Telemedicine in the Northern Territory: an assessment of patient perceptions in the preoperative anaesthetic clinic.

OBJECTIVE: We investigated patient perceptions of a virtual preoperative anaesthesia evaluation clinic linking Royal Darwin Hospital to Katherine Hospital. DESIGN: Descriptive study, cross-sectional survey. SETTING: Regional and rural areas of Northern Territory, Australia. PARTICIPANTS: Sample includes 27 respondents, five Indigenous, 18 non-Indigenous and four unknown. INTERVENTIONS: Introduction of a preoperative anaesthesia evaluation clinic. MAIN OUTCOME MEASURES: We designed a 10-item, 5-point Likert scale questionnaire assessing patient perceptions in four domains: (i) technical quality; (ii) perceived efficacy; (iii) affective patient experience; and (iv) patient preference. Qualitative responses are also reported. RESULTS: Twenty-seven out of 35 patients (77%) completed the questionnaire. Ninety-eight per cent were in positive agreement on technical quality with a mean score of 1.35 (SD: 0.53); Ninety-five per cent on perceived efficacy, 1.35 (SD: 0.65); Eighty-four per cent in negative agreement on affective patient experience (negative perception item), 4.19 (SD: 1.07); Eighty-one per cent in negative agreement on patient preference (negative perception item), 4.23 (SD: 1.14). There were no significant differences in the answers between Indigenous (five patients) and non-Indigenous patients (18 patients). CONCLUSION: Our study confirms the acceptability of telemedicine in the remote assessment of preoperative patients in the Northern Territory, with positive perceptions in all four domains.

The impact of fluid intervention on complications and length of hospital stay after pancreaticoduodenectomy (Whipple's procedure).

BACKGROUND: There is limited information on the impact on perioperative fluid intervention on complications and length of hospital stay following pancreaticoduodenectomy. Therefore, we conducted a detailed analysis of fluid intervention in patients undergoing pancreaticoduodenectomy at a university teaching hospital to test the hypothesis that a restrictive intravenous fluid regime and/or a neutral or negative cumulative fluid balance, would impact on perioperative complications and length of hospital stay. METHODS: We retrospectively obtained demographic, operative details, detailed fluid prescription, complications and outcomes data for 150 consecutive patients undergoing pancreaticoduodenectomy in a university teaching hospital. Prognostic predictors for length of hospital stay and complications were determined. RESULTS: One hundred and fifty consecutive patients undergoing pancreaticoduodenectomy were evaluated between 2006 and 2012. The majority of patients were, middle-aged, overweight and ASA class III. Postoperative complications were frequent and occurred in 86 patients (57%). The majority of complications were graded as Clavien-Dindo Class 2 and 3. Postoperative pancreatic fistula occurred in 13 patients (9%), and delayed gastric emptying occurred in 25 patients (17%). Other postoperative surgical complications included sepsis (22%), bile leak (4%), and postoperative bleeding (2%). Serious medical complications included pulmonary edema (6%), myocardial infarction (8%), cardiac arrhythmias (13%), respiratory failure (8%), and renal failure (7%). Patients with complications received a higher median volume of intravenous therapy and had higher cumulative positive fluid balances. Postoperative length of stay was significantly longer in patients with complications (median 25 days vs. 10 days; p < 0.001). After adjustment for covariates, a fluid balance of less than 1 litre on postoperative day 1 and surgeon caseloads were associated with the development of complications. CONCLUSIONS: In the context of pancreaticoduodenectomy, restrictive perioperative fluid intervention and negative cumulative fluid balance were associated with fewer complications and shorter length of hospital stay. These findings provide good opportunities to evaluate strategies aimed at improving perioperative care.

Functional evaluation and practice survey to guide purchasing of intravenous cannulae.

BACKGROUND: There are wide variations in the physical designs and attributes between different brands of intravenous cannulae that makes product selection and purchasing difficult. In a systematic assessment to guide purchasing, we assessed two cannulae - Cannula P and I. We proposed that the results of in-vitro performance testing of the cannulae would be associated with preference after clinical comparison. METHODS: We designed an observer-blinded randomised head-to-head trial between the 18, 20 and 22 gauge versions of Cannula P and I. Our primary end-point was pressure (mmHg) generated during various flow rates and our secondary end-point was the force (Newton) required to slide the catheter away from the needle. This was followed by a prospective electronic survey following a two-week clinical trial period. RESULTS: The mean difference in resistance between Cannula P and I was: 307 mmHg.L-1.hr-1 (95% CI: 289-325, p < 0.001) for 22G; 135 mmHg.L-1.hr-1 (95% CI: 125-144, p < 0.001) for 20G; and 27 mmHg.L-1.hr-1 (95% CI: 26-28, p < 0.001) for 18G. The mean difference in the force needed to displace the catheter away from its needle was: 1.41 N (95% CI: 1.09-1.73, p < 0.001) for 22G; 0.19 N (95% CI: -0.04-0.41, p = 0.12) for 20G; and 1.96 N (95% CI: 1.40-2.52, p < 0.001) for 18G. After a trial period, all 16 anaesthetist who had used both cannulae preferred Cannula I to P. CONCLUSIONS: The evaluation process described here could help hospitals improve efficient product selection and purchasing decisions for intravenous cannulae.

Perioperative blood management programme reduces the use of allogenic blood transfusion in patients undergoing total hip and knee arthroplasty.

