Ultrasound-guided popliteal sciatic nerve blockade in the severely and morbidly obese: a prospective and randomized study.

PURPOSE: Limited research data exist regarding optimal block techniques in the severely and morbidly obese patient population. We compared two approaches to sciatic nerve blockade at the popliteal fossa in severely and morbidly obese patients. The purpose of this study was to identify differences in pain scores, block onset characteristics, and adverse events between the proximal (prebifurcation) and the distal (postbifurcation) sites. METHODS: Patients with a body mass index ≥35 scheduled for unilateral foot surgery with a popliteal block were randomized to receive an ultrasound-guided popliteal block proximal or distal to the bifurcation of the sciatic nerve. The primary endpoint was numerical rating scale (NRS) scores in the post anesthesia care unit (PACU). RESULTS: Thirty patients were enrolled in each group for a total of 60 participants. Patients in the distal group had lower NRS scores upon entry into the PACU (0.70 ± 1.91) compared with the proximal group (2.17 ± 3.37), had a faster onset of sensorimotor blockade, and were less likely to require a repeat block procedure, conversion to general anesthesia, or local anesthetic supplementation by the surgical team. There was no difference in block procedure times or incidence of nerve injury between the two groups. CONCLUSIONS: The distal approach to the popliteal block provided several intraoperative and analgesic benefits without a difference in block procedural times in the severely and morbidly obese. It is a cost-free intervention that results in a higher likelihood of a successful block in a population where avoidance of opioids is desirable.

Tailoring the Blood Ordering Process for Cardiac Surgical Cases Using an Institution-Specific Version of the Maximum Surgical Blood Order Schedule.

BACKGROUND: Excess ordering of blood products for surgical cases is expensive and wasteful. Evidence has shown that institution-specific versions of the Maximum Surgical Blood Order Schedule (MSBOS) lead to better ordering practices. Most MSBOSs recommend a crossmatch for a minimum of 2 units of packed red blood cells (PRBCs) for cardiac surgical cases; however, studies have shown that >50% of these patients receive no transfusions. Our aim was to create a blood order algorithm for cardiac surgical cases that would decrease unnecessary crossmatching. METHODS: Retrospective data was collected for 264 patients from January 2011 through April 2012. The crossmatch-to-transfusion ratio (C:tx), transfusion probability (%T), and transfusion index (TI) were calculated for each type of procedure. RESULTS: All 264 patients were crossmatched and 98 patients were transfused, resulting in an overall transfusion probability (%T) of 37.12% (95% confidence interval 31.52-43.09). A total of 1175 units of blood were crossmatched, but only 370 units of blood were transfused, resulting in a C:tx of 3.17 (95% confidence interval 2.61-4.03). The average number of units transfused per procedure (transfusion index) was 1.40. C:tx was highest and TI was lowest for CABG, where approximately 11 units of blood were ordered for every 1 unit transfused (C:tx =11.70 ± 3.04), and the TI was 0.32. CONCLUSIONS: Using the gold standard C:tx of >2:1 as an indicator of inappropriate blood utilization, our analysis confirmed that excessive crossmatching occurred for several procedures. Now a subset of cardiac surgical cases only requires a type and screen order prior to surgery.

The Smoking Cessation Trust Program of Louisiana: The Pediatrician's Role in Identifying and Referring Eligible Caregivers.

BACKGROUND: A pilot study was conducted to determine whether the caregivers of children being seen at the Ochsner for Children health center were eligible for and using services provided by the Smoking Cessation Trust (SCT). METHODS: The study population consisted of pediatric patients' caregivers who visit the Ochsner for Children health center. Caregivers were offered a questionnaire to assess their age, sex, relationship to the child, medical insurance, smoking status, and prior cessation attempts and aids. Data about 3 other caregivers were also requested from the visiting caregiver. RESULTS: Of the 84 caregivers assessed, 26 (30.95%) smoked, of whom 12 (46.15%) began smoking prior to 1988 and were eligible for SCT services. The cohort of eligible caregivers included 4 grandmothers (33.33%), 2 grandfathers (16.67%), and 3 fathers (25.00%). Smoking prevalence in our cohort was higher than the national average (31% vs 18%). During the previous 12 months, 3 of 12 (25.00%) SCT-eligible caregivers had tried to quit smoking. Four (33.33%) SCT-eligible caregivers were interested in smoking cessation. CONCLUSION: Pediatricians are in a unique position to screen, counsel, and refer caregivers who smoke to the SCT.