The incidence of torsades de pointes with peri-operative low-dose ondansetron administration.

STUDY OBJECTIVE: The primary objective of this retrospective safety study was to determine the incidence of torsades de pointes (TdP) or death following perioperative administration of low-dose, 4 mg, ondansetron for postoperative nausea and vomiting. DESIGN AND SETTING: This is a single-center retrospective clinical trial. PATIENTS: The authors identified 32,737 patients who received 37,589 doses of ondansetron during a 2-year time frame between March 2009 and February 2011 for surgical nausea prophylaxis or treatment of nausea. MEASUREMENTS AND MAIN RESULTS: Patients were cross-matched with an electrocardiogram and adverse outcome database; this identified 4759 patients with documentation of a QTc >450 milliseconds (ms), all ventricular tachycardias including TdP within 48 hours of receiving ondansetron, or death within 7 days of receiving ondansetron. No patients developed TdP or died as a direct result of ondansetron administration (n = 0; event rate = 0.0 per 10,000, 95% CI 0.0 to 1.1 per 10,000). Forty-six of 32,737 surgical patients had documented monomorphic ventricular tachycardia (VT) (n = 14; event rate = 4.3 per 10,000, 95% CI 2.3 to 7.2 per 10,000) or died (n = 32; event rate = 9.8 per 10,000, 95% CI 6.7 to 13.8 per 10,000) within 48 h of ondansetron administration. All monomorphic VT episodes were precipitated by existing cardiovascular disease; and 7 of 14 patients had documented monomorphic VT prior to receiving ondansetron. Of the 32 surgical patients who died, all deaths were precipitated by pre-existing disease. CONCLUSION: No episodes of TdP were identified in patients receiving ondansetron perioperatively. This suggests that low-dose ondansetron does not contribute to the development of TdP.

A Novel Approach to Emergency Airway Simulation Using a 3D-printed Cricothyrotomy Task Trainer.

BACKGROUND: Cricothyrotomy is a final recourse for salvaging a difficult airway, yet most anesthesiology providers have little training, exposure, or comfort with the procedure. Pig tracheas are frequently used for training, but are single use and require special handling and storage. Other simulation models, such as mannequins and cadavers, are costly. Advances in 3dimensional (3D) printing have improved accessibility and decreased costs. This research project sought to determine whether an inexpensive 3D-printed task trainer was noninferior to pig tracheas for teaching surgical cricothyrotomy skills. METHODS: Anesthesiology residents were enrolled in an institutional review board-exempted, unblinded, randomized, controlled, single-institution, noninferiority trial. Participants were trained in the scalpel-finger-bougie technique for surgical cricothyrotomy. Participants were randomized to practice 5 repetitions on either a pig trachea or the 3D model and were assessed on time to cricothyrotomy completion on a pig trachea before and after practice. RESULTS: Demographic characteristics of the 25 workshop attendees were similar between study arms. Overall mean (SD) improvement in speed was 9 (12) seconds (P = .001). Postpractice times were similar between groups (analysis of covariance estimated difference of -0.1 seconds [95% confidence interval, -9.4 to 9.2]; P = .55). The 3D model was noninferior to the pig trachea at the prespecified noninferiority margin of 10 seconds (P = .017). CONCLUSIONS: The 3D model was noninferior to pig tracheas for improving the time to completion of a surgical cricothyrotomy. A 3D-printed model offers a viable alternative to pig tracheas for emergency airway simulation that is inexpensive, reusable, and readily modified to simulate challenging airway anatomy.

Comparison of dyad versus individual simulation-based training on stress, anxiety, cognitive load, and performance: a randomized controlled trial.

BACKGROUND: Dyad learning has been shown to be an effective tool for teaching procedural skills, but little is known about how dyad learning may impact the stress, anxiety, and cognitive load that a student experiences when learning in this manner. In this pilot study, we investigate the relationship between dyad training on stress, anxiety, cognitive load, and performance in a simulated bradycardia scenario. METHODS: Forty-one fourth-year medical school trainees were randomized as dyads (n = 24) or individuals (n = 17) for an education session on day 1. Reassessment occurred on day 4 and was completed as individuals for all trainees. Primary outcomes were cognitive load (Paas scale), stress (Cognitive Appraisal Ratio), and anxiety levels (abbreviated State-Trait Anxiety Inventory). Secondary outcomes were time-based performance metrics. RESULTS: On day 1 we observed significant differences for change in anxiety and stress measured before and after the training scenario between groups. Individuals compared to dyads had larger mean increases in anxiety, (19.6 versus 7.6 on 80-point scale, p = 0.02) and stress ratio (1.8 versus 0.9, p = 0.045). On the day 4 post-intervention assessment, no significant differences were observed between groups. Secondary outcomes were significant for shorter time to diagnosis of bradycardia (p = 0.01) and time to initiation of pacing (p = 0.04) in the dyad group on day 1. On day 4, only time to recognizing the indication for pacing was significantly shorter for individual training (hazard ratio [HR] = 2.26, p = 0.02). CONCLUSIONS: Dyad training results in lower stress and anxiety levels with similar performance compared to individual training.

New Q Waves and T-Wave Inversions Following Endovascular Surgery Lead to Diagnosis of Clinically Silent Myocardial Infarction Despite Negative Preoperative Cardiovascular Risk Evaluation: A Case Report.

In this case, a 79-year-old male presented with new anteroseptal Q waves and T-wave inversions across the precordial leads following an otherwise uneventful endovascular repair of his thoracoabdominal aortic aneurysm. The patient had no history of cardiac disease and had undergone a dobutamine stress echocardiogram within the preceding 6 months that showed no evidence of inducible ischemia. Nevertheless, routine postoperative electrocardiogram (EKG) revealed new Q waves and T-wave inversions and transthoracic echocardiogram that demonstrated akinesis of the left ventricle (LV) apex with chronic-appearing apical thrombus. We will further discuss preoperative evaluation of cardiovascular risk along with postoperative interpretation of EKG abnormalities.

Black Seed Oil and Perioperative Serotonin Syndrome: A Case Report.

Perioperative serotonin syndrome has been associated with a number of medications and herbal supplements. We report a patient who developed serotonin syndrome immediately after an endoscopic procedure in which the preoperative use of black seed oil appears to have played a role in stimulating the syndrome. Black seed oil has not been previously reported in association with perioperative serotonin syndrome. Anesthesia professionals should be aware that patients taking black seed oil supplements may develop serotonin syndrome postoperatively.

Hemorrhagic Shock After Epicardial Pacing Wire Removal: A Case Report.

Epicardial pacing wires are routinely used to avoid hemodynamic instability due to perioperative arrhythmias after cardiac surgery. In rare cases, pacing wires themselves can be associated with potentially life-threatening complications. Herein, we present a novel case of hemorrhagic shock and hemoperitoneum after temporary epicardial pacing wire removal.

The Extraordinary Case of the Hungry Woman: Large Foreign Body Ingestion With Respiratory Arrest.

Repeated ingestion of small objects has been previously reported in the psychiatric literature. We recently had a patient with repeated intentional foreign body ingestion syndrome who developed complete airway obstruction and cardiac arrest after ingesting a computer mouse tracking ball. We use our case to suggest a pathway that can be used for similar emergent airway problems.