Technology  escalating impact on perioperative  care : Clinical,compliance and medicolegal considerations

Brian J Cammarata and Brian J Thomas

APSF newsletter,Volume 29N1 1-24 June 2014–07–06

Vignette

A 57 year old female presents for a laparoscopic cholecystectomy

Following the uneventful induction of general anesthesia, the patient is prepped and surgery begins.

Intraoperatively, the patient becomes acutely hypotensive and tachycardic.

Despites intravenous fluids and phenylephrine, the hypotension persists.

The patient is ultimately resuscitated but slow to awaken postoperatively.

MRI of the head reveals an ischemic infarction.

She regains consciousness on postoperative day 1, but has persistent right sided weakness

The spouse and the surviving children bring suit against the anesthesiologist for failing to appropriately treat the hypotension resulting in a cerebro vascular accident.

During discovery, the circulating nurse and scrub technician testify that the anesthesiologists was on her cell phone and checking e-mail immediately prior to the event.

Plaintiff's attorney subpoenaed the cell phone and hospital computer records validating the allegation.

Comments - Cell phone and hospital computer records are discoverable and may be admissible evidence at trial.
In this case, the anesthesiologist's defensible care is compromised by the proven allegation of electronic distraction during the anesthetic

Monitoring temperature in children undergoing anaesthesia: a comparison of methods

 TFE Drake-Brockman, M Hegarty, NA Chambers, BS von Ungern-Sternberg

 Anaesthesia and Intensive care

Volume 42, Issue 3 May 2014,315-320

Children undergoing anaesthesia are prone to hypothermia. Perioperative monitoring of patient temperature is, therefore, standard practice. Postoperative temperature is regarded as a key anaesthetic performance indicator in Australian hospitals. Many different methods and sites of temperature measurement are used perioperatively. It is unclear to what degree these methods might be interchangeable. The aim of this study was to determine the relationships between temperatures measured at different sites in anaesthetised children. Two hundred children, 0 to 17 years, undergoing general anaesthesia for elective non-cardiac surgery, were prospectively recruited. Temperature measurements were taken in the operating theatre concurrently at the nasopharynx, tympanic membranes, temporal artery, axilla and skin (chest). Patient age and weight were documented. Temperatures varied according to site of measurement. 

The mean difference from nasopharyngeal temperature to temperatures at left and right tympanic, temporal, axillary and cutaneous sites were +0.24°C, +0.24°C, +0.35°C, -0.38°C and -1.70°C, respectively.

 Levels of agreement to nasopharyngeal temperature were similar at tympanic, temporal and axillary sites. Tympanic and temporal temperatures were superior to axillary temperatures for detection of mild hypothermia (<36°C). Skin temperature showed a large variation from nasopharyngeal measurements. Our findings indicate that measured temperatures vary between sites. Understanding these variations is important for interpreting temperature readings.  

The use of a nasogastric tube to facilitate nasotracheal intubation: a randomised controlled trial

 C.-W. Lim,S.-W. Min et al

Anaesthesia

Volume 69, Issue 6, pages 591–597, June 2014

During nasotracheal intubation, the tracheal tube passes through either the upper or lower pathway in the nasal cavity, and it has been reported to be safer that the tracheal tube passes though the lower pathway, just below the inferior turbinate. We evaluated the use of a nasogastric tube as a guide to facilitate tracheal tube passage through the lower pathway, compared with the ‘conventional’ technique (blind insertion of the tracheal tube into the nasal cavity). A total of 60 adult patients undergoing oral and maxillofacial surgery were included in the study. In 20 out of 30 patients (66.7%) with the nasogastric tube-guided technique, the tracheal tube passed through the lower pathway, compared with 8 out of 30 patients (26.7%) with the ‘conventional’ technique (p = 0.004). Use of the nasogastric tube-guided technique reduced the incidence and severity of epistaxis (p = 0.027), improved navigability (p = 0.034) and required fewer manipulations (p = 0.001) than the ‘conventional’ technique

Low intraoperative tidal volume ventilation with minimal PEEP is associated with increased mortality

 P. J. McCormick et al .

 BJA,Volume 113,Issue 1 Pp 07-108,July 2014

Anaesthetists have traditionally ventilated patients' lungs with tidal volumes (TVs) between 10 and 15 ml kg⁻¹ of ideal body weight (IBW), without the use of PEEP. Over the past decade, influenced by the results of the Acute Respiratory Distress Syndrome Network trial, many anaesthetists have begun using lower TVs during surgery. It is unclear whether the benefits of low TV ventilation can be extended into the perioperative period.