BACKGROUND: Optimisation of blood management in total hip (THA) and knee arthroplasty (TKA) is associated with improved patient outcomes. This study aimed to establish the effectiveness of a perioperative blood management programme in improving postoperative haemoglobin (Hb) and reducing the rate of allogenic blood transfusion. METHODS: This retrospective before and after study involves 200 consecutive patients undergoing elective TKA and THA before (Usual Care group) and after (Intervention group) the introduction of a blood management programme in an Australian teaching hospital. Patients in the Intervention group underwent preoperative treatment for anaemia and received intraoperative tranexamic acid (15 mg/kg). The primary outcomes were to compare postoperative Hb levels and the rate of blood transfusion. Secondary outcomes included measurements of total amount of allogenic blood transfused, transfusion-related complications, postoperative complications, need for inpatient rehabilitation and duration of hospital stay. RESULTS: There were no differences between baseline characteristics between groups. The mean (SD) preoperative Hb was higher in the Intervention group compared to that in the Usual Care group: 138.7 (13.9) vs. 133.4 (13.9) g/L, p = 0.008, respectively. The postoperative day 1 Hb, lowest postoperative Hb and discharge Hb were all higher in the Intervention group (p < 0.001). Blood transfusion requirements were lower in the Intervention group compared to the Usual Care group (6 vs. 20 %, p = 0.003). There were no differences in any of the secondary outcomes measured. Patients who were anaemic preoperatively and who underwent Hb optimisation had higher Hb levels postoperatively (odds ratio 5.7; 95 % CI 1.3 to 26.5; p = 0.024). CONCLUSIONS: The introduction of a perioperative blood optimisation programme improved postoperative Hb levels and reduced the rate of allogenic blood transfusion.

Fluid prescription practices of anesthesiologists managing patients undergoing elective colonoscopy: an observational study.

BACKGROUND: Routine fluid prescription is common practice amongst anesthesiologists caring for patients undergoing colonoscopy. However there is limited information about routine procedural fluid prescription practices of anesthesiologists in this setting. Routine fluid administration may also have important pharmaco-economic implications for the health care budget. Therefore we performed a prospective observational study assessing the fluid prescription practices of anesthesiologists caring for patients undergoing elective colonoscopy. METHODS: With Institutional Review Board approval, adult patients receiving procedural fluid intervention during elective colonoscopy were included. DATA COLLECTED: size of intravenous cannula inserted, volumes of fluid administered, adverse events, procedure duration, and pharmaco-economic costs associated with fluid prescription. Anesthesiologists and gastroenterologists were blinded to the study. RESULTS: We collected data on 289 patients who received fluid prescription by their attending anesthesiologist. Median patient age: 48 yrs (range 18-83), gender: 174 (60%) female; median duration of procedure: 24 minutes (range 12-48). Cannula size: 181 (63%) patients received a 22G cannula or smaller. Median volume of fluid administered during the colonoscopy was 325 ml (range 0 to 1000 ml). Median duration of the procedure: 25 minutes (range 12 to 48 minutes). Median volume of fluid administered in the post anaesthesia recovery unit: 450 ml (range 0 to 1000 ml). Fifteen patients (5%) became hypotensive during the procedure and two patients (<1%) developed hypotension in the PACU. There was no difference in the median fluid requirements between patients with hypotension and those without. Fluid volumes were strongly associated with increasing cannula diameter (p = 0.0001), however there was no association between fluid volumes administered and vasopressor use, peri-procedural adverse events, or procedure duration. At our institution fluid therapy currently cost about AUD$4.90 per patient: 1 L crystalloid $1.18 and fluid delivery set $3.77 Our institution performs over 9000 endoscopic procedures annually with fluid therapy costing about $45,000/year. CONCLUSIONS: Routine fluid prescription by anesthesiologists managing patients undergoing colonoscopy was ineffective with low actual fluid volumes delivered during the procedure. There was no association between volumes of fluid delivered and procedural hypotension, adverse events, or procedure duration. Anesthesiologists should question the clinical and pharmaco-economic value of routine fluid administration for patients undergoing elective endoscopy.

Dental extraction in a child with chronic idiopathic thrombocytopenia purpura: are preoperative platelet transfusions necessary?

Thresholds for platelet counts in patients at risk for bleeding are often used before surgery. We present a case report of a 13-year-old female with chronic idiopathic thrombocytopenia purpura for dental extraction with a platelet count of 4 × 10 L. Usually, therapies including platelet infusions, IV immunoglobulin, or corticosteroids would be used to increase platelet numbers. In this patient, rather than using any of these prophylactic therapies preoperatively, we used a "watchful waiting" strategy with a multidisciplinary team, the use of tranexamic acid and the aforementioned therapies available only as "rescue" agents.

Airway strategies for lung isolation in a patient with high-velocity nail gun injuries to the right cardiac ventricle and floor of the mouth: a case report.

INTRODUCTION: We report a case of deliberate self-harm in which three three-inch nails were fired from a nail gun resulting in mandibular fixation and two penetrating injuries to the right cardiac ventricle. This combination of high-velocity penetrating injury has not been previously described. CASE PRESENTATION: A 69-year-old Caucasian man with a medical history of chronic depression was brought to hospital after a failed suicide attempt. The attempt consisted of self-asphyxiation with car exhaust fumes and shooting himself thrice with a three-inch nail gun. He sustained a penetrating nail injury to the floor of his mouth, effectively pinning his mouth closed, and penetrating injuries to the right ventricular free wall and at the junction of the right atrioventricular septum. The patient required emergency surgery with requirements for thoracotomy and sternotomy, lung isolation and cardiopulmonary bypass. CONCLUSIONS: This is the first reported case of a combination high-velocity penetrating nail gun injury to the face and the right cardiac ventricle. This rare case offers airway strategies to accommodate the surgical requirement for lung separation for penetrating chest trauma in a patient with iatrogenically limited mouth opening.