the AT(1) receptor and iNOS immunostaining were primarily co-localized in infiltrated macrophages and SMCs adjacent to macrophages. eNOS expression was lower in ECs than in normal arteries, and absent in accumulated macrophages and SMCs. In fibrosclerotic plaques, ACE, the AT(1) receptor, and iNOS immunostaining were still positive in macrophages as well as new microvessels within the plaques. Interestingly, SMCs in vasa vasorum of the adventitia in atheromatous and fibrosclerotic plaques were also strongly positive for AT(1) receptor and iNOS, while ECs of the vasa vasorum were positive for ACE and eNOS. The present study demonstrates that multiple pro-atherosclerotic factors ACE, AT(1) receptor and iNOS are co-localized almost exclusively in infiltrated macrophages and SMCs that have accumulated in or adjacent to early and advanced atherosclerotic plaques, while the anti-atherosclerotic enzyme eNOS is reduced in ECs. These data therefore suggest that increased formation of Ang II and iNOS in infiltrated macrophages and medial SMCs might well play important roles in the development and progression of human coronary atherosclerosis.