Methods We reviewed the records of 29 343 patients who underwent general anaesthesia with mechanical ventilation between January 1, 2008 and December 31, 2011. We calculated TV kg⁻¹ IBW, PEEP, peak inspiratory pressure (PIP), and dynamic compliance. Cox regression analysis with propensity score matching was performed to examine the association between TV and 30-day mortality.

Results Median TV was 8.6 [7.7–9.6] ml kg⁻¹ IBW with minimal PEEP [4.0 (2.2–5.0) cm H₂O]. A significant reduction in TV occurred over the study period, from 9 ml kg⁻¹ IBW in 2008 to 8.3 ml kg⁻¹ IBW in 2011 (P=0.01). Low TV 6–8 ml kg⁻¹ IBW was associated with a significant increase in 30-day mortality vs TV 8–10 ml kg⁻¹ IBW: hazard ratio (HR) 1.6 [95% confidence interval (CI) [1.25–2.08], P=0.0002]. The association remained significant after matching: HR 1.63 [95% CI (1.22–2.18), P<0.001]. There was only a weak correlation between TV kg⁻¹ IBW and dynamic compliance (r=−0.006, P=0.31) and a weak-to-moderate correlation between TV kg⁻¹ IBW and PIP (r=0.32 P<0.0001).

Conclusions Use of low intraoperative TV with minimal PEEP is associated with an increased risk of 30-day mortality.

 

Impact of sevoflurane anesthesia on brain oxygenation in children younger than 2 years

Ossam Rhondali et al.

Pediatric Anesthesia

Volume 24, Issue 7, pages 734–740, July 2014

Children younger than 2 years, ASA I or II, scheduled for abdominal or orthopedic surgery were included.

 Induction of anesthesia was started by sevoflurane 6% and maintained with an expired fraction of sevoflurane 3%. Mechanical ventilation was adjusted to maintain an endtidal CO₂ around 39 mmHg. Brain oxygenation was assessed measuring regional cerebral saturation of oxygen (rSO₂c), measured by NIRS while awake and 15 min after induction, under anesthesia. Mean arterial pressure (MAP) variation was recorded.

Despite a significant decrease of MAP, 1 MAC of sevoflurane induced a significant increase in regional brain oxygenation. But subgroup analysis showed that MAP decrease had a greater impact on brain oxygenation, in children younger than 6 months. 

According to their results, MAP value during anesthesia should not go under 33 mmHg in children ≤6 months and 43 mmHg in children >6 months, as further changes in MAP, PaCO₂ or hemoglobin during anesthesia may be poorly tolerated by the brain.

Effects of a head elevated ramped position during elective caesarean delivery after combined spinal-epidural anaesthesia.

Cheesman K, Massey S, Preston R, Albert A, Douglas J.

Int J Obstet Anesth.     2014 May;23(2):106-12.

Elevating the parturient undergoing elective caesarean delivery into the Head Elevated Ramped Position immediately or once the block had been established did not appear to significantly alter time to an adequate block height of T4; however, the need for epidural supplementation was greater in the intervention groups. Cautious use of this novel position change can provide a more comfortable experience and provide a better airway position should conversion to general anaesthesia be required.

Carotid endarterectomy under local and/or regional anesthesia has less risk of myocardial infarction compared to general anesthesia: An analysis of national surgical quality improvement program database.

Kfoury E, Dort J, Trickey A, Crosby M, Donovan J, Hashemi H, Mukherjee D

.

Vascular. 2014 May 29. 

Our study compared 30-day postoperative myocardial infarction, stroke, and mortality between carotid endarterectomy under local or regional anesthesia and carotid endarterectomy under general anesthesia utilizing National Surgical Quality Improvement Program database

Carotid endarterectomy under local or regional anesthesia had a significantly decreased risk of 30-day postoperative myocardial infarction when compared to carotid endarterectomy under general anesthesia (0.4% vs 0.86%, p = 0.012). No statistically significant differences were found in postoperative stroke or mortality.